November 2013 JMSMA

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2013

No. 11

the launch of a crisp smart interactive new 1. User-Friendly Interface 2. Component-Society Toolkits 3. Endless CME Opportunities 4. Detailed Advocacy Info & Action Center 5. Improved Login & Member Dashboard 6. Quick Access to Staff & Member Contact Information 7. Informative History Section 8. Easily-Found Event Info & Simple Registration 9. Relevant news featuring all MSMA publications 10. Chat rooms for students, residents, & physicians

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Top 10 Reasons for you to check it out:

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor

Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association James A.Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

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.

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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.

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Official Publication

NOVEMBER 2013

VOLUME 54

NUMBER 11

Scientific Articles Pelvic Synovial Sarcoma of Unknown Primary Origin: Case Report and Literature Review

308

Christie Theriot MD; Karen Hughes, MD; John Mitchell, MD; Brandy Patterson, MD

Clinical Problem-Solving: Aloha, I’m Back

314

John P. F. H. Vanderloo, MD

Top Ten Facts You Need to Know - About Adult Tuberculosis

318

Dominique J. Pepper, MD; Risa M. Webb, MD; Michael Holcombe

Related Organizations Mississippi State Department of Health

320

MSMA Alliance

330

Departments From the Editor: To Live as Men and Women of Good Will

306

New Members

321

Poetry and Medicine: “Call” by Benjamin Morris

323

Physician’s Bookshelf: Wiggle Room by Darden North, MD

325

In Memoriam

327

About The Cover: Patient Pipe Progress - Built in 1973 with Hill-Burton funding, the Oktibbeha County Hospital in Starkville was recently renovated using a 2008 county bond issue. During the renovation these pipes from patient rooms were stacked for recycling purposes on a trailer. This photograph was taken by obstetrician/ gynecologist Dr. Tommy J. Cobb with a cell phone camera while walking back from a delivery at the hospital.

Dr. Cobb completed his education at the University of Mississippi School of Medicine in 1983. He finished his OB/GYN residency at the University of Tennessee School of Medicine in Memphis in 1987 and joined the staff at Starkville Clinic for Women that year. r November

VOL. LIV

2013

No. 11

of the MSMA Since 1959

November 2013 JOURNAL MSMA 305

From the Editor: To Live as Men and Women of Good Will

N

o one better expressed our duty as physicians in our rural and underserved state as the late journalist Hodding Carter (1907-1972) of Greenville, who in turn was quoting his mentor, writer/poet William Alexander “Will” Percy (1885-1942). Back in the mid-1930s, Percy and other progressive leaders of Greenville (including the wife of MSMA President Dr. Paul Gamble, 1947-8) recruited Carter from Hammond, LA to Greenville to start a new newspaper, which would eventually win the Pulitzer Prize.

In his 1965 essay, A Tale of Two Cities, Carter remembered his last encounter with the ill and dying Percy, who was trying to finish his classic memoir Lanterns on the Levee. On the eve of World War II, as war clouds encircled Europe and Asia, Carter came in uniform, soon off to service.

He asked Percy: “Will, it looks like everything is crumbling about us. What can I do when this war is over to help pick up the pieces?” Percy’s response deeply influenced Carter, and later Carter would recite it repeatedly to both himself and others. Percy said: “Neither you nor I is going to do anything

global. Our mission is to live as men of good will in Greenville, Mississippi, because it is the sum total of all the Greenvilles of our country that will make the kind of nation that we want or that we don’t want.” This advice, Carter added, “has been the compelling factor in my professional life– that of trying to live in an Lucius M. Lampton, MD obscure Mississippi city, as a man of good will, together with other men of good will…in this unending struggle to achieve dignity for all men.”

Mississippi physicians, both rural and urban, daily devote ourselves to our patients and our communities. Don’t get frustrated that our influence in often small worlds and circles is not making a difference. It is! Percy’s credo, adopted and promoted by Carter, affirms that our little furies and struggles for our own people in our own little towns as men and women of good will can transform our state and world.

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

William Lineaweaver, MD Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon

Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, Michael D. Maples, MD G.V. Montgomery VA Medical Center, Jackson Vice Preisdent, Chief of Medicial Operations Baptist Health Systems, Jackson

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Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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Working with Young Physicians November 2013 JOURNAL MSMA 307

• Scientific Articles • Pelvic Synovial Sarcoma of Unknown Primary Origin: Case Report and Literature Review Christie Theriot MD; Karen Hughes, MD; John Mitchell, MD; Brandy Patterson, MD

A

bstract

A case report of a 26-year-old woman with pelvic pain for one-month duration is presented. The physical exam was unremarkable, but a right pelvic mass was found on ultrasound.

Computed tomography (CT) of the abdomen/pelvis confirmed a heterogeneous 6 x 4.4 cm mass within the right pelvis adjacent to the superior-lateral aspect of the uterus. Laparoscopy was performed, and the mass was found to be friable and necrotic.

The origin of the mass was not able to be determined due to the collapse of the mass upon instrumentation. Histology revealed spindle cells. Further studies, including immunochemical staining, revealed a synovial sarcoma. Patient underwent laparotomy for staging and in hopes of obtaining clear tumor margins.

Surgery revealed subsequent tumors involving the mesentery of the small intestine and the peritoneal wall. Biopsies taken at surgery did not reveal the primary origin of the original pelvic tumor.

Objective A rare case of synovial sarcoma is presented to make the reader aware of a rare site synovial sarcoma, illustrating the necessity for a wide differential diagnosis, as well as including advanced immunohistochemical staining for accurate diagnosis when pelvic masses are found. This case also supports the importance of wide excision and long-term follow up to give the patient best survival probability.

Keywords: Synovial sarcoma, pelvic synovial sarcoma, abdominal synovial sarcoma, rare site synovial sarcoma, synovial sarcoma of unknown origin, small intestine synovial sarcoma, mesentery synovial sarcoma, duodenal synovial sarcoma, TLE-1.

Introduction Synovial sarcoma is a rare malignancy that arises from soft tissues. It represents approximately 5-10% of soft tissue sarcomas1-4 and most often arises from the extremities of young adults, usually between the ages of 15 and 35 years. 5,6 On rare occasions, it may arise from such sites as the head and neck,7 thorax,6 abdomen,8-15 pelvis,9,16 retroperitoneum, 9,17,18 vulva/ vagina,19,20 and inguinal region.21,22 Other rare sites of origin are from visceral organs such as the heart, 23 pleura/ lung,24 mesentery/omentum/small intestine (Table 1),5,25-30,31 kidneys,32 and prostate.33 These rare sites make up approximately 5-15% of synovial sarcoma locations12,15 with intra-abdominal synovial sarcomas being extremely rare. One study documents only approximately 33 known cases,9 with very few known cases of pelvic origin (Table 2).9,16 Based upon literature search, this is the second case to be documented involving the small intestine mesentery.

Synovial sarcoma histologically resembles synovium, exhibiting a distinctive biphasic or monophasic variation of spindle and epithelial cells with a poorly differentiated variety occasionally occurring. Synovial sarcoma is a mesenchymal tumor and not a malignancy of synovium, rarely involving the joints.2,3,8,18 Differentiating synovial sarcoma from other tumors with similar histology can be challenging.

Immunohistochemical staining with cytokeratin, vimentin,12 and EMA4,8,13,20,34 is an important part of diagnosis. Diagnosis is confirmed by presence of a reciprocal translocation t(x;18) (p11.2;q11.2) that leads to a SYT-SSX fusion gene, which is believed to lead to transcription dysregulation.1,3,4,34,35 In this paper, a new case of intra-abdominal synovial sarcoma is described with tumor of unknown primary and subsequent tumors involving the mesentery of the small intestine and peritoneal wall, with histological confirmation of synovial sarcoma.

Author Affiliations: Second year resident Family Medicine (Dr. Theriot); associate director and clinical faculty Family Medicine (Dr. Hughes); clinical faculty, Family Medicine, (Dr. Mitchell); Obstetrics and Gynecology (Dr. Patterson); North Mississippi Medical Center, Tupelo, Mississippi.

Case Report:

Corresponding Author: Christie Theriot, MD; 1665 South Green Street, Tupelo, MS 38801 (christie.theriot@gmail.com).

