Adam Kittai

Neisseria meningitidis as a cause of facial cellulitis

A 68-year-old man presented with facial cellulitis and found to have Neisseria meningitidis bacteraemia with no evidence of infection outside of the facial soft tissue. He was treated with a course of intravenous ceftriaxone and transitioned to oral amoxicillin on discharge with significant improvement of his symptoms. N meningitidis is best recognised as a causal agent of bacterial meningitis. To our knowledge N meningitidis cellulitis has only been described in 12 other cases. In this case series we describe and summarise our case, along with the 12 cases already reported in the literature. We report this case series to highlight the importance of recognising N meningitidis in the differential in patients presenting with acute skin and soft tissue infections especially involving the periorbital, head and neck regions.

Herpes Simplex Virus Blepharitis in a Patient with Crohn's Colitis

Herpes simplex virus reactivation may complicate treatment in patients who are receiving immunosuppressive medications, such as corticosteroids and antietumor necrosis factor antibodies. Optimum treatment and prophylaxis of herpes simplex virus infection in immunosuppressed patients are unclear. We present a case of a patient with Crohn’s disease who was treated with corticosteroids and in need of escalation of therapy to an antietumor necrosis factor agent, anddeveloped reactivation of herpes simplex virus blepharitis.

Granulocytic sarcoma in a patient with chronic myeloid leukaemia in complete haematological, cytogenetic and molecular remission

Granulocytic sarcoma, also known as myeloid sarcoma, is an extramedullary tumour composed of immature myeloid cells. Granulocytic sarcoma is typically found in patients with acute myeloid leukaemia, accelerated phase or blast crisis of chronic myeloid leukaemia, myelodysplastic syndrome, or as an isolated event without bone marrow involvement. We present a case of granulocytic sarcoma in a patient with chronic myeloid leukaemia in the setting of complete haematological, molecular and cytogenetic remission. Our patient was first treated with imatinib for chronic-phase chronic myeloid leukaemia. After maintaining remission for 42 months, he developed a granulocytic sarcoma in his spine. In this case report, we describe our case, along with the three other cases reported in the literature. In addition to being a rare diagnosis, this case demonstrates the importance of being vigilant in diagnosing the cause of back pain and atypical symptoms in patients with a history of leukaemia.

P-105 Gastroenterologist Laboratory Testing in Patients with Inflammatory Bowel Disease Does Not Increase Linearly by Decade

BACKGROUND: Laboratory testing is important in the overall management of chronic diseases. Aging can result in increased utilization of laboratory services. Individuals with inflammatory bowel disease (IBD) frequently require laboratory tests because they can serve as objective measurements of disease activity. There is limited data which has evaluated the use of laboratory testing in the different age ranges of adult patients with inflammatory bowel disease. This study correlated decade of age with the frequency of gastroenterologist-ordered laboratory testing in individuals with IBD. METHODS: A retrospective medical record review of inflammatory bowel disease patients at a university medical center during an 18 month period was performed using a multispecialty electronic health record. There were no exclusion factors. Patient age, gender, disease type, and laboratory testing performed by the gastroenterologist were obtained. A database, maintaining patient confidentiality, was created. Assessment of the frequency of laboratory tests were performed at the following age decades: <20, 20–29, 30–39, 40–49, 50–59, 60–69, and 70+ years. Statistical analysis was performed using ANOVA and T-testing, with statistical significance set at P < 0.05. The study was approved by the university institutional review board. RESULTS: Medical record of 316 IBD patients were reviewed. There were 189 women and 127 men, with a mean age of 41.8 years. One hundred seventy-one patients had Crohn’s disease, 143 with Ulcerative Colitis, and 2 with indeterminate colitis. A mean of 5.8 outpatient laboratory encounters occurred in patients <20, 6.8 in patients 20–29, 10.2 in patients 30–39, 11.1 in patients 40–49, 6.8 in patients 50–59, 7.0 in age 60–69 and 6.0 in patients age 70 or order during the study period (P = 0.034). Both young and geriatric patients received less laboratory studies on average when compared to patients age 30–50. This finding was pronounced in women: a mean of 9 outpatient laboratory occurred in women <20, 7.2 in women 20–29, 10.8 in women 30–39, 14.5 in women age 40–49, 6.9 age 50–59, 8.2 in women 60–69, and 5.1 in women 70 or older (P = 0.014). In men, however, differences in mean labs per decade did not reach statistical significance (P = 0.772). Women overall received an average of 9.3 tests during the study period while men received 7.2 (P = 0.044). CONCLUSIONS: Few studies have analyzed utilization of laboratory tests in inflammatory bowel disease at different age ranges. This study revealed that laboratory testing does not increase linearly with advancing decades of age. The number of gastroenterologist-ordered laboratory tests for inflammatory bowel disease peaked at age 30–50 years. The reason for this pattern is uncertain, but may represent new diagnoses or increased exacerbations. As this effect was statistically significant in women, this raises the question about the potential for gender-specific concerns. Less frequent laboratory testing in older patients may reflect gastroenterologist’ desire not to duplicate existing laboratory studies performed by other specialty providers. While inflammatory bowel disease is a chronic illness that warrants close monitoring, there is no evidence that laboratory expenditures by gastroenterologists linearly increase with advancing age. Further examination of physician laboratory testing patterns in inflammatory bowel disease is warranted.

