Abstracts of scientific posters.
Section on Anesthesiology
ANE-2. Trauma and Pregnancy: a Level I Trauma Center Perspective.
Edgard J. Pierre, MD, Jong Lee, MD, Clint Chirstensen, MD, and Miguel A. Cobas, MD, Department of Anesthesiology and Perioperative Medicine, Miller School of Medicine at the University of Miami, Ryder Trauma Center, Miami, FL.
Background: Trauma and/or accidental injury complicate 1 to 7% of all pregnancies. The management protocols for trauma in pregnancy are based largely on case reports and small series. The purpose of this study is to describe the demographics of pregnant trauma patients at a level I Trauma center; identify the value of fetal heart rate monitoring and recommend an evaluation and management protocol after trauma based on observational data rather than anecdotal reports.
Methods: This is an institution-approved, retrospective review of data looking at pregnant patients admitted to the Ryder trauma center from January 1999 through December 2004.
Results: There was a total of 14,209 admissions to the Ryder Trauma Center, of which 88 were pregnant (0.6%). The majority of these patients were involved in motor vehicle crashes (53) and domestic violence (13). Four patients underwent emergent cesarean section; there were two perinatal deaths and two maternal deaths. All the other patients were evaluated and discharged home without any serious sequelae. Fetal heart rate monitoring was abnormal in 3% of cases; however none of these tracings dictated emergency C-section conduct but rather the need to continue observation. The perinatal deaths were associated with blunt trauma caused by motor vehicle accidents. Most of the injuries from domestic abuse were from penetrating trauma and occurred more commonly during the first trimester. Motor vehicle crashes were distributed equally throughout the gestation.
Conclusions: In this series, it was found that prolonged monitoring (>4 hours) does not add any valuable information in the management of pregnant trauma patients. We recommend that initial external fetal monitoring be performed for 4 hours, and, if reassuring, the decision to admit be based on associated injuries and not on the pregnancy by itself.
Section on Cardiology
CAR-1. A Case of Sustained Ventricular Tachycardia in a Patient With Commotio Cordis and Prolonged QT Syndrome: Which Came First, the Chicken or the Egg?
Pramil Cheriyath, MD, Wyndham Owens, MD, Vishal Bhatia, MD, and Mukta Panda MD, University of Tennessee, Chattanooga Unit, Chattanooga, TN.
Objectives: To discuss the entity, commotio cordis, and differential diagnosis of arrhythmias in the setting of commotio cordis.
Case: A 21-year-old healthy Hispanic male came to the ER complaining of fast heart beat and shortness of breath after a MVA 1 week prior (he fell asleep on the steering wheel and hit the curb). There was no significant family history. Vitals were BP, 94/45 mm Hg; pulse, 176/min; temperature, 98.6[degrees]F; oxygen saturation, 99% RA. Physical examination was normal except for tenderness without bruising around chest wall, tachycardia, and [S.sub.3] gallop. Hearing was normal. CBC, CMP, ABG, and TSH values were normal; BNP was 696 pg/mL. CKMB index was 13.3; CKMB units, 5.6 ng/mL; CPK, 171 [micro]/L, and troponin, 0.07 ng/mL. Initial ECG revealed ventricular tachycardia, right bundle branch pattern, and left axis deviation. Chest x-ray was suggestive of CHF, with no rib fractures. The patient was started on amiodorone and underwent cardioversion. When the heart rate slowed, the ECG revealed long QT interval (QTc, 522). The echocardiogram revealed EF of 45% and mild hypokinesis of left ventricle. As the patient remained in sustained ventricular tachycardia, an EP study showed inducible sustained monomorphic ventricular tachycardia and long QT syndrome. The patient underwent successful implantation of a cardiac defibrillator. Repeat echocardiography before discharge showed EF of 70%, without hypokinesis.
Conclusions: Sudden death due to nonpenetrating chest wall impact in the absence of injury to the ribs or sternum and heart is known as commotio cordis. Commotio cordis impacts are typically of low energy and velocity. Ventricular fibrillation is the most common rhythm observed in commotio cordis followed by nonsustained ventricular tachycardia. It is hypothesized that the blunt trauma induced sustained ventricular tachycardia in the patient, who was predisposed due to his congenital prolonged QT syndrome. The tachycardia together with stunning of the myocardium also resulted in CHF. This case highlights the importance of recognition and prompt treatment of blunt cardiac trauma and the exploration of other underlying abnormalities.
CAR-2. A Massive Pericardial Effusion in a Patient with Common Atrioventricular Canal Defect and Down Syndrome.
Michael Nillas, MD, Mahmood Heydarian, MD, and Tina Sias, MD. Departments of Cardiovascular Services and Pediatrics, Marshall University-Joan C. Edwards School of Medicine; Huntington, WV.
Background: Downs syndrome is one of the most common chromosomal disorders and is associated with congenital heart defects (particularly common atrioventricular canal defect) and hypothyroidism.
Methods and Results: This case describes a 34-year-old woman with a history of Down syndrome and common atrioventricular canal defect, who underwent a routine 2-D transthoracic echocardiogram. The echocardiogram demonstrated a massive pericardial effusion without evidence of cardiac tamponade. Due to the size of the effusion, a pericardiocentesis for diagnosis was contemplated. However, the patient was asymptomatic. As Down syndrome is associated with hypothyroidism, hypothyroidism was suspected as the cause of the effusion. Effusions associated with hypothyroidism are characteristically large in size, asymptomatic in character, and indolent in progression. Laboratory studies demonstrated an abnormal serum TSH of 133 mIU/mL (normal, +0.37 to 4.42 mIU/mL), which confirmed clinical hypothyroidism. The endocrine disorder was treated appropriately with thyroxine replacement therapy. A pericardiocentesis was not performed. A repeat echocardiogram 3 months later demonstrated improvement of the pericardial effusion.
Conclusions: This case study is exceptional as it demonstrates (1) The association of Down syndrome with congenital heart defects and hypothyroidism; (2) the development of a massive pericardial effusion secondary to hypothyroidism; and (3) the challenges of managing a pericardial effusion in a patient with common atrioventricular canal defect.
CAR-3. A New Murmur Post-Acute Myocardil Infarction.
Mehiar O. El-Hamdani, MD, and Silvestre Cansino, MD, Department of Cardiovascular Medicine, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Background: A new murmur in the course of acute myocardial infarction represents serious complications for which the clinicians need to be aware. The differential diagnosis may include pericarditis, ventricular septal defect, mitral regurge, pseudoaneurysm of the left ventricle, left ventricular free wall rupture, and tricuspid regurge.
Methods and Results: This case presentation focuses on two of these possible clinical outcomes of acute myocardial infarction. An 83-year-old white male with history of myocardial infarction and coronary artery bypass grafting presented to ER with a typical angina. The diagnosis of ST-elevation myocardial infarction involving the inferior and lateral wall was made based on clinical and biochemical evidences. Emergency percutaneous intervention to the right coronary artery was performed, followed by cardiac rehabilitation, and patient discharged home on the 5th day. The patient returned the next day to the ER, with severe continuous constant retro-sternal pain and left shoulder and arm pain, with the pain somewhat eased by sitting up but never relieved. Hemodynamically stable, the examination revealed a new 4/6 pansystolic murmur and a friction rub, with ECG with persistent ST-elevation in the inferior and lateral leads. Acute stent restenosis was excluded by heart catheterization. Simultaneously an echocardiogram was performed and confirmed the presence of left ventricular free wall rupture and pseudoaneurysm formation of the posterior-lateral wall. The patient was treated conservatively and remained stable.
Conclusions: The National Registry of Myocardial Infarction found that the incidence of cardiac rupture less than 1% and responsible for 7% of all deaths. A pseudoaneurysm of the left ventricle is a myocardial rupture contained by pericardium and thrombus. It is a rare but life-threatening condition. Cardiac imaging is crucial in diagnosis, but history and physical examination remained the most important step in early detection of these complications and applying the appropriate management in timely fashion.
CAR-4. A Sea Anemone Living Inside the Heart: A Rare Intracardiac Tumor Causing Multiple Strokes.
Mehiar O. El-Hamdani, Silvestre Cansino, and Imran Arif. Department of Cardiovascular Services, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Background: Intracardiac sources of cerebrovascular ischemic events are increasingly being recognized and may account for the 15 to 20% of the 500,000 strokes that occur annually in United States. Primary cardiac tumors are found in only 0.002 to 0.03% of autopsy studies, with myxomas constituting more than 50% of these lesions. Papillary fibroelastomas are rare, benign tumors of the heart that often are incidental findings at autopsy or cardiac surgery or during echocardiography. It is the second most common tumor cardiac tumor and the most common valvular tumor of the heart. They resemble sea anemone in gross morphology, with frond-like arms emanating from a stalked central core.
Methods and Results: This report describes a patient with this rare tumor who had multiple cardio-embolic strokes.
Case Report: A 60-year-old male veteran underwent echocardiogram to look for cardiac source of embolism after having two episodes of stroke. The diagnosis of stroke was confirmed by MRI, with no clear cause found on routine testing. Echocardiography suggested a possible mass attached to aortic valve. TEE confirmed an elongated, highly mobile mass that was approximately 3 cm in size attached to ventricular side of right coronary cusp, most likely a fibroelastoma. Patient was started on coumadin and referred for aortic valve debridement. Surgery revealed a broken stalk on the noncoronary cusp and a mobile mass resembling fibroelastoma attached to right coronary cusp.
Conclusions: TEE should be done in patients with cryptogenic stroke. Cardiac papillary fibroelastoma is a benign tumor. Echocardiography, and particularly TEE, complemented by cardiac MRI, provides a defined structural resolution, location, and the extent of anatomic and hemodynamic involvement. Surgery is curative and holds an excellent short- and long-term prognosis. Those who are not surgical candidates should be subjected to long-term anticoagulation.
CAR-6. Anomalous Left Circumflex Coronary Artery and Sudden Cardiac Death.
John E. McGinty, MD, Silvestre Cansino, MD, and Imran Arif, MD. Department of Cardiovascular Services, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Background: The incidence of sudden cardiac death (SCD) in the United States varies from 250,000 to 400,000 annually. Structural abnormalities of the coronary arteries other than coronary atherosclerosis are infrequent causes of SCD. Among the congenital lesions, anomalous origin of the left circumflex coronary artery from the right aortic sinus has been reported in association with SCD. This is the most frequent coronary artery anomaly observed with an incidence of 0.5%. It is generally considered benign. This report describes a case of a 50-year-old male with an anomalous left circumflex coronary artery who had sudden cardiac death.
Case Report: The patient was referred for evaluation of exertional angina. An exercise stress test revealed poor functional capacity and met ECG criteria for myocardial ischemia. Myocardial perfusion was normal. Widely patent coronary arteries with preserved left ventricular systolic function was discovered on subsequent coronary angiography. The circumflex artery had an anomalous origin from the right aortic cusp with a retro-aortic course. Echocardiography was normal, and a Holter monitor demonstrated only frequent isolated premature ventricular complexes. He was tried on different anti-anginal therapies, but due to persistent exertional angina, he was referred for single-vessel coronary artery by-pass grafting (CABG). Two days before surgery, he had sudden cardiac death at home.
Discussion: Anomalous origin of the left circumflex from the right aortic sinus is usually considered a benign anomaly. Sudden cardiac death has not been widely associated with this anomaly although case reports, including associated ischemia and infarction, have been presented. Several theories have been postulated to explain ischemia, infarction and SCD including vasospasm, premature coronary atherosclerosis, and exercise-induced aortic dilatation, causing a slit-like compression of the proximal artery. No consensus opinion exists regarding definitive management. Medical therapy for atherosclerosis, including aggressive anti-anginal medications, has been used. Percutaneous coronary intervention and single-vessel CABG have also been performed.
Conclusions: We propose that single-vessel CABG may be the optimal therapy to control angina, eliminate ischemia, and prevent SCD for an anomalous circumflex coronary artery arising from the right aortic cusp.
CAR-7. Aortic Root Abscess Presenting as an Acute Coronary Syndrome.
Uzoma N. Ibebuogu, MD. Medical College of Georgia, Augusta, GA.
Background: Aortic root abscess is a life-threatening complication of infective endocarditis with a reported incidence of 40% in large autopsy series with endocarditis. This is a rare case of aortic root abscess presenting as an acute coronary syndrome.
Methods and Results: A 56-year-old male, status post renal transplant and coronary artery bypass graft for a three-vessel coronary artery disease and a prior history of coagulase negative staphylococcus bacteremia, presented with chief complaints of nausea, malaise, and lethargy. On examination, he was afebrile with a regular heart rate and a grade 2/6 systolic ejection murmur at the left sternal edge. He was admitted for presumed uremic syndrome secondary to transplant failure. In the dialysis unit, the patient had acute onset chest pain with nonspecific ST-T changes on electrocardiogram. The first set of cardiac enzymes was negative. Emergent treatment was initiated, and he was transferred to the coronary care unit (CCU) for further treatment. While in the CCU, chest pain recurred with an elevated second set of cardiac enzymes. Cardiac catherization done urgently showed patent grafts with good run off and patient improved on medical management. Three days after transfer to telemetry floor, the patient had acute shortness of breath with hypotension and was transferred back to the CCU. Chest x-ray showed diffuse pulmonary edema. Transesophageal echocardiogram revealed avulsion of the non coronary cusp with possible vegetation, severe aortic regurgitation, and an aortic root abscess. The patient was sent for aortic valve replacement. He improved clinically after surgery with no further episodes of chest pain or pulmonary edema.
Conclusions: Cardiac abscesses are reported in 30% of cases of infective endocarditis, and its presence is a poor prognostic factor. Although aortic root abscess is a well-recognized complication of aortic valve endocarditis, acute coronary syndrome from possible compression of the coronary arteries is an unusual mode of presentation
CAR-8. Dual Origin of Circumflex Coronary Artery: A Very Unusual Anomaly.
Pradeep K. Agarwal, MD, Pramod Menon, MD, Suresh Jain, MD, and D. Luke Glancy, MD, Section of Cardiology, LSU HSC at New Orleans, New Orleans, LA.
Background: A 61-year-old black male was referred for coronary angiogram for complaints of retrosternal chest pain.
Methods and Results: The medical history was significant for hypertension, smoking, and distal right coronary artery stent. The physical examination on presentation was unremarkable. The coronary angiogram revealed nonobstructive disease of left anterior descending and left circumflex artery. The right coronary artery had nonobstructive disease in proximal segment and widely patent distal stent. In addition, an anomalous circumflex artery was seen arising from right coronary cusp. This vessel had 70% disease in proximal segment and 50 to 60% in mid and distal segment. Due to small vessel size, coronary intervention was not done.
Conclusions: The prevalence of coronary artery anomalies varies from 0.3 to 1.3% in different series. The most commonly reported anomalies include separate origin of left anterior descending and left circumflex from left coronary cusp, anomalous origin of circumflex from right coronary cusp, and ectopic origin of right coronary artery from right coronary cusp. There is only one report of dual origin of left circumflex artery. In that case, anomalous circumflex artery originated above the left main from left coronary cusp. This is the first report of origin of circumflex artery from left and right cusp.
CAR-9. Embryology in the Elderly: Bilateral Coronary Artery Fistulae.
Michael B. Phillips, MD, and Keith R. Oken, MD. Department of Internal Medicine, Mayo Clinic, Jacksonville, FL.
Background: An 85-year-old male with known coronary artery disease and chronic moderate LV systolic dysfunction presented with acute worsening of dyspnea and orthopnea, associated with intermittent aching left sided chest pain of 5 minutes' duration. This pain resolved before presentation.
Methods and Results: Examination revealed symmetric upper extremity blood pressure of 142/84 while seated. The pulse was 88 beats per minute and the respirations were 22 breaths per minute. He was afebrile. Cardiac examination was remarkable for 1/6 systolic murmur and 2/6 diastolic murmur at the left sternal border. The jugular venous pressure was estimated at 6 cm [H.sub.2]O. The pulmonary component of the second heart sound was normal. The lungs were clear bilaterally. Extremities revealed normal arterial pulses with trace edema.