A 26-year-old nulliparous white female presented with complaints of pelvic pain. She described intermittent painful

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Table 1. Summary of previously reported cases of synovial sarcoma of the small intestine/mesentery/omentum

Reference Location Age/Sex Type Size (cm) Outcome Helliwell 1995 30 Ileal mesentery 46/M Biphasic 9x7x7 ANED 9m Chan 2004 26 Jejunum 28/M Monophasic 15 DOD 1m Hemmings 2004 5 Omentum 37/F NK 15 DOD 3y Wang 2006 15 Omentum 66/M Biphasic 20x20x10 DOD 2 m Schreiber-Facklam 2007 31 Duodenum 39/F Monophasic 5x4 ARD 8m 27 Company-Campins 2009 Duodenum 69/F Monophasic 8x7x3 DOD 1m Garcia-Ruiz 2010 29 Duodenum 70/M Biphasic 9 NK Eriksen 2010 28 Mid Ileum 39/F Monophasic 4x5 ANED 24m Alsharief 2010 25 Ileum 29/F Monophasic 8x7x3 ANED 24m ANED- alive, no evidence of disease, DOD- died of disease, ARD- alive with recurrent disease, DOC- died of other causes, LTF- lost to follow up, NK- not known, m- months after diagnosis, y- years after diagnosis

Table 2. Summary of previously reported cases of synovial sarcoma of the pelvis Reference Adam 1984 17 Fisher 2004 9

Location Age/Sex Type Size (cm) Outcome Pelvis- side wall 25/M Biphasic NK ANED 24m Pelvis- midline 72/F Monophasic 11 DOD 24m presacral Fisher 2004 9 Pelvis- side wall 38/M Biphasic NK DOD 24m Fisher 2004 9 Pelvis- side wall 45/F Monophasic 9 ARD 43m 16 19/M Poorly 1.5 x 1 x 0.4 NK- LTF Rekhi 2008 Pelvis- infero-lateral Differentiated to the urinary bladder extending into the thigh ANED- alive, no evidence of disease, DOD- died of disease, ARD- alive with recurrent disease, DOC- died of other causes, LTF- lost to follow-up, NK- not known, m- months after diagnosis

Fig 1. Computed tomography (CT) confirmed pelvic mass

Fig 1. Computed tomography (CT) confirmed a heterogeneous, vascular, soft tissue mass measuring 6 x 4.4 cm, located adjacent to the superior-lateral aspect of the uterus on the right.

episodes over the previous month. The pain was described as 8-9 out of 10 in intensity, located in the right flank and pelvis, with radiation to the groin. The sharp, throbbing pain began at maximum intensity and remained present for approximately 2-6 hours before subsiding. She reported five of these painful episodes without any association to time of day, eating, urination, bowel function, or menstrual cycle. She denied any other symptoms, including nausea, vomiting, menstrual irregularities, or changes in bowel or bladder function.

Her only medication was oral contraceptives and review of systems was negative except as stated.

Past medical history was significant for asthma, migraine headaches, and an aspirin-induced GI bleed. Past surgical history was significant for strabismus surgery. Family history was unremarkable.

The patient’s vital signs were within normal limits, and physical exam was unremarkable except for mild diffuse abdominal tenderness to palpation, slightly worse in the right lower quadrant but with no guarding or rebound and no appreciated masses. Initial work up consisted of blood work, including complete blood count, complete metabolic panel,

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urinalysis and a plain film abdominal x-ray. All laboratory tests and the abdominal film were within normal limits. Patient was then referred to a local gynecologist for further evaluation, as an ovarian cyst was suspected as the most likely cause. Transvaginal ultrasound revealed a large pelvic mass in the right adnexal region. Computed tomography (CT) confirmed a heterogeneous, vascular, soft tissue mass measuring 6 x 4.4 cm, located adjacent to the superior-lateral aspect of the uterus on the right (Figure 1). Based on these findings, a pedunculated fibroid was suspected and the patient was scheduled for diagnostic laparoscopy and resection of the mass.

During laparoscopic surgery, a large, very friable tumor was discovered in the right posterior aspect along the base of the broad ligament. Upon instrumentation, the mass collapsed and was removed with an endobag. No specific origin, attachment, or specific vascular supply was able to be identified, although the peritoneum where the mass was situated appeared very inflamed. All organs otherwise appeared normal upon inspection. Examination of a frozen section was performed intraoperatively and revealed highly cellular spindle cell architecture. The mass was sent out for further histologic identification.

(Figure 2A) Gross examination revealed a tan tumor with areas of hemorrhage. Advanced immunohistochemical staining was performed for definitive tissue diagnosis, and positive stains for pankeratin (Figure 2B) and TLE-1 (a marker for the unique SYT-SSX fusion transcript)(Figure 2C) ruled out other etiologies and confirmed synovial sarcoma grade 3.

Staging workup was then begun. The chest CT did not identify an origin for the mass, nor did it identify any lesions suspicious for lung metastasis. PET scan revealed another 2cm nodule and abnormal uptake in the pelvic peritoneum.

Due to lack of confirmation of clear margins from the initial laparoscopic procedure, the patient was scheduled for open laparotomy and cancer staging. Upon visual examination of the small bowel, a necrotic mass was noted on the mesentery approximately two feet from the terminal ileum. This finding resulted in a small bowel resection along with the involved mesentery and adherent omentum. Nodularity seen in the right peritoneum with thickening over the cul-de-sac and posterior uterus resulted in a radical hysterectomy and resection of culde-sac peritoneum. Appendectomy along with lymph node sampling and biopsy were also performed.

Pathology All resected tissue was sent for pathology along with peritoneal washings. There were no malignant cells identifiable within the washings. The small bowel section along with accompaning mesentery showed monophasic synovial sarcoma measuring 2.4 x 2 x 1.5 cm. Tissue staining was positive for vimentin, pankeratin, and EMA, with a mitotic rate of 18-20 per 10 HPF. These findings were consistent with the initial diagnosis of grade 3 synovial sarcoma. There was mesothelial

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hyperplasia and chronic inflammation of the omentum but no malignancy. There was also a focal monophasic synovial sarcoma satellite nodule on the right pericolic gutter peritoneum.

Sigmoid peritoneal biopsy revealed focal caseating granulomas which were negative for acid-fast bacteria (AFB) and Gomori’s methenamine silver (GMS) stains, with no malignancy. Uterus, fallopian tubes, ovaries, and serosa also showed caseating granulomas negative for AFB, GMS stains, as well as no malignancy. All lymph nodes examined were negative for tumor.

Subsequent Treatment The patient recovered from surgery well and began inpatient chemotherapy four weeks following surgery. Chosen chemotherapy treatment was six inpatient cycles consisting of Mesna, Adriamycin, Ifosfamide, and Dacarbazine (MAID).

Each cycle consisted of three 24-hour infusions of MAID and one additional 24-hour infusion of Mesna. All six cycles were completed. The patient’s follow up CT and PET scans at 6 months revealed no recurrence or metastatic disease. The patient then began treatment with 45 Gray (Gy) of external beam radiotherapy to the abdomen and pelvis.

Twenty-nine months post diagnosis including subsequent surgery and treatment the patient continues to do well. She has returned to her full normal activity, and all follow-up testing has shown no evidence of disease recurrence.

Discussion Synovial sarcoma is a slow growing, high-grade soft tissue sarcoma. It comprises approximately 5-10% of soft tissue sarcomas.3,4 It is generally a disease of adults, usually between the ages of 15 and 35 years.5,6 Synovial sarcoma is not, as its name implies, a malignancy of synovium, but rather a mesenchymal tumor.2,3,14,18,19 Histologically, synovial sarcoma consists of spindle or epithelial cells, with 30% being the biphasic subtype and 70% being the monophasic subtype.34 Poorly differentiated synovial sarcoma also exists with characteristic areas of high cellularity, little pleomorphism, numerous mitoses, and necrosis.9,19,20 All subtypes of synovial sarcoma exhibit a reciprocal translocation t(X;18) (p11.2; q11.2). The SYT (also known as SS18) gene on chromosome 18q11 becomes fused with SSX1, SSX2, or SSX4 on Xp11.2.19 The exact mechanism of oncogenicity is unclear. It is believed that the fusion gene SYT-SSX leads to transcription dysregulation1,3,4 by upregulation of NCOA3, a protein that has been linked to the formation of many cancers.35 Positivity to vimentin, cytokeratin, and EMA are important parts of diagnosis.1,4,8,12,20,34 Recently, over expression of a transcriptional co-repressor, TLE-1, has been identified as a highly specific method of diagnosing synovial sarcoma;1,34 however, presence of the translocation t(x;18) should be demonstrated by FISH or RT-PCR to accurately diagnose and predict prognosis.1,4,8,34 Finding the translocation is sufficient for diagnosis since the t(x;18) translocation is specific to synovial

sarcoma and occurs in 70-90% of cases.4,9,10,14,18,20 This case illustrates the importance of utilizing improved immunohistochemical staining techniques to accurately diagnose synovial sarcoma tumors in rare areas of the body.

