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Official Journal of the American College of Sports Medicine Anterior Drawer limited due to guarding. Posterior Drawer negative. McMurray positive. Patellar Apprehension and Varus/Valgus Stress Test negative. dIFFErENTIaL dIaGNOsIs: 1. Meniscal Tear 2. ACL Rupture 3. Juvenile Idiopathic Arthritis 4. Infectious Arthritis 5. Reactive Arthritis 6. Lyme Disease 7. Malignancy TEsT aNd rEsuLTs: Left knee Xray: Large joint effusion without bony abnormality Left knee joint aspiration: 60ml yellow slightly cloudy synovial fluid, no crystals, 1545 RBC, 3700 nucleated cells, 3 Segs, 1 Eos, 47 Lymphs, 19 Monos, 30 Macrophages. Gram Stain: no organisms. Aerobic, anerobic, chocolate agar cultures: no growth CBC: WBC 7.8, Hgb 15.6, Plt 156 ANA Neg CRP 0.5, ESR 4 Rheumatoid Factor 8.6 Lyme Disease Serology Positive, Lyme Disease Western Blot Negative. Left Knee MRI without contrast: Large joint effusion with small to moderate intraarticular debris. Meniscus and ACL intact. Rheumatology Consult: Unlikely to be JIA, most likely traumatic injury to knee. Cannot exclude systemic cause. Urine Amplified DNA: Chlamydia positive, Gonorrhea negative FINaL WOrKING dIaGNOsIs: Reactive arthritis secondary to Chlamydia trachomatis infection TrEaTMENT aNd OuTCOMEs: 1. Azithromycin 1 g PO X 1 2. Ceftriaxone 250 mg IM X 1 3. Repeat urine GC/CT testing in 3 weeks 4. Tested for HIV, Hepatitis B & C, Syphilis: Negative 5. Safer sex counseling; Notify, test all sexual contacts 6. Naproxen for knee pain & swelling 7. Upon further questioning, patient reports sexual intercourse several months preceding injury and condom use with every encounter. 1034 May 30, 8:20 AM - 8:40 AM Exercise Induced hemoptysis: a hemodynamic Intervention Case report Miranda E. Contursi, Aaron L. Baggish, Gregory D. Lewis. Massachusetts General Hospital, Boston, MA. (No relationships reported) hIsTOry: A 47-yo male presented with recurrent episodes of exercise-induced hemoptysis (EIH) that consisted of 1-3 tbsp of bright red blood following intense bouts of aerobic exercise. He had no known history of heart or lung disease. PhysICaL EXaMINaTION:1.8m, 97kg, HR=77, BP=132/86, jugular venous pressure 5cm, regular S1 and S2 without murmurs, rubs or gallops, lungs clear to auscultation and percussion, no clubbing, cyanosis, or edema. PhysICaL EXaMINaTION: Bronchitis, bronchiectasis, malignancy, foreign body, infectious processes, inflammatory disorders, pre- or post-capillary pulmonary hypertension, pulmonary embolism. TEsT aNd rEsuLTs: Chest CT scan: mild mosaic attenuation with non-specific peripheral ground glass opacities; no nodules, pulmonary embolism, or pleural thickening/effusion. Bronchoscopy: petechiae on bronchial surfaces with slight hemorrhage when he coughed against the bronchoscope. Bronchoalveoloar lavage and coagulation studies: unremarkable. Incremental, upright cycle ergometery cardiopulmonary exercise testing (CPX) was performed with continuous invasive hemodynamic monitoring by radial and pulmonary arterial catheters: Normal peak VO2 (30.6 mL·min-1·kg-1, 112% predicted), peak cardiac output (17L/min), and resting hemodynamics but marked elevation in systemic BP (peak BP=261/134) and pulmonary capillary wedge pressure (peak PCWP=28mmHg) with normal pulmonary vascular resistance (exercise PVR = 1 Wood unit). FINaL WOrKING dIaGNOsIs: Exaggerated systemic BP response and diastolic dysfunction during exercise, leading to increased hydrostatic pressure transmitted to the lung, which increased the patient’s propensity to develop hemoptysis. TrEaTMENT aNd OuTCOMEs: Following the invasive CPX, we tested the hypothesis that pre-exercise nitrate therapy would attenuate systemic hypertension and elevation in PCWP in response to exercise. Repeat serial non-invasive CPXs before and after isosorbide dinitrate 10mg showed that nitrates reduced exercise BP (peak BP 188/80 vs. 230/110). We inferred dual contributions to EIH: pulmonary vascular fragility