VOL. LX • NO. 4 • 2019 by Journal MSMA

VOLUME LX • NO. 4 • 2019

Regularly priced at $80, the book is on sale now! Imag s in Mississippi Medicine: hocographi Hi mry f

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Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “ Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs. The volume is a piece of our history that every Mississippian can appreciate.” – Curtis Wilkie, journalist, author, and professor at Ole Miss

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LX • NO. 4 • APRIL 2019

SCIENCE OF MEDICINE

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

THE ASSOCIATION President Michael Mansour, MD President-Elect J. Clay Hays, Jr., MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Richard D. deShazo, MD Sheila Bouldin, MD Wesley Youngblood, M3 and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Acting Executive Director Claude D. Brunson, MD

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Jill Gordon, MSMA Director of Marketing. Ph. 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2019 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

Top 10 Facts You Need to Know about Knee Radiographs Dustin Hofstede, MD; Daniel L. Gilmer, MD; Robert W. Morris, MD

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Central Line Associated Thrombus vs. Superimposed Vegetation 145 in the Setting of Staphylococcus aureus Bacteremia Richard D. Ballard, MD; James B. Brock, MD; Edmund K. Kerut, MD; Ervin R. Fox, MD, MPH; Douglas Wolfe, MD, MPH; Michael E. Hall, MD, MS

A Novel Case of Minocycline-Induced Myofasciitis 149 in a Sixteen-Year-Old Girl Jesse J. Xie, MD, BS; Vikas Majithia, MD; Anna Mathew, MD; Nina Washington, MD, MPH

DEPARTMENTS From the Editor – Evolving Soul and Southern into Mediterranean Lucius M. Lampton, MD

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President’s Page – Incarceration of the Mentally Ill – A Public Health Crisis 154 Michael Mansour, MD Letters

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In Memoriam

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Images in Mississippi Medicine – Mississippi Baptist Hospital, 163 1950 and 1960 Lucius M. Lampton, MD Poetry and Medicine – Two Things I Will Remember as Long as I Live Merrill Moore, MD

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RELATED ORGANIZATIONS MSDH – Mississippi Provisional Reportable Disease Statistics

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ABOUT THE COVER “Causeyville General Store” – Dr. Martin Pomphrey, a retired orthopedic surgeon in Mayhew, took this photo of an old country store on Causeyville Road in Lauderdale County. The building was originally a trading post between European settlers and the native Choctaw Indians before the county flourished as a vital and vibrant hub of railroad commerce until the Civil War. Built in 1895, the E.W. Hagwood Company is now known as the Causeyville General Store. The historic building, listed on the National Register of Historic Places, has housed a voting precinct, physician’s office, movie theatre, and the Increase post office. Its primary function today is as a general store selling hoop cheese, hot roasted peanuts cooked in an antique roaster, glass bottled Coca-Cola, and miscellanies. The grist mill also is still in operation, and there is a large collection of antiques on display, including pianos and player pianos, radios, movie posters, old-timey electronics and furniture. A ghost dog, a sneezing spook and a musical spirit are just some of the hard-to-explain activities and haunts that have been seen and heard there among shelves and corners stocked with relics of the American past (“Ghost dog guards historic store” The Meridian Star, Oct 30, 2011). n VOLUME LX • NO. 4 • 2019

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Evolving Soul and Southern into Mediterranean

n the late nineteenth century, the brilliant physician Sir William Osler asserted the centrality diet plays in health. He often quoted an old maxim “the platter kills more than the sword” and emphasized that a human “digs his own grave with his teeth.” What he called “dietic sinning” consisted of gluttony (overeating) and not eating a nutritious diet. A recent study in JAMA underscores his long-ago assertions and concludes Lucius M. Lampton, MD that the diet most in the South are eating Editor (a high intake of fried foods, organ meats, processed meats, high-fat dairy, sugar-sweetened beverages, etc.) is killing us. [Howard G, Cushman M, Moy CS, et al. Association of clinical and social factors with excess hypertension risk in black compared with white US adults. JAMA. 2018;320(13): 1338–1348.] This analysis found that “the largest statistical mediator of the difference in hypertension incidence between black and white participants was the Southern dietary pattern.” As evidence mounts against the Soul and Southern diets, another cooking-style, the Mediterranean diet, has been associated with a

reduced risk of cardiovascular mortality as well as overall mortality. This diet, inspired by the traditional cooking patterns of countries that border the Mediterranean Sea, promotes such foods as fish, fruits, vegetables, beans, and whole grains. Allowing for liberal use of olive oil and a moderate intake of wine, it does not include many meats, dairy products, or sweets. It seems obvious that physicians must take the lead in transforming and evolving our deadly Southern diet into more hearthealthy Mediterranean-style cooking. The American South as a region shares much with those countries bordering the Mediterranean. We too are in a temperate climate not far from the equator, with a rural landscape capable of growing a wide variety of healthy vegetables and agricultural products. The South sits above our own sea, the Gulf of Mexico. Few areas in the world more resemble geographically the Mediterranean region. Modifying basic aspects of our diet in the manner of the Mediterranean would not be a huge adjustment. Armed with this new research, physicians must target dietary discussions as high priority when talking with our patients, especially our African-American patients. n Contact me by slow mail at Magnolia Clinic, 111 Magnolia Street, Magnolia, MS 39652 or at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD

MEDICAL STUDENT John F. G. Bobo, M3

GASTROENTEROLOGY James Q. Sones, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

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GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Carter Milner, MD INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD

NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT / FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD VASCULAR SURGERY Taimur Saleem, MD

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Top 10 Facts You Need to Know about Knee Radiographs DUSTIN HOFSTEDE, MD; DANIEL L. GILMER, MD; ROBERT W. MORRIS, MD Introduction Knee radiographs are commonly performed in the acute and primary care settings for the evaluation of knee pain or trauma. While many findings on knee radiographs are readily identified, there are subtle and uncommon findings that may go unrecognized. Here we present 10 examples of such findings that can have important clinical implications.

A joint effusion can be identified on a lateral view of the knee. A joint effusion can be recognized on a lateral knee radiograph as an opacity in the suprapatellar region of the knee. This corresponds to fluid within the distended suprapatellar pouch of the knee joint, which will cause separation of the quadriceps fat pad from the prefemoral fat pad. Lateral knee radiographs are 88% accurate in the diagnosis of joint effusion.1 A joint effusion may be symptomatic on its own or may be related to underlying intraarticular pathology (Figure 1).

Lipohemarthrosis is indicative of an intraarticular fracture. Lipohemarthrosis is a mixture of fat and blood extruded into the joint from the marrow cavity of a bone due to an intraarticular fracture. It is recognized as layering of fat on blood in the suprapatellar region, best demonstrated on cross-table lateral view obtained with the patient supine. Lipohemarthrosis is seen in approximately 35% of intra-articular fractures2 and is pathognomonic of an intraarticular fracture. If no fracture is identified radiographically, then CT or MRI is recommended to assess for occult fracture (Figure 2). Figure 2. Lipohemarthrosis. There is layering of lucent fat (short arrow) on dense blood (long arrow) in the suprapatellar region, in this radiograph obtained with the patient supine.

Figure 1. There is a suprapatellar opacity (black arrow) which separates the quadriceps fat pad (short red arrow) from the prefemoral fat pad (long red arrow).

A Segond fracture is highly associated with an anterior cruciate ligament tear. A Segond fracture is an avulsion fracture of the lateral proximal tibia at the capsular/ligamentous attachment that results from internal rotation and varus stress. A Segond fracture can be identified on the anteroposterior (AP) radiograph as a vertically oriented bone fragment adjacent to the lateral tibial plateau. A Segond fracture is associated with an anterior cruciate ligament (ACL) tear 75-100% of the time,3 and so MRI is recommended to evaluate the ACL (Figure 3).