Synovial sarcoma most often involves the extremities, near joints, especially the knee. There, however, have been other primary sites noted, some exceptionally rare. These include the head and neck,7 thorax,6 abdomen (Table 1),8,-11,13-15 pelvis (Table 2),9,16 retroperitoneum,9,17,18 inguinal region,21,22 vulva/vagina,19,20 and multiple organs including the heart,23 lungs/pleura,24 small intestine/mesentery/omentum,5,12,2,-30,31 kidneys,32 and prostate.33 Synovial sarcoma of nerves has also been documented.36 This case represents one of very few pelvic cases of known synovial sarcoma. It is not uncommon for the primary site of retroperitoneal synovial sarcoma to be listed as unknown in the literature, especially when tumor size is large. In this case, there is no definitive location of primary of the original pelvic tumor. It is not believed that this tumor was an extension of the mesentery tumor or peritoneal tumors found during laparotomy, due to distinct locations that were not within one plane. The tumor within the small intestine mesentery is, to the author’s knowledge, only the second documented in this area in the current literature. Finally, there are no other distant synovial sarcoma tumors detected; therefore, this pelvic synovial sarcoma may represent a primary tumor and is not felt to represent distant metastasis. Synovial sarcoma is an aggressive disease,

and prognosis is generally poor. The presence of large tumor size, metastases at diagnosis, high histological grade, disease of the trunk, and inability to get clear margins at surgery are all associated with a worse prognosis.2,19 Metastasis is often seen in 50-70% of cases.2 Five year survival rates are approximately 25-75%.2,13 Local recurrence is not uncommon, and distant, sometimes late, metastasis2,12,18 particularly to the lung,2,9,14,18 is often seen with pelvic synovial sarcoma.8,9,13 Surgery with wide local excision or amputation of an affected extremity is the mainstay of treatment.28 The roles of chemotherapy and radiotherapy are controversial but are often used to aid in preventing or suppressing metastasis.2,12,28,37 The use of wide excision was utilized in this case and affirms the need for clear margins to give the patient the best opportunity for survival. It also tests the use of systemic chemotherapy and pelvic radiotherapy as a means of preventing metastasis in an aggressive strategy against an aggressive malignancy.

Conclusion

Better identification techniques have helped to identify synovial sarcomas arising from unusual sites throughout the body. Therefore, synovial sarcoma should remain as a rare entity on the differential diagnosis of masses within the abdomen/ pelvis. This case illustrates a rare case of synovial sarcoma of the pelvis with an unknown primary origin with an additional rare secondary site on the small bowl mesentery, of which only one prior case is found in the literature. It also illusFig 2. Photomicrographs of pelvic tumor and positive staining trates the importance of staining techniques to accurately diagnose tumors in atypical locations. This case serves as an example of the use of wide resection, chemotherapy/radiation treatment, and the importance of long term follow-up to monitor for recurrent disease and disA B tant metastasis.

In summary, this is a case of a 26-year-old Fig 2. (A)- High power female with pelvic synophotomicrograph of the pelvic tumor vial sarcoma of unknown illustrating a high grade spindle cell primary origin and subsetumor. quent tumors of the small (B)-Immunohistochemical staining intestine mesentery and showing spindle cells positive for peritoneal wall which Keratin. were felt to represent distinct primary tumors but (C)- Spindle cell tumor positive could have represented for TLE-1 confirm the diagnosis of C extension of the primary synovial sarcoma. tumor.

November 2013 JOURNAL MSMA 311

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3. Naka N, Takenaka S, Araki N, et al. Synovial sarcoma is a stem cell malignancy. Stem Cells.2010;28:1119-1131.

4. Tsuji S, Hisaoka M, Morimitsu Y, et al. Detection of SYT-SSX fusion transcripts in synovial sarcoma by reverse transcription-polymerase chain reaction using archival paraffin-embedded tissues. Am J Pathol.1998;153(6):1807-1812.

5. Hemmings C, Fisher C. Primary omental synovial sarcoma: a case with cytogenetic confirmation. Pathology. 2004;36(2):208-211.

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Gen Thorac Cardiovasc Surg. 2010;58(2):95-97.

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13. Narula MK, Madan R, Prakash Pathania O, et al. Primary intra-abdominal synovial sarcoma. Appl Radiol. 2007;36(7):48A-48D. 14. Vera J, Garcia MD, Marigil M, et al. Biphasic synovial sarcoma of the abdominal wall. Virchows Arch. 2006;449(3):367-372.

15. Wang YJ, Wen SC, Chien ST, et al. Primary intra-abdominal synovial sarcoma. J Chin Med Assoc.2006;69(10):492-495.

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17. Adam Y, Oland J, Halevy A, Reif R. Primary retroperitoneal soft-tissue sarcomas. J Surg Oncol. 1984;25(1):8-11.

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20. Sumathi VP, Fisher C, Williams A, et al. Synovial sarcoma of the vulva and vagina: A clinicopathologic and molecular genetic study of 4 cases. Int J Gynecol Pathol. 2011;30(1):84-91.

8. Buiga-Potcoava R, Crisan D, and Olinici CD. Primary intraabdominal synovial sarcoma: a case report. Rom J Gastroenterol. 2005;14(1):67-69.

21. Fernandez BB, Hernandez FJ. Poorly differentiated synovial sarcoma. A light and electron microscopic study. Arch Pathol Lab Med.1976;100(4):221-223.

9. Fisher C, Folpe AL, Hashimoto H, Weiss SW. Intra-abdominal synovial sarcoma: a clinicopathological study. Histopathology 2004;45(3):245-253.

22. Xu J, Wang J, Cui L, Wu X. Malignant inguinal monophasic synovial sarcoma: report of a case and review of the literature.World J Surg Oncol.

2010;8:102.

10. Kashima T, Matsushita H, Kuroda M, et al. Biphasic synovial sarcoma of the peritoneal cavity with t(X;18) demonstrated by reverse transcriptase polymerase chain reaction. Pathol Int.1997;47(9):637-641.

11. Kishino T, Morii T, Mochizuki K, et al. Unusual sonographic appearance of synovial sarcoma of the anterior abdominal wall. J Clin Ultrasound.

2009;37(4):233-235.

23. Zhang L, Qian J, Li Z, Jing H. Primary synovial sarcoma of the heart.

Cardiol J. 2011;18(2):128-133.

24. Zonta S, Lovisetto F, Morbini P, Cobianchi L, Nazari S. Thoracic-abdominal approach in primary pulmonary synovial sarcoma. Asian Cardiovasc Thorac Ann. 2005;13(1):85-87.

25. Alsharief A, Fageeh M, Alabdulkarim Y. Monophasic synocial sarcoma presenting as a primary ileal mass: a case report and review of the literature.

J Med Case Rep. 2012;6(1):83.

26. Chan GS, Yuen ST, Chan KW. Synovial sarcoma presenting as a polypoid jejunal mass. Histopathology. 2004;44(2):191-193.

27. Company Campins MM, Morales R, Dolz C, et al. Primary monophasic synovial sarcoma of the duodenum confirmed by cytogenetic analysis with demonstration of t(X;18): a case report. J Gastroint Liver Dis. 2008;18(1):89-93.

28. Eriksen C, Burns L, Bohlke A, Haque S, Slakey DP. Management of monophasic synovial sarcoma of the small intestine. JSLS. 2010;14(3):421-425.

29. Garcia-Ruiz S, Jimenez-Rodriguez RM, Alcaide-Leon P. et al. Synovial two-phase sarcoma in third portion duodenal: clinical case and review of the literature. Re Esp Enferm Dig. 2010;102(1):62-63.

30. Helliwell T, King AP, Raraty M, et al. Biphasic synovial sarcoma in the small intestinal mesentery. Cancer. 1995;75(12):2862-2866.

31. Schreiber-Facklam H, Bode-Lesniewska B, Frigerio S, Flury R. Primary monophasic synovial sarcoma of the duodenum with SYT/SSX2 type of translocation. Hum Pathol. 2007;38(6):946-949.

32. Divetia M, Karpate A, Basak R, Desai SB. Synovial sarcoma of the kidney.

Ann Diagn Pathol. 2008;12(5):333-339.

33. Jun L, Ke S, Zhaoming W, Linjie X, Xinru Y. Primary synovial sarcoma of the prostate: report of 2 cases and literature review. Int J Surg Pathol.

2008;16(3):329-334.

34. Knosel T, Heretsch S, Altendorf-Hofmann A, et al. TLE1 is a robust diagnostic biomarker for synovial sarcomas and correlates with t(X;18): analysis of 319 cases. Eur J Cancer. 2010;46(6):1170-1176.

