Internal Medicine Commons^™

Deletion Of Chemokine Receptor 6 Augments Ductular Reaction And Fibrosis In A Mouse Model Of Cholestatic Liver Injury, Nazli Begum Ozturk, Kaiyel Cutshaw, Anuradha Krishnan, Gregory J. Gores

Conference Presentation Abstracts

Background: The chemokine CCL20 is expressed by activated cholangiocytes implicating its’ receptor, CC-chemokine receptor 6 (CCR6) in immune cell trafficking to the liver during cholestatic liver injury. In particular, the innate immune cells macrophages and neutrophils have been identified in cholestatic liver injury. Therefore, our aim was to investigate the effect of CCR6 deletion on a mouse model of 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) diet-induced cholestatic liver injury. Methods: Age and gender matched WT and Ccr6-/- mice were placed on an DDC or a control diet for 21 days. Serum biochemistry, liver injury and the ductular reaction (DR) were examined by standard …

The Diagnostic Role Of Cytokeratin 8/18 Immunohistochemical Marker For Lean Non-Alcoholic Fatty Liver Disease, P Telli, M Buyuk, Nazli Begum Ozturk, Z Istemihan, K Nuriyev, A Atasoy, B Cavus, A Cifcibasi Ormeci, U Akyuz, K Demir

Conference Presentation Abstracts

Introduction

Non-alcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver diseases. NAFLD spectrum begins from simple steatosis to non-alcoholic steatohepatitis (NASH), progressive fibrosis, cirrhosis, and even hepatocellular carcinoma. Although most NAFLD patients are overweight and obese, 30% are lean. We analyzed lean and non-lean NAFLD patients’ liver biopsies for cytokeratin 8/18 immunohistochemical staining differences.

Aims & Methods

Thirty biopsy-proven NAFLD patients (15 patients with BMI ≤ 25 kg/m2, 15 patients with BMI > 25 kg/m2) were included in the study. Demographic, biochemical, and histologic features of the patients were recorded. Biopsy specimens from our archive were …

Bet Protein Complexes With Ets1 And Mediates The Senescence-Associated Secretory And Apoptotic Resistant Phenotypes Of Senescent Cholangiocytes, Jeong-Han Kang, Patrick Splinter, Christy Trussoni, Nicholas E. Pirius, Maria Eugenia Guicciardi, Anuradha Krishnan, Nazli Begum Ozturk, Gregory J. Gores, Nicholas F. Larusso, Steven P. O'Hara

Conference Presentation Abstracts

Background: We reported that cholangiocyte senescence is a pathogenic feature of Primary Sclerosing Cholangitis (PSC) and is regulated by the transcription factor, ETS1. We also showed that Histone 3 Lysine 27 is acetylated at senescence-associated loci. The bromodomain and extra-terminal domain (BET) proteins are epigenetic readers that bind acetylated histones, recruit transcription factors, and drive gene expression. Thus, we tested the hypothesis that BET proteins interact with ETS1 to drive gene expression and promote cholangiocyte senescence. Methods: We performed immunofluorescence to assess cholangiocyte expression of two BET proteins, BRD2 and BRD4, in tissue from PSC patients and PSC mouse models …

Impact Of Serum Igg Levels Against Sars-Cov-2 On Clinical Outcomes For Hopitalized Covid Patient, Bipin Ghimire, Bijaya Thapa, Nishant Aggarwal, Luai Madanat, Melinda Sager, Daniel O'Connor, Alexandra Halalau

Conference Presentation Abstracts

BACKGROUND: The SAR-CoV-2 pandemic continues to negatively impact the healthcare system globally with over 800,000 deaths in the United States and millions more worldwide. The cases are rising despite availability of vaccines. For most immunocompetent patients these vaccines will generate a humoral response and also a memory T-cell response. Few if any studies have reported data that measure anti-spike IgG titers and also correlate those titers with clinical outcomes in the instance of breakthrough infection.