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A deep lateral femoral sulcus also has an association with an ACL tear. The lateral condylopatellar sulcus (or notch) is a normal shallow indentation of the lateral femoral condyle at the

Figure 3. Segond fracture. The elongated, vertically-oriented bone fragment (arrow) along the lateral proximal tibia is due to a Segond fracture.

Figure 4. Deep lateral sulcus. The lateral sulcus (short arrow) is abnormally deep relative to a line drawn tangential to the femoral condyle articular surface (black line). There is also a joint effusion (long arrow).

Figure 5. Arcuate fracture. The horizontally-oriented bone fragment (arrow) proximal to the head of the fibula is due to an arcuate fracture.

the femoral articular surface. Given the association of ACL tear, MRI should be considered (Figure 4).

An arcuate fracture is highly associated with a posterior cruciate ligament tear. An arcuate fracture is an avulsion fracture of the head of the fibula at the insertion of the arcuate ligament complex which includes the lateral collateral ligament. It is visualized on the AP radiograph as a horizontally oriented bone fragment adjacent to the head of the fibula. An arcuate fracture is associated with posterior cruciate ligament (PCL) injury in up to 100% of cases,5 and so MRI is recommended to evaluate the PCL (Figure 5).

Chondrocalcinosis has a characteristic appearance of joint space calcification. Chondrocalcinosis is calcification of cartilage, including hyaline articular cartilage and fibrocartilage such as the menisci.6 Chondrocalcinosis is best seen on the AP radiograph as calcifications conforming to the menisci and calcification extending along the articular surfaces. While classically associated with calcium pyrophosphate deposition disease, it is also commonly seen in osteoarthritis and can be associated with hemochromatosis and hyperparathyroidism (Figure 6).

junction of the weight-bearing and patellofemoral articular surfaces. An abnormally deep sulcus of 1.5 mm or greater is seen with impaction injury of the lateral femoral condyle and is found in 12% of patients with a tear of the ACL.4 The depth of the sulcus on the lateral radiograph is measured relative to a line drawn tangential to

Prepatellar bursitis can be visualized in the setting of trauma, infection or gout. Prepatellar bursitis is inflammation of the prepatellar bursa, a synovial sac that lies between the patella and overlying soft tissues. It is best demonstrated on the lateral knee radiograph as localized prepatellar soft tissue swelling, possibly with associated calcifications in the setting of chronic hemorrhage7 or gout. Mechanical irritation from chronic kneeling is a frequent cause

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Figure 6. Chondrocalcinosis. Calcifications of the menisci (short arrows) and femoral articular cartilage (long arrow) represent chondrocalcinosis.

Figure 7. Prepatellar bursitis. Localized prepatellar soft tissue swelling (long arrow) with small calcifications (short arrow) is due to prepatellar bursitis in this patient with gout.

Figure 8. Parsons’ knob. The bony prominence (arrow) along the anterior intercondylar region of the tibia is Parsons’ knob.

Figure 9. Pellegrini-Stieda. Ossification along the medial femoral epicondyle (arrow) is a Pellegrini-Stieda lesion.

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Figure 10. Patella alta. The ratio of the length of the patellar tendon (blue arrow) to the length of the patella (red arrow) is abnormally increased.

Patella alta can be associated with patellofemoral pain and instability. Patella alta is also known as a high riding patella. It is defined radiographically using the ratio of the patellar tendon length to the length of the patella on the lateral radiograph, preferably with the knee in 30 degrees of flexion (the Insall-Salvati ratio). A ratio greater than 1.2 is considered to be patella alta. Patella alta can be associated with patellofemoral pain and instability and may predispose to patellofemoral osteoarthritis10 (Figure 10). Conclusion There are multiple subtle or uncommon findings on knee radiographs that may have important clinical implications. Knowledge of these findings is important for any practitioner who obtains and reviews knee radiographs in order to make the proper diagnosis and direct the patient to appropriate therapy. n References 1. Hall F. Radiographic diagnosis and accuracy in knee joint effusions. Radiology. 1975;115(1):49-54. 2. Lee JH, Weissman BN, Nikpoor N, et al. Lipohemarthrosis of the knee: a review of recent experiences. Radiology. 1989;173(1):189-191. 3. Goldman AB, Pavlov H, Rubenstein D. The Segond fracture of the proximal tibia: a small avulsion that reflects major ligamentous damage. AJR Am J Roentgenol. 1988;151(6):1163-1167. 4. Cobby MJ, Schweitzer ME, Resnick D. The deep lateral femoral notch: an indirect sign of a torn anterior cruciate ligament. Radiology. 1992;184(3):855858. 5. Huang GS, Yu JS, Munshi M, Chan WP, et al. Avulsion fracture of the head of the fibula (the “arcuate” sign): MR imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament. Am J Roentgenol. 2003;180(2):381-387. 6. Twigg HL, Zvaifler NJ, Nelson CW. 1964;82(4):655-659.

Chondrocalcinosis.

Radiology.

(housemaid’s knee). Septic bursitis should be considered in cases of penetrating trauma (Figure 7).

7. Donahue F, Turkel D, Mnaymneh W, Ghandur-Mnaymneh L. Hemorrhagic prepatellar bursitis. Skeletal Radiol. 1996;25(3):298-301.

8. Nishimori M, Furuta T, Deie M. Parsons’ knob, the bony landmark of the tibial insertion of the anterior cruciate ligament, evaluated by three-dimensional computed tomography. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2014;1(4):126-131.

Parsons’ knob is a normal variant that might be mistaken for a pathologic finding. Parsons’ knob is a bony prominence along the anterior intercondylar region of the tibia. When present, it is best demonstrated on the lateral view of the knee. Parsons’ knob serves as the attachment site of the ACL and anterior horn of the medial meniscus. It is seen radiographically in 10% of patients8 and can become enlarged in the setting of osteoarthritis. It is important to recognize as a normal variant rather than a bony lesion (Figure 8).

A Pellegrini-Stieda lesion denotes previous injury of the medial collateral ligament. A Pellegrini-Stieda lesion is calcification along the proximal medial collateral ligament (MCL) adjacent to the medial femoral condyle, best seen on the AP radiograph. This occurs as a result of prior MCL injury. The calcification may first become visible a few weeks following MCL injury9 with progressive ossification over time. In the setting of medial pain and limited range of motion, resection of the lesion and MCL reconstruction may be indicated (Figure 9).

Callen HS. Pellegrini-Stieda’s Disease. Radiology. 1937;29(2):158-165.

10. Stefanik JJ, Zhu Y, Zumwalt AC, et al. The association between patella alta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis: The multicenter osteoarthritis study. Arthritis Care Res (Hoboken). 2010;62(9):1258-1265.

Author Information Resident, Department of Radiology, University of Mississippi Medical Center (UMMC) (Hofstede, Gilmer). Assistant Professor, Division of Musculoskeletal Imaging, Department of Radiology, UMMC, Jackson, MS (Morris). Conflicts of Interest: None. Corresponding Author: Robert W. Morris, MD, Department of Radiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. (rwmorris@umc.edu).