coupled with dynamic pulmonary venous hypertension, which was successfully attenuated by pre-exercise nitrate therapy. The patient was able to resume regular training without further hemoptysis. Vol. 45 No. 5 Supplement S187 1035 May 30, 8:40 AM - 9:00 AM General Medicine-unusual Cause of Thoracic Pain Wade M. Rankin, Ryan Sprouse. University of Kentucky, Lexington, KY. (No relationships reported) hIsTOry:A 33y African American male, with past medical history significant for familial adenomatous polyposis, presented with mid-back paraspinal muscle pain/ tightness intermittently for 8 months. Initially patient was diagnosed with paraspinal muscle spasms and managed conservatively with ibuprofen, heat therapy, physical therapy, and posture correction. Patient reported the pain/tightness is worse with activity and radiated to his lower back. He denied any injury/trauma to the area. He denied any radicular symptoms, extremity weakness, shortness of breath, or fever/ chills. The pain/tightness became acutely worse and he has recently noticed a mass in the paraspinal musculature between the right scapula and spine. PhysICaL EXaM: Well appearing, thin male with no lymphadenopathy or masses noted to his neck, lungs clear to auscultation, non-labored breathing, heart RRR, equal pulses bilaterally. Two firm palpable 5x5cm non fluctuant masses with ill-defined borders over the mid-thoracic area with obvious visual malformations. Minimally tender to palpation over the spinous process between the two masses. Strength 5/5 in bilateral upper extremities. No sensory deficits. PhysICaL EXaMINaTION: Muscle spasm Muscle strain Myositis Tumor/mass Lipoma Scapulothoracic bursitis Vertebral fracture Hyperkyphosis Hematoma Abscess TEsTs aNd rEsuLTs Wbc 5.9, Hgb12.8, Hct 37.5 US Chest: avascular solid mass measuring 7.3x2.1cm between right scapula and mid thoracic spine. MRI T-spine: 10x8x3 cm mass lesion within the bilateral erector spinae musculature, T6-T9 levels. Lesion effectively replaces the mulfidus and longissimus thoracis muscles at that level. Likely represents myositis of the longissimus thoracis and multifidus muscles with focal myonecrosis and/or a chronic hematoma. Biopsy: Non-atypical fibroproliferative process infiltrating skeletal muscle with mild chronic inflammation and rare possible regenerating myofibers. No evidence of metastatic carcinoma is seen on the touch prep slides or within the core biopsies. Possible diagnostic considerations include fibromatosis (desmoids tumor). FINaL/WOrKING dIaGNOsIs: Desmoid Tumor TrEaTMENT aNd OuTCOMEs 1. Radiotherapy noted to lesion 2. Adjuvant chemotherapy 3. Patient currently undergoing above treatment 1036 Withdrawn 1037 May 30, 9:00 AM - 9:20 AM skin Infection in an Offensive Lineman Kyle E. Geissler, James Borchers, FACSM. Ohio State University, Columbus, OH. (No relationships reported) hIsTOry: 18 year old male presented with the complaint of left buttock pain and drainage. He is a lineman and started practice the week prior. He popped what appeared to be a pimple on his left buttock three days ago. The patient had increased pain, buttock erythema, intermittent fevers, nausea, and malaise for the two days prior to evaluation. He denied vomiting, dysuria, hematuria, or diarrhea. The patient reported having a history of a skin infection on his face while wrestling in high school, but did not know if he had MRSA. He was not on any prescribed medications. PhysICaL EXaM: In general, the patient appeared ill but was in no acute distress. Vital signs: temperature 100.6, pulse 97, blood pressure 148/55. His left buttock contained significant induration with a central area that was draining serosanguinous fluid. There was an area of fluctuance around the draining area. The erythema was approximately 10cm in size and extended to the rectum and perineum, but not to the scrotum. The rest of the external genitalia was normal in appearance. PhysICaL EXaMINaTION: Cellulitis, Perirectal abscess, Colorectal fistula, Fournier’s gangrene, Vascular occlusion syndromes, Necrolytic migratory erythema TEsTs/rEsuLTs: Labs: WBC 20K, BUN/Cr 11/1.25. The rest of the CBC and Chem 7 were within normal limits. CT scan of the pelvis revealed soft tissue stranding in the left ischiorectal fossa and medial aspect of the left buttock that courses towards the canal. FINaL dIaGNOsIs: Perirectal abscess progressing to Fournier’s gangrene Abstracts were prepared by the authors and printed as submitted. Thursday, May 30, 2013