Methods and Results: The patient was admitted for elective cardiac catheterization. His films are shown. A massive coronary artery fistula was noted, emanating from the mid-left anterior descending artery to the main pulmonary artery. The left circumflex coronary artery arose in an anomalous fashion from the proximal portion of a dominant right coronary artery. It fed a medium-sized A-V fistula in the posterior surface of the left atrium, which appeared to drain via normal venous channels in the region of the vein of Marshall. Moderate left main coronary artery stenosis and moderate ostial left circumflex coronary stenosis were noted as well. Qp/Qs was calculated at 1.3:1. Pulmonary artery pressures were normal.
Conclusions: The patient's cardiac problems were medically managed due to symptomatic critical carotid artery disease and acute cholecystitis. The fistulae had been diagnosed 30 years earlier at an outside institution and surgical intervention was deferred at that time. As his other problems were managed successfully, his angina resolved and he has done well subsequently.
CAR-11. Failing Heart, Famished Kidneys.
Kelly Roberts III, MS, Sujata Agnani, MD, Naveen K. Atray, MD, and Tushar J. Vachharajani, MD, Overton Brooks VA Medical Center and Louisiana State University Health Sciences Center, Shreveport, LA.
Objectives: To understand the physiologic and hemodynamic consequences of congestive heart failure (CHF) on renal function and to understand the principles of CHF and renal failure management.
Background: Renal hypoperfusion causing prerenal azotemia can be from intravascular volume depletion, a change in vascular resistance or reduced cardiac output. Poor left ventricular ejection fraction (LVEF) can significantly reduce renal blood flow despite an increase in total body water.
Case: A 66-year-old male presented with severe azotemia, decompensated CHF, and altered mental state with medical history significant for CHF (ejection fraction, 15%), chronic atrial fibrillation, DM-2, and chronic kidney disease with baseline serum creatinine (Crt.) of 2.0 mg/dL and BUN of 52 mg/dL. Aggressive management of his CHF with ACE inhibitors and diuretics caused hypotension, requiring transfer to MICU, with further worsening of BUN to 261 mg/dL, Crt. of 4.3 mg/dL, K of 3.7 mEq/L, and C[O.sub.2] of 26 mmol/L. The urine sediment was bland. The fractional excretion of sodium was less than 1%, and blood and urine cultures were sterile. Stool hemeoccult was negative. Renal ultrasound showed normal-sized kidneys without hydronephrosis. Hemodynamic monitoring with a Swan-Ganz catheter revealed pulmonary wedge pressure (PWP) of 20 mm Hg, cardiac index (CI) of 1.4, and cardiac output (CO) of 2.9 L/min and systemic vascular resistive index (SVRI) 2200 dyne/sec/[m.sup.2]/[cm.sup.5]. After inotropic support, the PWP, CI, and CO improved to 14 mm Hg, 2.9 L/min/[m.sup.2], and 6.0 L/min, respectively. The renal chemistry improved significantly after approximately 3 weeks of therapy to BUN of 27 mg/dL and Crt. of 1.3mg/dL.
Conclusions: Acute renal failure due to hypoperfusion secondary to poor LVEF and diminished effective circulating volume is a well-known phenomenon. Severe azotemia as seen in our patient is an unusual presentation. The dramatic and complete recovery, without renal replacement therapy, with improvement in renal blood flow highlights the importance of correcting the underlying cause of hypoperfusion.
CAR-12. Genetics and Cardiovascular Disease Risk Factors in Obese West Virginians.
J.M. Chappell, A. Watson, M. Flood, C. Clark, S. Hesson, B. Hill, J. Jeong, N. Liette, M. Ramey, B. Kahle, G. Wright, T. Green, M. Studeny, P. Wehner, and E.E. Murray. Marshall University and Marshall University School of Medicine, Huntington, WV, and Fairmont State University, Fairmont, WV.
Background: Polymorphisms in genes involved in homocysteine (Hcy) metabolism (MTHFR) and coagulation (Factor V Leiden [FVL]) have been associated with venous thrombosis and cardiovascular disease (CVD), especially in patients with high Hcy levels. Elevated Hcy levels are a significant risk factor for CVD. The MTHFR variants (677T and 1298C) have been reported to modestly elevate Hcy in subjects consuming a low folate diet. FVL 1691A causes resistance to activated protein C, increasing venous thrombosis risk. Although obesity increases CVD risk, the role genotype plays in elevated Hcy in the obese is unknown.
Methods and Results: Using PCR and pyrosequencing, 581 subjects were genotyped for the MTHFR 677, MTHFR 1298, and FVL 1691 variants; 154 of the 581 subjects had plasma Hcy levels analyzed using the Abbott Diagnostics IMx immunoanalyzer. 77.2% of subjects were obese (BMIB Burnette 114033137Please check missing symbols. ? 30) and 10.9% were overweight (BMI ? 25 < 30). There is no significant difference between genotype distributions in the obese compared with a WV population of European origin not selected for obesity. The MTHFR 1298A allele is linked to MTHFR 677T, and the 1298C allele with 677C (P ? 0.001). Linkage disequilibrium (LD) is observed between MTHFR 1298A and FVL 1691G and between 1298C and 1691A (P ? 0.05). The FVL 1691 and MTHFR 677 loci had no LD.
Conclusions: Only the MTHFR 1298 genotype positively correlates with obesity. Additional genotyping of other variants associated with CVD is being performed on these DNA samples and is discussed.
CAR-13. Left Ventricular Outflow Obstruction Caused by Accessory Mitral Valve Tissue with Associated History of Coarctation of the Aorta.
Sarah J. Rinehart, MD, and Silvestre Cansino, MD. Department of Cardiovascular Services, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Introduction: Accessory mitral valve tissue is a rare cause of left ventricular outflow obstruction that increases the risk of sudden cardiac death.
Objectives: The objective of this study is to present a case report of a patient with multiple congenital cardiac anomalies in which accessory mitral valve tissue was initially identified after surgical repair of coarctation of the aorta and to discuss clinical implications.
Methods: Literature search was completed to review incidence of accessory mitral valve tissue, associated conditions, and treatment plans available.
tk;2Summary: This case was diagnosed by 2D-echocardiography in a 22-year-old asymptomatic pregnant female undergoing cardiac evaluation after surgical repair of coarctation of the aorta. She was found to have residual coarctation of the aorta, bicuspid aortic valve, and accessory mitral valve tissue causing left ventricular outflow obstruction.
Conclusions: After literature research, the patient has a rare cardiac anomaly that has significant implications regarding mortality, which is easily rectified with surgery. Although the accessory mitral valve tissue is associated with other congenital cardiac anomalies, the presence of the accessory mitral valve tissue, bicuspid aortic valve, and history of coarctation of the aorta makes this case unique.
CAR-14. Mitral Stenosis and Deep Vein Thrombosis: Recognizing the Common Link!
Shadi Ayyoub, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize the association between MS with left atrial (LA) thrombi and/or spontaneous echo contrast (SEC) and hypercoagulable states.
Case: A 46-year-old, mildly obese female with no history was diagnosed 1 week prior with extensive deep vein thrombosis (DVT) of the left lower extremity. This was her first episode; she was anticoagulated and discharged on coumadin. Two days later, she presented with acute-onset dyspnea and palpitations. She was a nonsmoker and not on hormones. She denied trauma or long travel. Family history was unremarkable. Exam was unrevealing except for tachycardia and left thigh tenderness. The ECG showed supraventricular tachycardia (178/min); INR: 3.24; ABG, normal. Cardiac enzymes were negative. CT angiogram showed LA filling defect and no evidence of pulmonary embolism; TEE, severe MS, LA spherical mass, and SEC. The patient underwent mitral valve replacement, and the left atrial mass was a thrombus. Thrombophilia studies were only significant for mild elevation of fasting plasma homocysteine.
Conclusions: LA SEC, or "smoke," is a frequent finding on TEE but rarely detected with TTE is present in almost all patients with LA thrombus. LA SEC predicts future embolism and death and therefore assists in selecting patients with MS who benefit most from anticoagulation. Hematological studies have shown that LA SEC is a marker of hypercoagulable state, elevated venous levels of fibrinogen and soluble P-selectin. LA thrombi have been associated with significantly higher levels of plasma homocysteine than those without as in our patient. Mid-diastolic rumble is characteristic of MS, however may be difficult to hear in patients with tachycardia. The diagnosis of DVT requires detailed attention to identify potential risk factors. In the absence of obvious causes a workup for hypercoaguble states is helpful. Although the incidence of mitral stenosis in the USA is declining, clinicians must be able to recognize its clinical manifestations and potential complications including hypercoagulable states.
CAR-15. Outside of the Loop: Hemolytic Anemia after Mitral Valve Repair.
Scott Duffy, MD, Tina Sias, MD, Arthur McUnu, MD, Travis Hansbarger, MD, and Silvestre Cansino, MD. Department of Cardiology, Joan C. Edwards School of Medicine, Huntington, WV.
Background: Hemolytic anemia is a very rare complication of mitral valve repair surgery. A study at Cleveland Clinic identified only 32 such patients over an 11-year period. The proposed mechanism appears to be damage to red blood cells within the regurgitant jet.
Case Presentation: The patient was a 62-year-old white male who underwent repair of the mitral valve with ring annuloplasty for severe mitral regurgitation. Two months later, the patient presented with fatigue and shortness of breath. Hemoglobin at the time was 8 g/dL and had been normal before surgery. After further laboratory evaluation, a diagnosis of hemolytic anemia was made. TEE showed a fragmented regurgitant jet and what appeared to be a partial dehiscence of the mitral annular ring. At the time of surgery there was a small perforation of the posterior leaflet in the presence of a central jet from an anterior chordal rupture.
Discussion: Hemolytic anemia after mitral valve repair is rare, reported primarily in case reports. Significant hemolysis appears to occur only with regurgitation. Regurgitant jets after valve surgery can be divided according to fluid dynamics into five distinct categories. Only those jets creating shear forces greater than 3,000 dyne/[cm.sup.2] are associated with significant RBC destruction. This patient had a fragmented jet, which numeric simulation has shown to be associated with a maximum shear stress of 6,000 dyn/[cm.sup.2] and probably had some component of collision and acceleration.
Conclusions: Hemolytic anemia is a rare complication of mitral valve repair surgery. Very specific patterns of regurgitant flow on Doppler echocardiography are associated with significant hemolysis. Echocardiography is a valuable tool for assessing the etiology of hemolytic anemia in a patient who has undergone mitral valve replacement.
CAR-16. Reversible Right Ventricular Failure in an Elderly Patient with HIV Infection.
Division of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX.
Background: Cardiomyopathy associated with human immunodeficiency virus (HIV) infection commonly presents as biventricular failure and carries poor prognosis. The role of antiretroviral therapy in the management of heart failure is unclear.
Methods and Results: This report describes a 68-year-old white male with severe bilateral lower extremity swelling, arthralgias, unsteady gait, bilateral lower extremity weakness, and numbness. The patient was homosexual by history and denied use of alcohol, tobacco or illicit drug abuse. Physical examination was notable for elevated jugular venous pressure, edema of legs, positive Romberg test, mild weakness, and absent deep tendon reflexes in the lower limbs. Examination of heart, lungs, and abdomen were unremarkable. Laboratory studies showed pancytopenia, HIV test was positive with a viral load of 74091 (HIV BDNA, quantitative assay) and an absolute CD4 count of 183 (cu/mL). Serologic tests for opportunistic infections were negative. Nerve conduction studies revealed mixed polyneuropathy in the lower limbs. Echocardiogram showed moderate right ventricular enlargement, inferior vena cava and hepatic vein dilatation, consistent with right ventricular failure. Left ventricular size, function, and pulmonary artery pressures were normal. Treatment was started with zidovudine, lamivudine, and nevirapine. Low-dose diuretic was given for symptomatic improvement of edema. During 3 years of follow-up, symptoms of right ventricular failure progressively and remarkably improved; the patient regained leg strength and the gait normalized. HIV-RNA level became undetectable, CD4 count improved to 604 (cu/mL), and the pancytopenia improved. Diuretic therapy was stopped and a repeat echocardiogram showed significant regression in the size of right ventricle and atrium.
Conclusions: In the absence of other causes, it appears that the right ventricular failure in this patient was most likely due to isolated involvement of right ventricle by HIV infection. This case also illustrates that the antiretroviral therapy might reverse HIV induced cardiomyopathy.
CAR-17. Role of First-Drawn Indeterminate Troponin I Levels in the Emergency Department.
S. Mehta, R.M. Bautista, and B.A. Adams. Brooke Army Medical Center, Fort Sam Houston, TX.
Objectives: Although patients with elevated cardiac troponin I (TnI) are known to be at an increased risk of death, an indeterminate TnI (ITnI) level offers minimal prognostic value in determining which patients are at risk for adverse outcomes. This study determines the predictive value of the first-drawn Emergency Department (ED) ITnI level for adverse composite end-points (acute myocardial infarction, hospital invasive procedure, readmission for any diagnosis within 90 days, or hospital death).
Methods: This retrospective case-control study evaluated patients at a 50,000 annual visit ED between March 2001 and February 2004 who had negative or indeterminate first-drawn TnI levels obtained during the patient's ED course. All patients had at least two TnI levels drawn. There were approximately 6,500 negative TnI (NTnI) and 1,100 ITnI during the study period. One hundred fifty patients for each arm were randomly chosen from the sample and assigned to their respective study groups.
Results: Sixty-six ITnI patients (44%) had some adverse outcome compared with 36 NTnI patients (24%) (OR, 2.488; P < 0.001). Twenty-two ITnI patients (15%) were diagnosed with an acute myocardial infarction compared with 5 (3%) (OR, 4.984; P = 0.001). Twenty-seven ITnI patients (18%) required a hospital invasive procedure compared with 12 (8%) (OR, 2.524; P = 0.016). Thirty-two ITnI patients (21%) required readmission within 90 days compared with 22 (15%) (OR, 1.578; P = 0.176). Ten ITnI patients (7%) died during that hospitalization compared with 3 (2%) (OR, 3,500; P = 0.089).
Conclusions: The first-drawn ED ITnI value was significantly associated with an acute myocardial infarction, hospital invasive procedure, and adverse composite end points. In patients presenting to the ED with symptoms concerning for an acute myocardial infarction, the first-drawn ITnI may be predictive of higher morbidity rates and adverse outcomes.
CAR-18. Sarcomatous Pleural Mesothelioma Metastatic to Left Ventricular Endocardium.
Neelavathi Senkottaiyan, MD, Jessica A. Birchem, DO, Matthew A. Fraley, MD, and Martin A. Alpert, MD. St. John's Mercy Medical Center, St. Louis, MO.
Background: Malignant mesothelioma is a rare, locally aggressive, asbestos-related malignancy. It usually arises from the pleura and is known to invade contiguous tissues such as lung, pericardium and myocardium. Endocardial involvement without pericardial or myocardial invasion is rare. Only one case of primary mesothelioma involving left ventricular endocardium has been reported.
Methods and Results: This report describes a patient with sarcomatous pleural mesothelioma metastatic to left ventricular endocardium without pericardial or myocardial invasion. A 71-year-old man had transient dysarthria and right facial weakness. Seven months earlier, he had been diagnosed with malignant pleural mesothelioma (sarcomatous type). Transesophageal echocardiography showed a mobile 2.0 X 2.0 X 2.0 cm mass near the left ventricular outflow track. At surgery, the tumor adhered to posteromedial endocardium near the papillary muscle base and was resected en bloc. There was no evidence of pericardial, myocardial or pulmonary vein involvement on gross inspection. Histopathology showed interlacing fascicles of plump spindle cells with pleomorphic nuclei and prominent nucleoli. Immunohistochemical staining was positive for WTI gene product, (a marker characteristic of mesothelioma) and was negative for mucicarnine, carcinoembryonic antigen and epithelial related antigen-MOC31. Despite treatment with chemotherapy his pleural disease progressed. Ten months after his original neurologic event, he presented with similar symptoms and was found to have a 2.5 X 2.4 X 3.8 cm mass in the left atrial cavity at the base of the mitral valve. He died 1 month later.