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Central Line Associated Thrombus vs. Superimposed Vegetation in the Setting of Staphylococcus aureus Bacteremia RICHARD D. BALLARD, MD; JAMES B. BROCK, MD; EDMUND K. KERUT, MD; ERVIN R. FOX, MD, MPH; DOUGLAS WOLFE, MD, MPH; MICHAEL E. HALL, MD, MS

Abstract Superior vena cava (SVC) thrombosis and infection are common complications of indwelling catheters. In patients with bacteremia, it is difficult to differentiate SVC thrombus from infectious vegetation or septic thrombophlebitis based on imaging techniques. Furthermore, treatment strategies and duration of therapy for each complication are debatable and lacking robust clinical data. We present two cases involving patients with recently removed central venous catheters (CVC) who were found to have large echodensities in the SVC by transesophageal echocardiography (TEE). Both patients presented with sepsis from Staphylococcus aureus bacteremia and underwent TEE for the evaluation of cardiac vegetations. It was unclear whether the echodensities represented thrombus, vegetation, or a combination of both. Therefore, six weeks of culture-directed antibiotics and therapeutic anticoagulation were recommended until repeat imaging confirmed resolution of the echodensities. Here we propose a strategy for management of presumed CVC-related SVC thrombus in the setting of sepsis from Staphylococcus aureus bacteremia. Key Words: S uperior vena cava thrombosis; septic thrombophlebitis; Staphylococcus aureus bacteremia Introduction Superior vena cava (SVC) thrombosis is commonly associated with indwelling catheters and is a well-described clinical entity.1 In patients with concomitant bacteremia, it is virtually impossible to differentiate SVC thrombus from infectious vegetation based on noninvasive imaging techniques. This case series presents two cases in which patients with recently removed internal jugular (IJ) or subclavian central venous catheters (CVC) were found to have large echodensities in the SVC by transesophageal echocardiography (TEE). Both patients presented with sepsis from Staphylococcus aureus (S. aureus) bacteremia.

occur together.3 When CVC thrombosis occurs in the setting of bacteremia, removal of the catheter and initiation of antibiotics are clearly indicated.4 The duration of antibiotic therapy is a topic of debate, as it is difficult to determine if the thrombus is secondarily infected and should thus be treated like septic thrombophlebitis with prolonged antibiotics.4 The need for concomitant therapeutic anticoagulation is also unclear in this setting, though there is evidence that anticoagulation is beneficial.2 This case series aims to review echocardiographic features of thrombi and vegetations as well as the current practice guidelines for this scenario. Case Descriptions Case 1 This patient is a 68-year-old woman admitted to the Oncology ward with recurrent breast cancer who was previously treated with bilateral mastectomy and neoadjuvant chemotherapy. She was undergoing radiation treatment and was admitted for weakness and acute kidney insufficiency. She had an indwelling right IJ chemotherapy port which had been placed five months prior, and removed after blood cultures grew methicillin-sensitive Staphylococcus aureus (MSSA). Figure 1. A 1.64 cm x 0.45 cm echodensity observed in the superior vena cava in the bicaval view. There also appears to be a fibrin sheath from the previously extracted catheter that was removed the day prior. (yellow arrow). RA= right atrium, LA= left atrium, SVC= superior vena cava

Management of CVC-associated thrombosis usually involves removal of the associated catheter and anticoagulation, though the necessity of anticoagulation is debatable.2 Previous studies have shown that CVC infection commonly precedes the formation of thrombus, suggesting that CVC infection and thrombus often APRIL â&#x20AC;˘ JOURNAL MSMA

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Additionally, she was found to have a psoas abscess and osteomyelitis of the lumbar spine. After the chemotherapy port was removed, TEE was ordered to evaluate for infective endocarditis, and revealed a large echodensity in the SVC (Figure 1). The Infectious Diseases Service was consulted and recommended six weeks of intravenous (IV) oxacillin. Cardiology was also consulted and recommended therapeutic anticoagulation as well as SVC thrombus could not be ruled out. The Oncology team opted for enoxaparin due to her recent malignancy; however, she developed a lower gastrointestinal hemorrhage two weeks after the initiation of enoxaparin, necessitating cessation. Subsequent TEE after six weeks of IV oxacillin and two weeks of anticoagulation showed complete resolution of the prior echodensity. Case 2 This patient is a 44-year-old woman admitted to the Obstetrics and Gynecology ward with methicillin-resistant Staphylococcus aureus (MRSA) sepsis thought to be secondary to an infected peripherally inserted central catheter (PICC). The PICC was placed thirty days prior and was being used for total parenteral nutrition after an exploratory laparotomy had been performed to remove a large adnexal mass and resect a small segment of large bowel. Surgical pathology revealed the mass to be a benign hemorrhagic cyst. TEE was ordered to evaluate for cardiac vegetations in the setting of MRSA bacteremia. The PICC was removed two days prior to the TEE. The TEE showed a mildly reduced left ventricular ejection fraction and a large echodensity within the SVC extending into the right atrium, measuring 6 cm x 1.1 cm (Figure 2). The Infectious Diseases Service was consulted and recommended six weeks of IV vancomycin. The primary team elected to treat with warfarin with a goal international normalized ratio (INR) of 2-3 and to repeat a TEE after completion of antibiotic therapy. Six weeks after the initial TEE, a repeat TEE Figure 2. An echodensity (yellow arrow) was observed in the SVC extending into the right atrium in the bicaval view. RA= right atrium, LA= left atrium, SVC= superior vena cava

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confirmed resolution of the previous echodensity at which time anticoagulation and antibiotics were discontinued. Discussion In both cases, patients presented with sepsis from infected indwelling CVC’s, blood cultures grew S. aureus, and subsequent TEE discovered large echodensities concerning for thrombus versus bacterial vegetation. Classically, bacterial vegetations are described echocardiographically as being irregularly shaped and exhibiting chaotic independent motion.5 According to the Duke Criteria, vegetations are defined as mobile oscillating echodensities implanted on a valve or implanted in prosthetic material with no alternative anatomical explanation.6 These descriptions, however, are intended for evaluation of cardiac valvular vegetations and not vegetation associated with central lines or thrombus. It is nearly impossible to differentiate bacterial vegetation from sterile thrombus with imaging modalities such as TEE. Furthermore, S. aureus bloodstream infection is unique among bacterial bloodstream infections in that it is associated with very high rates of metastatic foci of infection, around 20% overall.7 These include infectious endocarditis, septic arthritis, vertebral and long bone osteomyelitis, splenic/hepatic abscess, septic pulmonary emboli and brain abscess. Expert guidelines recommend treating most cases of S. aureus bacteremia with four to six weeks of an IV antistaphylococcal drug, ideally a beta-lactam if MSSA and vancomycin if MRSA, and six weeks if infective endocarditis.8,9 A minority of S. aureus bloodstream infections, referred to as uncomplicated S. aureus bacteremia, can safely be treated with a shorter two-week course. The criteria for uncomplicated infections include: “exclusion of endocarditis by TEE; no implanted prostheses; follow-up blood cultures performed on specimens obtained two to four days after the initial set that do not grow MRSA; defervescence within 72 hours of initiating effective therapy; and no evidence of metastatic sites of infection.”8 Neither of these patients met criteria for uncomplicated bacteremia as both had persistently positive blood cultures, and one of the two had evidence of metastatic foci of infection (psoas abscess and vertebral osteomyelitis). Additionally, in patients with S. aureus bloodstream infection and venous thrombus or endocardial thrombus, the risk of bacterial seeding of the thrombus is quite high, and the consequences of inadequate therapy are potentially catastrophic. Patients with venous or endocardial thromboses, regardless of the above criteria, should be managed as septic thrombophlebitis/infective endocarditis as the risk/benefit ratio strongly favors prolonged IV antibiotic therapy. These recommendations are in line with expert guidelines on catheter-related bloodstream infections which define suppurative thrombophlebitis as a positive blood culture and a thrombus on imaging.4 No imaging, laboratory or clinical information can reliably distinguish uninfected venous thrombus from suppurative thrombophlebitis. Therefore, due to the lack of evidence-based guidelines, the inability to definitively rule out bacterial vegetation and the fact that these echodensities persisted despite removal of the associated catheters, we elected to take a comprehensive approach to treatment for both patients. This included removal of the affected catheter, six weeks of culture directed intravenous antibiotics

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and therapeutic anticoagulation for 6 months. Current evidence suggests it is safe to discontinue anticoagulation sooner if repeat imaging confirms resolution of the previously noted thrombus. This approach was successful in both cases as repeat TEE showed complete resolution of the previous findings. Conclusion There is currently no method to definitively differentiate sterile thrombus from infectious vegetation by echocardiography. Due to the common coexistence of infection and thrombus, we propose that patients with positive blood cultures and echodensities seen on TEE receive both culture-directed antibiotics and therapeutic anticoagulation followed by repeat imaging to confirm resolution (Figure 3). n References 1. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore). 2006;85(1):37-42. 2. Stavroulopoulos A, Aresiti V, Zounis C. Right atrial thrombi complicating hemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm. Nephrol Dial Transplant. 2012;27(7):2936-2944. 3. van Rooden CJ, Schippers EF, Rosendaal FR, et al. Infectious complications of central venous catheters increase the risk of catheter-related thrombosis in hematology patients: a prospective study. J Clin Oncol. 2005;23(12):2655.