35. Sun Y, Perera J, Rubin BP, Huang J. SYT-SSX1 (Synovial Sarcoma Translocated) regulates PIASy to cause overexpression of NCOA3 J Biol Chem. 2011;286(21): 18623-18632.

36. Scheithauer BW, Amrami KK, Folpe AL, et al. Synovial sarcoma of nerve.

Hum Pathol. 2011;42(4):568-577.

37. Sugawara S, Ehara S, Hitachi S, Okada K. Patterns of soft-tissue tumor extension in and out. Am J Roentgenol. 2010;194(3):746-753.

November 2013 JOURNAL MSMA 313

• Clinical Problem-Solving • Aloha, I’m Back John P.F.H. Vanderloo, MD

A

61-year-old African-American male presented via ambulance to the emergency department with a chief complaint of back pain. He was a poor historian with insufficient hygiene and a disheveled appearance. It was the heat of the summer, and the patient wore a Hawaiian shirt that was completely unbuttoned and opened to the front. He stated the pain began 3 months ago, was achy in character and radiated down his left leg. He had been seen by another provider at this same emergency department 3 days ago and prescribed hydrocodone with acetaminophen (Lortab). The patient stated he did not fill the prescription “because it was missing something.” He had a past medical history of chronic low back pain but stated that it was progressively worsening. According to the ambulance report, the patient was found in bed, unable to walk or stand.

Low back pain is a pervasive condition that affects at least 70% of the general population.1 The differential diagnosis can be divided into 3 main subsets: mechanical (e.g. trauma or strain), non-mechanical (e.g. neoplastic, infectious, or inflammatory) or visceral disease (e.g. nephrolithiasis, pancreatitis, or aortic aneurysm). Also, when narcotics are involved in treatment, malingering is to be considered, and prescription use must be verified. Ninety-five percent of patients with back pain have a benign and self-limited course of symptoms, but further history and physical exam findings are needed to help distinguish the cause.2 At this point I will obtain more history.

Author Information: Dr. Vanderloo is an assistant professor in the Department of Family Medicine at the University of Mississippi School of Medicine.

Corresponding Author: John P.F.H. Vanderloo, MD, Department of Family Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216 Telephone: (601)984-6800, Fax: (601)984-6811 (jvanderloo@umc.edu).

314 JOURNAL MSMA November 2013

The patient’s review of systems was positive only for back pain. He denied all other complaints. The patient had a long history of poorly controlled hypertension. He had a surgical history positive for back surgery, and a right above-the-knee amputation, which was secondary to a motorcycle collision roughly 30 years ago. He denied any positive family history. He smoked 2 packs of cigarettes and drank two-32 ounce beers daily but denied illicit drug use.

He reported no known food or drug allergies, and his only home medication was amlodipine (Norvasc) 5mg by mouth, daily for hypertension.

Since the patient has a limited complaint list on review of systems, a history of trauma and prior surgery to his back and chronicity of symptoms, I am initially considering a mechanical cause of his low back pain. It is important to rule out red flags of low back pain that may indicate a serious cause, such as a spinal cord injury. He denies fever or recent infection, no new significant trauma, no loss of bowel or bladder function and no unexplained weight loss or history of cancer. He does have a history of risk factors for cancer (i.e. smoking and alcohol use) and is a poor historian. With these concerns, I will conduct a thorough physical exam.

Upon physical examination, the patient was noted to have an oral temperature of 98.6°F, an elevated blood pressure of 165/105 mmHg, a borderline tachycardic heart rate of 100 beats per minute, a respiratory rate of 14 breaths per minute and an oxygen saturation of 97% without supplemental oxygen. The patient was lying on a stretcher in an awkward diagonal position and appeared to be in mild pain. He had a malodorous body smell combined with cigarette smoke and had a disheveled appearance.

Upon musculoskeletal exam, the patient was found to have a right above-the-knee amputation that was well healed.

His left leg was abducted, externally rotated at the hip, and contracted at the knee. Passive range of motion of his ankle,

knee and hip elicited pain in all directions. The patient was unable to passively flex his knee less than 100 degrees or extend greater than 150 degrees. His cranial nerves IIXII were grossly intact. His left patellar reflex was absent, but he had a weak Babinski reflex on the left foot. The patient was awake, oriented to person and place. His affect was somewhat blunted. He had mild paucity of speech in answering questions and subtle word-finding difficulty.

Given the acuity of his lower extremity findings and my high suspicion of substance use, the focus of investigation remains on the musculoskeletal workup. The differential includes spinal or hip pathology causing neurologic impairment. There is also a possibility of central nervous system involvement given the neuropsychiatric findings. I am considering whether the patient’s affect, paucity of speech and word-finding difficulty are due to substance use, which may be contributing to the patient’s poor verbal history. The next step is to obtain imaging to further evaluate for fracture, dislocation or mass. I will start with radiographs to evaluate fracture or dislocation and, if inconclusive, consider magnetic resonance imaging (MRI) to assess for a mass or soft tissue finding such as tendinopathy or myopathy.

A lumbar spine radiograph was negative for acute fracture, dislocation or mass effect. Hip, femur, tibia and fibula radiographs were also negative for acute findings.

An MRI of the left hip showed a small, non-specific left hip effusion. An MRI of the left lower extremity was also ordered but the lower leg could not be imaged because the positioning of his externally rotated leg precluded him from fitting into the scanner.

So far, it is interesting that the workup for this patient’s back and leg pain has been non-diagnostic. The results of the imaging have failed to indicate a mechanical cause for the findings. The emergency department is continuing to bring in new patients, and it could be tempting to write another pain prescription and discharge the patient. This case is, as previously stated, complicated by the patient being a poor historian. As I consider each possible diagnosis in the differential, I wonder if the subtle neurological findings are real or imagined. The investigator in me decides that one more chance for any history could illicit other symptoms that might indicate the cause of his acute worsening back pain.

Upon further questioning, the patient stated he usually ambulated well using a right lower extremity prosthesis since his amputation. However, he had been unable to walk using his left leg for the previous 2 weeks as it suddenly “gave out.” The resultant immobility, therefore, exacerbated his chronic low back pain.

I now must consider an acute neurologic cause of his lower extremity weakness, being most suspicious for a possible cerebrovascular accident (CVA). The combination of mild difficulty with word-finding, speech delay and blunted affect, which had previously piqued my index of suspicion

for substance use, now fits well into the stroke differential.

The weakly positive Babinski reflex might indeed be a subtle finding of an upper motor neuron lesion. The test of choice for acute stroke is a non-contrasted computed tomography (CT) scan of the brain to evaluate for both ischemic and hemorrhagic types of CVA. A brain CT scan showed findings consistent with an acute to early subacute cortical infarct of the right medial frontal lobe. A neurologist surmised that the stroke likely concurred with his loss of walking ability, by history, approximately 2 weeks earlier. The neurologist recommended continuing the stroke workup with an MRI of the brain, a trans-thoracic echocardiogram (TTE) and a CT angiogram (CTA) of the head and neck. The patient was prescribed aspirin 325mg by mouth daily and admitted to the inpatient service for the subsequent workup. The MRI showed an acute cortical infarct in the right medial frontal lobe and probable sequelae of small vessel occlusive disease in the periventricular white matter. The TTE showed diastolic dysfunction with normal left ventricular systolic function. The CTA showed multiple calcified plaques at the origin of the left internal carotid artery and in the proximal right internal carotid artery, as well as in the carotid siphon bilaterally, all without significant stenosis. However, there was also a small focal thrombus in the left internal jugular vein and multiple pulmonary emboli (PE) scattered throughout both lungs.

An acute CVA! With multiple scattered emboli! It seems that I am now left with more questions than answers. The findings above confirm the cause of the patient’s neurologic symptoms but raise further questions regarding the cause of the multiple thrombi. I recall from freshman medical physiology that Virchow’s triad postulates that venous thrombi have 3 general causative factors: stasis, hypercoagulability and endothelial injury to blood vessels. This patient has had decreased mobility for at least 2 weeks, has hypertension and uses both tobacco and alcohol, which can all contribute to endothelial injury. Given his age, an intrinsic coagulation deficiency is less likely, but malignancy has a high likelihood. It is important to continue the workup now for causes of his multiple thrombi.

The patient was given heparin, and a pulmonologist was consulted to assist with the evaluation and management of the pulmonary emboli. A hypercoagulation panel was normal. A left lower extremity venous ultrasound did not show evidence of deep vein thrombosis. A trans-esophageal echocardiogram with bubble study did not show a thrombus, valvular abnormality, patent foramen ovale or right-toleft shunts. A CTA of the chest showed emphysematous changes but did not show lesions suspicious for malignancy.

