Schwannoma with Psammoma Body

We present a case of a 59-year-old male veteran with a chronic history of right foot soft-tissue mass that was causing pain in his shoes, but not functional or neurologic symptoms. Excision of the mass and pathologic evaluation resulted in multidisciplinary involvement and evaluation. In this example, the mass was found to be either an unusual schwannoma that happens to be psammoma body–rich or an unusual psammomatous melanocytic schwannoma that deviates from conventional examples, as a diagnostic consensus was unable to be reached. Schwannomas are an uncommon finding in the foot, and even more uncommon are those that contain psammoma bodies. Although rare, these tumors can be concerning for more systemic, life-altering diseases such as Carney complex, for which our patient refused genetic testing.

Carfilzomib-induced pulmonary hypertension with associated right ventricular dysfunction: A case report

Carfilzomib, a selective proteasome inhibitor, is approved for use in relapsed and refractory multiple myeloma. Its link to left ventricular dysfunction is well established but little is known about its effects on the right ventricle. One of its rare complications is pulmonary hypertension, which at its extreme may result in right ventricular dysfunction. Here, we present a case of an elderly male veteran with multiple myeloma status post various failed therapies who developed acute dyspnea after four cycles of carfilzomib and subsequently found to have severe pulmonary hypertension with resultant acute right ventricular failure, which recovered after cessation of carfilzomib. This case highlights the need for careful cardiovascular surveillance while on carfilzomib and the importance of knowing even its rarest complications as these cardiotoxicities are reversible with discontinuation of the drug.

Abstract 14375: Does Race Provide Protection From New Onset Atrial Fibrillation After Typical Flutter Ablation in Male Veteran Patients?

Introduction: Patients undergoing typical atrial flutter (AFL) ablation remain at risk of developing atrial fibrillation (AF). However, it is unknown whether common risk factors associated with AF occurrence, particularly race, bear out in this population. Hypothesis: We sought to compare the occurrence of new AF in male veteran African-American (AA) and Caucasian (Cau) patients with AFL following successful cavo-tricuspid isthmus ablation. Methods: A retrospective review of patients undergoing AFL ablation between 2002 and 2019 was performed. Patients with prior history of AF were excluded. Records were reviewed and demographics, comorbidities and post-ablation outcomes including new AF and stroke were recorded. The overall incidence of AF and cases per 1000 person-years (CPTPY) were determined. Results: The study cohort comprised 217 patients (age: 66±9.3 years, AA: 97 [45%], Cau:108 [50%]; see Table) with a mean follow-up of 55±42 months after AFL ablation. New AF was detected in 30 (31%) AA and 45 (42%) Cau patients (p=0.21 by Log Rank test). Overall incidence of AF was 78 CPTPY (67 and 91 CPTPY cases in AA and Cau patients, respectively). Time to occurrence of AF was earlier in Cau than AA patients (p=<0.001). New stroke events occurred in 9 (4.4%) patients (4 AA, 5 Cau; p=0.86). Conclusions: Male AA and Cau patients have similar significant risks for developing AF and experiencing stroke after AFL ablation.

Acceptance and Commitment Therapy Delivered via Telehealth for the Treatment of Co-Occurring Depression, PTSD, and Nicotine Use in a Male Veteran

Symptoms of depression, posttraumatic stress, and substance use disorders commonly co-occur and are a tremendous health burden among the U.S. military veteran population. Acceptance and Commitment Therapy (ACT) is an evidence-based, transdiagnostic, integrated approach that has been used to treat these problems. Delivering psychotherapy via telehealth helps to break down barriers to care. This case study describes the application of ACT via telehealth with a male veteran with co-occurring symptoms of depression, PTSD and nicotine addiction. His depressive symptoms, PTSD symptoms, and nicotine use decreased substantially over the course of therapy. He demonstrated increased willingness to experience negatively evaluated internal experiences such as emotions and urges to use nicotine, defusion from self-critical and other unhelpful thoughts, more consistent engagement in values-consistent behaviors, and increased behavioral engagement in his social life. Treatment implications and unique aspects of the telehealth modality are discussed. Recommendations are made for training clinicians who may be considering providing services via telehealth or using ACT.