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5. Otto, C. The Textbook of Clinical Echocardiography. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2009:379. 6. Durack DT, Lukes AS, Bright DK, et al. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med. 1994; 96:200–2009. 7. Fowler VG, Jr., Olsen MK, Corey GR, et al. Clinical identifiers of complicated Staphylococcus aureus bacteremia. Arch Intern Med. 2003;163(17):2066-2072. 8. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1;52(3):e18-55. doi: 10.1093/cid/ciq146. Epub 2011 Jan 4. 9. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132(15):1435-86.

Author Information Division of Cardiology, University of Mississippi Medical Center (UMMC) (Ballard, Fox, Wolfe, Hall). Division of Infectious Diseases, UMMC (Brock). Heart Clinic of Louisiana (Kerut). Conflicts of Interest: None. Corresponding Author: Richard D. Ballard, MD, Division of Cardiovascular Diseases, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, Ph: (601) 984-5640; Fax: (601) 984-5638 (rdballard@umc.edu).

4. Mermel LA, Allon M, Bouza B, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1-45.

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A Novel Case of Minocycline-Induced Myofasciitis in a Sixteen-Year-Old Girl JESSE J. XIE, MD, BS; EMILY H. WARD, MD; VIKAS MAJITHIA, MD; ANNA MATHEW, MD; NINA WASHINGTON, MD, MPH Abstract

Case report

Introduction: Minocycline, a member of the tetracycline family, and often used for the treatment of acne in teenagers, is associated with new onset autoimmune syndromes.

A 16-year-old Caucasian female with a past medical history significant for asthma was referred to the clinic in January of 2014 with polyarthralgia. This progressed to polyarthritis, myalgia, fatigue, and generalized weakness. Symptoms began the week before Christmas with an episode of flu-like symptoms followed by swelling of her hands and ankles. She described the joint pain as aching and stabbing in nature. Initial evaluation by her primary care physician yielded concern for influenza, although the patient reported receiving the flu vaccine. She was instructed to take NSAIDs and azithromycin but showed no improvement upon completion of therapy. The patientâ&#x20AC;&#x2122;s primary care physician then tested for Lyme disease and EBV. Both tests returned negative. CBC and UA were within normal limits, but erythrocyte sedimentation rate (ESR) was elevated at 45mm/hr. She was then referred to pediatric rheumatology for evaluation and management of possible underlying rheumatologic disease process.

Summary: Here we describe a 16-year-old female with a 2-year history of minocycline use presenting with myalgia and polyarthralgia. Initial laboratory workup was not suggestive of an underlying rheumatologic process. Minocycline was stopped, and with initiation of high dose steroid therapy her clinical symptoms significantly improved. Results of a left thigh muscle biopsy were consistent with a diagnosis of myofasciitis. Treatment with subcutaneous methotrexate, a disease modifying anti-rheumatic drug (DMARD), was initiated with subsequent resolution of arthralgia, myalgia and fatigue. Subsequent patient follow-up visits showed no relapse of symptoms and labs remained within normal limits. Conclusion: In patients presenting with polyarthralgia, myalgia, and history of minocycline use, a high degree of suspicion is warranted for minocycline-induced autoimmune syndrome. Though steroids allowed for prompt resolution of symptoms, steroid-sparing agents, in this case, methotrexate, were ultimately most effective in treating the underlying process. Key Words: Myofasciitis, minocycline, autoimmune Introduction Minocycline, a member of the tetracycline family, is often used for treatment of acne.1 In a 2008 study, it was estimated that 15.2 million pediatric patients in the United States were prescribed minocycline on an annual basis for treatment of acne. Minocycline is associated with the onset of multiple autoimmune syndromes including minocycline-induced lupus (MIL), serum sickness, vasculitis and autoimmune hepatitis.2,3 The mechanism underlying minocyclineinduced reactions is under investigation. Prognosis varies with presenting symptoms and treatment.4 Myofasciitis, inflammation of the muscle and associated connective tissue, is a poorly understood entity with few known triggers. It has not been previously linked to minocycline use. Here we describe a case of myofasciitis in a 16-year-old girl, likely associated with longterm minocycline use.

Upon presentation to the pediatric rheumatology clinic, the patient denied recent illnesses, rashes, insect bites or trauma. However, on further questioning, she reported a 2-year history of minocycline use for treatment of acne. Vital signs were within normal limits on initial presentation. Labs obtained at that time were notable for an ESR of 37mm/hr and positive anti-cardiolipin IgG and IgM antibodies. Antinuclear, anti-histone, anti-dsDNA, Lyme, infectious Mononucleosis, lactate dehydrogenase and rheumatoid factor antibodies were all normal. CK was also within normal limits. She was instructed to stop minocycline. High dose corticosteroid therapy was initiated with significant improvement in symptoms. At her subsequent follow-up visits, ESR initially rose to 52 but with adherence to steroid therapy trended down to 44 and 36mm/hr, respectively. Her C-reactive protein (CRP) also trended down from 1.8 to 0.9mg/dL. She reported decreased episodes of myalgia and arthralgia but continued to complain of joint swelling and generalized weakness. She soon proved to be steroid-dependent with the return of myalgia and arthralgia following each attempt to wean her steroid dose. Labs obtained following an attempt to wean steroids were notable for an increase in CRP (4.2) and ESR (48). Six months after initiation of steroid therapy, the patient began to have intermittent episodes of full body tingling and numbness. Brain MRI and nerve conduction study were unremarkable.

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Figure 1. Green arrow indicates PAS stain highlighting perivascular inflammation consisting of lymphocytes

Figure 2. Red arrow indicates CD4 immunohistochemical stain highlighting CD4 positive perivascular lymphocytes

Electromyogram (EMG) showed mild to moderate myopathy. Labs were notable for persistently elevated CRP and ESR. Muscle biopsy of the left thigh revealed epimysial perivascular inflammation and mitochondrial proliferation, consistent with the diagnosis of myofasciitis. Treatment with subcutaneous methotrexate, a disease modifying anti-rheumatic drug (DMARD) and steroid-sparing agent, was initiated with subsequent resolution of arthralgia, myalgia and fatigue. Labs were repeated 6 weeks after initiation of therapy and were within normal limits with the exception of a mild reactive thrombocytosis. Continued therapy with methotrexate allowed for successful weaning of steroids without relapse of symptoms. Inflammatory markers remained within normal limits at subsequent visits. (See Figures)

Discussion Minocycline, a member of the tetracycline family, is often used in the treatment of acne in the pediatric patient population.2 Minocycline and its potential and tendency to cause autoimmune disease is well documented. Case reports of this association extend as far back as the early 1990s. Severity of symptoms range from mild fatigue to acute drug reaction with eosinophilia and systemic symptoms (DRESS).5 The mechanism of minocycline-induced autoimmune syndromes remains poorly understood, and related myofasciitis has not been previously described in literature. Myofasciitis is a relatively uncommon condition and is not well understood. In the literature, it is most often linked with vaccines

Table. Comparison of two diseases commonly associated with minocycline and our patient Table. Comparison of two diseases commonly associated with minocycline and our patient

Clinical findings

Significant laboratory findings

Minocycline‐induced lupus 

Fever



Malaise



Rash



Arthralgia



Arthritis

 



Minocycline‐induced drug reaction with eosinophilia and systemic symptoms (DRESS)



Fatigue



Arthralgia



Myalgia



Generalized weakness

Eosinophilia >700/microL



No eosinophilia



Lymphocytosis



No lymphocytosis



Elevated alanine aminotransferase



Normal liver function panel



Negative ANA, negative antidsDNA, and anti-histone



Morbilliform skin eruptions.