The pulmonologist debated starting long-term warfarin (Coumadin) therapy. However, the frequent monitoring required and the patient’s socioeconomic situation and poor history skills were considerations. Ultimately it

November 2013 JOURNAL MSMA 315

was determined the patient would be reliable enough for outpatient monitoring, and warfarin was started.

With the workup concluded, the patient had no signs of malignancy or hypercoagulability; therefore, intrinsic stroke risk factors have contributed to the patient’s clinical presentation.

According to the American Heart Association /American Stroke Association Guidelines for the Prevention of Ischemic Stroke, this patient has numerous risk factors that contribute to stroke: African-American ethnicity, male gender, age over 55 years, uncontrolled hypertension, mild carotid stenosis, a massive smoking history, alcohol use, and physical inactivity.4 In summary, the patient’s acute ischemic stroke leaves him unable to ambulate, becoming essentially bed-ridden for up to 2 weeks, which causes the venous thromboembolism.

Fifteen months after discharge, the patient was still smoking but reportedly decreased his drinking significantly.

His blood pressure and cholesterol were being aggressively managed, and his warfarin therapy continued. He completed physical and occupational outpatient rehabilitation but still relied on a wheelchair for mobility. He had no new concerns for malignancy and was doing well overall.

The fact that this patient was so focused on his back pain and had no cardio-pulmonary complaints almost allowed his thromboses to be missed. Nearly 25% of PE cause immediate

death, and one-week survival rates are only 71%.5 Had I simply refilled his hydrocodone with acetaminophen and chalked his case up to being “another abuser,” he might have succumbed to a worse fate. He will forever remain on my mind with his Hawaiian shirt flowing freely in the breeze of the air conditioner.

Aloha, sir.

Key Words: back pain, hypertension, stroke, pulmonary embolism

References 1.

Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007; 75[8]:1181-1188.

2.

Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Annals of Internal Medicine. 2002; 137[7]:586-597.

3.

Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009; 79[12]:1067-1074.

4.

Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:517-584.

5.

Heit JA, O’Fallon WM, Petterson TM, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism.

Arch Intern Med. 2002; 162:1245-1248.

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316 JOURNAL MSMA November 2013

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November 2013 JOURNAL MSMA 317

• Top Ten Facts You Need to Know • About Adult Tuberculosis Dominique J Pepper, MD; Risa M. Webb, MD; Michael Holcombe

I

ntroduction

Tuberculosis (TB) is a contagious and potentially lethal disease caused by the immune system’s response to Mycobacterium tuberculosis (Mtb).1 Spread of infection is reduced by use of airborne isolation and early appropriate treatment.

1. Active pulmonary TB is infectious; Latent TB is not.

Active TB is diagnosed when symptoms or signs of active TB accompany growth of M.tb bacilli; symptoms include cough, night sweats, loss of weight, and/or fatigue.2 Patients with active pulmonary TB are considered infectious until after appropriate treatment and an initial response with negative sputum smears.

Latent TB infection (LTBI) is diagnosed in those without symptoms or signs of active TB who do not culture M.tb bacilli and who have either a positive tuberculin skin test (TST) or interferon gamma release assay (IGRA).2-4 2. Mississippi has about 100 cases of active TB a year. In 2011, 91 active TB cases and 2667 LTBI cases were diagnosed in Mississippi. In the US 10,528 active TB cases were reported the same year.5 3. Anyone can develop TB if exposed but certain factors increase the risk of active TB. Factors that increase the risk of active disease in patients with LTBI or recent exposure to M.tb include HIV co-infection, injecting illicit drugs, current or prior smoking, living in or employment at prisons or homeless shelters, immigrating from countries with endemic TB, and living in resource-poor communities.6-8 4. Smear microscopy and culture are the gold standards of TB diagnosis. Definitive diagnosis of active TB requires Author Information: PGY-3 Resident, Department of Medicine, University of Mississippi School of Medicine, Jackson (Dr. Pepper); Professor of Medicine, Division of Infectious Disease University of Mississippi School of Medicine, Jackson, State TB Consultant, Mississippi State Department of Health, Jackson (Dr. Webb); TB Control Program Manager, Office of TB and Refugee Health, Mississippi State Department of Health, Jackson (Mr. Holcombe).

Corresponding Author: Dominique J Pepper, MD, PGY-3 Resident, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Telephone: (601)9845601, (dpepper@umc.edu).

318 JOURNAL MSMA November 2013

culture of M.tb from sputum, pleural fluid, or a tissue biopsy.

Some patients may be treated as a clinical case if signs and symptoms suggest TB even though the culture is negative.

TSTs and IGRAs are useful in the diagnosis of LTBI but may be falsely negative in active TB.2 5. Treatment of LTBI is 70-90% effective in preventing active TB. Daily LTBI regimens may be self-administered (SA), but regimens that are given once or twice weekly or that are administered to patients with HIV must be directly observed (DOPT). The MSDH offers LTBI treatment to appropriate patients to greatly decrease the risk of active disease: 9 i) Isoniazid given for 9 months daily (SA) or twice weekly (DOPT) ii) Isoniazid and Rifampin given for 3 months once weekly (DOPT only) iii) Rifampin given for 4 months daily (SA or DOPT).

6. Four drugs should be initiated for active TB until sensitivities are available. All regimens for active TB are directly observed and are provided by the MSDH. The initial phase of TB treatment involves 8 weeks of isoniazid, rifampin, pyrazinamide and ethambutol. The continuation phase consists of at least 18 weeks treatment with isoniazid and rifampin.

When cavitary lesions, prolonged positive sputum smears, prior active TB, HIV co-infection, drug resistance, and pregnancy are concomitant, treatment may be prolonged to 9, 12 or 18 months.10 7. Regular clinical and laboratory monitoring must be performed for TB treatment. The MSDH routinely monitors side effects with each administered dose per ATS/CDC guidelines.2, 10 During treatment, the MSDH performs tests for hepatitis, peripheral neuropathy (including optic neuropathy), leucopenia, thrombocytopenia, anemia, and renal failure.

8. Isolation of TB suspects helps to prevent inadvertent spread of TB. Early detection, airborne precautions, and treatment of suspected or confirmed TB disease are necessary to minimize transmission of M.tb. Most active TB patients are quarantined at home for a minimum of two weeks after starting appropriate treatment. In health care settings, patients should

wear a surgical mask when they have to leave the isolation room for tests. Health care workers should be fitted and wear N-95 respirators to protect themselves when in contact with TB cases or TB suspects.11 9. Patients in Mississippi still die from TB. Twelve TB related deaths occurred in Mississippi in 2011. In 2009 in the US, there were 529 reported TB-related deaths.12 Predictors of death during TB treatment in the US include non-infective comorbidities, sputum smear-positive disease, and alcohol and substance misuse.13 10. Health care workers in Mississippi must report TB suspects to the MSDH at first knowledge or suspicion of disease. TB should be reported to the Reportable Disease Hotline (M-F 8am-5pm) 1-800-556-0003 or 601-576-7725, to the TB division at 601-576-7700, or to the county health department in which the patient lives. After hours, weekends and holidays call 601-576-7400.

Conclusion Diagnosis and management of tuberculosis is essential knowledge for all physicians. Prompt reporting and referral to the Health Department is critical to protect public health.

References 1.

Barry CE 3rd, Boshoff HI, Dartois V, et al. The spectrum of latent tuberculosis: rethinking the biology and intervention strategies. Nat Rev Microbiol. 2009;7:845-55.

MSHOSPASSN_Layout 1 7/24/12 8:24 AM Page 1

2.

CDC. TB Basic Facts. Retrieved December 5, 2012. http://www.cdc.gov/ tb/topic/basics/default.htm.

3.

Diel R, Loddenkemper R, Nienhaus A. Evidence-based comparison of commercial interferon-gamma release assays for detecting active TB: a metaanalysis. Chest. 2010;137:952-968.

4.

WHO. Policy Framework for Implementing New Tuberculosis Diagnostics. Retrieved December 5, 2012. http://www.who.int/tb/ laboratory/whopolicyframework_rev_june2011.pdf.

5.

CDC “Reported Tuberculosis in the United States, 2011 table 1” Retrieved December 5, 2012. http://www.cdc.gov/tb/statistics/reports/2011/table1.htm.

6.

Martinson NA, Hoffmann CJ, Chaisson RE. Epidemiology of tuberculosis and HIV: recent advances in understanding and responses. Proc Am Thorac Soc. 2011;8:288-293.