Acute Transverse Myelitis After SARS-CoV-2 Infection: A Rare Complicated Case of Rapid Onset Paraplegia in a Male Veteran

Background: SARS-CoV-2 (COVID-19) is a new human pathogen, and currently, the world has been plagued by its pandemic and there are no specific treatment options, mostly affects the respiratory system, ranging from mild flu-like symptoms to severe acute respiratory syndrome (SARS), but extra respiratory multi-systemic involvement has also been reported.Case presentation: A 63-yr-old Caucasian male veteran (retired army colonel), known case of controlled Type 2 diabetes, chronic renal failure and ischemic heart disease, about 4 days after the onset of flu-like syndrome (with no trauma history) experienced loss of control over both lower limbs, absent sensation from the chest below with constipation and urinary retention. Due to world SARS-CoV-2 (COVID-19) outbreak, his nasopharyngeal specimen was tested for COVID-19 reverse transcription polymerase chain reaction (RT-PCR) and positive result obtained. Chest x-ray and HRCT suggested severe pulmonary involvement. Immediately, he was admitted at emergency ward, treated based national COVID-19 protocol and a series of diagnostic procedures were started up to find out the cause of his non-heterogeneous peripheral (spinal) neuromuscular manifestations. Brain CT scan and MRI were normal, but spinal MRI with gadolinium contrast agent showing extensive increased T2 signal involves central grey matter and dorsal columns, extension between C7 and T12 with linear sagittally oriented enhancement posteriorly within the cord in the mid and lower thoracic cord. The CSF specimen obtained from LP shown pleocytosis, positive RT-PCR for SARS-CoV-2 and elevated IgG index. Clinical presentations, MRI, CSF and laboratory findings, after ruled out the other numerous possible causes with specific methods, suggested the Acute Transverse Myelitis (ATM) as a probably complication of COVID-19 infection. Intravenous methylprednisolone and then human immunoglobulin was added to treatment regimen. At the end, complete resolution of dysaesthesia, urinary retention and constipation were achieved. After continuous and long respiratory and motor rehabilitation programs, he was discharged home asymptomatic. Conclusions: We believe that SARS-CoV-2 has a potential to produces different extra respiratory multi-systemic involvement as immune-mediated process and complexes, and this should be kept in mind whenever encounter a patient with acute onset of neurological manifestations, especially after microbial infections or vaccinations.

Prevalence of Thyroid Incidentalomas from 1995 to 2016: A Single-Center, Retrospective Cohort Study

Background Incidental detection of thyroid nodules on nonthyroid imaging may contribute to increased diagnosis of thyroid cancer. We investigated the prevalence of thyroid incidentalomas across imaging modalities among a predominately male veteran population. Methods Thyroid nodules were identified on nonthyroid-directed radiology reports using natural language processing. All reports from 1995 to 2016 for chest computed tomography (CT), carotid ultrasound (US), and neck magnetic resonance imaging (MRI) were reviewed. Individuals with multiple studies were included at their initial study and duplicates removed. Results A total of 25 763 carotid US, 23 526 chest CTs with contrast, 39 262 noncontrast chest CTs, and 9503 MRIs were reviewed. With duplicates removed, 14 642 carotid US, 12 923 chest CTs with contrast, 17 416 noncontrast chest CTs, and 6926 MRIs were included. Mean age was 66.2 years and 1834 were female (3.53%). Thyroid nodules were reported on 0.84% carotid US, 3.45% MRIs, 5.84% chest CTs with contrast, and 5.14% noncontrast chest CTs. Women had a higher rate of thyroid nodules on MRI (6.46% vs 3.20%, P = .003), chest CT with contrast (9.80% vs 5.72%, P = .007), and noncontrast chest CT (8.77% vs 5.02%, P = .002), but not on carotid US (1.99% vs 0.81%, P = .12). Incidentaloma prevalence increased with age on MRI, chest CT with or without contrast, but not on carotid US, and were more commonly reported from 2007 to 2016 compared to before 2007 across all modalities. Conclusions Thyroid incidentalomas are commonly reported, are more common among women, and increase with age. The rate of reported incidental thyroid nodules is increasing, likely contributing to the increase in thyroid cancer.