Conclusions: This is the first reported case of malignant pleural mesothelioma to metastasize to left ventricular endocardium without first invading pericardium or myocardium. Given the absence of involvement of pericardium, myocardium, and extrapulmonary pulmonary vein, it is plausible that metastasis occurred via invasion of an intrapulmonary tributary of a pulmonary vein with subsequent embolization of a tumor fragment. Thus, pleural mesothelioma may metastasize to left ventricular endocardium without prior pericardial or myocardial invasion.
CAR-19. Takotsubo Cardiomyopathy: A Mimicker of ST-Segment Elevation Myocardial Infarction.
Maria Conley, CPT, MC, Casey Cotant, CPT, MC, and Richard Krasuski, MAJ, MC. Wilford Hall Medical Center, San Antonio TX.
Background: Takotsubo cardiomyopathy, otherwise known as transient left ventricular apical ballooning, is an uncommon condition most often found in elderly women after an emotional or physiological stressor. The syndrome consists of reversible extensive akinesia of the apical and mid portions of the left ventricle with hypercontraction of the basal segment, resembling the shape of a Japanese fishing pot or takotsubo.
Methods and Results: The presentation of the syndrome is similar to that of an ST-elevation MI, with ST-segment elevations in [V.sub.2]-[V.sub.4] with mildly elevated cardiac enzymes. A 77-year-old white female presented with respiratory distress requiring intubation. Her ECG revealed ST elevations in [V.sub.2]-[V.sub.4]. Initial n-t-BNP was 2035 pg/mL, with a troponin T peak of 0.63 ng/mL. Bedside echocardiography showed an ejection fraction of 30%. The patient was rushed to the catheterization laboratory for presumed anterior myocardial infarction. Catheterization did not reveal any obstructive coronary disease; however, ventriculography demonstrated an abnormal left ventricle with basilar hyperkinesis and apical hypokinesis. The patient was then medically treated with diuretics and antihypertensives. ECG findings evolved from ST-segment elevation and Q waves in [V.sub.2]-[V.sub.5] to deep T-wave inversions and disappearance of Q waves 4 days later. Subsequent echo performed 3 days after admission showed an ejection fraction of 60% with normalization of left ventricular wall motion. Spontaneous clinical recovery occurred and the patient was discharged after 6 days.
Conclusions: Clinical presentation in Takotsubo cardiomyopathy includes ST elevation and mildly elevated cardiac enzymes without obstructive coronary artery disease. A peculiar shape of the left ventricle is seen, representing a transient dysfunction which completely normalizes within days to weeks. Possible causes of this syndrome include excessive sympathetic stimulation, multivessel epicardial spasm and metabolic injury. Takotsubo cardiomyopathy should be considered in any patient presenting with an apparent acute coronary syndrome without evidence of obstructive coronary artery disease.
Section on Chest Diseases
CHE-1. Multiple Bilateral Rib and Pelvic Fractures: An Uncommon Presentation of Sarcoidosis.
Uzoma N. Ibebuogu, MD, and John O. Oyakhire, MD. Medical College of Georgia, Augusta, GA.
Background: Sarcoidosis is a multisystem disorder of unknown cause characterized by noncaseating granuloma with varying presentation and a reported prevalence of 10 to 20/100,000. Involvement of the bones occurs in 5% of patients and commonly affects the hands and feet, with the involvement of the ribs rarely seen.
Methods and Results: This report describes a rare case of sarcoidosis presenting as multiple bilateral rib and pelvic fractures in a postmenopausal woman. A 54-year-old black woman with a history of hypertension presented with chief complaints of fever, pleuritic chest pain, nonproductive cough, poor appetite, and weight loss. Examination revealed an acutely ill-looking woman with temperature of 39.3[degrees]C. She was tachycardic with crackles in the right lower lung zone and bilateral lower extremity crusted plaques. Laboratory test revealed microcytic anemia, elevated calcium and angiotensin converting enzyme levels. HIV serology was negative. Urine and blood cultures were also negative. Chest x-ray showed multiple healing rib fractures and bibasilar airspace disease. CT scan revealed bilateral airspace disease, multiple bilateral rib and pelvic fractures with lytic changes (which have been described in osseous sarcoidosis) noted in the right public bone. Biopsy of her skin lesions revealed non caseating granuloma with negative cultures.
Conclusions: The diagnosis of osseous sarcoidosis was made after other potential diagnoses including physical abuse, granulomatous, metabolic, infectious and metastatic disorders were excluded on history, laboratory data, imaging studies and pathologic findings.
CHE-2. Not the Usual Community-Acquired Pneumonia.
Jasmine Shah, MD, and Mukta Panda MD. University of Tennessee College of Medicine-Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize the differential diagnosis and importance of tissue diagnosis in nonresponsive pneumonia and to recognize the importance of the "hidden curriculum" in pursuing treatment availability for patients.
Case: A 52-year-old male presented with 2 weeks of shortness of breath, dry cough, night sweats, and 3-lb weight loss despite azithromycin. He had significant smoking history and high-risk behavior. Examination showed normal vitals, ABG, skin, lung, and heart. Laboratory values showed mild leukocytosis, otherwise normal; CXR, bilateral upper lobes noncavitary infiltrates; blood, initial sputum cultures; AFB smears, PPD, HIV, and hepatitis panel negative. The patient did not respond to conventional CAP therapy. BAL was negative for malignancy; AFB, fungi and PCP. Biopsy showed granulomata with encapsulated yeast. BAL grew blastomyces at 10 weeks. As in most resident clinics, patient was indigent. Time-consuming special requests to multiple sources led to provision of itraconazole for 6 months with successful management.
Conclusions: Blastomycosis is a systemic polygranulomatous infection caused by inhalation of blastomyces dermatitidis conidia and can mimic a variety of infectious and neoplastic diseases. Diagnosis needs a high index of suspicion, especially in nonresponsive CAP. Special stains of sputum help in early diagnosis. Cultures take 5 to 10 weeks. Asymptomatic pulmonary infection may be observed. Symptomatic pulmonary, disseminated, and infections in immunocompromised hosts need treatment. Treatment includes Amphotericin B for life-threatening infections; itraconazole for non-CNS infections. Itraconazole is very expensive but the only one effective in non-CNS infection. Despite obstacles, residents need to be patient advocates, and teamwork can be successful. Despite no insurance and time poverty, patience and persistence pay off.
Section on Colon and Rectal Surgery
COL-1. The Safety and Efficacy of a Less Invasive Anal Sphincteroplasty.
Rodney L. Clingan, MD, FACS, George Y. Apostolides, MD, FACS, Francessco Grasso, MD, FACS, Howard Berg, MD, FACS, Lisa M. Savoie, MD, Debra A. Vachon, MD, FACS, and Clifford F. Melick, PhD. Greater Baltimore Medical Center, Mercy Medical Center, Northwest Hospital, Baltimore, MD.
Purpose: This study compares the outcomes of overlapping and reefing sphincteroplasty for delayed repair of anterior anal sphincter defects.
Methods: Patients who underwent anterior anal sphincteroplasty, using an overlapping or reefing technique, from 1989 to 2003 were identified at three institutions. Demographic and perioperative data were obtained from chart review of hospital and private office records. Questionnaires returned by patients and completed by telephone interview were used to determine the current degree of fecal incontinence and associated quality of life using the fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (QOL). Questions evaluating patient satisfaction and postoperative outcome were included in the questionnaire.
Results: The charts and hospital records of 65 patients were reviewed with a median age of 54 (range, 25 to 94) years. Questionnaires were completed by 33 (58% response) patients (21 reefing, 12 overlapping), with a median follow-up of 34 (range, 4 to 74) months after sphincter repair. The median FISI score for the overlapping and for the reefing group was 25 (scale, 0 to 61) and 26 (scale, 0 to 57), respectively. The patient-rated score and the surgeon rated score were similar for both groups. The median QOL index for the overlapping and reefing groups were 2.9 (scale, 0 to 4) and 2.7 (scale, 0 to 4), respectively. There were 44 complications in 35 (54%) patients (24 overlapping, 11 reefing) identified in the review. Major complications occurred in 13 patients. There was no surgically related mortality in either group. Pain scores, based on a linear analog scale, were 7.1, 6.0, 4.4, and 3.7 for the overlapping group and 5.8, 4.8, 3.9, and 2.6 for the reefing group on days 1, 3, 7, and 14. The hospital length of stay was significantly shorter for the reefing group (1.3 days) than the overlapping group (2.8 days). The average time of return to regular activity and diet, after surgery, was 16 and 17 days for the reefing group and 26 days for the overlapping group.
Conclusions: This comparative study shows that both overlapping sphincteroplasty and reefing sphincteroplasty are safe, effective therapies for anal incontinence. The reefing technique requires less dissection, allowing for a shorter hospital stay and lower complication rate. The reefing technique is also associated with improvement in quality of life, postoperative pain, and faster return to regular activities and diet.
Section on Dermatology
DER-1. Cowden Disease in a Patient with a Long History of Atypical Verruca Vulgaris.
Sylvia L. Parra, MD, and Darryl S. Hodson, MD. Department of Dermatology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX.
Background: A 53-year-old Hispanic male presented for evaluation of multiple flesh colored facial papules.
Methods and Results: He was referred by gastroenterology, where he was under evaluation for bright red blood per rectum and iron deficiency anemia. The patient had been seen by dermatology in the past for multiple verrucous lesions that were biopsied and read as verruca vulgaris. His medical history was significant for hypertension, GERD, hepatitis C, bipolar disorder, sleep apnea, COPD, and an active thyroid nodule with subsequent thyroidectomy in 1992. His family history included breast, colon, CNS, and lung cancer. On physical examination, macrocephaly with multiple 2- to 3-mm, flesh-colored papules on the face and ears and diffuse papillomas of the oral mucosa were noted. He had multiple translucent punctate papules on his palms and soles and keratotic papules on his dorsal hands and feet. Additionally, there was a 1.5-cm yellow nodule on his left upper back. Shave biopsy of this nodule showed thickened, eosinophilic collagen bundles arranged in a storiform fashion typical of a sclerotic fibroma. Biopsy of a representative ear papule revealed pallisading cells with eosinophilic, glassy cytoplasm characteristic of a tricholemomma. Subsequent endoscopy demonstrated hundreds of benign hamartomatous polyps throughout the gastrointestinal tract as well as glycogenated acanthosis of the esophagus.
Conclusions: Given this constellation of findings, the patient was diagnosed with Cowden disease, a diagnosis subsequently confirmed by genetic testing. Cowden disease is an autosomal dominant genetic disorder caused by mutations in the tumor suppressor gene PTEN. It is characterized by typical mucocutaneous lesions and neoplasms of the breast and thyroid. Cowden disease is likely more common than is generally reported, as clinical findings can be subtle and mistaken for common warts. It is important to consider the diagnosis of Cowden disease in patients with characteristic mucocutaneous lesions given its strong association with potentially life-threating malignancies.
Section on Emergency Medicine
EM-1. A Video-Based Training Program Improves Defibrillator Inspection Compliance.
Elaine Stuffel, RN, CPT, Henry Shih, MD, LTC, and Bruce D. Adams, MD. Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX.
Background: Improperly maintained defibrillators comprise an important cause of defibrillation delay or failure during in-hospital cardiac arrest. It was researched whether a brief training video of how to properly inspect crash carts and defibrillators would improve the quality and frequency of these inspections.
Methods: The study was a before-after cohort design. Crash cart inspection logs and interrogation of the electronic archive records of the defibrillator were examined. The compliance and quality of inspections before and after implementation of the training video program were compared.
Results: The defibrillator missed inspection rate significantly improved from 6.9% to 8.9% (P = 0.037) after video training program implementation. The crash cart missed inspection rate, however, actually worsened from 2.7% before to 8.0% (P = 0.0001).
Conclusions: Introduction of a new crash cart inspection training video program improved the frequency and the quality of defibrillator inspections, but not crash cart inspections. Inspection of crash carts and defibrillators is a vital hospital task. Because training time for clinical personnel is limited, our 15 minute video can be viewed on a ward computer workstation at the most convenient time.
EM-2. New-Onset Severe Renal Failure in a 15-Year-Old Male.
Antonio E. Muniz, MD, Steve Liner, MD, Sam Bartle, MD, Chris Woleben, MD, and Robin L. Foster, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.
Background: Acute renal failure in children is rare. In patients with prune belly syndrome, a number of renal, ureteral, and urethral abnormalities exist, which increases the likelihood of developing renal failure.
Methods and Results: A 15-year-old male presented with a 1-day history of dyspnea, inability to speak, and drooling. He also complained of neck swelling for 1 week with some dysphagia. He denied chest pains, fever, nausea, or vomiting. His medical history was remarkable for prune belly syndrome. He had no previous surgeries. He took no medications. He denied alcohol, illicit drugs or smoking. He had a temperature of 36.7[degrees]C; blood pressure, 155/90; heart rate, 109/minute; and respiratory rate, 25/minute. He was very weak and was unable to talk. His examination was remarkable for ptosis and facial and neck edema. His lung, heart, and abdominal examination was normal. He had hemmocult (+) stools. He had no peripheral leg edema. His WBC count was 14,800/[mm.sup.3], with 92% neutrophils; hemoglobin was 5.1 g/dL; and platelets were 131,000/[mm.sup.3]. His electrolytes showed a potassium level of 6.6 mmol/L; BUN, 202 mg/dL; and creatinine, 24.8 mg/dL. His head CT scan was normal. His 12-lead ECG showed a NSR with peaked T-waves. His hyperkalemia was treated with calcium, bicarbonate, insulin/dextrose 50%, and hemodialysis. He was hospitalized and was started on antihypertensive therapy. He was given blood transfusion and epoetin alpha (Epogen) for his anemia. His hospital course was complicated by peritonitis after placement of a peritoneal dialysis catheter, but he responded well to antibiotics. He was discharged 20 days later in good condition.
Conclusions: A child with prune belly syndrome typically is male with a lax abdominal wall and a long dilated prostatic urethra from prostatic hypoplasia. Morbidity relates to the urinary tract, in which poor urethral peristalsis and weak forward propulsion of urine in the ureters results in stasis, infection, and stone formation. Renal failure results from underlying renal dysplasia and the aforementioned complications of urinary stasis. The management of the developmental abnormalities is somewhat controversial, ranging from conservative therapy to surgical reconstruction.
EM-3. Respiratory Distress from a Congenital Cystic Adenomatoid Mallformation.
Antonio E. Muniz, MD, Sam Bartle, MD, Chris Woleben, MD, Robin L. Foster, MD, and Steve Liner MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.
Background: Respiratory distress in children is a common presenting complaint to a pediatric emergency department. However, on occasion a rare cause is identified as a congenital cystic adenomatoid malformation (CCAM).
Methods and Results: A 4-week-old female presented with tachypnea and increased work of breathing for 2 days. There was no fever, vomiting, diarrhea, or decrease urination. Her medical and birth history were unremarkable. She took no medications. Temperature was 37.3[degrees]C, heart rate was 138/minute, and respiratory rate was 74/minute. Her head and neck examination were normal. Lung examination revealed decreased breath sounds to left lung. The rest of the examination was normal. Her WBC count was 7,800/[mm.sup.3], with 77% neutrophils; hemoglobin, 10.9 g/dL, and platelets, 635,000/[mm.sup.3]. Her electrolytes, BUN, creatinine, and glucose were normal. Her CXR showed a multicystic filled structure occupying most of his left chest and causing mediastinal shift. She was hospitalized, and a CT scan of the chest confirmed the diagnosis of a congenital cystic adenomatoid malformation. She underwent a lower lobe lobectomy. She did well and was discharged on the third day.