7.

van Zyl Smit RN, Pai M, Yew WW, et al. Global lung health: the colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. Eur Respir J. 2010;35:27-33.

8.

Raoult D, Foucault C, Brouqui P. Infections in the homeless. Lancet Infect Dis. 2001;1:77-84.

9.

CDC. Treatment Options for Latent Tuberculosis Infection. Retrieved December 5, 2012. http://www.cdc.gov/tb/publications/factsheets/ treatment/LTBItreatmentoptions.htm.

10. CDC. Treatment of Drug-Susceptible Tuberculosis Disease in Persons Not Infected with HIV. Retrieved December 5, 2012. http://www.cdc.gov/ tb/publications/factsheets/treatment/treatmentHIVnegative.htm .

11. CDC. Respiratory Protection in Health-Care Settings. Retrieved December 5, 2012. http://www.cdc.gov/tb/publications/factsheets/ prevention/rphcs.htm.

12. CDC “Reported Tuberculosis in the United States, 2011 table 19” Retrieved December 5, 2012. http://www.cdc.gov/tb/statistics/reports/2011/table19. htm.

9.

Waitt CJ, Squire SB. A systematic review of risk factors for death in adults during and after tuberculosis treatment. Int J Tuberc Lung Dis. 2011;5:871–885.

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November 2013 JOURNAL MSMA 319

• MSDH • Mississippi Reportable Disease Statistics

September 2013 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR figures, visit the Mississippi State Department of Health website: www.HealthyMS.com. † Data not available.

320 JOURNAL MSMA November 2013

• New Members • Baranano, ANNE, Hattiesburg; Specialty: Ophthalmology.

Hatfield, ARLIN, Jackson; Specialty: Diagnostic Radiology.

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Beard, NAHUM, Southaven; Specialty: Family Medicine.

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Lichaa, HADY, Greenville; Specialty: Cardiovascular Disease.

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Calling All Mississippi Physician-Photographers

enter the JMSMA 2014 cover photo contest

L

oad your camera or grab your digital. Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physician/photographer.

Size: Vertical format 5 x 7� or 8 x 10� Deadline: November 29, 2013 Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

266 JOURNAL MSMA September 2013

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 322 JOURNAL MSMA November 2013

• Poetry and Medicine • [This month, we print a poem by Benjamin A. Morris, (right) a Mississippi born poet who lives in New Orleans. Morris is the son of Hattiesburg urologist and MSMA member Dr. Toxey M. Morris (left). “Call” is the first poem in a fascinating collection of poetry by Benjamin called “Coronary.” This poem explores the denial and delay of a physician/patient to go into the hospital with serious complaints, in this case an acute MI, as well as the fear and emotion of family members facing the illness with him. Published in 2011, the book includes 24 sonnets all centered on a similar theme: the personal experience of his father Toxey’s illness and hospitalization. (Toxey is in good health today!) The lovely volume includes original artwork by Dr. Morris on its cover.

Now in its third edition, copies are available at independent bookstores in the New Orleans area and at Main Street Books in Hattiesburg. Benjamin is the author of numerous works of poetry, fiction, nonfiction, and drama. He has received many honors for his writing, including a fellowship for poetry from the Mississippi Arts Commission. More information, including how to purchase “Coronary,” is available at benjaminalanmorris.com. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

Call The call comes in at ten. Seconds later and I’m in the car you gave me, drinking up these highway miles like water.

Nine hours since you went in, thinking it was only minor pain―possibly angina― searching in your dresser for the pills.

When can I call the EMTs, she asked. Virginia, you said, fetal on the floor, soon. Her will trumped yours, they came at one, and by two you were prepped and on the table.

By five you had a stent, and by seven you were in intensive care. Driving past the limit is the least that I could do.

The only word I heard her say was stable.

—Benjamin A. Morris, New Orleans November 2013 JOURNAL MSMA 323

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324 JOURNAL MSMA November 2013

• Physician’s Bookshelf • [A native of the Mississippi Delta, MSMA member Darden H. North, MD is board-certified in obstetrics and gynecology practicing with Jackson Healthcare for Women. He was recently appointed a member of the JMSMA Editorial Advisory Board. The award-winning novelist has written three previous novels—Fresh Frozen, House Call, and Points of Origin, which received the national IPPY Award, Southern Fiction category. Dr. North lives with his wife Sally in Jackson. The JMSMA welcomes book reviews from Mississippi physicians such as this one submitted by retired surgeon and employee of the Hudspeth Center Walter R. Jones, Jr., MD.] —Ed.

Wiggle Room

by Darden H. North, MD ISBN: 978-0-9889474-7-4, 266 pages Paper, $19.95 (eBook $3.99)

A

bout Wiggle Room...While serving as an Air Force surgeon at the height of the Iraq War, Major Brad Cummins fails to save an injured soldier yet must mend the Iraqi national maimed in the same IED blast. Brad survives the medical tribunal’s inquest over the GI’s unexplained death but endures rigid criticism from his peers. Still blaming himself for losing the soldier after successful surgery, Brad is haunted by the Iraqi’s words: “Maybe you should rethink what you really are.” When he returns from deployment, Brad resumes surgical practice with his twin brother in Mississippi—until he discovers his twin shot to death in a suspected robbery. When he finds their name tags mistakenly switched, Brad cannot forget a haunting, anonymous message—I will give you a little wiggle room— and is certain that he was the intended target. But when the police, and even his fiancée, discount his fears as paranoia, Brad is forced to uncover the truth—even if that means risking his life and the lives of those closest to him. Expect the unexpected in this exhilarating and extraordinary page turner.

A tense and terrifying contemporary thriller, Wiggle Room has garnered high advance praise, including: “This new effort by Dr. North is his fourth adventure into the milieu of the crime novel. Wiggle Room is a compelling and intricately woven novel of deception, treachery, and rapid reversal of story line. In a journey that carries us from the operating theaters of Iraq to the warm southern haunts of his native Mississippi homeland, a strange series of unexplained surgical deaths follows our protagonist. Is the culprit a swarthy Iraqi soldier saved by our hero’s quick thinking, ethics, and skill, or the product of jealousy and power born long ago at home, or the result of a twisted tale of butchered relationships? Only by enjoying Dr. North’s efforts will the reader find the answers to the puzzle.” —Walter R. Jones, Jr., MD “A rollercoaster ride of murder, intrigue, and plot twists. Wiggle Room keeps you turning the pages to the final, climactic finish.”— Robert Dugoni, New York Times best-selling author of The Conviction “An action-packed, edge-of-the-seat thriller.” — Carolyn Haines, author of Bonefire of the Vanities “[A] fine medical thriller…Wiggle Room is expertly wrought.” —John Hough, Jr., author of Seen the Glory “…cleverly plotted, strongly written, Wiggle Room will pull you into a story world filled with danger, excitement, and conflict at every turn.” —D.P. Lyle, Macavity award-winning author of Run to Ground “Darden North’s Wiggle Room is a compelling story packed with suspense, murder, and intrigue… a fastpaced, action-packed thriller.” —Neil White, author of In the Sanctuary of Outcasts

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Save the Date!

May 24-27, 2014 12th Annual CME in the Sand Sandestin Golf and Beach Resort Tentative Agenda Saturday, May 24 9:00 - 4:00 MSMA BOT Meeting 11:00 - 2:00 CME Sessions

Sunday, May 25 9:00 - 1:00 6:30 PM

CME Sessions Welcome Reception with Children’s Activities

Monday, May 26 7:15 8:00 9:00 6:30

- 8:00 -12:30 AM PM

Breakfast with Exhibitors CME Sessions Spouse/Children’s BINGO Family Dinner with Children’s Activities

Tuesday, May 27 7:15 - 8:00 Breakfast with Exhibitors 8:00 -12:30 CME Sessions

For more information visit www.MSMAonline.com 326 JOURNAL MSMA November 2013

• In Memoriam • Larry Joe Hammett, MD Hattiesburg Dr. Larry Joe Hammett, 75, of Hattiesburg, MS, passed away peacefully on August 4, 2013, at Forrest General Hospital. Dr. Hammett was born September 18, 1937, in Fort Worth, TX, to James W. and Lois Hammett. He graduated from Bolton High School in Alexandria, Louisiana, in 1955 and from Louisiana State University in 1959, where he played collegiate tennis for four years. In 1963, he graduated from LSU Medical Center in New Orleans, LA, and married the love of his life, Patsy Ann Cormier, from Church Point, LA. He completed his internship and residency in otolaryngology at Confederate Memorial Hospital in Shreveport, LA, in 1969. He practiced as an ENT in Hattiesburg, MS, for 39 years. Larry loved talking to all his patients about God more than their illnesses.