Fever



Malaise



Lymphadenopathy



Organ injury (most commonly liver, kidney, and lungs)

+ANA



+Anti-double stranded DNA antibody +P-ANCA

150 VOL. 60 • NO. 4 • 2019

This patient with minocycline‐induced myofaciitis

Figure 3. Time line of Disease Course

Past Medical History

Asthma, acne Minocycline use (2 years) Initial Symptoms Flu-like symptoms with swelling of the hands and ankles

Christmas 2013

Presenting Symptoms at Primary Care Physician Polyarthralgia, myalgia, fatigue, and generalized weakness

Labs Lyme and EBV negative. CBC and UA within normal limits Elevated ESR (45mm/hr)

Treatment NSAID and azithromycin

Initial Visit at Pediatric Rheumatology Clinic Polyarthralgia, myalgia, fatigue, and generalized weakness. Denied rash or trauma. Vital signs within normal limits

Follow-up Visit No improvement. Referred to pediatric rheumatology clinic.

January 2014

Labs Elevated ESR (37mm/hr), +anti-cardiolipin IgG, +IgM antibodies. Antinuclear, anti-histone, anti-dsDNA, Lyme, infectious mononucleosis, lactate dehydrogenase, rheumatoid factor antibodies, and CK were all within normal limits. Treatment Minocycline was stopped. Follow-up Visit Steroid therapy initiated.

March 2014 May 2014

Follow-up Visit Significant improvement in symptoms. Steroids weaned.

July 2014

Follow-up Visit Symptoms returned. Steroid wean stopped. Moderate steroid dose resumed.

August 2014

Follow-up Visit Muscle biopsy showed myofasciitis. Methotrexate initiated and steroids again weaned.

Subsequent Follow-up Visits

Patient remained symptom-free and labs continued to be within normal limits.

containing aluminum hydroxide.6,7 Aluminum-induced myofasciitis typically demonstrates focal accumulation of aluminum-loaded, basophilic macrophages. In contrast, this patientâ&#x20AC;&#x2122;s pathology was notable for mild epimysial perivascular inflammation, minimal mitochondrial proliferation, non-necrotic fibers and lack of myophagocytosis. As a result, this case of myofasciitis (confirmed by muscle biopsy) suggests a novel manifestation of minocyclineinduced autoimmune disease.

In patients presenting with polyarthralgia, myalgia and history of minocycline use, a high degree of suspicion is warranted for minocycline-induced autoimmune syndrome, including MIL, autoimmune hepatitis, vasculitis and myofasciitis. Females are at higher risk of developing these syndromes, consistent with the theory that females have an underlying predisposition for autoimmune diseases.3,8 Comparison of 2 diseases commonly associated with minocycline and our patient is listed below: APRIL â&#x20AC;˘ JOURNAL MSMA

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In our patient, steroids allowed for prompt resolution of symptoms. However, steroid-sparing agents, in this case methotrexate, were ultimately most effective in treating the underlying process – not unlike non-drug induced autoimmune diseases.9 It should be noted that it is not uncommon for patients to have prolonged minocycline use prior to onset of symptoms. In fact, one paper showed patients receiving minocycline for 3 years prior to the first manifestation of arthralgia and myalgia.10 Another study of 27 patients demonstrated duration of minocycline use of up to 23 months prior to diagnosis, only half of which had rapid recovery after discontinuation of the medication and some still having active disease at 48 months.11 In this patient, initial workup included a wide range of drug-induced rheumatological diseases given her history of minocycline use. However, many of these diseases were ruled out due to the lack of eosinophilia (50-220 cells/mcL), normal renal function, normal liver function test, and negative labs including ANA, anti-histone antibodies, anti-dsDNA antibody, and rheumatoid factor. The abnormal EMG and muscle biopsy ultimately confirmed the diagnosis of myofaciitis. Given minocycline’s propensity to cause drug-induced autoimmune disorders and the patient’s lack of risk factors (no personal or family history of autoimmune disease, no illicit drug use or prescription drug use that has been linked to autoimmunity, young age), it is extremely unlikely that this is secondary to an alternative agent or occurred spontaneously. In conclusion, myofasciitis should be considered in the differential diagnosis of patients with a history of long-term minocycline use who present with polyarthralgia, myalgia and elevated inflammatory markers, especially when presentation is not entirely consistent with MIL or autoimmune hepatitis. n References 1. Elkayam O, Yaron M, Caspi D. Minocycline-induced autoimmune syndrome: An overview. Semin Arthitis and Rheu. 1999;28(6):392-397. 2. Corona R. Minocycline in acne is still an issue. Arch Dematol. 2000;136(9):11431145.

3. El-Hallak M, Giani T, Yeniay BS, et al. Chronic minocycline-induced autoimmunity in children. J Pediatr. 2008;153(3):314-319. 4. Brown RJ, Rother KI, Artman H, et al. Minocycline-induced drug hypersensitivity syndrome followed by multiple autoimmune sequelae. Arch Dermatol. 2009;145(1): 63-66. 5. Lan J, Lahoti A, Lew DB. A severe case of minocycline-induced DRESS resulting in liver transplantation and autoimmune sequelae. Ann Allergy Asthma Immunol. 2016; 116(4):367-368. doi: 10.1016/j.anai.2015.12.010. 6. Rigolet M, Aouizerate J, Couette M. Clinical features in patients with longlasting macrophagic myofasciitis. Front. Neurol. 2014; 5(230). doi: 10.3389/ fneur.2014.00230. 7. Ragunathan-Thangarajah N, Le Beller C, Boutouyrie P, et al. Distinctive clinical features in arthro-myalgic patients with and without aluminum hydroxydeinduced macrophagic myofasciitis: An exploratory study. J Inorg Biochem. 2013;128:262-266. 8. Fairweather D, Frisancho-Kiss S, Rose NR. Sex differences in autoimmune diseases from a pathological prospective. Am J Pathol. 2008;173(3) 600-609. 9. Davidson A, Diamond B. Autoimmune diseases. N Engl J Med. 2001;345(5)340350. 10. Elkayam O, Levartovsky D, Brautbar C, et al. Clinical and immunological study of 7 patients with miniocycline-induced autoimmune phenomena. Am J Med. 1998;105(6); 484-487. 11. El-Hallak M, Giani T, Yeniay BS, et al. Chronic minocycline-induced autoimmunity in children. J Pediatr. 2008;153(3):134. Epub 2008 Apr 28.

Author Information Internal medicine resident, University of Arkansas for Medical Sciences (Xie). Graduate of UMC School of Medicine, Medical officer in the United States Navy (Ward). Director of Rheumatology and Molecular Immunology, University of Mississippi Medical Center (Majithia). Assistant professor of Clinical Pathology, Keck School of Medicine, University of Southern California (Mathew). Director of Pediatric Rheumatology, Mississippi Center for Advanced Medicine (Washington). Conflicts of Interest: None. Corresponding Author: Jesse J. Xie, MD, Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St, #634, Little Rock, AR 72205.

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P R E S I D E N T ’ S

P A G E

Incarceration of the Mentally Ill – A Public Health Crisis “A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights.”

—AMA Code of Medical Ethics

erhaps this code of ethics ingrained in us as physicians drives us as a profession to speak for those who have no voice and represent the health concerns for those who have no standing.