Conclusions: Congenital cystic adenomatoid malformation is a developmental harmartomatous abnormality of the lung with adenomatoid proliferation of cysts resembling bronchioles. Large lesions are associated with fetal hydrops, pulmonary hypoplasia and polyhydramnios. The use of antenatal ultrasound scanning has been recently able to diagnose some of these conditions. The presenting symptom in newborns is respiratory distress and on occasion respiratory failure requiring ventilatory support and on occasion ECMO. Other symptoms are recurrent infections, hemoptysis, chest pains and failure to thrive. Diagnosis is by plain radiographs and CT scan. Chest radiographs show the appearance of a mass containing air-fluid cysts. CT scan is best to delineate the extent and show multilocular cystic lesions with thin walls surrounded by normal lung tissue. Surgical intervention is the mainstay of therapy for CCAM, which include fetal surgery, termination of pregnancy, postnatal surgical resection.
EM-4. Seizures in a Patient with Methylmalonic Acidemia.
Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.
Background: Seizures are a common presentation in children and they may be caused by infections, trauma or idiopathic, however on occasion a rare cause is identified.
Methods and Results: A 9-month-old female presented with a 45-minute episode of upper extremity seizure activity. The mother reported fever, decreased activity, and fussiness for the last day. Her medical history was remarkable for methylmalonic acidemia and developmental delay. Birth history was remarkable for prematurity. She took vitamin [B.sub.12] but was on L-carnitine. Her diet consisted of a low protein diet. She had a temperature of 38.2[degrees]C; heart rate, 160/minute; and respiratory rate, 20/minute. Her physical examination was unremarkable except for a 2/6 systolic murmur. Her WBC count was 18,400/[mm.sup.3], with 76% neutrophils; hemoglobin was 6.7 g/dL and platelets were 900,000/[mm.sup.3]. Her electrolytes showed a C[O.sub.2] of 5 mmol/L, whereas the rest were normal. A venous blood gas showed a pH of 7.53; pC[O.sub.2], 16 mm Hg; p[O.sub.2], 94 mm Hg; and HC[O.sub.3], 13.6 mmol/L, with a base excess of (-)9.2 mmol/L. Her lactate was 5.7 mmol/L and ammonia 31 [micro]mol/L. She was started on an infusion of Dextrose 10% and given L-carnitine, a blood transfusion, and vitamin [B.sub.12]. The infant was hospitalized in the PICU. Bicarbonate was also given. She also had intermittent seizure activity of the upper extremities but these resolved as her metabolic derangements improved. She was discharged in stable condition.
Conclusions: Methylmalonic acidemia (MMA) is heterogenous group of disorders that are characterized by accumulation of methylmalonic acid and a few of it's by products in biological fluids. MMA are due to a deficiency of the adenosylcobalamin-dependent enzyme methylmalonyl-CoA mutase, a defect in intracellular cobalamin metabolism, transcobalamin II deficiency, intrinsic factor deficiency, or dietary cobalamin deficiency, which is found in vegetarians. The newborn presents with poor feeding, progressive lethargy, floppiness and hypotonia. Older infants may present during an episode of decompensation with lethargy, seizures, and hypoglycemia. Infants with MMA are at increased risk for metabolic decompensation, especially during episodes of increased catabolism, such as infections, trauma, and surgery. Treatment consists of limited protein intake with the addition of glucose and carnitine. Severe hyperammonenemia may require hemodialysis.
Section on Family Practice
FP-1. Acrocyanosis and ARDS in a Woman With Vasculitis.
Oded Zmora, MD, Ephraim Back, MD, and Gary Dunkerley MD. St. Clare's Family Practice Residency Program, St. Clare's Hospital, Schenectady, NY.
Background: This report describes a case of a 60-year-old female admitted with respiratory distress and acrocyanosis. On the day of admission the patient had respiratory distress and was intubated in the field. On admission, she was found to have black-blue discoloration of her distal phalanges on both hands. Chest x-ray (CXR) showed pulmonary edema with pleural effusions. CT of the head was normal. She was started on antibiotics and steroids.
Methods and Results: Two months before admission, the patient presented to our clinic with swelling of eyes and was treated with antihistamines. One week later, she still had swelling about the eyes and some nasal drainage. At that time her sedimentation rate was 45 mm per hour; antinuclear antibody was negative. The patient received a methyl prednisone dosepak. After a few days, the patient noted intermittent purplish discoloration of her fingertips. CXR at that time was normal. After admission the patient was transferred to the intensive care unit. The patient was noted to be febrile and blood work revealed mildly elevated liver enzymes. Blood cultures were negative. CT of chest and abdomen revealed a 4-cm lesion in the liver consistent with hemangioma and bilateral pleural effusion. The patient underwent a lung biopsy. The initial pathology report showed findings consistent with adult respiratory distress syndrome (ARDS) and bronchiolitis obliterans organizing pneumonia (BOOP) and possibly a pulmonary embolism. The final diagnosis of the lung biopsy from was "interstitial IgM, granular deposits and diffuse fibrinogen deposits." Multiple laboratory studies were sent. All were negative. The patient's condition slowly improved, and she was discharged to a rehabilitation center.
Conclusions: A literature review of vasculitis and ARDS showed the latter to be a rare albeit a serious complication of several rheumatologic conditions. Vasculitis should be considered in the differential diagnosis when dealing with severe respiratory conditions of unknown origin. Acrocyanosis and ARDS are rarely coexistent in vasculitides.
FP-2. Case Study: Hypothermia Secondary to Erythroderma.
Lori A. Fos, MD, Gordon M. Magonet, MD, Andre F. Guidry, MD, and Katharine Judson, MD. East Jefferson General Hospital, Family Practice Residency Program, Metairie, LA.
Background: Hypothermia is defined as the inability of the body to sustain normal temperature. The syndrome of hypothermia is usually caused by exposure-induced heat loss and can be exacerbated by conditions such as dehydration, alcohol, impaired consciousness, drugs/medications, poor circulation, sepsis, endocrine dysfunctions, metabolic disturbances, neurologic injury, or skin diseases.
Methods and Results: This case study describes a patient whose hypothermia was precipitated by exfoliative dermatitis and exacerbated by a presumed episode of sepsis. A 48-year-old Pakistani male was admitted to the psychiatry ward with a diagnosis of psychosis. The patient was assessed regarding profound weakness. The initial physical examination was notable for a sublingual temperature of 84.3[degrees]F, nonpalpable pulses, and cold, blue extremities. After transfer to the ICU, a systolic blood pressure of 55 and a pulse of 30 were obtained. Examination of the skin revealed diffuse desquamation. The patient was endotracheally intubated and resuscitated with atropine and pressors. Broad-spectrum antibiotics were initiated for presumed sepsis. The patient had severe anemia and thrombocytopenia requiring albumin, hetastarch, vitamin K, erythropoietin, and transfusions of packed red blood cells, fresh-frozen plasma, and platelets. The patient had acute renal failure that gradually resolved. The patient's dermatologic condition was diagnosed as psoriasiform dermatitis, having progressed to frank erythroderma with resultant hypothermia, a sepsis-like syndrome, hypotension, hypoalbuminemia, and total cutaneous failure. The patient was treated with systemic and topical steroids, chlorhexidine topical cleanser, and topical emollient ointment, with good results. He was discharged in good condition.
Conclusions: The chances of future exacerbations could be decreased through judicious use of topical steroids and a skin regimen of hydration, emollients, and gentle exfoliation.
FP-3. GBS Endocarditis Masquerading as a TIA.
I. Shvachuk, G.R. Dunkerley, A.S. Bachwani, and H. DeBlock. St. Clare's Hospital, Schenectady, NY.
Background: A 74-year-old white female presented to the ER with acute onset of left leg weakness and incontinence.
Methods and Results: The patient's PMH was significant for hypertension, diabetes, CAD s/p CABG and PCI, CVA, and a spontaneous right brachial thrombosis with a negative hypercoaguable workup. PE revealed tachycardia, intact CNS, and right great toe cellulitis with normal peripheral circulation. Laboratory work revealed mildly elevated WBC, mild hyponatremia, mild hypokalemia, and a normal unenhanced cranial CT. A presumptive diagnosis of sepsis stemming perhaps from the cellulitis was made and she was admitted to the medical floor on piperacillin/tazobactam. Shortly thereafter, telemetry picked an asymptomatic SVT that resolved with adenosine. Repeat blood-draws showed mildly elevated CK, normal troponin, mild thrombocytopenia, and unchanged electrolytes. Diltiazem was started and her electrolytes corrected. A few hours later, her cultures grew group B-streptococcus of blood, whereas her urine remained sterile. At this point, she registered a fever and showed subtle signs of sepsis. The next day, a new II/VI tTricuspid systolic murmur was detected. TTE confirmed mod-TI. Her antibiotic spectrum was narrowed to PCN+gentamicin and she was transfered to the ICU for monitoring. TEE showed mobile mitral vegetations. She refused intervention and soon after developed a dense right hemiplegia. MRI showed an acute infarct of the pons, cerebellum, and right cerebellar peduncle. MRA revealed a 7-mm saccular aneurysm at the origin of the right MCA. Her blood was recultured; her platelets climbed gradually. Her right toe abscess was drained. Her blood work approached normal and repeat cultures remained negative. Despite intensive scrutiny, focus of her infection could not be identified, and her wish not to be resuscitated or intubated was supported.
Conclusions: Despite our aggressiveness and best efforts, her health continued to decline steadily and she died of sepsis 2 weeks after she was admitted.
FP-4. Pancreatitis in a Woman Taking an Herbal Supplement.
LCDR David S. Lesser, MD, and LT Paul B. Hillesheim, DO. US Naval Hospital, Pensacola, FL, and Naval Aero-Medical Institue, Pensacola, FL.
Background: A woman had development of acute pancreatitis 1 week after starting a popular supplement composed of 11 herbs that claims to enhance a woman's libido.
Case Report: A 28-year-old female presented to the ED with a chief complaint of dull RUQ pain that radiated to her back for 2 days, not related to meals, worse with increased movement. She had no nausea, diarrhea, or dysuria; no prior medical problems; did not drink; and smoked one-half ppd. The only surgery was lap-choly 4 years ago for cholycystitis. The only medication Depo-provera. She had started taking a popular supplement that claims to enhance a woman's libido 1 week earlier. Her physical examination revealed pain to deep palpation of the RUQ. An US of the RUQ revealed no obstruction, and acute abdominal series was normal. Lipase was 1972 U/L; amylase, 354; ALT, 342; and AST, 173. WBC, t-bili, Alk-phos, LDH, and UA all were normal. She was instructed to stop taking the supplement and followed as an outpatient. Enzymes normalized by day 10. Follow-up CT scan revealed no evidence of pancreatic obstruction.
Discussion: A Medline search revealed two prior cases from herbal supplements: a fatal pancreatic abcess in a 67-year-old male from a concoction containing Nux vomica and Rhus toxicodendron and a 34-year-old male with an acute case of pancreatitis ascribed to a mixture of 19 different ingredients including ranunculaceae species, thuja, betual, and juniper. None of these ingredients are included in this blend. A review of the eleven substances listed for this blend showed no reports of pancreatitis but some association with hepatotoxicity.
Conclusions: As the sales of this product have reached $110 million a year and spawned a host of copy-cat competitors, it would be prudent to take a careful history of anyone presenting with idiopathic pancreatitis.
FP-5. Treatment of Chronic Moderate-to-Severe Nonmalignant Pain with KADIAN[R] Using Individualized Doses and Dosing Frequencies.
A. Weil, MD, J. Sasaki, MD, E. Ross, MD, and B. Nicholson. Nonsurgical Orthopaedic and Spine Center, PC, Atlanta, GA, Casa Colina Centers for Rehabilitation, Pomona, CA,; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, and Pain Specialists of Greater Lehigh Valley, Allentown, PA.
Background: Opioids are effective in treating moderate-to-severe pain, with long-acting formulations recommended for chronic pain. Pure opioids, such as morphine, have no ceiling dose in usual clinical circumstances, allowing clinicians to prescribe the dose with the best efficacy/tolerability balance for each patient. This analysis assessed the efficacy and tolerability of the KADIAN formulation of sustained-release morphine sulfate--at individualized doses and with once- or twice-daily dosing options--in patients with chronic moderate-to-severe nonmalignant pain.
Methods: Patients in this community-based, prospective, open-label, blinded end point study (n = 1,428) were randomized to once-daily AM or PM dosing with KADIAN to treat chronic moderate-to-severe pain that was previously unsuccessfully treated (pain score ofB Burnette114033139Please check missing symbols. ?4 on a 1 to 10 scale). Treatment lasted 4 weeks, with dose adjustments permitted after weeks 1 and 2. Patients could switch to twice-daily dosing after week 2 if needed. Outcomes included pain and sleep assessments (0 to 10 scale), patient and clinician satisfaction (-4 to +4 scale), and quality of life (SF-36v2[TM] Mental [MCS] and Physical [PCS] Component Summary scores).
Results: Regardless of total daily dose or dosing frequency (once-daily vs twice-daily), patients generally attained similar reductions in pain (-2.5) and sleep disturbance (-1.9) scores, improvements in patient (+2.5) and clinician (+2.8) assessments of therapy, and increases in SF-36v2 scores (MCS, +5.5; PCS, +3.9) (P < 0.001, baseline vs week 4). The overall adverse event (AE) rate was 39.7%; the most common AEs were constipation (12.1%) and nausea (10.4%). AE rates were similar regardless of dosing frequency; rates were lower in patients requiring higher daily doses (?200 mg) than those requiring lower doses.
Conclusions: Individualized dosages afforded by pure opioids such as morphine, as well as the once-daily or twice-daily dosing options unique to KADIAN, enabled patients to attain balanced efficacy and tolerability in treating chronic moderate-to-severe non-malignant pain.
FP-6. Venezuelan Equine Encephalitis (VEE) from an 18-Year-Old Visiting Central America.
Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.
Background: Stupor, coma, and other alterations of consciousness are among the most serious life-threatening emergencies faced by the emergency department physician. The primary goal in the management of these patients is to prevent further organ and tissue damage with stabilization of the vital signs. This report describes a rare case in the United States.
Methods and Results: An 18-year-old female was in Belize on a medical relief mission. Everyone in her group had vomiting and diarrhea; however, her symptoms worsened. She also complained of high fevers, myalgias, and headaches. She went to an ED and was suspected of having bacterial enteritis. Intravenous fluid hydration and chloramphenicol was given. Her initial sodium was 107 mEq/L. Over the next few hours she had disorientation and had a generalized seizure. She was given diazepam, 50% dextrose, phenytoin, mannitol, and vitamin K. A CT scan of the head was unremarkable. Repeat laboratory values 4 hours later showed that her electrolytes, BUN, and creatinine were normal. Her parents arranged for a medical air transport. Her examination showed moderate distress and restlessness. She was only able to scream and cry. Her motor examination was equal but did not follow commands. She was admitted to the ICU. Abnormal laboratory test included a CK of 270,000, AST of 729 IU/L, and ALT of 139 IU/L. Over the next week her mental status improved and was discharged back to baseline.
Conclusions: When a patient arrives with altered mentation form abroad, the normal causes that occur in the United States must be considered. However, other unusual causes must be excluded, such as Venezuelan Equine Encephalitis (VEE), dengue fever, or enterovirus encephalitis. VEE is an acute viral disease characterized by fever, child headache, nausea, vomiting, lumbosacral pain, and myalgias that may progress to encephalitis. Laboratory abnormalities are common and include elevated LFTs, lymphocytosis, eosinophilia, and thrombocytopenia. Complete recovery is expected within several weeks.
Section on Gastroenterology
GAST-1. An Unusual Cause of GI Bleed: A Mole in the Stomach.
Anupama Ravi, MD, Kshamica Nimalsuriya, MD, and Robert Osburne, MD. Atlanta Medical Center, Atlanta, GA.
Background: A 50-year-old white male presented with a 9-month history of hematemesis, a 20-pound weight loss over the past month, and a history of epigstric pain. He had peptic ulcer disease in the past. The patient denied any history of previous cancerous lesions of the skin.
