REACTIVE AMYLOID A PROTEIN AMYLOIDOSIS IN THE SETTING OF INFECTIVE ENDOCARDITIS MANIFESTING AS BILATERAL ORBITOPATHY AND CHOROIDOPATHY.

PURPOSE: To describe a case of amyloid A protein amyloidosis that produced an orbital inflammatory response with a novel presentation. METHODS: Case report. RESULTS: A 24-year-old Caucasian women with a history of intravenous heroin use was hospitalized for tricuspid valve endocarditis and methicillin-resistant Staphylococcus aureus bacteremia, as well as acute renal failure. She received hemodialysis and intravenous daptomycin and had negative blood cultures for 3 weeks, when she developed sudden bilateral orbital swelling and blurred vision. Visual acuity was 20/200 in the right eye and 20/400 in the left eye. Examination revealed proptosis, conjunctival chemosis and desiccation, optic disk swelling, creamy choroidal infiltrates, and inferiorly located exudative retinal detachments in both eyes. Multimodal imaging demonstrated thickening of the sclera, choroid, and choriocapillaris as well as outer retinal disruption, subretinal fluid, and deposits of hyperfluorescent debris within the choriocapillaris, outer retina, and vitreous. Oral prednisone at 60 mg per day resolved the choroidal infiltrates and exudative detachments. Persistent nephrotic syndrome called for a renal biopsy, which demonstrated amyloid A protein amyloidosis. CONCLUSION: Orbital and choroidal Amyloid A protein amyloidosis can induce a local inflammatory response manifesting as orbital swelling, papillitis, posterior scleritis, choroiditis, and exudative retinal detachment, which responds to steroid therapy. The underlying pathology is likely a reactive inflammatory, vasoocclusive process involving the choriocapillaris and orbital vasculature to the presence of amyloid fibrils.

A rare presentation of Horner syndrome due to internal jugular phlebectasia.

Horner syndrome occurs due to disruption of the oculosympathetic pathway. We present a case of acquired Horner syndrome in a 30-month-old boy due to phlebectasia of the internal jugular vein. To our knowledge, this rare entity has been reported only once before.

A case of ulcerative colitis associated with teprotumumab treatment for thyroid eye disease.

PURPOSE: To present a case of ulcerative colitis associated with teprotumumab treatment for thyroid eye disease. OBSERVATIONS: A 46-year-old Indian female was treated with teprotumumab (Tepezza) for severe thyroid eye disease within 9 months of diagnosis. The patient noted progression of her disease on oral prednisone and demonstrated severe, debilitating proptosis accompanied by eye ache and dry eyes. After 5 infusions of teprotumumab over a four-month period, the patient developed bloody diarrhea and fecal urgency. These symptoms progressively worsened and after two additional treatments, she underwent a colonoscopy. This confirmed the diagnosis of ulcerative colitis (UC). Treatment with teprotumumab was halted prior to the administration of the 8th infusion; however, the patient continued to have severe gastrointestinal symptoms two months after her last treatment. CONCLUSIONS AND IMPORTANCE: Teprotumumab is an insulin-like growth factor-1 receptor (IGF-1R) inhibitor demonstrated to improve proptosis in patients with active thyroid eye disease. Most adverse events reported are mild or moderate in severity; however, inflammatory bowel disease (IBD) is a serious adverse event that can develop as a result of treatment.

Breaking Bad: a case of Lactobacillus bacteremia and liver abscess.

We present a case of a 46-year-old Hispanic male with a past medical history significant for uncontrolled diabetes presenting with abdominal pain, nausea and vomiting and found to have Lactobacillus bacteremia and liver abscess. A PubMed and Clinical Key literature review of the other known cases of Lactobacillus liver abscess was performed. Through examination of previous case reports, the patient presented in this paper, and the associated risk factors of Lactobacillus liver abscess it is likely that the incidence of this rare condition will increase and would therefore be prudent to further study Lactobacillus as a pathogenic bacteria so that its complications may be better treated and prevented.