Thursday, May 30, 2013 S188 Vol. 45 No. 5 Supplement TrEaTMENT/OuTCOME: The patient was admitted to the hospital and started on IV Vancomycin. Pain and nausea were treated symptomatically. An infectious disease consult was obtained and Daptomycin, ciprofloxacin, and Flagyl were started to additionally cover for enteric bacteria. Colorectal surgery was consulted, and they peformed a bedside incision and drainage. On day 3 of admission, the erythema had spread to the scrotum. The next day, the patient was taken for surgical debridement and drainage of a perirectal abscess. Following debridement, a diagnosis of Fournier’s gangrene was made. IV antibiotics were continued and the patient was discharged home on day 6 on oral ciprofloxacin and Flagyl, in addition to daily wet to dry dressing changes. He was able to return to play six weeks after discharge. C-22 Clinical Case Slide - Lower Extremity I May 30, 2013, 8:00 AM - 10:00 AM Room: 117 1038 Chair: David Olson. University of Minnesota, St. Paul, MN. (No relationships reported) 1039 discussant: Brian M. Babka. Lutheran General Hospital, Elmhurst, IL. (No relationships reported) 1040 discussant: Elizabeth E. Rothe. Maine Medical Center Sports Medicine, Portland, ME. (No relationships reported) 1041 May 30, 8:00 AM - 8:20 AM Leg Pain- rowing Kathryn Miller, Aurelia Nattiv, FACSM. UCLA, Los Angeles, CA. (No relationships reported) hIsTOry: 21 year old NCAA Division 1 female rower with prior rib stress fracture with right leg pain x 3 weeks starting in August 2012. Pain started during sprint intervals on track. Pain was aching pain along posterior, lateral thigh. Injury initially managed as quad strain by ATC, but pain continued to worsen despite relative rest. Over the summer, she had been running 60-70 miles weekly. Past medical/surgical History: None Except, Rib Stress Fracture (Spring 2012), Eumenorrheic, Menarche Age 12, No History Of Disordered Eating, Weight Stable Meds: None Family History: No History Of Osteoporosis Or Fractures Social History: Full Time Student, Junior, No Tobacco, Occasional Binge Drinking, No Milk, 6 Oz Yogurt/Week, No other sources dietary calcium ROS: Negative 14-point system review PhysICaL EXaMINaTION: 5’9”; 163 lbs. Healthy appearing. Normal gait, pes planus. No palpable masses, erythema, edema, ecchymosis over right thigh. Mild tenderness to palpation over lateral right thigh. Hip ROM full bilaterally. No pain with active/passive ROM of hip. No pain over spinous processes, paraspinal muscles, hamstrings, IT band insertion. On right +hop test, + fulcrum test, -FABER, -FADIR, +OBERS, -SLR bilaterally. PhysICaL EXaMINaTION: 1.Femoral stress reaction/fracture 2.Quad strain 3.IT Band Syndrome 4.AVN of femoral head 5.Referred pain TEsTs aNd rEsuLTs: Plain Radiographs of Right Femur and AP Pelvis: Normal MRI Right Femur: Periosteal edema along medial aspect of proximal femur with bone marrow edema for 4.4 cm along insertion of site of adductor longus. Also, small linear area of cortical signal visualized consistent with a small cortical stress fracture. Labs: TSH 1.2, PTH 20, Calcium 9.8, vitamin D 25-OH 56 DXA: Spine Z-score +0.5; Total Hip Z-score +0.3; Femoral Neck Z-score -0.2. Normal BMD for age. Final Working Diagnosis: Femoral stress fracture TrEaTMENT aNd OuTCOMEs: 1.Non-weight bearing x 3 weeks 2.Transitioned to full weight bearing over 1 additional week 3.Started swimming 4 weeks after diagnosis with increased pain with breaststroke kick 4.Able to resume full pool workouts 