Methods and Results: Physical examination showed pallor of the conjunctiva and mild epigastric tenderness. A complete examination of his skin, including oral and anal mucosa showed no suspicious lesions. Fundus examination was likewise normal. EGD revealed a large necrotic ulcerated gastric mass extending from the antrum to the body of the stomach. Biopsy of the mass was reported as a poorly differentiated tumor of unknown type. CT of the abdomen and pelvis showed thickening of the posterior wall of the body of the stomach with extension into the gastric lumen and into the adjacent fat, with two enlarged lymph nodes. Surgery was done to better delineate the mass. It revealed that the tumor involved 50% of the stomach including the gastro-colic ligaments and was extending into the pancreas. Palliative surgery was done. The final pathology of the tumor showed neoplastic cells in a sheet-like growth pattern showing no glandular differentiation. S100, HMB45 and melan A staining were strongly positive, thus confirming a diagnosis of gastric melanoma. The final diagnosis of primary gastric melanoma was made as a thorough skin and eye exam was negative for melanoma. The patient is scheduled to be started on interferon therapy shortly.
Conclusions: Primary gastric melanoma is an extremely rare clinical entity. Immunohistochemical stains like S-100, melan-A, and HMB-45 have increased the diagnostic sensitivity of the biopsy and cytology. Many a diagnosis of malignant melanoma could be missed if the pathologist does not perform appropriate staining tests in poorly differentiated tumors. The prognosis is very poor when diagnosis is delayed.
GAST-2. Hemobilia from Hepatic Artery Pseudoaneurysm Twelve Years after Laproscopic Cholecystectomy.
John W. McDonald, MD, Mandeep Singh, MD, Martin Pilat, MD, and Jian Huang, MD. Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA.
Background: Although hemobilia is a rare cause of GI bleeding, it should be considered in all patients with a recent history of hepatobiliary injury or surgery. This report describes a case of GI bleeding due to hemobilia caused by a hepatic artery pseudoaneurysm 12 years after laproscopic cholecystectomy.
Methods and Results: A 72-year-old black female with hypertension, diabetes mellitus, and ESRD presented with a 2-day history of intermittent upper abdominal pain and multiple episodes of dark-red hematochezia. She denied any history of GI bleeding. She underwent laproscopic cholecystectomy 12 years ago for recurrent cholecystitis without perioperative complications. Vitals were BP, 136/64 mm Hg; HR, 80/min; RR, 18/min; and temperatur, 98.7[degrees]F. Physical examination, including abdominal examination, was unremarkable. Laboratory tests on admission revealed hemoglobin of 8.6 g/dL, AST of 163 U/L, ALT of 192 U/L, alkaline phosphatase of 512 U/L, and total bilirubin of 2.9U/L. While in the hospital, her extensive GI evaluation included colonoscopy, EGD, tagged RBC scan, small bowel enteroclysis, and capsular endoscopy, all of which failed to elucidate the source of bleeding. Abdominal CT scan revealed a 2.5-cm, well-circumscribed, blood collection in the porta hepatis adjacent to the surgical clip from her prior cholecystectomy. Angiography revealed a right hepatic artery pseudoaneurysm, which was successfully embolized. Postprocedure laboratory tests showed stable hemoglobin, normalized transaminases, and decreased alkaline phosphatase. The patient was asymptomatic on discharge, and GI bleeding did not recur during subsequent follow-up.
Conclusions: Hepatic artery aneurysms after laproscopic cholecystectomy occur in only 0.5 to 0.8% of procedures. Hemobilia from hepatic artery pseudoaneurysms after laproscopic cholecystectomy is rare and has been reported up to 13 months after the procedure. In this case, hemobilia from a hepatic artery pseudoaneurysm occurred 12 years after the procedure. Hemobilia, although rare, should remain in the differential diagnosis for any patient with unexplained GI bleeding, especially those with a history of laproscopic cholecystectomy.
GAST-3. Overeating Can Kill You: The Boerhaave Syndrome.
Ali Vahabzadeh, MD, and Beverton Moxey, MD. University of Virginia Roanoke-Salem Program, Roanoke, VA.
Background: Boerhaave syndrome is characterized by a transmural perforation of the esophagus. It results from a sudden rise in intraluminal esophageal pressure against a closed cricopharyngeus during emesis. The most common anatomic location of the perforation is the left posterolateral wall of distal third of the esophagus.
Methods and Results: A 30-year-old male presented to the emergency department for evaluation of severe left sided chest pain of two days duration after an acute episode of vomiting. On examination he was ill appearing with a temperature of 100.8[degrees] and a pulse of 133. His trachea was midline and neck examination revealed crepitus bilaterally that extended down to the anterior chest wall. He had decreased breath sounds on lung auscultation and dullness to percussion of the posterior two third of the chest. Chest radiograph showed an air fluid level in the left lung, a left lower lobe infiltrate and subcutaneous emphysema in the neck bilaterally. CT thorax revealed a large left-sided empyema, compression atelectasis and significant mediastinal emphysema extending into the neck. There was extravasation of contrast from the distal esophagus suggestive of esophageal perforation that was confirmed with a gastrografin esophagogram. He subsequently had a left thoracotomy with primary repair of his esophageal perforation and left lung decortication. The hospital course was complicated by recurrent fever, mediastinitis, pancreatitis, and pericardial effusion. Ultimately he did well and was discharged home.
Conclusions: Boerhaave syndrome is the most lethal perforation of the gastrointestinal tract, with an overall mortality rate of 35%. Survival is dependent on early recognition and prompt surgical intervention and declines to 10% if surgery is delayed more than 48 hours. Overindulgence in food and alcohol are the primary risk factors and patients typically present with the classic Mackler triad of vomiting, lower thoracic pain and subcutaneous emphysema.
GAST-4. Reversal of Liver Cirrhosis Without Sustained Virologic Response in Chronic Hepatitis C.
A. Osowo and T. Kothari. Unity Health System, Rochester, NY.
Background: Chronic hepatitis C virus infection is the leading cause of liver cirrhosis and hepatocellular carcinoma, therefore increasing the population in need of liver transplantation. The use of interferon and ribavirin has reduced the morbidity and mortality of this disease.
Case: A 49-year-old black female had elevated ALT and AST (alanine and aspartate aminotransferases) on routine checkup. She quit alcohol and intravenous drug abuse 14 years ago. Vital signs and physical examination were unremarkable. Complete blood count, electrolytes, iron studies, thyroid function, amylase, lipase, and alpha 1-antitrypsin were normal. Hepatic panel was normal except for ALT 68 and AST 99. HIV, hepatitis A and B, alpha feto protein, and screening for autoimmune hepatitis were unremarkable. Pretreatment liver biopsy showed severe piecemeal and bridging necrosis (grade 3) and cirrhosis (stage 4). She received two 12-month courses of ribavirin and interferon alpha-2b with partial viral response. Five months after the last treatment, pegylated interferon alpha-2b and ribavirin were started with partial response after 12 months. Repeat liver biopsy showed mild piecemeal necrosis (grade 1) and mild fibrosis (stage 1).
Conclusions: The goal of treatment in hepatitis C infection is to prevent complications. Infection is considered eradicated when there is sustained virologic response, defined as absence of virus in serum by RNA testing after treatment and 6 months after. The primary benefit of treatment is histological, that is, prevention of cirrhosis and hepatocellular carcinoma. Several studies have shown that there is histological advantage in treatment without eradication of the virus. As seen in this case, there was complete reversal of cirrhosis without eradication of the virus. It is hoped that as more data become available, there will be a stronger recommendation for this modality of treatment in a selected population, which will benefit from it.
Section on Geriatric Medicine
GER-1. Administration and Scoring Systems Affect the Association Between Clock Drawing Tasks and Executive Function.
Thu-Tam T. Huynh, MD, Donald R. Royall, MD, Laura K. Chiodo, MD, and M.J. Polk, PhD. Division of Geriatrics and Gerontology, University of Texas Health Science Center, San Antonio, TX, and GRECC, South Texas Veterans Health Care System, San Antonio, TX.
Background: Clock drawing tests (CDT) are widely used to assess cognition and are thought to measure executive control function (ECF). It is unknown whether their association is mediated by methods of administration or scoring. This study compares two administration and three scoring methods.
Methods: Participants in the second wave of the Freedom House Study underwent cognitive, ADL, IADL, and neuropsychological assessments. CDT were administered to command and copy conditions, according to the method of Royall et al (ie, CLOX), and scored using methods by Sunderland, Wolf-Klein, and Royall. Multivariate regression tested the effect of CDT administration vs scoring system on neuropsychological tests, ADL, and IADL. Subject, age, gender, level of care, education, and healthcare utilization were covariates in a nested within subject design.
Results: Mean age and education were 75 and 15 years. Mean MMSE was 27. Method of CDT administration was associated with Boston-Naming, MMSE, EXIT25 (bedside ECF measure), and Block-Design (all partial P < 0.05). CLOX was associated with IADL, Boston-Naming, MMSE, EXIT25, Vocabulary, and Block-Design (P < 0.05). Wolf-Klein score was only associated with Block-Design (P < 0.05). Sunderland score was not associated with any measure, independent of CDT method and covariates. No CDT scores were associated with verbal-fluency, California-Verbal-Learning-Test, Mattis DRS-Memory subtest, Trails A or B, Digit-Symbol-Test, categories, or perseveration on the Wisconsin-Card-Sort.
Conclusions: The CDT administration method has an effect on measures of functional status and neuropsychological test performance independent of the scoring system used. Both CLOX and the Wolf-Klein systems are associated with visuospatial function (Block-Design), but only the CLOX scoring system is associated with tests of executive function (EXIT25). Method of CDT administration is also associated with ECF, independent of CDT scoring. Thus, subtle differences in either CDT administration or scoring may affect sensitivity to ECF. Finally, frontal functions are multidimensional, and CDTs correlate with some tests of frontal functions.
GER-2. Combining Geriatrics and Palliative Care into an Inpatient Consultation Service: A Innovative Model of Care for the Elderly.
Adeeba Akhtar, MD, and Sandra Sanchez-Reilly, MD. Department of Medicine, Division of Geriatric, University of Texas Health Science Center, San Antonio, TX.
Background: Rapid growth in older populations has led to a more significant hospital presence nowadays. Inpatient geriatric consultation services (GCS) have emerged to care for hospitalized elderly. GCS have shown controversial results. Some studies showed positive results regarding patient outcomes, and others failed to do so. Hospital-based interdisciplinary palliative care (PC) teams are increasing to provide high-quality comfort care and symptom management. There is no evidence of combined programs (geriatrics and PC), with physicians and interdisciplinary team members that may provide dual knowledge. Recently, a new combined inpatient consultation service in geriatrics and PC was created at the South Texas Veterans Healthcare System, offering geriatrics and PC expertise to hospitalized elderly.
Objectives: To describe a new interdisciplinary model-of-care for inpatient elderly and/or patients needing PC expertise.
Methods: Three hundred sixty-one Veterans were seen in a 4-month period (08/04 to 11/04). Mean age was 67 years, mostly males (356). Consulting services were Medicine (57%), surgery (29%), psychiatry (6.7%), and critical care (7%). Common diagnosis was cancer (22%), pain/other symptoms (18%), cardiopulmonary disease (15.5%), PVD (8%), "weakness" (7%), altered mental status (5%), stroke (5%), and fractures (4%); 242 consults were directed to geriatrics, the remaining to PC. Interventions included disposition assistance, rehabilitation, management of geriatric syndromes such as delirium and pain/other symptoms, and advance care planning.
Conclusions: This new model-of-care represents a practical solution to provide geriatrics and PC to older adults. It could potentially be a cost-effective solution and improve quality-of-care towards hospitalized elderly. Further research is needed to measure quality-of-care improvement, decrease of inpatient complications, and cost-effectiveness of this model.
GER-3. Dose-Ranging Safety and Immunogenicity Study of Live Attenuated Varicella-Zoster Virus Vaccine (Oka/Merck) Administered to Adults 60 Years of Age or Older.
Myron J. Levin, Michael N. Oxman, Arthur M. Bobrove, Frederick G. Hayden, Anthony R. Hayward, Michael Irwin, Paul M. Keller, Carol A. Cheney, Tina M. Sterling, Ivan S.F. Chan, Xin Yan, Andrew D. Robertson, Christina Y. Chan, and Jeffrey L. Silber. University of Colorado Health Sciences Center, Denver, CO, University of California San Diego and San Diego VA Medical Centers, La Jolla, CA, Palo Alto Medical Foundation, Palo Alto, CA, University of Virginia, Charlottesville, VA, and Merck Research Laboratories, West Point, PA.
Background: The frequency and severity of herpes zoster (HZ) and its most common complication, postherpetic neuralgia, increase with age. These clinical effects correlate with declines in VZV-specific cell-mediated immunity (CMI) that accompany aging, suggesting that boosting VZV-specific immunity in older individuals might prevent or attenuate HZ. In pilot studies, VZV vaccine boosted VZV-specific immunity in older subjects. To further evaluate the safety and immunogenicity of a candidate vaccine to prevent HZ, we investigated six different VZV vaccine potencies in older subjects.
Methods: A total of 276 subjectsB Burnette114033140Please check missing symbols. ?60 years old participated in a randomized, double-blinded, placebo-controlled study of Oka/Merck VZV vaccine. Subjects received a single dose of placebo or vaccine at potencies ranging from 2,000 to 67,000 plaque-forming units (PFU) and containing varying concentrations of VZV antigen, in a dose-escalating manner. Subjects were followed for safety for 42 days. CMI to VZV was assessed using ELISA-detection of cytokines (interferon-gamma, IL-2, and IL-10) secreted by peripheral blood mononuclear cells stimulated with VZV antigen in vitro and by a limiting dilution responder cell frequency (RCF) assay.
Results: The vaccine was well tolerated at all potencies. No vaccine-related serious adverse experiences occurred. The frequency of vaccine-related adverse experiences was similar in subjects receiving vaccine or placebo. Vaccination with ~19,000 PFU or more led to increases in VZV-specific immunity as measured by greater secretion of interferon-gamma and IL-10 but no increase in IL-2 secretion. CD4-positive memory T-cells measured by RCF were also significantly increased by VZV vaccination. Additional VZV antigen had marginal booster effect, beyond potency in PFU alone. The largest fold-rise in immune response was achieved in subjects with the lowest prevaccination immunity.
Conclusions: In this trial, high-potency formulations of a live attenuated Oka/Merck VZV vaccine were generally well tolerated and immunogenic in older adults.
GER-4. Factors Associated with the Stress Component of Stress and Arousal Checklist (SACL).
I. Syed, Luis F. Amador, Soham Al-Snih, Malcolm Cutchin, Dong Zhang, and J. Goodwin. Internal Medicine/Geriatrics, UTMB, Galveston, TX.
Background: The behavioral adjustment of man to his environment may involve complex physiologic changes. An acute situation, such as an acute hospitalization due to a medical condition can cause a considerable amount stress on an individual. The use of mood adjective checklists (MACL) has been a popular method of gathering data about an individual's phenomenological awareness of bodily processes. Epidemiological investigations have shown a consistent relation between physiological parameters and a number of environmental variables, including stress. The purpose of this study is to examine the association of physiological parameters (blood pressure, pulse rate, respiratory rate, and temperature) and demographics with the stress component of the SACL, measured during hospitalization of elderly patients, age 65 and above at UTMB.
Methods: The stress component of the SACL was used as a tool to screen elderly individuals, aged 65 and above admitted to the floor with a medical condition. During the hospitalization, blood pressure, pulse rate, respiration rate and temperature were measured and demographics such as age, gender and ethnicity were recorded.
Results: Of the 78 patients screened, 55 were female and 23 were male, with a mean age of 78 [+ or -] 7.5. The majority of the population was white (72%). In a multivariable analyses, subjects aged 75 to 84 were significantly more likely to have a low stress level as compared to the oldest group (85 and above). Other factors such as ethnicity, blood pressure, pulse rate, respiratory rate, and temperature were not significantly associated with the stress component of the SACL.