METHODS: We conducted a pilot prospective observational clinical study enrolling 30 immunocompetent patients who were admitted with a positive SARS-CoV-2 PCR. Leftover blood from admission …

A Systematic Review And Meta-Analysis Of Diagnostic Accuracy Of Whole-Body 18f-Fdg Pet And 18f-Fdg Pet/Ct In Detecting Occult Malignancy In Patients With Idiopathic Inflammatory Myopathy, A Ali, R Alkilany, J Asif, B Basida, Z Al-Sagri, N Mahabadi, H Sarakbi

Conference Presentation Abstracts

Background Idiopathic inflammatory myopathies (IIMs) are chronic, systemic autoimmune diseases that can cause muscle inflammation, weakness, and skin manifestations. Several studies have confirmed the association between IIMs and malignancy in adult population with varied frequency (4-42%), highest in patients with dermatomyositis. Detecting occult malignancy is a diagnostic challenge involving cost- and time-consuming methods. The (18)F] fluorodeoxyglucose positron emission tomography ([(18)F] FDG-PET) role in this context has been studied in multiple studies.

Objectives The purpose of this study is to assess the diagnostic performance of whole-body 18F-FDG PET or 18F-FDG PET/CT for detection of occult malignancy in patients with IIMs.

Methods …

Pituitary Metastasis Of Non-Small Cell Lung Cancer, Faris Alkhouri, Joseph Salib, Jack Artinian

Conference Presentation Abstracts

Lung cancer is the most commonly diagnosed cancer worldwide. Metastasis to other organs is also common. Of these, approximately 25% involve metastasis to the brain. In the brain, however, it is known that only 1% of brain metastasis involve the pituitary gland. In this report, we present a 70-year-old woman that was diagnosed with Non-Small Cell Lung Cancer (NSCLC) a year ago presenting with metastasis to the pituitary. A 70-year-old woman with past medical history of longstanding tobacco abuse, COPD, hypertension, and lung cancer (NSCLC stage IB in the upper right lobe diagnosed 1 year ago) presented to the emergency …

A Case Of Acute Unilateral Adrenal Hemorrhage Associated With Metastatic Lung Adenocarcinoma, Batoul Nasser, Ramona Berghea

Conference Presentation Abstracts

The most common cancer that metastasizes to the adrenal glands is lung cancer. Adrenal hemorrhage due to metastasis of lung cancer is extremely rare and associated with unilateral adrenal hemorrhage, while bilateral adrenal hemorrhages are typically associated with cardiovascular diseases and systemic anticoagulant therapy. Our 55-year-old male with a past medical history significant for metastatic lung adenocarcinoma and coronary artery disease (CAD) presented with acute right upper quadrant abdominal and flank pain. On presentation, patient was in distress, with fatigue, weakness, pain with deep inspiration, nausea, and vomiting. Patient also had anemia (hemoglobin 11.2). A CTA of the abdomen and …

Cannabis And Acute Coronary Syndrome: A Case Report Exploring Potential Links, Fawaz Habba

Conference Presentation Abstracts

No abstract provided.

Aml: A Real Pain In The Sacrum, Markie Zimmer, Hazem Alakhras, Daniel Misra, Sara Aguinaga

Conference Presentation Abstracts

A 60 year old previously healthy female presented for evaluation of a painful sacral decubitus ulcer. In the initial workup, CBC showed leukocytosis of 51 with a monocytic differentiation and 55% blasts, macrocytic anemia of 4.6 Hgb, and thrombocytopenia of 32. She denied any classic B-type symptoms, but did have four days of fatigue and chronic night sweats, previously attributed to menopause. She had no evidence of bleeding, and was transfused appropriately, but had ongoing severe thrombocytopenia. Oncology was consulted and bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia with monocytic differentiation. After initiation of antibiotic therapy for …

Hepatoid Adenocarcinoma Of Lung: A Rare And Challenging Tumor, Bipin Ghimire, Ashbina Pokharel, Samiksha Pandey, Ujjwal Jung Karki, Can Wang, Michael Stender

Conference Presentation Abstracts

Hepatoid adenocarcinoma (HAC) is an extremely rare extra-hepatic malignant tumor having hepatic features on pathology. Stomach is the most common site, and hepatoid adenocarcinoma of lung (HAL) accounts for 2.3 – 5% of all HACs. Less than 100 cases of HAL have been reported worldwide since its concept was put forward in 1990. A 63-year-old female presented to the ED with back pain. Initial evaluation revealed anemia (hemoglobin 6.7), hypercalcemia (12.1 mg/dl), GFR 54 mL/min. X-ray thoracic spine and chest showed two vertebral compression deformities and lytic lesions on multiple ribs. Initially, multiple myeloma was considered likely but further evaluation …