He enjoyed tennis, golf, fishing, and praising the Lord. He was a cofounder of the Hattiesburg Racquet Club and served as President for several terms. Professionally, he was elected as Secretary of the South MS Medical Society and President of the Medical Staff at Wesley Medical Center. Larry is survived by his wife, Patsy; daughters Susan Wilmore and her husband Randy of Alexandria, LA; son Michael Hammett, MD, and his wife Christy of Hattiesburg, MS; daughter Holly Hammett of Hattiesburg, MS; and daughter Anne-Marie Cancienne and her husband Craig of Austin, TX. He is also survived by seven grandchildren: Travis, Thomas, Alex, Hunter, Addison, Mary Hadley, and Emma; and his brother Dr. Malcolm Hammett and his wife Carolyn of Tyler, TX; and several nieces, nephews, and dog Angel. Visitation was held at the Moore Funeral Home and again prior to a celebration of life service at Main Street United Methodist Church. Reverend Walter Pigott officiated, assisted by Reverend Vicki Hughes and Father Godfrey. Memorials may be made to a special fund at Forrest General Hospital to purchase reclining chairs for the ICU/ CCU Waiting Area.

Fraternity. He taught at Jones County Community College, William Carey University, and the University of Southern Mississippi, all while working on his Ph.D in microbiology.

He received a M.D. from the University of Mississippi Medical Center where he completed his residency in family medicine and served as chief resident. He also completed a fellowship in addiction medicine from the University of Mississippi. He began his career in medicine practicing in Byram. He owned and practiced in three separate medical clinics before ending his career at Byram Family Doctors.

Brent loved his career and serving the community of Hinds County. Brent was a Civil War connoisseur, an avid gun collector, and loved anything to do with Ole Miss. He had a wonderful sense of humor. Many have said, “You could not be around him without a prank being pulled on you.” Brent was described by one as, “an unselfish, awesome, genius, loving man.” He was a brilliant man, respected by many, with a mind like a steel trap. Most of all he loved being a paw-paw. Brent was a member of the Mississippi State Medical Association, a fellow of the American Academy of Family Medicine, and the American Society of Addictionology. He was also a member of the National Rifle Association and many more. Survivors include his daughters, Lauren Cooper and husband Gabe of Madison and Kristin Meador and fiancé Calvin Tillman of Terry; grandchildren, Austin Brent Tillman, Miles Cooper, and Remington Cooper; fiancé, Dawn Moran and her daughter Reagan Moran; mother of Brent’s children, Joan Moran.

Pallbearers will be Gabe Cooper, Calvin Tillman, Brian McCurley, John McNeil, Darin Walters, and George Sandifer.

Honorary pallbearers were Rod Erikson, James Black, and Allen Rhinehart. Visitation and services were held at Country Woods Baptist Church, followed by interment at Garden of Memories in Florence. The family requests that all donations please be made to the American Cancer Society, P.O. Box 22718, Oklahoma City, OK 73123-1718.

C. Brent Meador, MD Jackson Dr. Carroll Brent Meador, 62, passed away September 6, 2013 at his home in Jackson. Dr. Meador was born in the town of Laurel, MS, on October 23, 1950. He was the only child of William Carroll and Vivian Olivia Meador. He graduated from R.H. Watkins High School in Laurel. He completed his undergraduate degree from the University of Mississippi where he served as president of the Sigma Phi Epsilon

John M. Patterson, MD Pontotoc

Retired physician John Melvin Patterson, 87, died August 20 at North Mississippi Medical Center in Tupelo. A true Southern gentleman, Dr. Patterson was a loving father and grandfather and a devoted husband to his wife Maxine, who died in 2010. Named Mississippi’s Family Physician of the year in 1992, Dr. Patterson practiced medicine in Pontotoc for 48 years, retiring in 2003 at the age of 77. Dr.

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Patterson began practicing medicine at time when it wasn’t unusual for patients to have the same physician from birth to death. He made house calls, set broken bones, performed appendectomies, and delivered babies at all hours of the night. Often, he played the role of trusted confidant as much as medical professional. His patients could count on him to be there for a medical emergency, a personal crisis, and even a little help in the kitchen. Once on a house call, he recommended chicken soup for a patient, and she handed him a rifle and sent him outside to shoot a chicken for her. Born in the Evergreen community of Itawamba County on Dec. 16, 1925, Dr. Patterson was the son of John Lee and Melva Black Patterson. He graduated from Itawamba Agricultural High School in 1944 and served in the U.S. Navy before attending college on the G.I. Bill. He graduated from the University of Mississippi in 1948 and attended the then two-year University of Mississippi Medical School. He married Maxine McDaniel on August 24, 1952, and they moved to Philadelphia where he completed his education at Jefferson Medical College. After graduating from Jefferson in 1954, Dr. Patterson completed an internship at Baptist Memorial Hospital in Memphis. Dr. and Mrs. Patterson moved to Pontotoc in 1955, and he practiced medicine in the same office on Washington Street for his entire career. He said many times that he enjoyed the last day of practicing medicine as much as the first. Within weeks of Mrs. Patterson’s death in 2010, Dr. Patterson was diagnosed with lymphoma. After chemotherapy weakened his immune system in 2010, he gradually learned to receive care from others as graciously as he had given it for so many years. Dr. Patterson set high standards for himself and for others, yet was forgiving and understanding. He served in numerous leadership positions professionally and at Pontotoc First United Methodist Church. He served as chief of staff at Pontotoc Community Hospital and was a member of the courtesy staff of North Mississippi Medical Center in Tupelo. He was on the board of the University of Mississippi Medical Alumni Association in Jackson, district director of the Mississippi Academy of Family Physicians, and president of the Family Health Foundation of Mississippi. Dr. Patterson had a brief career in the theater, playing the role of the doctor in the final scene of Arsenic and Old Lace at Pontotoc Community Theater in 2008. He is survived by his sister Dot Schumpert of Nettleton; daughters Claire McGee (Bob) of Watkinsville, Ga., Mary Lise Parsons (Mike) of Dothan, AL, and Patti Smith (Ritchie) of Memphis; and grandchildren, Alyson McGee Gembala (Ryan) of San Francisco, Robert McGee of Birmingham; Raynor Clifton and Brennan Clifton, both of Montgomery; and Rena Parsons, John Michael Parsons, and Anna Parsons, all of Dothan, Ala. A memorial service was held at Pontotoc First United Methodist Church with visitation at Browning Funeral Home and again at the Pontotoc Community House. In lieu of flowers, the family requests that memorials be made to the building fund of the Pontotoc First

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United Methodist Church, P.O. Box 308, Pontotoc, MS 38863 or other charitable organization.

Charles Herbert Laney, MD Madison On August 4, 2013, Dr. Charles “Chuck” Herbert Laney, beloved husband, father, and grandfather, passed away peacefully in his sleep. He had a heart of gold, lived his life to the fullest, and will be remembered by his family and friends as always putting others before himself. Chuck was born in Greenwood, MS, on January 29, 1949. He spent his early years growing up in the Mississippi Delta. He spent all the time he could in the outdoors. He attended the University of Mississippi, where he was a member of Phi Delta Theta Fraternity, serving as Secretary his senior year.

He then attended the University of Mississippi School of Medicine followed by Internal Medicine training at UAB in Birmingham, AL, and a Nephrology Fellowship at Parkland Hospital in Dallas, TX. He then established a Nephrology practice in Jackson, MS. He dedicated 35 years to the love and care of his patients. Chuck married the love of his life, Suzan Elaine Turner, on February 15, 1975. His “Curly” spent the next 38 years as his best friend and partner. They had three boys, Charles Allen, Bradford Turner, and Lucas Sanford. He always instilled in his family that God and family come first in life. Chuck had many hobbies including hunting with his wife and his boys. His favorite hunting spot was in a little Delta town called Bugger Den at Fighting Bayou.

He also enjoyed working in his garden and with what would later be known as Chuck’s famous bees. “Chuck’s bees” soon grew from producing a few jars of honey to filling the entire garage. His beloved Curly even had to step in and help. His other passions included Ole Miss sports, golf, and a good book. No one will ever be able to forget his gourmet, homecooked meals including Chuck’s homemade honey ice cream (the grandchildren’s favorite). He was an active member of Madison United Methodist Church in Madison, MS. He is survived by his loving wife of 38 years; his children Cal and Adair, Brad and his fiancé Emily, and Luke; his grandchildren Jackson Turner Laney, Lucille Adair Laney, and Reid Johnsten Laney; his mother Ann Miller Gray; his siblings Ann Jeanette Bond, Robert Leighdel Laney, Ronnie Glenn Gray, Gay Gray Moss, and L.A. Gray III; and his numerous nieces and nephews. Visitation was held at Wright and Ferguson in Ridgeland and the memorial service at Madison United Methodist Church. In lieu of flowers, please send donations to the Madison United Methodist Church.