Conclusions: The younger group of patients admitted to the to the hospital floor were found to be less stressed as compared to the oldest old in this sample, however, there was no significant association between the physiological parameters and the stress level as measured by the stress component of the SACL.
GER-5. Hip Fractures Among Hospitalized Elder Mexican Americans.
Jeanette S. Ross, Sandra L. Oakes, Robert C. Wood, and David V. Espino. Family and Community Medicine/Geriatrics Division, University of Texas Health Science Center, San Antonio, TX.
Purpose: To determine the total charges and length of stay (LOS) associated with hip fracture in hospitalized elder Mexican American (MA) Medicare beneficiaries and to compare the characteristics of MA with hip fractures to black (B), non-Hispanic white (W), and other Hispanics (H) with hip fractures.
Methods: Subjects 65 years of age and over with a primary hospitalization diagnosis of hip fracture were selected from the south-western states of California, Arizona, Colorado, New Mexico, and Texas. Subjects with a history of systemic neoplasms or severe trauma were excluded. The MA group were subjects of the Hispanic Established Population for the Epidemiological Study of the Elderly (EPESE), who were selected as a weighted probability sample. Those subjects with Medicare numbers were matched to the Center for Medicare Services (CMS) Medicare/Medicaid hospitalization dataset. B, W, and H were selected from the remainder of the CMS data set for the Southwestern states selected. The selected subjects were then compared by age, gender, total charges, LOS, and number of diagnoses.
Results: The total number of MA, B, W, and H were 2,842, 3,623, 119,909, and 1,458, respectively. A higher percentage of MA who had fractures were under age 75 (MA = 51.8%, B = 78.7%, W = 83.8%, H = 67.3%; P < 0.001). Also, a higher percentage of MA were male (MA = 43.6%, B = 29.4%, W = 29.2%, H = 37.7%; P < 0.001). LOS was not equivalent across the groups, however the actual differences were slight. Total charges for MA was lower than any other. MA also have lower mean number of diagnoses at admission than the other groups (MA = 4.41, B = 5.99, W = 5.85, H = 5.72%: P < 0.001).
Conclusions: MA elders in the Southwestern United States are hospitalized for hip fractures at a younger age, affecting more males, and are relatively healthier. MA elders may have poor bone quality compared to the black, white, and other Hispanics groups.
GER-6. Idiopathic Pancreatitis with a Pseudocyst in a Senior Patient.
Jaclyn Rosenblum, James Bernick, MD, Muayad Salem, MD, and Fred Quenzer, MD. Baylor College of Medicine, Houston, TX, and San Jacinto Methodist, Baytown, TX.
Backgraound: Acute pancreatitis accompanied by a pseudocyst typically affects middle-aged patients with alcohol overuse or gall-bladder disease. Idiopathic pancreatitis complicated by pseudocyst formation in a senior patient occurs infrequently.
Methods and Results: A 68-year-old female presented to the emergency room with a 2-day history of epigastric pain radiating to her back associated with nausea. The patient denied vomiting, fever, or chills. Laboratory studies revealed an elevated amylase, lipase, and white blood count consistent with acute pancreatitis. She indicated no history of pancreatitis, gallbladder disease, alcohol use, recent illness, abdominal trauma, or insect bites. The patient was not taking any prescription or over-the-counter medications. On physical examination, she appeared nonicteric, and her abdominal examination revealed epigastric tenderness without guarding or rebound. Upon admission to the hospital, further diagnostic studies were obtained to evaluate the etiology of pancreatitis. A gallbladder ultrasound indicated no cholelithiasis. Calcium, triglycerides, and liver function tests appeared within normal limits. CT of the abdomen and pelvis revealed a pseudocyst that measured 3 cm in diameter located in the proximal tail of the pancreas. Inflammatory changes surrounded the pseudocyst and included the region of peripancreatic fat. GI and surgical consultation were obtained, and the patient received conservative management. By the fourth hospital day, the patient's abdominal pain and nausea resolved, pancreatic enzymes diminished, and she tolerated a low-fat diet. After discharge, outpatient follow-up included CT scan at 6 weeks after hospitalization to evaluate the pseudocyst.
Conclusions: In the geriatric patient, pancreatitis is usually associated with gallstones or alcohol overuse. Pancreatic pseudocysts are most frequently seen with chronic alcoholic pancreatitis or acute abdominal trauma. This case provides a unique presentation of a pancreatic pseudocyst in a geriatric patient with idiopathic pancreatitis. Pancreatic pseudocysts associated with acute pancreatitis may be managed conservatively in the senior patient.
Section on Gynecology and Obstetrics
GYN/OB-1. Antenatal Sonographic Detection of Retrorectal Cystic Hamartoma.
Mercer University School of Medicine, Memorial Health University Medical Center, Savannah, GA.
Background: Retrorectal cystic hamartomas are characterized by unilocular or multilocular cysts lined by squamous, transitional, or glandular epithelium. The most likely embryologic source of these cysts is the tail gut and the diagnosis is usually made in adulthood. Here, we describe a case of a retrorectal cystic hamartoma found on antenatal ultrasound.
Case: A 30-year-old white female gravida 2, para 1-0-0-1 at 13 weeks of estimated gestational age, presented to her obstetrician for prenatal care. A routine ultrasound revealed a fetus at 13 weeks, 4 days EGA with a dominant cystic mass at the base of the sacral spine measuring 1.6 cm in length, 1.6 cm in anterior-posterior length, and 1.7 cm in width. No other gross fetal anomalies were identified. Findings were most consistent with an open neural tube defect or sacrococcygeal teratoma. After a genetic counseling consultation and discussion regarding the suspected prognoses, medical interruption of pregnancy was performed. After delivery of the fetus, pathologic examination revealed a 46-gram fetus with a sacrococcygeal tailgut cyst (retrorectal cystic hamartoma). Fetal tissues were not identified within the cyst. The placenta and fetal membranes were unremarkable.
Comments: The prenatal diagnosis of retrorectal cystic hamartoma (sacrococcygeal tailgut cyst) has not been previously described, based upon literature and MEDLINE searches. Our case may represent the first reported antenatal sonographic findings of this rare entity. Retrorectal cystic hamartoma should be a part of the differential diagnosis when a sacrococcygeal mass is visualized during prenatal ultrasound.
GYN/OB-2. Evolution of a Pseudo-Sinusoidal Rhythm in a Fetus with Fetal-Maternal Transfusion.
David Lesser, MD, LCDR MC, and Steven Kewish, MD, LCDR MC. USN Naval Hospital, Pensacola, FL, and USN Naval Hospital, Camp Lejeune NC.
Background: Sinusoidal fetal heart rate (SFHR) patterns are rare and associated with poor fetal outcome. This case illustrates a pseudo-sinusoidal fetal heart rate (FHR) tracing that gradually became more regularly wave-like with decreased short term variability. Workup indicated fetal anemia and chronic fetal-maternal transfusion.
Case: A term 21-year-old g2p1 with an uncomplicated prenatal course presented with decreased fetal movement. A period of regular waveforms occurred in the first hour, but short-term variability was preserved. Further episodes occurred during the next 6 hours with regular wave patterns of 10 to 15 beats per minute (bpm) amplitude. The FHR was reassuring for the next 10 hours, but the regular waveform began to return during the last 8 hours of labor. Vaginal delivery occurred 18 hours after induction began with APGARs of 0/5/7.
Methods and Results: After delivery, the infant's hematocrit was 17.5% (requiring transfusion); reticulocyte count was 16.8%; Maternal Kleihauer-Betke was 14.3%, indicating a fetal-maternal transfusion of 125%. This suggested a chronic low-level fetal-maternal transfusion that may have significantly worsened during labor. Pathological examination of placenta was normal. At 6-month follow-up, the infant had normal growth and neurological functioning.
Discussion: Research indicates true SFHR patterns with no areas of normal FHR variability are rare, occurring in 0.3 to 1.7% of all pregnancies. One study of 1,520 tracings found no true SFHR patterns, but 15% were classified as pseudo-sinusoidal heart rate patterns defined as an undulating waveform with absent variability persisting for at least 10 minutes with normal intervening variability. A poor outcome was associated only when pseudo-sinusoidal pattern had an amplitude greater than 25 bpm.
Conclusions: Pseudo-sinusoidal waveforms are transient in nature and easily missed, but this case demonstrates urgent intervention is required. Early Kleihauer-Betke testing and future development of computerized analysis of FHR may help focus attention on tracings that need higher levels of attention.
GYN/OB-3. Parasitic Infestation of Gynecologic Tract.
Majmudar Bhagirath, MD. Emory University at Grady Health System, Pathology Department, Atlanta, GA.
Background: A growing awareness of parasitic diseases has become mandatory because of an ever-increasing influx of immigrants from all parts of the world in the United States.
Methods and Results: Although the parasitic diseases are most commonly seen in the gastrointestinal tract, its incidence in the Gyn tract is thought to be so rare as to escape clinical and/or pathological attention. This report presents five clinicopathologically significant cases of parasitic involvement of the Gyn tract by parasites. All these cases were collected from the surgical pathology files of Grady Health System. One case was of a vulvar amoeboma mistakenly treated as carcinoma, one case of pelvic dracunculosis treated as leiomyoma, two cases of tubal and cervical schistosomiasis each, and one case of tubal oxyuriasis.
Conclusions: Cervical schistosomiasis has recently drawn much interest because of its association with cervical oncogenesis. The relevant clinical and pathological points of discussion in all these cases is presented.
GYN/OB-4. Reproductive Trauma: The Psychology of Infertility and Pregnancy Loss.
Martha Diamond, PhD, David Diamond, PhD, and Janet Jaffe, PhD. Center for Reproductive Psychology and Alliant International University, San Diego, CA.
Background: This report discusses the psychological impact on patients of adverse reproductive events, such as infertility, miscarriage, and stillbirth. These events can be conceptualized as psychological traumas, with symptoms including flashbacks, confusion, sleep disorders, mood swings, depression, and anxiety. Emotions may vacillate between sadness, anger, guilt, and a profound sense of failure. The trauma complicates the patient's multiple levels of loss, including loss of the baby, of the experience of pregnancy and birth, and of one's sense of self as a healthy and normal adult. Fundamentally, reproductive trauma derives from the disruption to a person's parental identity, or "reproductive story," the unconscious narrative that people develop from childhood, when ideas of what it will be like to be a parent begin. When unrecognized, the trauma and grief reactions can compromise a patient's ability to cope with the losses, to make constructive treatment decisions, and to work cooperatively with medical staff.
Methods and Results: Specific suggestions for how to talk to patients about such events and their treatment are provided, with the aim of enhancing the doctor/patient alliance and patient compliance with treatment recommendations. This report is based on clinical experience with multiple patients who have undergone adverse reproductive events. Treatment methods include psycho-education to normalize patients' profound sense of trauma and loss. Patients are helped to identify their reproductive stories, grieve their losses, and choose medical interventions that will optimize the realization of their wishes to be parents.
Conclusions: Clinical observation and therapeutic success strongly support the usefulness of the concept of reproductive trauma, the role of complicated grief, and the importance of recognizing disruptions to the reproductive story in helping patients to cope effectively with treatment. Patients benefit enormously from understanding the psychological impact of adverse reproductive events. The recognition of such events as both trauma and loss normalizes for both patients and doctors the wide-ranging emotions and sense of failure often experienced. When validated, patients are more able to cope and make appropriate decisions about how to become parents.
Section on Medicine
MED-1. A 65-Year-Old Man with Spastic Paraparesis.
Sandra Illum, MD, and Ronald G. Washburn, MD. Department of Medicine, Louisiana State University Health Sciences Center, VA Medical Center, Shreveport, LA.
Background: HTLV-I infection is uncommon, with a wide spectrum of symptoms similar to that of HIV-I. This report describes a patient with rapidly progressive HTLV-I associated myelopathy/tropical spastic paresis (HAM/TSP) and reviews the literature relative to epidemiology, pathophysiology, and treatment.
Methods and Results: A 65-year-old man presented with a 3-month history of progressive weakness and spastic paresis of the lower extremities. Imaging studies of the central nervous system (CNS) were normal. Cerebrospinal fluid (CSF) findings revealed nucleated cells (95% lymphocytes), elevated protein, IgG, and myelin basic protein. HTLV-I/ HTLV-II screening was positive, whereas HIV-I/ HIV-II screening was negative.
Summary of Clinical Relevance: HAM is a progressive demyelinating disease affecting the CNS, including the spinal cord. Common presenting symptoms include lower extremity weakness and gait disturbance. CD 4+ T-cells are mainly infected, occasionally also CD 8+ cells, which may be responsible for myelin and axonal destruction. HTLV-I is mainly transmitted through sexual intercourse, blood products, and by breastfeeding. The infection in the United States is found mainly in the southeast. Carriage is more common than clinical disease, with lifetime incidence of HAM being less than 5% in HTLV-I-seropositive individuals. Magnetic resonance imaging of the CNS can be normal or show atrophy and lesions similar to those seen in multiple sclerosis. CSF contains elevated protein and immunoglobulin, and often oligoclonal bands. No durable treatment is available, with only transient responses being reported. Corticosteroids and danazol are currently the most commonly used agents.
Conclusions: HAM/TSP is a devastating neurological disease that remains uncommon in the United States. This patient had classic but rapidly progressive manifestations of HAM/TSP and serves as a reminder of how HTLV-I infection can present. The rapid progression from ambulatory to wheelchair-bound in 3 months was unusual. On 18-month follow-up, his bilateral spastic paraparesis has remained stable, with no therapy.
MED-2. A Challenging Case: Distinguishing Thrombocytopenic Microangiopathies.
Jason Lee, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize the critical therapeutic and prognostic importance of diagnostic algorithms in identifying and distinguishing subtle differences among patients with thrombocytopenic microangiopathies.
Case: A 22-year-old female presented with intermittent headache for 5 days associated with red spots on her lower legs. There were no visual symptoms. WBC was 6.3; hemoglobin, 6.1/hematocrit 15.1; platelets, 10 (12 hours prior); indirect bilirubin, 0.8; total bilirubin, 1.2; ESR, 0.5; LDH, 895; normal BUN, creatinine, and negative UDS. Urine albumin was 100, with blood large (patient menstruating). Fibrinogen was 378; HIV and pregnancy test negative. Peripheral blood smear negative for schistocytes. With findings of neurologic abnormalities, hemolytic anemia, and thrombocytopenia, the index of suspicion for TTP was high. The patient received 6 days of plasma exchange with significant improvement, discharge platelet count 128,000.
Conclusions: Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) describes acute syndromes with multiple systems involvement. Although studies appear to distinguish the two, presenting features are similar. Neurologic abnormalities are dominant and acute renal failure minimal or absent in TTP. TTP-HUS should be suspected in patients with characteristic clinical and laboratory findings, ic, microangiopathic hemolytic anemia, thrombocytopenia, often with purpura, acute renal insufficiency, neurologic abnormalities, and fever, without apparent cause. In this patient, headache was the only neurologic symptom, renal function was normal, schistocytes were not present, and her urine was positive for blood, but she was menstruating. Therefore, the diagnostic decision-making process was clouded. This case emphases the importance of carefully sifting through seemingly contradictory information and weighing the importance and validity of each piece of data.
MED-3. A Rare Case of Recurrent Lower Gasrointestinal Bleeding: Dieulafoy Lesion of the Ileum.
Sarabjeet Singh, MD, Tung Vir Singh Arya, MD, DM, Anant Sharma, MD, and Jasleen Duggal, MBBS. Rosalind Franklin University of Medicine and Sci-CMS Department of Medicine, North Chicago, IL, Lala Lajpat Rai Memorial College and Sardar Vallabh Bhai Patel Hospital, Department of Medicine, Meerut, India, and Maulana Azad Medical College and Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, India.
Background: The source of lower GI bleeding can be difficult to localize despite the advances brought on by the endoscopy and angiography. Dieulafoy lesion is one of the rare causes of obscure lower GI bleeding. It is important to bear in mind the rare location of these lesions in the small bowel, especially when the routine investigations are nonrevealing. Only 10 such cases in the small bowel have been reported worldwide. This report describes a case of Dieulafoy lesion in the ileum.