Merkle Cell Carcinoma While On Rituximab - Is It A Coincidence?, Bana Antonios, Emma Herrman, Mohammad Muhsin Chisti

Conference Presentation Abstracts

A 79-year old woman with history of relapsed Stage II, grade III follicular lymphoma was treated with four cycles of rituximab and bendamustine with an excellent response. She was subsequently placed on maintenance rituximab infusions every eight weeks. Six months later, she presented to the dermatology clinic with a newly raised erythematous papule on her left cheek. Excisional biopsy confirmed a diagnosis of Merkel cell carcinoma which was resected with wide margins. Merkel cell carcinoma (MCC) is a rare aggressive skin malignancy, with a dramatic increase in incidence in the past few decades. It grows and metastasizes rapidly and diagnosis …

Small Cell Carcinoma Of The Anal Canal: A Rare Entity, Shailesh Niroula, Ujjwal Jung Karki, Bipin Ghimire, Shrinjaya Thapa

Conference Presentation Abstracts

Neoplasm of anal canal are <5% of the malignancy of gastrointestinal tract. Majority of the cancers are squamous cell and adenocarcinoma. Primary small cell carcinoma of the anal canal is a very rare diagnosis with only handful of cases reported in literature. 66-year-old female with multiple co-morbidities presented with rectal pain. She had initially noticed hemorrhoids six months prior to presentation. CT abdomen and pelvis showed bilateral inguinal lymphadenopathy and diverticulosis. Patient then had colonoscopy which showed mass in the anal canal, initial biopsy showed squamous cell carcinoma with basaloid features. Lymph node biopsy was also positive for metastatic cancer likely anal in origin. PET scan showed metastatic lesion in the lumbar vertebra. Review of slides was done before starting chemotherapy as component of small cell carcinoma was also seen. Due to diagnostic dilemma, patient was initially started on Carboplatin and Paclitaxel first cycle as it is effective against both squamous and small cell carcinoma. Repeat evaluation of the slides confirmed small cell cancer as the diagnosis and chemotherapy was changed to carboplatin and etoposide. Patient received 3 cycles of the carboplatin and etoposide after which atezolizumab was added. She received total of 6 cycles of the chemotherapy. Repeat PET scan showed partial favorable response. Due to rarity of the disease, there was significant delay in diagnosis of the cancer. Diagnosis of small cell carcinoma in the anal canal relies on neuroendocrine differentiation. There is no formal evidence-based recommendation regarding treatment. They are considered equivalent to pulmonary small cell carcinoma and treated in similar manner.

9-Month Course Of Refractory Anti-Nmda Receptor Encephalitis With Initial Negative Markers: Diagnostic And Therapeutic Challenges, Camilla Cascardo, Alexander Ismail, Francisco Davila, Nicole Marijanovich

Conference Presentation Abstracts

Anti-NMDA receptor encephalitis is a progressively debilitating, clinically heterogeneous, frequently fatal disease caused by autoantibodies directed against the N-methyl-D-aspartate receptor that affects 1 in 1.5 million people each year. Risk of misdiagnosis or delayed treatment is high due to variable presentations and potential false negative results.

Recurrent Myopericarditis Following Mrna-1273 Sars-Cov-2 Vaccination In A Patient With Previous Sars-Cov-2 Myopericarditis, Lauren Reinhold, Simon R. Dixon, Carl B. Lauter

Conference Presentation Abstracts

Introduction: Coronavirus disease (COVID-19) caused by SARS-CoV-2 infection has been associated with myocarditis. The novel mRNA vaccines, BNT162b2 and mRNA-1273, that encode the SARS-CoV-2 spike glycoprotein have shown to be a safe combatant to the pandemic. Myocarditis has become a rare, newly recognized complication of the SARS-CoV-2 mRNA vaccinations. The mechanism remains unknown, but multiple have been proposed. Case description: A 24-year-old healthy Caucasian female presented to the hospital with acute chest pain. The patient received her first dose of mRNA-1273 SARS-CoV-2 vaccine two days prior to onset of symptoms. She reported sharp mid-sternal chest pain worse with inspiration and …

A Rare Case Of Segmental Arterial Mediolysis, Ashbina Pokharel, Lauren Reinhold, Ashbita Pokharel, Judith Bateman