5 weeks after diagnosis 5.Light stationary bike without pain 8 weeks after diagnosis 6.No impact activity for at least 10 weeks 7.Plan to gradually add erging prior to running 8.Referred to sports dietitian for consult MEDICINE & SCIENCE IN SPORTS & EXERCISE ® 1042 May 30, 8:20 AM - 8:40 AM rugby Player sustains Lower Extremity Injury during a Tackle Hamish A. Kerr. Albany Medical Center, Albany, NY. (No relationships reported) hIsTOry: 15 minutes into the 1st home game of the season, a 21 year old rugby player goes down in the center of the field. He does not get up. The athletic trainer and physician covering run on to evaluate. The player is in a great deal of discomfort, but cannot localize what hurts. He says he tried to get up but couldn’t weight bear on his right leg. Past Medical History: Acromio-clavicular sprain of his left shoulder. Denied any current medications and has no known drug allergies. He is a college student and this is his 2nd year playing rugby. He is a forward. He denied any contributory family history. On review of systems, he denied any back pain, or any paresthesiae in the lower extremity. He denied any trauma to his head, neck, or spine. He denied losing consciousness. PhysICaL EXaMINaTION (Er): BP 143/109, HR 64, RR 20; SpO2 100%; Height 175cm, Weight 94.35kg, BMI 30 Generally he appeared in some distress. He was alert and oriented to time, place and person. His right leg was being held in a flexed position at the knee and hip. He had very large, muscular thighs. He had a palpable dorsalis pedis pulse. He was able to wiggle his toes on command. His sensory function of the distal right extremity was intact for light touch. Manipulation of his right thigh and hip provoked pain. He could flex his knee. There appeared to be deformity of his right buttock and the right leg appeared shorter than the left. dIFFErENTIaL dIaGNOsIs Fractured right femur Dislocated patella Dislocated right hip TEsTs aNd rEsuLTs: Patient was transported via EMS to the Emergency Department where initial X-ray imaging confirmed a posterior hip dislocation. FINAL WORKING DIAGNOSIS: Right Hip Dislocation TrEaTMENT aNd OuTCOMEs: The patient required conscious sedation with propofol and fentanyl to relocate the hip. He underwent computed tomography (CT) of the hip, confirming relocation and noting a small anterior, superior acetabular fracture. He was immobilized and maintained non-weight bearing. He was provided oral opiate analgesia. He was seen in follow-up at 48 hours and 3 weeks post-injury, when he was able to partially weight bear, had regained 90 degrees of hip flexion and 30 degrees of internal/external rotation. He understood he was not going to be able to return to rugby that season. 1043 May 30, 8:40 AM - 9:00 AM hip Pain-Water skiing Christopher S. Karam1 , Andrew H. Gordon2 , Arthur J. De Luigi1 . 1MedStar National Rehabilitation Network, Washington, DC. 2The Johns Hopkins Hospital, Baltimore, MD. (Sponsor: Stuart Willick, FACSM) (No relationships reported) hIsTOry: A 42-year-old woman injured her right hip while waterskiing. She waterskied with one ski on her left lower extremity. She rested her right lower extremity, not placed into the ski, posteriorly on the ski attached to the left foot. When performing a twisting motion while skiing, she felt a deep pressure in her right hip while keeping balance on the ski. She initially rated her pain as 4/10, having some success using conservative measures of oral anti-inflammatory medications (diclofenac) and anesthetic patches (lidocaine) in combination with physical therapy and home exercise program. No imaging was obtained during the course of her initial injury. Approximately six months later, she aggravated her right hip injury while snow-skiing. She reported a constant 6/10 deep aching hip pain. Her right hip pain especially worsened with exercise, so she then stopped exercising. ACSM May 28 - June 1, 2013 Indianapolis, Indiana
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