Results: A 53-year-old female with history of recurrent malena was admitted previously to the hospital. At that time she had undergone upper and lower endoscopy, enteroclysis, and Tc-99m scan, which were all reported to be normal. This time, she presented 3 months after with chief complaint of malena. Colonoscopy revealed bleeding coming from ileum. Laparotomy with intraoperative endoscopy was done. A vascular abnormality was identified in the ileum. Histology revealed this to be Dieulafoy type.
Conclusions: Small bowel Dieulafoy lesion should be a diagnostic consideration in patients with obscure lower GI bleeding. Routine endoscopic procedures, enteroclysis, and scans may all be unrevealing in the patient of small bowel Dieulafoy lesion. Hence, it may be necessary to perform an intraoperative endoscopy to localize this rare cause of bleeding.
MED-4. Acute Myocardial Infarction in the Face of Platelet Abnormalities: A Clinical Challenge.
Warta Greta, DO, MPH, and Seema Haq, MD. Department of Internal Medicine, University of Oklahoma College of Medicine, Tulsa, OK.
Background: Thrombotic thrombocytopenic purpura (TTP) is characterized by severe thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, renal failure, and fever. The pathogenesis involves damage to small vessels by an unknown factor in plasma with formation of platelet thrombus over endothelial lesions. Platelet thrombi obstruct microvasculature producing organ damage. Hemolytic uremic syndrome (HUS) is similar to TTP clinically except it is usually confined to the kidney.
Methods and Results: Acute myocardial infarction (AMI) occurs when there is a thrombotic occlusion in a previously narrowed vessel. Standard of care includes aspirin, anticoagulation and often reperfusion therapy. This report describes an interesting case of a patient admitted with TTP who subsequently had AMI and the challenges faced with treatment.
Case Presentation: A 49-year-old female with history of stent placed in right coronary artery was admitted with abdominal pain and hematochezia. Her blood work showed hemolytic anemia, thrombocytopenia, and acute renal failure with anuria. Her diagnosis was HUS versus TTP. During hospitalization, she had an episode of hypotension and low-grade substernal chest pain. Elevated cardiac enzymes indicated acute myocardial injury. A 12-lead electrocardiogram demonstrated Q waves in the inferior leads. She was treated with intravenous metoprolol in addition to plasmapheresis and hemodialysis. Standard treatment of acute myocardial infarction, consisting of anticoagulation and cardiac catheterization, was not considered due to low platelets, gastrointestinal bleed, and renal failure. The patient's coronary arteries reperfused without intervention. Her outcome was uneventful.
Conclusions: This case highlights the clinical challenge faced by clinicians in treating a patient who presents with platelet abnormalities complicated by AMI. Although both conditions manifest with organ damage caused by platelet thrombus occlusion, the cause of AMI as a complication of TTP remains uncertain. Possible mechanisms may include increased blood viscosity, anemia, or microthrombosis. A review of the literature demonstrates that AMI is an unusual complication of TTP. Specific treatment of patients with such was not found.
MED-5. Acute Porphyria in the Critically III Patient.
Kamran Akram, MD, Ketino Kobaidze, MD, Bedri Yusuf, MD, and Miriam Parker, MD. Atlanta Medical Center, Atlanta, GA.
Background: The prophyrias are a group of metabolic disorders involving various enzymes of the heme synthesis pathway. Disease manifestations depend on the type of the excess heme intermediate and related porphyrins. If the excess is of the early precursor molecules (delta aminolevulenic acid [ALA], or porphobilinogen [PBG], or both), the manifestations are neurovisceral. If the excess is of the distal intermediates (uroporphyrin, corpoporphyrin, and protoporphyrins), the manifestations are cutaneous, and, finally, if the excess is of both the early and the distal porphyrins, the presentations are both neurovisceral and cutaneous. The porphyrias are uncommon and complex metabolic conditions. Stress, surgery, multiple medications, malnutrition, and alcohol can trigger manifestation of underlying enzyme deficiency.
Methods and Results: A 35-year-old white female was admitted to the hospital for cocaine-induced aortic dissection. She was previously healthy, with no significant family history. Her hospital course was complicated by multiple surgical procedures, renal failure, and severe anemia. She received multiple red blood cell transfusions for anemia management. The patient remained in the ICU for a prolonged time and became hemodialysis and ventilator dependent. After 2 months of hospitalization, she had progressive ascending muscle weakness resulting in quadriplegia and sensory loss. An EMG study suggested axonal damage, and a diagnosis of critical illness neuropathy was made. Her neurological status deteriorated further and she developed new onset seizures. She was treated aggressively with two anticonvulsant medications and remained seizure free. At that time, physical examinatation of the skin revealed multiple bullous lesions. The diagnosis of drug-induced dermatitis was entertained, and all possible offending medications were discontinued. Nevertheless, patient's skin condition worsened; she had fragile hyperpigmented skin with fine facial hypertrichosis. Acute porphyria was suspected. The total plasma porphyrins demonstrated an 81-fold increase. There was 52-fold elevation of urine PBG and a 4-fold increase of ALA level. Thus, the laboratory studies confirmed the severe acute porphyria diagnosis. The patient was placed in a no-sun-exposure room and treated with a course of intravenous hematin, with little improvement in sensory but no motor function.
Conclusions: This case demonstrates the rare metabolic disorder of acute porphyria presenting at age 35 in a previously healthy woman. We believe that a severe stress triggered the expression of this disease. The manifestations of cutaneous and neurovisceral porphyria, occurring in this patient, are extremely rare presentation. The diagnosis of porphyria is often delayed, and currently it is highly recommended to keep a high index of suspicion to timely recognize and treat this uncommon, complex, and potentially deadly disease.
MED-6. Acute ST-Elevation Myocardial Infarction Secondary to Acute Leukemia.
Gerald Thomas Arbour, Jr, MD, Scott Beach, MD, Adrian Sequeira, MD, Dennis Sula, MD, and Jian Huang, MD. Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA.
Background: There are few reported cases of ST-elevation myocardial infarction due to acute myelogenous leukemia. This report describes the case of a 48-year-old white male with negative medical and family history who presented with a 1-week history of fever, chills, malaise, cough, pleuritic chest pain, and dyspnea on exertion.
Methods and Results: The patient was diagnosed with pneumonia at a local clinic and sent home with antibiotics. He returned to the ED 5 days later, hypotensive, tachycardic, tachypneic, and hypothermic. Examination was unremarkable except for bibasilar rales. Laboratory values were consistent with acute renal failure, thrombocytopenia, and anemia. WBC was 59,500, with 35% blasts. Troponin I was 11.95, and beta-naturetic peptide was 1,130. A DIC panel was negative. An ECG revealed NSR and 3-mm ST-segment elevations in inferior and lateral leads. Bone marrow biopsy showed refractory anemia with excessive blasts with early evolution to acute myelogenous leukemia. Leukophoresis was performed immediately, but the patient did not respond. He deteriorated quickly and, despite aggressive ICU care, died.
Conclusions: ST-elevation myocardial infarction is an extremely rare complication of acute leukemia. The cause is thought to be secondary to myocardial infiltration by leukemic cells rather than occlusion of coronary arteries. However, this mechanism has been suggested only by a limited number of case reports. The elevation of cardiac enzymes and characteristic ECG changes in this case confirmed myocardial damage, but an autopsy was not obtained to further verify the cause. The patient had a myocardial infarction, presumably secondary to his underlying leukemia, considering he had no identifiable CAD risk factors. This unique case highlights an unusual complication of acute leukemia that is very rarely reported.
MED-7. An Incidental Finding: Presentation of Pulmonary Mycobacterium Kansasii as Abdominal Pain.
Teabra Dixson, MD, and Mukta Panda MD. University of Tennessee, Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize the atypical presentation s of Mycobacterium kansasii infection.
Case: A 60-year-old female presented with several days of burning abdominal pain. She denied any accompanying nausea, vomiting, or diarrhea. The patient also admitted to occasional cough, some shortness of breath, and night sweats. She was a 20 pack-year smoker and had no history of international travel or occupational exposures. Family history was positive for lung cancer. The patient had no increased risk factors for immunosupression. On presentation, she had an oxygen saturation of 97% and appeared well developed and nourished. Lung examination revealed scattered rales but was otherwise normal. Abdominal ultrasound for pancreatic or biliary tract involvement was negative. Chest x-ray revealed a left upper lobe cavitary lung mass. PPD was negative and three sets of sputum stains for acid fast bacilli were negative. PET scan was negative for uptake in the lymph nodes or any organ. CT fine-needle aspiration and bronchial washing culture grew M kansasii. The patient was started on isoniazid, ethambutol, pyridoxine, and eifampin for 18 months.
Conclusions: Nontuberculosis mycobacterium are typically commensal. M kansasii is found in tap water in endemic cities. Endemic areas include southern states, California, as well as central states. COPD, malignancy, and geography may predispose one to M kansasii infection. Symptoms include fever, night sweats, and weakness. Immunocompetent hosts may manifest a pulmonary infection or cutaneous sporotrichosis. Pulmonary disease was subacute and nonspecific in both immunocompetent and immunosupressed patient groups, whereas abdominal pain was the first symptom of most patients immunosupressed patients with disseminated disease. This patient, however, had localized disease. This case illustrates a presentation of pulmonary M kansasii infection as abdominal pain in an immunocompetent host with localized disease. This patient's smoking history and geographical location may have predisposed her to M kansaii infection.
MED-8. An Interesting Case of Primary Pyogenic Liver Abscess.
Marina Grigorian, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.
Objectives: To discuss the common causes of liver abscess and to recognize that Klebsiella liver abscess is a distinct entity and its association with diabetes mellitus.
Case: A 73-year-old Filipino female with type 2 diabetes immigrated to the United States 2 years ago; she presented with fever for 1 day, weakness, and fatigue for 3 months. She denied nausea, vomiting, abdominal pain. No recent travel was reported. The patient appeared ill, was febrile, hypotensive, and tachycardic. Physical examination was unremarkable, and the abdomen was nontender. Pertinent data: WBC, 16,200/[mm.sup.3]; 81.1% neutrophils; HB, 9 g/dL; HCT, 26.3%; alkaline phosphatase, 113 U/L; AST, 107 U/L; ALT, 77 U/L; HbA1c, 8.1%. Workup revealed Klebsiella pneumonie bacteremia and a multiloculated 7-cm hepatic abscess. CT-guided drainage of abscess showed purulent material and culture grew K pneumonie. She received parenteral cephalosporins followed by oral quinolones for 6 weeks. Repeat CT of the abdomen demonstrated more than 50% reduction in size of the abscess. The patient improved.
Conclusions: Pyogenic liver abscess is rare and presents with different clinical manifestations. Most patients do not have symptoms directly referable to the right upper quadrant. Common causes include suppurative cholangitis or pylephlebitis, arising from abdominal/pelvic infection. In the United States, most liver abscesses are either polymicrobial or caused by Escherichia coli. Klebsiella liver abscesses are more common in Southeast Asiaians and more strongly associated with diabetes. Solitary abscesses are more frequent in the Klebsiella group. Another distinct feature is its higher propensity to metastasize to the eyes, brain, and joints. Management includes drainage and antibiotics until CT scan shows resolution. In most patients, the source remains indeterminate, as in this case. An understanding of the differences between polymicrobial and Klebsiella liver abscesses is important for the proper management. Physicians should have a high index of suspicion of K pneumoniae hepatic abscess in their diabetic patients with fever and elevated liver enzymes, since often, no localizing signs are present.
MED-9. An Unusal Initial Presentation of Dermatomyositis.
Anupama Ravi and Luther Burse, Jr. Atlanta Medical Center, Atlanta, GA.
Background: Dermatomyositis/polymyositis are rare disorders with prevalence rates estimated at about 1 per 100,000 in the general population. This report describes a case of dermatomyositis with an unusual initial presentation of dysphagia.
Methods and Results: A 41-year-old female presented with a history of gradually progressive dysphagia for 4 months. Medical history was noteworthy for hypertension and gastritis. She had a significant smoking history. Review of systems was remarkable for progressive arm weakness and pain for 3 months and a 25-pound weight loss over 3 months. Physical examination was significant for decreased motor power and minimal tenderness in her deltoids and gluteals bilaterally. There were no skin lesions. Laboratory data demonstrated an elevated creatinine kinase, elevated liver transaminases, and an elevated aldolase. ANA was positive. Antibodies for other connective tissue diseases were negative. Barium swallow and abdominal ultrasound were normal. EGD revealed antral gastritis and a patulous gastroesophageal junction. EMG showed myopathy associated with features of increased muscle irritability. A deltoid muscle biopsy showed necrotizing inflammation and atrophy in the perivascular and perifascicular areas, thus confirming a diagnosis of dermatomyositis. During the course of the hospital stay she received intravenous steroids and hyperalimentation. She is currently in remission. Her dysphagia has fully resolved. A malignancy workup done as an outpatient was negative.
Conclusions: This case emphasizes the importance of a thorough history and physical examination. Clinical correlation between arm weakness and dysphagia was instrumental in establishing her diagnosis. Dermatomyositis must be considered in the differential diagnosis of dysphagia even in the absence of skin lesions. Also, as 10% of dermatomyositis patients have an associated underlying malignancy, it is imperative that we initiate a malignancy workup as early as possible to reduce the mortality and morbidity in these patients.
MED-10. An Unusual Case of Frostbite.
K. Pachipala, S. Naidu, and M.S. Chapel. Geisinger Health System, Danville, PA, and Grandview Health Homes, Danville, PA.
Background: A 70-year-old nursing home resident with a history of dementia, multiple strokes, and diabetes was admitted with second-degree burns to her face and neck. The patient had been on continuous oxygen therapy at a nursing home and on the day of admission was connected to a portable liquid oxygen tank to allow mobilization in a wheel chair. Shortly afterward, nursing staff noticed a white haze around her head with whitening of her skin near the oxygen tubing. She was immediately disconnected from the oxygen source and rushed to the hospital.
Methods and Results: Physical examination revealed second-degree burns involving the face and neck, with extensive involvement of the mucus membranes of her mouth, pharynx, and larynx. The patient was admitted and was treated conservatively with humidified oxygen and intravenous fluids. She was closely monitored with serial chest x-rays and airway evaluation by ENT physicians. She eventually recovered and was discharged back to the nursing home in stable condition. The oxygen tank was sent back to the manufacturer for testing, and the FDA was informed.
Conclusions: Oxygen has therapeutic value, but its use can be harmful if exposure to liquid oxygen occurs. Liquid oxygen is stored at -361.8[degrees]F. Equipment failure can lead to exposure to, and inhalation of, liquid oxygen, causing freeze burns or frostbite in exposed tissues. First aid consists of immediate removal of the victim from the source of contamination and washing of the affected skin with lukewarm water. Medical attention is needed in all cases involving inhalation. Treatment is mainly symptomatic and supportive, and patients should be closely monitored for airway compromise and pulmonary edema.
MED-11. An Unusual Case of Hypokalemia-Induced Paralysis.
Vasundhara Cheekati and Miriam Parker. Atlanta Medical Center, Atlanta, GA.
Background: Patients with urinary diversions present with unique challenges to internists who have an important role in their long-term management. These patients are prone to many metabolic abnormalities secondary to the interaction of urine with the absorptive surface of the bowel.