Conference Presentation Abstracts

Segmental arterial mediolysis (SAM) is a rare vasculopathy of unknown etiology characterized by disruption of the arterial layer, which can result in vessel dissection, hemorrhage and ischemia. Literature review has demonstrated a varied presentation ranging from benign abdominal pain to life threatening hemorrhage. We report a case of 58 year old female with past medical history of deep vein thrombosis/pulmonary embolism secondary to Protein C and S deficiency on Coumadin who presented with right flank pain for 3 days. Complete blood count and complete metabolic panel were within normal limits. CT scan of abdomen and MRI showed ischemia of segment …

Evaluating Emotional Distress Among Michigan Food Insecure Communities During The Covid-19 Pandemic, Abiba Salahou, Deidre Hurse, Angela Gill, James F. Grogan

Conference Presentation Abstracts

No abstract provided.

Clinical Pathways Leading To Antibiotic Initiation In Patients With Suspected Infection And Their Association With Delays And Mortality, X Han, C Lopez-Espina, P A. Verhoef, A Spicer, A Bhargava, L Schmalz, Matthew Sims, Alexandra Halalau, Nicholas Maddens, Aimee Espinosa

Conference Presentation Abstracts

Rationale: Delayed antibiotic therapy is associated with increased mortality in patients hospitalized with infection. The decision toinitiate therapy in patients with suspected infection is influenced by a variety of information, such as vital signs, and laboratoryresults. Identifying different patterns of events that lead to initiation is necessary to discover factors that could serve as targets forinterventions to expedite this process. We aimed to identify the most common sequences of events that precede antibioticordering and to quantify the time intervals between each event that contribute to antibiotic delays. Methods: This was aretrospective study of adult patients hospitalized at 4 community hospitals …

From Head To Hilum: Angiosarcoma With Pulmonary Metastasis, Tanaz Salimnia, Lauren A. Abplanalp, Raashi Chawla, K Hughes, R Ghandchi, Matthew Weatherhead, Sanjay Dogra

Conference Presentation Abstracts

With an estimated five-year survival of less than 40 percent, angiosarcomas are rare and often misdiagnosed fataltumors originating from blood or lymphatic vessels with a predilection for the head and neck. They account for 1percent of all soft tissue sarcomas and are often mistaken for benign mimickers leading to the late-stage diagnosiswhen the body is already riddled with metastatic disease with the lung being the most common site of metastases.This case illustrates the myriad of pulmonary complications associated with this uncommon but fatal vasoformativemalignancy. The patient is a 73-year-old male diagnosed with angiosarcoma of the right scalp status post excision,reconstruction, …

Hiv-Associated Nephropathy Presenting As The First Manifestation Of Hiv-2 Infection, Kamil Sardarli, Rania Daboul, Sumesh Khanal, Sami Zarouk

Conference Presentation Abstracts

HIV-2 is distinguished from HIV-1 with low virulence, longer asymptomatic period, slower decline in CD4 count, low viral load, and low mortality from AIDS. While the kidney pathology associated with HIV-1 is well established, due to its low prevalence, kidney pathology in HIV-2 is not well documented. We report a case of HIV associated nephropathy (HIVAN) as the first presentation in a patient with HIV-2. A 65 year old man from Ghana presented within a few days of arrival to the United States with nausea, loss of appetite, shortness of breath, and bilateral lower extremity edema. He has a past …

Detection Of Progression Or Regression Of Gynecologic Cancers By Circulating Tumor Dna (Ctdna), Bipin Ghimire, Ujjwal Karki, Emma Herrman, Mohammad Muhsin Chisti

Conference Presentation Abstracts

Objectives The use of post-operative circulating tumor DNA (ctDNA) to detect cancer recurrence has been reported in various studies but the literature describing variable changes in ctDNA is limited. The objective of this study is to describe the utility of single and serial ctDNA values in detecting the progression or regression of gynecological cancers.

Methods This is a retrospective observational study including nineteen patients, aged >=18 years who had the ctDNA test completed at hematology/oncology clinic of William Beaumont – Royal Oak and Troy Hospitals, Michigan, USA.

