Faculty Bibliography

Effective screening in primary care among asylum-seekers in the US is critical as this population grows. This study aimed to evaluate disease prevalence and screening methods in this high-risk group. Two hundred ten new clients from 51 countries, plus Tibet, who were accepted into a program for asylum seekers from 2012 to 2014 were included. Screening rates and outcomes for infectious, non-communicable, and mental illnesses were evaluated. Screening rates were highest for PTSD, depression, hepatitis B, and latent tuberculosis. Seventy-one percent of clients screened positive for depression and 55 % for PTSD, followed by latent tuberculosis (41 %), hypertension (10 %), hepatitis B (9.4 %), and HIV (0.8 %). Overall screening rates were high. Point of care testing was more effective than testing that required a repeat visit. A large psychiatric and infectious disease burden was identified. These findings can inform future primary care screening efforts for asylum seekers in the US.

Background: The number of asylum seekers in the US has risen dramatically over the past 10 years. This study aimed to measure the prevalence of selected infectious, non-communicable and psychiatric illnesses within this population and to evaluate the success of a program for asylum seekers in screening for these conditions. Methods: Two hundred ten new clients from 51 countries, plus Tibet, who were accepted into an urban hospital-based program for asylum seekers from 2012-2014 were included. Screening rates and outcomes for infectious, non-communicable, and mental illnesses were evaluated based on intake data and review of the medical record. Informed written consent was obtained during the intake process. Findings: 71% percent of patients screened positive for depression (n=144 positive/204 total screened) and 55% screened positive for PTSD (n=111/193), followed by latent tuberculosis (41%, n=65/ 159), hypertension (10%, n=21/210), hepatitis B (9.4%, n=19/ 202), and HIV (0.8%, n=1/124). Rates of completed screenings were highest for PTSD, depression, hepatitis B and latent tuberculosis. Interpretation: This population is at very high risk of PTSD, depression, and latent tuberculosis, and at increased risk of hepatitis B. Screening rates for these diseases were high at this dedicated program for asylum seekers. Point of care testing was more effective than testing that required repeat visits. These findings call for special attention to the primary care needs for asylum seekers in the US

LEARNING OBJECTIVE 1: Identify indications for surgical intervention in the case of hepatic abscesses LEARNING OBJECTIVE 2: Review appropriate management of new pleural effusions CASE: A 56 year-old woman presented with weight loss, malaise and polyuria for two months. On admission, HR 135, BP 107/80, RR 22, T 101, O2 94% on RA. Exam revealed cachexia, bilateral lower extremity edema, decreased breath sounds in lower half of right lung with decreased tactile fremitis and coarse crackles superiorly. Labs were notable for WBC 33 and glucose 559. EKG showed sinus tachycardia. CXR revealed a right pleural effusion. Patient was pan-cultured and empirically started on vancomycin, piperacillin/tazobatam and azithromycin for presumed pneumonia. Despite insulin and IV fluids, she remained tachycardic. CT angiogram revealed a large pulmonary embolus in the left basal pulmonary artery and a large loculated right pleural effusion with no pleural enhancement. Abdominal CT revealed 8 cm septated hepatic mass, hepatic vein thrombus extending into the IVC, and a small amount of air in the wall of the gallbladder. Heparin drip was started and patient was taken for percutaneous drainage of hepatic mass and thoracentesis. Only small samples were obtained given loculation. Pleural fluid was exudative, gram stain showed white cells but no organisms, pH 7.22, glucose 169. Chest tube was placed. Strep viridans grew from pleural and hepatic fluid; blood cultures grew strep anginosus and c. albicans. Antibiotics were narrowed to ceftriaxone and caspofungin. Given pneumobilia, hepatic abscess was presumed to be from GI source with empyema formation from local spread of infection and hepatic vein thrombus from local inflammation. EGD/colonoscopy failed to find communicating track between bowel and biliary systems. Surgical intervention was deemed risky given large clot burden and patient was managed with antibiotics alone. Repeat imaging two months later at discharge showed significant resolution of hepatic and pulmonary!

LEARNING OBJECTIVE 1: Recognize hepatosplenic lymphoma as a rare subtype of T-cell lymphoma LEARNING OBJECTIVE 2: Recognize the dangers of early diagnostic closure CASE: A 30 year-old Guinean man with no past medical history presented with cough, fever, night sweats and weight loss for two months. The patient immigrated to the US 6 years ago. Exam showed cachexia, HR 122, T 101.3, BP 105/72, RR 22, O2 96% on RA, splenomegaly, normal lung exam and no appreciable lymphadenopathy. Labs were significant for a WBC 3.0 with 73%N, Hbg of 7 and a negative rapid HIV. CXR was unremarkable. Patient was isolated for possible tuberculosis. CT revealed splenomegaly, multiple scattered low-density lesions in the liver, prominent mediastinal, hilar, axillary and retroperitoneal lymphadeopthy, with the largest node measuring 3.7 x 2.8 cm. CT-guided biopsy of the retroperitoneal lymph node revealed fibrocollagenous tissue with necrosis. AFB, fungal stains, and cultures were negative. High fevers persisted to Tmax 105.7 F. Despite three negative AFB sputums, patient was started on a liver-sparing TB regimen given clinical suspicion for extra-pulmonary tuberculosis and worsening liver function. A bone marrow biopsy was performed revealing normal bone marrow with slight megakaryocyte hyperplasia but no evidence of lymphoma. Repeat core biopsy of the retroperitoneal lymph node showed necrotic tissue with few CD3+ T cells; AFB and cultures again negative. The course was further complicated by acute hepatic failure and transfusion dependent pancytopenia. On day 20, as the risks of invasive surgical testing increased, decision was made to perform excisional biopsy of a small superficial inguinal lymph node seen on CT. Preliminary pathology showed T-cell lymphoma with cytotoxic features. TB treatment was stopped and chemotherapy with a modified EPOCH regimen was initiated. After biopsy, flank pain, severe agitation from hepatic encephalopathy and DIC developed. This was concerning for retroperitoneal bleed and led to in!