P-055 Evaluating Whether Platelet Counts Are a Low Cost Alternative to ESR and CRP in the Evaluation of IBD Patients

BACKGROUND: Inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly checked in IBD patients who present with symptoms of active disease. These markers have been shown to correlate with disease activity. Inflammatory markers can be costly and are affected by other factors including age, anemia, temperature and time to processing. Thrombocytosis has also been shown to positively correlate with disease activity. In an effort to reduce the financial burden associated with the delivery of healthcare, we evaluated whether measuring thrombocytes is an effective alternative to monitoring inflammatory markers in IBD patients with active disease. METHODS: Medical records of 321 patients with ulcerative colitis (UC) and Crohn’s disease at an urban academic inflammatory bowel disease center during an eighteen-month period were evaluated. All encounter-types in which either platelets, ESR, or CRP were available within one week of the visit were examined. Patient age, disease type, symptom activity, ESR and CRP were obtained. A database was created using Microsoft Excel. Statistical analysis was performed using Fisher’s Exact test with significant set at P <0.05. The study was approved by the institutional review board. RESULTS: In 165 encounters of patients with symptoms of active disease, platelets were obtained in 144 encounters, ESR in 57 encounters and CRP in 59 encounters. In 343 encounters of patients without symptoms consistent with active disease, platelets were obtained in 299 encounters, ESR in 79 encounters and CRP in 78 encounters. Thrombocytosis (P = 0.0047), elevated ESR (P = 0.0051) and elevated CRP (P = 0.0039) were all found to be significantly associated with active disease symptoms. In 52 encounters with symptomatic patients, ESR and platelet counts were obtained concurrently. Among encounters associated with elevated ESR, 36% had thrombocytosis while 64% had normal platelet counts. There was no significant difference in these groups (P = 0.12). In 50 encounters with symptomatic patients, CRP and platelet counts were obtained concurrently. Thirty-one percent of encounters associated with elevated CRP values had thrombocytosis, while 69% had normal platelets. There was no significant difference in these groups (P = 0.32). CONCLUSIONS: With the rising cost of healthcare and initiatives such as the Affordable Health Care Act, there is increasing pressure to deliver quality, cost-effective care to patients. Thus, it is important that testing not only enhance the quality of medical care, but be financially appropriate. Similar to previous reports, thrombocytosis, elevated ESR, and elevated CRP were all significantly associated with symptoms of active disease in IBD patients. In this study, thrombocytosis did not significantly correlate with elevated inflammatory markers. While not statistically significant, the inflammatory markers were more commonly elevated in symptomatic patients compared to the presence of thrombocytosis. These outcomes may be due to the low total number of patient encounters in which both tests were obtained. Despite additional costs, judicious use of ESR and CRP is appropriate in the evaluation of patients whose symptoms are suggestive of active disease. Further studies are needed to examine the cost-effectiveness of these tests.