Results Among the nineteen patients, fifteen had breast, three had ovarian, and one …

Dual Paraneoplastic Syndrome In Small Lung Cancer, Kamil Sardarli, Austin M. Morris, Jamal Abukhaled

Conference Presentation Abstracts

Introduction: Small cell lung cancer (SCLC) is an aggressive neuroendocrine lung cancer associated with paraneoplastic syndromes – syndrome of inappropriate ADH (SIADH) in 7-16% of cases and Ectopic ACTH Syndrome (EAS) in 3.5-4.3% of cases. Both syndromes are associated with a poor prognosis in patients with SCLC. We describe a patient who presented with SIADH, leading to a diagnosis of SCLC who subsequently developed EAS. Case Description: A 71-year-old female with a past medical history of hypertension, depression, and tobacco use presented with lethargy. She noted headache, but otherwise was unable to provide history due to altered mentation. Per her …

Identifying Novel Subphenotypes In Covid-19 Using Protein Biomarkers, A Spicer, P A. Verhoef, C Lopez-Espina, A Bhargava, L Schmalz, M Sims, A V. Palagiri, K V. Iyer, M J. Crisp, A Halalau, N Maddens, A Espinosa

Conference Presentation Abstracts

RATIONALE: COVID-19 is widely heterogeneous in presentation, even across patients with similar demographics and medical history. Identification of subphenotypes based on host immune responses that are biologically discrete and predict outcomes may enable personalized COVID-19 therapies. Accordingly, using a composite of electronic health record (EHR) data and 36 research biomarkers, we sought to compare COVID-19 immune responses across patients of varying disease severity, identify subphenotypes within hospitalized COVID-19 patients, and test for heterogeneity of treatment effect (HTE) to intravenous corticosteroids across these subphenotypes. METHODS: In this multicenter retrospective analysis of prospectively collected data, patients presenting to three medical centers from …

Cost-Effectiveness Of Recombinant Zoster Vaccine For Vaccinating Immunocompromised Adults Against Herpes Zoster In The United States, Desmond Curran, Ahmed Salem, Stephane Lorenc, Brandon Patterson, Justin Carrico, Katherine A. Hicks, Elizabeth M. La, Sara Poston, Christopher F. Carpenter

Conference Presentation Abstracts

Background. Individuals who are immunocompromised (IC) due to disease or therapy are at increased risk of herpes zoster (HZ), with HZ cases in IC populations also resulting in increased health care resource use and costs as compared with the immunocompetent population. This study assesses the cost-effectiveness of recombinant zoster vaccine (RZV) versus no vaccine for the prevention of HZ in IC adults aged ≥ 18 years in the United States (US). Methods. A Markov model with a one-year cycle length was developed to follow a hypothetical cohort of one million IC individuals for a 30-year time horizon. The model estimates …

A Novel Combination Chemotherapy Targeting Extramedullary Disease In Multiple Myeloma Following First-Line Treatment Failure, Ruaa M. Elteriefi, Nourelhuda Abbas Hamed, Omar Nasser Rahal, Faisal Musa

Conference Presentation Abstracts

Introduction:

Multiple Myeloma (MM), a plasma cell neoplasm that resides in the bone marrow’s intramedullary space.

Extramedullary disease (EMD) occurs when plasma cells extend through the bone cortex or via hematogenous spread to different organs.

This case of EMD of MM didn’t respond to the first line RVD regimen per NCCN guidelines which includes Lenalidomide (Revlimid), Bortezomib (Velcade), and Dexamethasone (Decadron). Therefore, new combination chemotherapy including Daratumumab, and Carfilzomib was initiated with excellent response.

Case description:

62-year-old female presenting to the oncologist for progressive right hip pain for 4 weeks. Initial hip x-ray and bone scan suspected malignancy. MRI showed …

Synergistic Bleomycin Toxicity And Evali: A Lethal Combination, Daniel O'Connor, Nader Mina, Hira Iftikhar

Conference Presentation Abstracts

Introduction: Both vaping and bleomycin-based chemotherapy regimens are known risk factors for acute lung injury. Few, if any, cases are documented in the literature of these insults co-occurring. Case description: A 20-year-old male was diagnosed with Stage III testicular cancer in Autumn of 2020. He began BEP (bleomycin-etoposide-platinum), of which he completed three cycles before developing pulmonary sequelae. Social history was notable for marijuana use and vaping, including during his active chemotherapy, to help with cancer-related nausea, anxiety, and anorexia. Winter 2021, he visited the ED for dizziness, fatigue, and diarrhea, felt to be consistent with chemotherapy side effects, but …