The United States Department of Justice Bureau of Justice Statistics has identified more than half of all prison and jail inmates as having a mental health problem based on symptoms specified in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV. 1

Current law requires those accused of a crime to be evaluated for mental illness. Courts require an accused person to be competent to stand trial and recognized as sane at the time of allegedly committing a crime. The mental health evaluation may, however, take years to obtain while the accused waits in a county jail. Neither the court system nor a county jail are equipped to deal with the mentally ill. Local hospitals are often not equipped to deal with the mentally ill, especially those who may also have violent tendencies.

About 74% of state prisoners and 76% of the local jail inmates who had a mental health problem also met criteria for substance dependence or abuse.1

Integrated treatment that addresses both substance abuse and mental disorders is known to be effective in treating those who suffer from substance abuse and disorders such as depression and anxiety. The main benefits of integrated drug treatment include reduced substance abuse, a higher quality of life, and decreased hospitalization and arrest.2,3

154 VOL. 60 • NO. 4 • 2019

In 2017, Texas enacted legislation that requires jailers to make an immediate determination of the mental health status of an inmate and divert those who have a mental illness or substance abuse problem to a treatment facility instead of jail.

Michael Mansour, MD

In Houston, Texas, Harris County opened a mental health diversion center to care for those with mental health issues who had committed nonviolent, low-level crimes, thus turning people away from jail and instead providing them mental health care. This center is functionally a psychiatric treatment facility with 29 beds, staffed with psychiatrists, counselors, nurses, and other physicians who care for these patients. Today some 3000 people receive psychiatric treatment at the Harris County Jail each day, more than any other mental health hospital in Texas. Certainly this would be a great model for Mississippi to emulate.4

Like every state, Mississippi incarcerates more individuals with severe mental illness than it hospitalizes. Criminal justice officials are responding to the criminalization of individuals with innovative programs designed to divert individuals with severe mental illness from the criminal justice system. Two of the most promising programs are mental health courts and crisis intervention training. However, on average, only 8% of the prison population is served by these methods.5

Several months ago I sent the following letter to Governor Phil Bryant, Senator Roger Wicker and Senator Cindy Hyde-Smith to both raise their awareness and encourage action on this matter.

L1~

online.com MISSISSIPPI STKI'EstMEOICALASSOC1ATION -6733 | MSMA 39157 | (601) 853 Parkway Place 58 | 408 We geland, MS 391 PO Box 2548, Rid

ance and sting your assist tion, I am reque . cia so als As du l ivi ica ind ted te Med ent for incarcera Mississippi Sta On behalf of the ntal health treatm me to ss ce PRESIDENT ac prove medical ur, MD they are to get leadership to im Michael Manso ter police than alth Greenville ious mental he likely to encoun ser re ve mo ha are ls jai sis into eded alth cri ve access to ne women booked le in mental he ha of t op % no Pe 30 do d CT an ess LE n me l illn PRESIDENT-E teen percent of ates with menta n resulting in Fif tio inm MD l lp. iza Jr., jai he tim ys, of Ha vic nt y J. Cla risk for ghty-three perce Jackson ill people are at conditions. Ei erated mentally atment. Incarc tre al dic me . T , PAST PRESIDEN ir mental illness ithout healthcare worsening of the antham, MD health care. W William M. Gr ysical cess to needed ph ac ic Clinton ve ron ha r ch r ge no lon and suffe l, many people e minimally to be homeless After leaving jai ssary to provid are more likely REASURER considered nece mental illness is th et this le wi op me le pe SECRETARY-T to op ls pe 00 , MD many state fai per 100,0 W. Mark Horne rel illness. Every 00 um of 50 beds Lau severe mental beds per 100,0 th c illness. A minim wi tri als hia du yc ps ivi c es. bli for ind ximately 16 pu than it hospitaliz uate treatment pro ess eq ap ad s illn l ha i nta R ipp KE me ere SPEA ississ ividuals with sev um standard. M ind nim MD re mi d, mo ilan tes We Geri Lee state incarcera with innovative Vicksburg people. Every of individuals criminalization the the criminal to m fro ing ay nd po res ess aw ere mental illn tice officials are sev jus l and crisis th s ina wi urt im ES als co Cr TE du h US ivi healt BOARD OF TR ned to divert ind ms are mental programs desig promising progra st mo the of o MD Tw Jennifer J. Bryan, d justice system. Chair, Flowoo rs with ining. ns for Offende intervention tra stice Interventio Ju l ina are im s MD Cr , , urt alth co Joseph D. Austin urg an evaluation City mental he titute released two New York Vice Chair, Vicksb handled in the The Urban Ins s participants in whose cases are ow rs sh de t en tha off ss r ne ila sim tal Ill n en tha M MD d r, en gne off Sto Steven W. s likely to resburg significantly les Secretary, Hattie m. ms. The ional court syste dit tra am (CIT) progra s vens, MD Intervention Te s program that ha Roderick C. Gi enwood isi er Cr nd th po wi res nd Gre sed first es have been fou se in a tho ative police ba ov for inn ion an ers is Similar success l div Team of pre-arrest jai s Intervention n, MD l health care to Brett C. Lampto ford emphis Model" Memphis Crisi those in menta Ox known as the "M rtnership with lly pa ily members, na in tio fam na rks , wo ess me T CI l illn beco . The Memphis duals with menta sis ivi cri ind h to alt he DO dly , l nel menta t are frien Katherine G. Pan Oxford m of services tha provide a syste rs. ng ice off e lic help the departi and the po illiams, MD er program could Loretta Jackson-W tance use disord icaid or another bs Jackson ed su d M an gh h, ou alt thr l he coverage vism, decrease medical, menta idi ate rec ical insurance pri e ed pro uc M ap red ss to l DO ccessfully acce ses the potentia those J. Lee Valentine, an inmates more su healthcare increa ductive lives for Meridi ss to appropriate chance for pro the se rea inc d services. Acce n, an re-incarceratio MD John F. Pappas, rt the high cost of l illness. Gulfpo ing with menta son reform. liv als du ivi ind ersation on pri a broader conv of rt state and our r pa ou as d of MD , half addresse John Cross ult issues on be fic ues can be best dif iss se se the the YPS, Jackson ng ps Perha in addressi your leadership Thank you for Chelsea Rick, DO Fulton country. , Resident/Fellow, Sincerely yours

11 '

Avani K. Patel Jackson Medical Student,

RECTOR EXECUTIVE DI n, MD Claude D. Brunso

The cost of lost productivity of incarcerated individuals compounded by the actual monetary cost of imprisonment and recidivism far outweigh the cost of mental health treatment. Understanding this problem concerning the magnitude of the human tragedy along with the financial loss to our state may incite political leaders to action. With compassion and respect for human dignity, let us hope that this public health crisis will be properly addressed. n

Michael Mansour, MD President, Mississippi State Medical Association

References 1. Mental Health Problems of Prison and Jail Inmates. http://www.ojp.usdoj.gov/ bjs/mhppji.htm. 2.

h ttp://www.mayoclinic.org/diseases-conditions/drug-addiction/basics/riskfactors/con-20020970.

https://www.samhsa.gov/disorders/co-occurring#criminal-justice.

4. http://www.houstonchronicle.com/news/houston-texas/houston/article/ New-bills-take-12165720. 5. Prevalence of Mental Health Diversion Practices: A Survey of the States (http:// tacreports.org/diversion-study).