Bernard S. Patrick, MD Jackson Bernard S. Patrick, a fourthgeneration physician, was born in Booneville, MS, February 16, 1927, grew up in Corinth, MS, and graduated from Corinth High School in 1944 as the top student in his class. He was an allconference end on the Corinth football team and student band director. He attended Tulane University and then the University of Mississippi Medical School for 2 years. He was a Sigma Chi and founder of Alpha Kappa Kappa Medical Fraternity chapter at Ole Miss. He was also the Drum Major of the Ole Miss Marching Band. He was elected into Pi Kappa Epsilon scholastic honorary fraternity at the University of Illinois where he graduated with a medical degree in 1950.

Dr. Patrick served 2 years in the U.S. Air Force as a flight surgeon during the Korean War. After that, he completed his residency in neurosurgery at the Illinois Neuropsychiatric Institute of the University of Illinois in 1957. He then moved to Memphis, TN, and started practice as part of the Semmes, Murphy Neurological group. He later went into solo private practice in Memphis until he moved to Jackson to join the faculty at the University Medical Center. There he taught for 10 years as a professor of Neurosurgery. He has published 34 papers, with interest primarily in cranial tumors, diagnosis in disc disease, and treatment of pain, particularly facial pain, including tic douloureux. Dr. Patrick introduced the Anterior Approach for Cervical Discectomy in the mid-South in 1962, which has become the standard operation for ruptured cervical discs. After 10 years at UMC, Dr. Patrick returned to private practice at St. Dominic’s Hospital for 24 years during which time he developed his sub-specialty of Facial Pain Management. He belonged to many medical organizations and was the President of the Congress of Neurological Surgeons, a national and international organization. He was also awarded the “Distinguished Neurosurgeon” award from the Southern Neurosurgical Society in 2005 at the age of 78 and the “Outstanding Neurosurgeon” by the Mississippi Neurosurgical Society as the First Lifetime Member. Dr. Patrick served on many Jackson area boards including the Mississippi Symphony Board and was President of River Hills Club. As his grandchildren say, “He was an author, composer, musician, aviator, sailor, athlete, chess master, car mechanic, and retired surgeon.” He is survived by his wife of 63 years, Jo Irene Kurns; his 4 daughters Karen Orsini, Kim Gerra (Mike), Kris Mink (Rob), Kathy Morgan (Mike); 10 grandchildren and 1 great-grandchild: Jennifer Lewis, Megan Mink, Robby

Mink, Lauren Orsini, Patrick Mink, Rachel Farrow, Michael Morgan, Gage Morgan, Robert Gerra, Ria Gerra, and Dominic Mink. Visitation and a service celebrating Dr. Patrick’s life was held at St. Columb’s Episcopal Church in Ridgeland, MS on September 28. The family requests any memorials be made to the Mississippi Youth Symphony Orchestra (MYSO) 201 E. Pascagoula St., Jackson, MS 39201 or charity of your choice.

George Dandridge (Dan) Van Cleve Jackson George Dandridge Van Cleve [Dan], 51, died October 3, 2013. Dr. Van Cleve was born on February 9, 1962, in Jackson, MS, to Peggy Dandridge Van Cleve and William Early Van Cleve. He was preceded in death by his father, William Early Van Cleve.

He is survived by his mother, Peggy Dandridge Van Cleve, his brother Photo courtesy of Horrell Photography William Early Van Cleve, Jr. and wife Stacy, and their daughters, Shelby and Caroline of Dallas, TX, as well as Odie, his golden Labrador. Dan graduated from Jackson Preparatory High School, attended undergraduate school at Mississippi State University, and received his medical degree from the University of Mississippi Medical School. He captained the Mississippi State Bulldog baseball team which earned a trip to the College World Series in 1985 in Omaha, Nebraska. Dan still holds the school record for most runs scored and bases stolen. He was later drafted by the Texas Rangers and played two seasons in the Ranger’s minor league farm system. Dr. Van Cleve spent 4 years at Baylor Medical and 5 years at Texas Heart Institute in Houston, TX, training under Michael DeBakey and Denton Cooley, followed by 8 years as a cardio-vascular surgeon in Meridian, MS, at Rush Hospital, and a 2-year fellowship at UT Medical Center in Memphis, TN. He studied with Dr. David Adams at Mt. Sinai Hospital in New York City prior to his present position at St. Dominic’s Hospital in Jackson, MS, where he was born. When he was not in the operating room, he divided his time hunting and competing in the American Cutting Horse Association finals. Visitation was held in the Parish Hall at St. James Episcopal Church followed by a formal funeral service with Holy Eucharist on October 7. Sebrell Funeral and Cremation Services assisted with arrangements. The family requests any memorials be made to St. James Episcopal Church, 3921 Oakridge Dr., Jackson, MS 39216.

November 2013 JOURNAL MSMA 329

Thomas L. Vinson, MD Columbus

his thirty plus years of medical service, he served at Baptist Memorial Hospital, North Mississippi Medical Center, and many other local facilities, while also committing himself to his local practice. Personally, he devoted himself to his wife and family, friends, and patients. His fervent passions included owning and showing Tennessee Walking horses and supporting Ole Miss Athletics. He came to know the Lord in 1961 and was baptized at Yellow Leaf Baptist Church in Lafayette County. Survivors include: His wife: Patricia Jean Vinson, Columbus; daughter: Whitney Allen (Jeff), Oxford; sons: Corey Vinson, Oxford, Paul Hawkins (Katelyn), Dallas, TX Tony Hawkins, Denver, CO; brother: Jimmy Vinson (Diane), Oxford; grandchildren: Hardy Allen Scout Hawkins River Hawkins and Ryder Hawkins; and mother-in-law: Ellen Davis, Hamilton, MS. The Pallbearers were Bill Dorrah, Edgar Abernathy, Corey Vinson, David Shepherd, Paul Hawkins, and Tony Hawkins. Services were held October 1, 2013 at Memorial Funeral Home Chapel with Rev. Granville Wiggins and Rev. Walter Butler officiating; burial followed at Memorial Gardens of Columbus. In lieu of flowers memorials may be made to: UAB Neuro-Oncology Program, 510 20th Street South FOT 1020, Birmingham, AL 35294.

Dr. Thomas Lynn “Tommy” Vinson, 64, died September 29, 2013 at North Mississippi Medical Center in Tupelo. Dr. Vinson was born on September 1, 1949 in Oxford, MS, to the late James Preston and Gertrude Fooshee Vinson.

He was a member of First Baptist Church, Columbus. He graduated from Oxford High School in May of 1967, then graduated from the University of Mississippi in 1971 with a degree in Liberal Arts–Pre-Medicine, and in 1975 graduated from the University Medical Center. He moved to Mobile, AL, to complete his residency and internship at Mobile General Hospital, which he completed in 1980. Dr. Vinson was a member of the USAFROTC at University of Mississippi and upon finishing his medical residency was commissioned to the United States Air Force. He completed four years of military service at Columbus Air Force base from 1980-1983. During

Wishing You and Yours a Very Happy Thanksgiving from the Mississippi State Medical Association Alliance Board of Directors

The MSMA Alliance is happy to give back to the medical community by raising funds for M3/M4 scholarships, the MS Rural Physicians Scholarship, and the Mississippi Professionals Health Program Family Fund.

Seated: Dottie Estess, Mollie Pontius, Jo Terry (AMA Alliance President), and Jean Hill Standing: Kathryn Brandon, Dianne Tipton, Amy Gammel, Heather Rifkin, Karen Morris, Beth Hartness, Lauren Darsey, Eileene McRae, Lauren Reed, Angela Ladner, Danita Horne, Susan Rish, Nancy Lindstrom, Bo Zimmerman, and Donna Witty

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Small gene pool?

Are medical journals headed for the endangered species list? Not on your life. Scientific medical publications continue to be a primary source for up-to-date data. Your Journal of the Mississippi State Medical Association is alive and kicking. Immerse yourself. Read the Journal online or in print.

Contact us today for information on cost-efficient advertising opportunities to reach an upscale audience of physicians statewide with our monthly medical magazine.

Karen A. Evers, Managing Editor, 601.853.6733

November 2013 JOURNAL MSMA 331

332 JOURNAL MSMA November 2013

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