Diabetic Preventative Care In A Resident Clinic: A Quality Improvement Study, Karishma Chopra, Charity Owusu-Asare, Aimee Espinosa, Alexandra Halalau

Conference Presentation Abstracts

Introduction: Studies have shown significant gaps in diabetic preventative care in resident clinics compared to private clinics of practicing physicians. In our medicine-pediatrics resident clinic at Beaumont Hospital, diabetic point of care resources are largely underutilized. We aim to improve the care of patients with diabetes by increasing resident awareness of point of care A1c and retina scan resources. Methods: A team of residents, attendings, and nurses was created. Baseline data looking at use of point of care resources, specifically the number of orders placed in electronic medical record for A1c and retina scan tests, was obtained. A root cause …

Type 1 Cryoglobulinemia Secondary To Primary Plasma Cell Leukemia, Antonio Faieta, Khatoon Tawhida

Conference Presentation Abstracts

Primary plasma cell leukemia (pPCL) is a rare and aggressive form of plasma cell dyscrasia that comprises 1% of the plasma cell dyscrasias. Even more rare is its association with type 1 cryoglobulinemia which management can be challenging. A 63-year-old African American male with no past medical history presented with severe burning pain in his legs, necrotizing rash, constitutional symptoms and severe acute kidney injury (AKI). HIV, hepatitis B and C were negative. Serum electrophoresis revealed an M-spike of 5.67, IgG of 7000, free lambda of 152.10 with a K/L of 0 and cryoglobulin of 81%. CT revealed extensive lytic …

Massive Pulmonary Embolism After Pfizer Vaccine, Samiksha Pandey, Bipin Ghimire, Emma Herrmann, Dilip Khanal

Conference Presentation Abstracts

Introduction Vaccines against COVID -19 have been reported to cause venous thromboembolism (VTE). To our knowledge, this is the first case to report the massive, near-fatal Pulmonary Embolism (PE) associated with BNT162b2 Covid-19 (Pfizer/BioNTech) vaccine and discuss the associated risk factors for PE. Case 41-year-old, non-smoker, female on OCP, presented for syncope and seizure-like activity. Upon presentation, she was obtunded and tachypneic. Initial labs showed leukocytosis, mild anemia, and thrombocytopenia, respiratory and metabolic acidosis. She deteriorated quickly to cardiac arrest requiring Cardiopulmonary Resuscitation and intubation. Tissue Plasminogen Activator administered for possible PE. Computed Tomography Angiography (CTA) pulmonary confirmed sagittal pulmonary …

Improving Telemetry Utilization In An Inpatient Hospital Setting, Kamil Sardarli, Lauren Reinhold, Ankit Arora, Sumesh Khanal, Pradeep Kaminoulu, Alexandra Halalau

Conference Presentation Abstracts

Background: Telemetry is a cardiac monitor that continuously records heart activity and monitors abnormal rhythms. Most current clinical indications are limited to 48 hours maximum, but telemetry monitoring service (TMS) is commonly used for a greater duration. This leads to resource exploitation that may create limitations of the resource and also comes with economic burden. Limiting usage to appropriate indications and durations can reduce overall costs and improve profit margin for the hospital and also cut down on unnecessary burden for patients. Through our study, we aim to decrease TMS overuse. Methods: The study was done at Beaumont Hospital Royal …

Granular Cell Tumor Of The Breast: A Breast Malignancy Mimicker, Emma Herrmann, Markie Zimmer, Bana Antonios, Bipin Ghimire, Mohammad Muhsin Chisti

Conference Presentation Abstracts

Granular cell tumors are soft tissue neoplasms that can arise from virtually any body site. They are thought to arise from Schwann cells of the peripheral nervous system. The overwhelming majority are benign, with only 1-2% of cases being malignant. Granular cell tumors of the breast can often mimic breast malignancy. A 62-year-old female with past medical history of hypertension and prior tobacco use had abnormal screening mammography. Family history was positive for breast malignancy in 2 sisters and a maternal first cousin. Prior mammography was unremarkable, aside from one year prior which revealed a concerning 6 mm nodule in …