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L E T T E R S

Dr. Currier shares her “path to public health” in an address to honor society

Dear JMSMA Editor, I read your article [Merideth PT. “A new person to push the boulder.” J Miss State Med Assoc. 2018; 59(10):21] about Dr. Thomas Dobbs becoming State Health Officer upon Dr. Mary Currier’s retirement, after more than 30 years of service in public health for the state of Mississippi. Following her retirement, she addressed future physicians in the new School of Medicine at the University of Mississippi Medical Center as the Alpha Omega Alpha Honor Society’s Fall seminar speaker. Dr. Currier spoke about what led her into the field of medicine, specifically the field of public health. Her talk was entitled “My Path to Public Health (or How a Serious Introvert Ended Up with a Public Speaking Job).” She asserted that a combination of luck, meeting the right people, and hard work culminated into her future career as the State Health Officer.

As the child of parents who were both involved in medicine (her father was a neuropsychiatrist, and her mother served as a teacher in a polio ward), she grew up playing with the chalkboard in her father’s office while he rounded on the weekends. It was there she discovered and developed a love for word problems. Her father’s area of research involved multiple sclerosis, and he traveled to Ireland while conducting twin studies. She later visited Ireland during her senior year of college and narrowed down her career choices to becoming a physician or a commercial airline pilot. She jokingly stated that with her sense of direction, the public is lucky that she was accepted to medical school.

156 VOL. 60 • NO. 4 • 2019

Dr. Mary Currier with third year medical student and AOA Seminar Chair, Hannah Badon

While attending UMMC, her love for word problems and epidemiology grew, and she struggled to find a field and residency program that was right for her. She serendipitously met Dr. Alton Cobb, then State Health Officer, through friends in medical school including Dr. Tim Alford. Dr. Cobb and his wife often hosted dinner for this group of budding physicians and helped to encourage and inspire Dr. Currier’s future career in public health.

Dr. Mary Currier recently retired as State Health Officer after over 30 years in public health.

At this time, Mississippi did not yet have a public health program, so she began a residency in pediatrics. After a year, she decided that it was not the right fit and she began working with the Mississippi Department of Health as a staff physician for its prenatal, family planning, STD, and pediatrics program. She ultimately moved to Johns Hopkins in Baltimore with her husband while he finished a fellowship in ophthalmology. Dr. Currier balanced family life with a young child at home and another on the way, all while paying for her own tuition for a preventative medicine residency training in public health at the Johns Hopkins School of Hygiene and Public Health. After completing her training, she received a call from Dr. Alton Cobb, with news of a job offer back in Mississippi. Since her return to Mississippi, she has served two terms as State Epidemiologist and was named State Health Officer in 2010. She encouraged students to keep pushing ahead and reassured all that there is a field of medicine for everyone. She concluded her speech saying, “Even if you’re weird like me, there is a place for you.” n

Hannah Roberts Badon, M3 AOA Seminar Chair

L to R: Hannah Badon, Kelly Windham, Dr. Mary Currier, David Li, Michael Robbins

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Honoring the Lives and Legacies of our Fellow Physicians Dr. James Anderson died on August 7, 2018, in Jackson, Mississippi, at the age of 82. Dr. Anderson graduated from Meharry Medical College. In 1970, Dr. Anderson assisted Dr. Aaron Shirley in founding Jackson-Hinds Comprehensive Health Center, one of the oldest community health centers in the United States and the largest in Mississippi. Over the years, James Anderson, MD Dr. Anderson served not only as a physician at Jackson-Hinds but also as Medical Director and Chief Executive Officer until his retirement in 1998. Anderson was part of the Student Non-Violent Coordinating Committee during the civil rights movement. He was one of the first three African American physicians to be admitted to the Mississippi State Medical Association and thus be credentialed for hospital staff privileges. Mississippi lawmakers honored Anderson in 2017, noting he had worked for more than 50 years to provide health care in low-income, uninsured and minority communities. Dr. Anderson held professional memberships in the National Medical Association, Mississippi Medical and Surgical Association, National Association of Community Health Centers, and the Mississippi Primary Health Care Association. He was a member of the National Association for the Advancement of Colored People (NAACP), the Southern Christian Leadership Conference (SCLC), the Monday Evening Club, and Alpha Phi Alpha and Sigma Pi Phi Fraternities. Dr. Anderson is a former member of the Board of Directors of The Algebra Project, Inc. Dr. David Lee Clippinger died on August 7, 2018, in Gulfport, Mississippi at the age of 84. Dr. Clippinger graduated from University of Mississippi School of Medicine and was a general practice physician. He interned at Chatham County Memorial Hospital in Savannah, Georgia, from 1959-1960 before moving to Hazlehurst, Mississippi, in 1960 David Clippinger, MD where he engaged in the general practice of medicine. Dr. Clippinger moved to Gulfport in 1970 where he practiced alongside Dr. Tom Benefield from 1970-1990. He served as staff physician for the Armed Forces Retirement Home in Gulfport, Mississippi, until his retirement in 2012. After Hurricane Katrina, he volunteered as a physician with Volunteers for America, which became Bethel Free Clinic, where he served

as medical director until he was unable to continue due to health problems. He was recognized as Mississippiâ&#x20AC;&#x2122;s Family Physician of the Year in 2001 by the Mississippi Academy of Family Physicians, and in 2017, he was recognized by the City of Biloxi as Senior Citizen Volunteer of the Year. Dr. Clippinger was a Past President of the Coast Counties Medical Society and was a former member of the Board of Directors of the Mississippi State Medical Association. He is survived by his loving wife of 64 years, Martha DeLoach Clippinger; children, Tracy Chapman (Ray) of Oxford, Mississippi, and Courtney Thompson of Gulfport, Mississippi; grandchildren, Audra Brinkley, Whitney Marshall (Sean), Michael Barnett (Anna Claire), Jeremy Thompson (Hillary), and Nicholas Thompson (Amanda); twelve great-grandchildren; and two sisters, Sandra Harvey and Kay Graves (Jimmy). Dr. Walter Robert Jones, Jr. died on August 7, 2018, at the age of 77. Dr. Jones graduated from University of Mississippi School of Medicine and practiced surgery. He completed a surgery residency at UMMC under Dr. James D. Hardy and a surgical fellowship at Peter Bent Brigham Hospital, Boston, Massachusetts. Upon conclusion of his Walter Jones Jr., MD surgical training, he entered the United States Army Medical Corps with the rank of Major, serving as a surgeon with the 67th Evac Hospital in Qui Nhon, Vietnam. Following retirement from his surgical practice in 2004, he served as a physician at the Hudspeth Regional Center, providing compassionate care for severely disadvantaged patients. He was a Diplomate of the American Board of Surgery and Fellow of the American College of Surgery. Dr. Jones is survived by his loving wife of 22 years, Kathy; sister Dorothy Duncan Walcott (Dexter) of Greenwood, and brother Dr. Christopher Riddell Jones of Birmingham, Alabama; sons Walter Robert Jones, III (Alese) of Flowood, Christopher Andrew Jones (Leslie) of Columbus, Ohio, Rev. William Jeremy Jones (Maylon) of Memphis, Tennessee, and Clay Metcalf Jones of Oxford; stepson John Michael Saucier of Flowood, stepdaughters Sara Saucier Revell (Josh) of Flowood, Keith Smythe Meacham (Jon) of Nashville, Tennessee, and May Smythe of Nashville; and grandchildren Caroline Alese Jones, Robert Duncan Jones, Isaac Walker Jones, Lucy Hollis Jones, Nathan Jackson Jones, Irene Fairley Jones, Ellis Andrew Lockett Jones, John Noah Saucier, Ava Grace Revell and John Brice Revell.

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Dr. Richard C. Miller died on August 7, 2018, at the age of 88. Dr. Miller graduated from Harvard Medical School and practiced surgery, specializing in pediatrics. He practiced at the University of Mississippi Medical Center (UMMC) at the time of his retirement. Richard Miller, MD He served UMMC for 43 years, caring for infants and children, training new physicians and holding multiple administrative roles, including interim Chairs of the Anesthesiology and Surgery Departments, Associate Dean for Clinical Affairs, and Medical Director of University Hospital. He was awarded an honorary Doctor of Science degree from Millsaps College in 2011, and the Richard C. Miller Pediatric Surgery Chair at UMMC was named in his honor in 2017. Dr. Miller was a captain in the United States Air Force at Whiteman Air Force Base in Missouri from 1957 to 1959.

Dr. Miller is preceded in death by his parents and his brother, Paul Miller. He is survived by his sister Alice Englert and by his wife Suzanne and their children: Sara (Robert) Rasmussen, Joanna (William) Storey, Cardy (Kristen) Miller and Robert (Jennifer) Miller as well as 12 grandchildren: Jax, Jace, and Fritz Rasmussen, Ian, Andrew, Neil, Robin and Graham Storey, Nilah and Ricky Miller, and DeDe and Macy Miller. n

SAVE THE DATE CME in the SAND Destin, Florida May 24-28, 2019

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November 24-26, 2019 Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also, include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letter writers. You can submit your letter via email to KEvers@ MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

160 VOL. 60 â&#x20AC;˘ NO. 4 â&#x20AC;˘ 2019

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M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

Mississippi Mississippi Mississippi Provisional Reportable Disease Statistics* Provisional Reportable Disease Statistics* Provisional Reportable Disease Statistics February 2018 January January 20192019

*Monthly statistics are provisional. Disease totals may change depending on additional reporting

from healthcare providerstotals and public health investigation. These numbers do not reflect the final case *Monthly statistics are provisional. Disease may change depending on additional reporting counts. from healthcare providers and public health investigation. These numbers do not reflect the final case counts. Public State

Mycobacterial Diseases

Chlamydia

0175 139 1

Extrapulmonary TB

295 192

209

Poliomyelitis Measles

Diphtheria

Mumps

Hepatitis B (acute)

Invasive H. influenzae disease

Measles

Salmonellosis Shigellosis

Campylobacteriosis

Hepatitis B (acute)

E. coli O157:H7/STEC/HUS

Invasive H. influenzae disease

Animal Rabies (bats)

Lyme disease

Rocky Mountain spotted fever

West Nile virus

1 115

165 1 1156

249 0

0 1

1 1

0 0

114 1 460

0 Jan 4 2019 82

0 4 0 VIII IX 56 21 60

Feb 2018

1 175 14 196

VIII

7 133

VII

0362

1550 126

Totals*

3 VI VII 66 57 131

Hepatitis A (acute)

Poliomyelitis

0 0

Invasive Meningococcal disease

Enteric Diseases

1940 536 9 0

Mycobacteria Other Than TB

Salmonellosis

Tetanus

12 0

Pertussis

Hepatitis A (acute)

Pulmonary Tuberculosis (TB)

Mumps

Diphtheria

Extrapulmonary TB

0 Pulmonary Tuberculosis (TB) 122 93 105 1010 244

HIV Disease

Zoonotic Diseases

Vaccine Preventable Diseases

III

Mycobacteria Other Than TB

Invasive Meningococcal disease

Enteric Diseases

HIV Disease

Gonorrhea

1 V 69

Gonorrhea

Early Latent Syphilis

Tetanus

Zoonotic Diseases

Early Latent Syphilis

Chlamydia

Pertussis

Primary & Secondary Syphilis

Public I II III Health District 0 3 0

Primary & Secondary Syphilis

Vaccine Preventable Diseases

Mycobacterial Diseases

Sexually Transmitted Diseases

Health District

1 0

0 2

0 4

0 0

07 00

0 0

50 0

00 10 02

2 0

2 2

26 1,633 77 58

3 859

500

59 0

0 10

0 38

7 31

20 75

6 0

00 78 0 24

Totals include and District. 2 reports 5 from1Department 2 of Corrections 5 4 those3not reported 6 from 2a specific 30

1 5

21 0

0 11

2 0

50 0

290

16 5

0 0

0 21

0 59

43 YTD 72 2018 954

29 0

3995

9 5859 1 1,057

3758 34

14 2,842

YTD 2017

282 4 2,237 1,849442,237 1,849 3 45 81 0

2 117 0 1,057 0

16Jan 39 YTD 50 2018 2019 603 527 1274

26 859 1,529

7 39

Feb YTD State 2017 2018 Totals* 20 31

0 3 21

3 0

0 11

0 3

Shigellosis

Campylobacteriosis

E. coli O157:H7/STEC/HUS

Animal Rabies (bats)

Lyme disease

Rocky Mountain spotted fever

West Nile virus

Totals include reports from Department of Corrections and those not reported from a specific District.

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ISSISSIPPI BAPTIST HOSPITAL, TWO VIEWS, 1950, 1960 – This Images completes a series of views on the development of Jackson’s Mississippi Baptist Hospital, which was founded in 1908. [See Lampton, L. “Mississippi Baptist Hospital, Jackson, 1914,” January 2019;60(1):34; Lampton, L. “Mississippi Baptist Hospital, From North State Street, 1922,” March 2019;60(3):132.] The core of the original brick hospital was built in 1914, with significant additions in 1922 and 1929. The Green Annex opened on September 20, 1939, dedicated to the care of AfricanAmerican patients. Besides the Gilfoy School of Nursing, the hospital also began training physician interns, with Dr. William Lotterhos serving as the first intern in 1941. The hospital acquired a final lot at North State and Carlisle Streets in 1940, which completed almost one city block of Baptist-owned property. Construction of the Hederman Addition on the southern aspect of the property was completed in November 1947 and included the Hartfield Ward for crippled children. Mississippi Baptist Hospital, with over 400 beds, held the distinction of being the largest private hospital in the state. This massive hospital would operate here until it moved diagonally across North State Street to its present site in 1976, changing its name to Mississippi Baptist Medical Center. The top photo, from the 1950s, shows the original structure to the left, the 1929 addition in the middle, and the 1947 Hederman Addition to the right. The image below is from the 1960s and reveals subsequent alterations to the hospital’s facade, including an enlarged entrance. This Jackson landmark would be razed in 1985. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@ cableone.net or by snail mail to the Journal. n — Lucius M. “Luke” Lampton, MD JMSMA Editor APRIL • JOURNAL MSMA

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EDITED BY LUCIUS LAMPTON, MD; JMSMA EDITOR [This month, I continue a multi-issue focus on the poetry of the late physician-poet Merrill Moore, MD (1903-1957), a noted American psychiatrist and neurologist who also achieved fame as a poet and sonneteer. Born and educated in Tennessee, he received his MD from Vanderbilt School of Medicine in 1928. While always a prolific poet, he specialized in psychiatry and neurology, conducting a large psychiatric practice while teaching at Harvard Medical School and publishing research on alcoholism, addiction, suicide, and the psychoneurosis of war. “TWO THINGS I WILL REMEMBER AS LONG AS A I LIVE” is a compelling poem, certainly among Moore’s most powerful and insightful. Poetry scholar David R. Slavitt, who recently published “XxX:100 Poems” by Merrill Moore (Little Island Press, 2016), described this “piece” as “exemplary of the physician’s poise I find so attractive.” He states further: “In this sonnet, nearly flawless, there comes surprise first and then at the end admiration.” Expect more Moore sonnets in coming months. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] — Ed.

TWO THINGS I WILL REMEMBER AS LONG AS I LIVE (And both, come to think of it, are similar; I had not realized that until this moment) They are: the look on the face of (believe me) a fish When he is jerked out of water, by the hook And is trying to disengage it from his mouth In a dumb brute animal way that is pitiful Also the effort in the eye itself To see, to comprehend this awful state The look of wild defeated frustration there As the fish is suffocating in thin air Gasping, gulping, convulsively moving his gills And body, seeking water to cure his ills. The other, I nearly forgot it, the other is The look on the face of a man dying of heart failure. — M errill Moore, MD (1903-1957) 164 VOL. 60 • NO. 4 • 2019

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