Methods and Results: Adequate knowledge about the careful management of patients with uretero-sigmoid anastomoses can prevent many complications, which include severe electrolyte and acid-base abnormalities, bone disease, ammoniagenic coma, urological sequelae, neurological complications and malignancy. A case of a 35-year-old white female with a history of uretero-sigmoid anastomosis was admitted with inability to move both her legs. Physical examination was normal except for 1/5 lower extremity strength. Laboratory studies revealed potassium, 2.7 mEq/L; bicarbonate, 12.2 mEq/L; pH 7.23; and pC[O.sub.2], 28.3. Admission diagnosis was metabolic acidosis and paralysis induced by hypokalemia, which proved rapidly reversible with adequate potassium and bicarbonate repletion. Paralysis due to hypokalemia in conjunction with hyperchloremic metabolic acidosis is a common emergency presentation among patients with uretero-sigmoidostomy. Absorption of urinary chloride in the intestinal lumen with secretion of bicarbonate leads to metabolic acidosis. Ammonium derived from urine and colonic bacteria is thought to compete with potassium for absorption leading to hypokalemia. Excess ammonium produced in situations of urinary tract infection and distal intestinal obstruction can cause encephalopathy. Persistent metabolic acidosis may lead to complications ranging from asymptomatic bone demineralization to osteomalacia and increased fracture risk. Patients are also susceptible to frequent urinary tract infections, urinary reflux and stone formation. Increased risk of malignancy at the uretero-sigmoidostomy junction requires frequent endoscopic surveillance.
Conclusions: Preclusion of the above abnormalities with precise management is critical to avoid the above mentioned complications. Prevention of metabolic acidosis and hypokalemia with bicarbonate supplementation, early recognition of complications, and regular screening for malignancy should be the standard of care in these patients.
MED-12. Big Jaw, Large Hands, Bad Back.
Kevin Luce, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga, TN.
Objectives: To explore the differential diagnosis of cauda equina syndrome and its possible association with spinal stenosis and to discuss the diagnostic workup of suspected acromegaly.
Case Report: A 60-year-old woman had a several-week history of gradual onset left lower extremity weakness and worsening chronic back pain. History included several years of pain management for severe spinal stenosis. Initial examination revealed profound right distal extremity weakness, sensory abnormalities consistent with a cauda equina syndrome, and poor rectal tone. Magnetic resonance imaging (MRI) revealed interim worsening of her spinal stenosis with areas of disc herniation and nerve impingement.
Methods and Results: Neurosurgical intervention resulted in significantly improved motor function and resolution of sensory and rectal abnormalities. The neurosurgeons expressed surprise that the severity of the patient's spinal stenosis led to the presentation of cauda equina syndrome, resembling an epidural abscess or vertebral neoplasm. On further examination of the patient, there were subtle physical findings such as a prominent mandible, large hands, a prominence of the sternum, and thick heel pads that were consistent with a possible underlying endocrine abnormality. This suspicion led to a detailed research effort into possible secondary causes of spinal stenosis, first screened with a serum insulin growth factor-I (IGF-I) level (4.0 [micro]g/dL; reference, 1.5 to 2.4 [micro]g/dL normal) and then confirmed using a glucose suppression test of serum growth hormone (2.6 ng/dL; reference <1.0 ng/dL normal), establishing the diagnosis of acromegaly. Brain imaging revealed an enlarged sella turcica, which could be indicative of a pituitary adenoma. However, the patient reviewed the treatment options available and chose a conservative approach with oral cabergoline therapy.
Conclusions: When faced with a neurologically debilitating case of spinal stenosis, secondary causes should be considered. The examination findings, diagnostic approach, and treatment options for acromegaly are shown and discussed.
MED-13. Bilateral Adrenal Hemorrhage Associated with Essential Thrombocytosis.
Krishna Pachipala and David Gutnecht. Geisinger Medical Center, Danville, PA.
Background: A 78-year-old male with a history of essential thrombocytosis, who was on chronic anagrelide therapy, presented with a 3-day history of malaise, poor oral intake, abdominal and back pain, and diarrhea.
Methods and Results: Physical examination was positive for minimal central abdominal tenderness. The platelet count was 520,000. A CT scan of the abdomen was suggestive of bilateral adrenal hemorrhage and was confirmed by an MRI scan. An ACTH stimulation test confirmed adrenal insufficiency. A hypercoagulablity workup was negative. The patient improved with saline hydration and hydrocortisone treatment and was discharged on oral hydrocortisone. A follow-up CT scan of the abdomen was scheduled.
Discussion: Bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency. The signs and symptoms of adrenal hemorrhage are nonspecific with chest, back, flank pain, hypotension, fever, and electrolyte abnormalities. The diagnosis is difficult because of the nonspecific nature of the symptoms, which are frequently inseparable from those of the concurrent major illness. The diagnosis requires a high index of suspicion in a high-risk patient and can be confirmed by the CT of the abdomen. Once the diagnosis is suspected, steroid replacement therapy is instituted. Bilateral adrenal hemorrhage is usually secondary to meningococcal sepsis, antiphospholipid antibody syndrome, renal vein thrombosis, anticoagulant therapy, trauma, shock, surgical and medical stress, or the postoperative state. This patient did not have any of these usual risk factors for adrenal hemorrhage, but essential thrombocytosis is associated with hemorrhagic complications secondary to platelet hypoaggregation and dysfunction. These complications usually include gastrointestinal bleeding and epistaxis. A literature search had shown a single report linking essential thrombocytosis with adrenal hemorrhage.
Conclusions: Although bleeding is usually associated usually with very high platelet counts (>1,000,000), it is known to occur in patients with mild to moderate increase in platelet count. Our patient was already on treatment at the time of presentation and reducing the platelet count below 400,000 was seen as a way to further reduce hemorrhage risk.
MED-14. Breathing Easier Upside Down: A Case of Osler-Weber-Rendu.
Mary Ninan, MD, Nidal Boutros, MD, Miriam Parker, MD, and Paul King, MD. Atlanta Medical Center, Atlanta, GA.
Background: Internal Medicine was consulted for epistaxis, which occurred shortly after the initiation of heparin therapy in a 42-year-old female admitted to the Neurosurgical service with a left internal carotid occlusion. A hypercoagulable evaluation before admission was negative, and the patient's ICA occlusion was thought to be secondary to a carotid artery dissection.
Methods and Results: On further review, the patient was found to have had recurrent episodes of epistaxis, since adolescence as well as intermittent hematochezia. The family history was negative for a diagnosed bleeding disorder, although the patient's son and cousin also had frequent epistaxis. On physical examination, multiple telangiectasias of the patient's tongue were present, no bruising was seen. Laboratory findings revealed iron deficiency microcytic anemia, with a normal platelet count, normal bleeding time and high normal vw factor. A tentative diagnosis of Osler-Weber-Rendu (Hereditary Hemorrhagic Telangiectasia, HHT) was made. The patient had noted shortness of breath while seated, which was relieved in the supine position and while standing on her head in the practice of yoga. CXR demonstrated a nodular density of the right middle lobe; a subsequent CT scan of the chest revealed several pulmonary AV fistulas in the right middle and lower lobe, likely responsible for her sense of platypnea with accompanying orthodeoxia. EGD and colonoscopy demonstrated multiple telangiectasias. The patient underwent successful embolization of the pulmonary AVMs with improvement in her pulmonary symptoms. The concomitant diagnosis of ICA occlusion and HHT made anticoagulation impossible, and the patient was discharged only on iron supplementation and supplemental oxygen with pulmonary and neurosurgical follow-up.
Conclusions: HHT is an autosomal dominant disease. Two genetic defects has been identified, both involving proteins that bind to transforming growth factor-beta (TGF-B). These mutations impair blood vessel growth and repair resulting in generalized vascular dysplasia. HHT prevalence has been estimated to be 1/100,000; however, more recent studies have indicated it to be a more common disease. Diagnosis of HHT requires the presence of three of the four criteria: recurrent, spontaneous epistaxis, mucocutaneous telangiectasia, visceral lesions, and appropriate family history. This case reminds internists to consider HHT in the differential diagnosis of recurrent epistaxis as well as demonstrating the salient features of symptomatic pulmonary AVMs that can occur in this disease entity.
MED-15. Cockatiel Birds Causing Hypersensitivity Pneumonitis.
Seema Haq, MD, and Sadaf Saghier, MBBS, DOW. The University of Oklahoma College of Medicine, Tulsa, OK, and Medical College, Karachi, Pakistan.
Background: Hypersensitivity pneumonitis (HP) is an inflammation of the lung caused by the body's immune reaction to small air-borne particles.
Case Presentation: This was an interesting case of HP associated with interstitial lymphoplasmacytic infiltrate: A 60-year-old white woman presented with an 11-month history of progressive dyspnea and nonproductive cough. The patient had no history of respiratory illnesses. Social history indicated that she had Cockatiel birds for the past few years. Physical examination and laboratory tests revealed severe hypoxia (PO2 49) and peripheral cyanosis but no signs of infection. The patient had negative results for TB, Aspergillosis, Blastomycosis, Candida, Coccidial, and Histoplasmosis. Chest x-ray showed cardiomegaly with prominence of the pulmonary vasculature. BNP and serial cardiac enzymes were negative. Spiral chest CT showed noncardiogenci pulmonary edema with hyperplastic versus neoplastic lymphadenopathy. Open lung biopsy showed interstitial lymphoplasmacytic infiltrates without any evidence of lymphoma. In addition, the findings of patient's significant antibody titer to cockatiel bird droppings suggested HP. However, the pulmonary lymphocytic infiltrate seems less than that usually seen in lymphocytic interstitial pneumonitis. The patient was treated with albuterol/atrovent breathing treatments, oxygen, and steroids in the hospital, during which her respiratory distress resolved. The patient's house was professionally cleaned and the pet birds were removed. She was then discharged home in stable condition.
Discussion: Review of the literature shows that 6 to 15% of bird breeders may have HP. Prolonged and repeated exposures can lead to permanent lung damage, scarring, and significant disability.
Conclusions: a comprehensive environmental history and lung biopsy are required to establish the diagnosis. Treatment is mainly avoidance of exposure to the offending particles. With early diagnosis and prevention, prognosis is favourable.
MED-16. Coronary Artery Stenting in Patients with Left Ventricular Ejection Fraction Less Than 40%.
Farhan Aslam, MD, and James Blankenship, MD FSCAI. Geisinger Medical Center, Danville, PA.
Background: Patients with severe left ventricular dysfunction have poor long-term prognosis. Percutaneous coronary intervention (PCI) in these patients in the pre-stent era was associated with high in-hospital complication rates and high long-term mortality. Current PCI techniques may yield better outcomes.
Methods: Data on all patients with undergoing PCI at our institution from 7/01 to 6/03 were prospectively entered into the American College of Cardiolgy National Cardiovascular Data Registry. Patients undergoing PCI as primary therapy for acute myocardial infarction were excluded. Patients with ejection fraction (EF) less than 40% (n = 149) were studied. Follow-up was not possible in only 1 patient (a prisoner). Mean follow-up was 24 months (range, 6 to 42 months). Clinic and hospital records were used to confirm data obtained by telephone interview.
Results: Patients were male (75%), with multivessel coronary disease in 80%, previous PCI in 43%, previous coronary bypass surgery in 31%, and congestive heart failure in 33%. Mean left ventricular EF was 35 [+ or -] 10 (range, 15 to 40%). Angiographic and clinical success was achieved in all patients with no deaths, Q-wave myocardial infarctions, or emergency coronary surgery. At follow-up, 33% of patients reported chest pain since PCI, 26% had been hospitalized, 17% had repeat coronary angiography, 4% had intervention for in-stent restenosis, and 4% required coronary bypass surgery. Including those treated with repeat intervention, 90% of patients were alive and 85% had sustained clinical improvement at the time of follow-up. Of 17 patients who died, 9 (53%) were due to noncardiac causes. A parallel analysis of patients with left ventricular ejection fraction of 35% of less yielded nearly identical results.
Conclusions: Current PCI techniques produce excellent PCI success rates and short-term clinical results. Long-term mortality remains significant, at least in part due to noncardiac causes of death. Most survivors report that symptoms at follow-up are improved compared to symptoms before PCI.
Table 1. Clinical follow-up data Patients with Events from PCI until follow-up event Chest pain since PCI 49 (33%) Hospitalization 38 (26%) Repeat coronary intervention 27 (17%) In-stent stenosis 7 Different vessel 20 Coronary artery bypass surgery 6 (4%) Deaths 17 (11%) Congestive heart failure 6 Myocardial infarction 2 Noncardiac 9 Symptoms improved compared to before 125 (85%) PCI (patients)
MED-17. Evaluation of Melena with Surprise Findings of Plasmacytoma of Small Bowel.
Asma Ashraf, MD, and Marco Araneda, MD, UTHSCSA, Regional Academic Health Center, Harlingen, TX.
Background: The evaluation of epigastric pain and melena is usually straightforward with the cause usually identified by endosocopy. Persistent "red flag" symptoms such as melena despite a normal initial evaluation require an extensive assessment, which may require more invasion procedures. This report describes a case in which this resulting evaluation led to the surprising diagnosis of a rare entity.
Case: A 44-year-old man was evaluated on multiple occasions for complaints of epigastric pain and melena. He reported a 10-lb weight loss. He and no history of fever and night sweats. His laboratory test showed a normal chemistry panel, hemoglobin and hematocrit of 9.3 gm/dL and 28.1%, respectively. Upper and lower endoscopies were nonrevealing. A visceral angiogram was done that showed two masses arising off the superior mesenteric artery, each at left and right upper quadrant. He underwent segmental small bowel resection with primary anastomosis and excision of peritoneal lymph nodes. Neoplastic cells were found that were reactive with CD138 had monoclonal staining pattern for lambda-immunoglobulin light chains. No monoclonal protein was detected. Bone marrow biopsy showed mild erythroid and megakaryocytic hyperplasia and normal number and morphology of plasma cells. The findings support the diagnosis of plasmacytoma of small bowel.
Conclusions: Plasmacytoma are considered an uncommon variant of myeloma. These lesions often occur in younger individual, have a relatively good prognosis, and usually do not have an M component. Patient symptoms often reflect the location of plasmacytoma, which in this case resulted in both melena and pain. Although plasmacytoma of the small bowel has been reported, the authors are unaware of any cases presenting as melena; they believe that the critical aspect in this patient care was that a persistent evaluation is necessary in patients with unexplained "red" flag symptoms and in this case led to an unusual diagnosis.
MED-18. Foscarnet-Induced Penile Ulcerations in an Allogenic Stem Cell Transplant Patient.
Zakari Aliyu, MD. National Institutes of Health, Bethesda, MD.
Background: Foscarnet has been used for the treatment of cytomegalo virus (CMV) disease in HIV/AIDS and in peripheral stem cell transplant (PBSCT) patients with CMV disease. An unusual but potentially serious side effect of this drug is genital ulceration. Although several cases of penile ulceration related to foscarnet administration have been reported in patients with acquired immunodeficiency syndrome such reports in PBSCT/BMT patients are limited.
Case Report: A 26-year-old, uncircumcised male with history of acute myeloblastic leukemia day +52 after a mycloablative PBSCT was admitted with fever and positive blood cultures for methicillin-resistant Staphylococcus epidermidis. He was treated with vancomycin for 3 days but continued to remain febrile. He had a Hickman line that was removed; he became culture-negative but remained febrile. He underwent extensive workup for his fever including bone marrow aspirate and biopsy, lumbar puncture, and computer tomographic scans, all of which were negative. MRI of the brain was suggestive of nonspecific white matter lesions on the diffusion images, and the CSF culture was inconclusive for human herpes virus 6. He was started on intravenous foscarnet and given a donor leukocyte infusion. On day 8 of foscarnet therapy, he had three painful superficial linear penile ulcerations that healed with wet to dry dressing and application of petroleum jelly and topical antibiotic while continuing foscarnet therapy.
Conclusions: Foscarnet-induced penile ulcers are the result of direct skin irritation by the drug or to the concentration of unchanged drug in the urine. Penile ulceration is generally observed after 1 to 4 weeks of intravenous foscarnet therapy and is characterized as localized, painful, erythematous ulcerations. Uncircumcised males are at higher risk for this complication. Resolution of the ulceration occurs after withdrawal of foscarnet. Preventive measures include thorough cleaning of the glans and foreskin of the penis after each urination and application of barrier agents, eg, petroleum jelly.
MED-20. Guillain-Barre Syndrome and Acute Transverse Myelitis: Similar Yet Different.
Asma Khan, MD, and Mukta Panda, MD. University of Tennessee, College of Medicine, Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize clinical presentations of Guillain-Barre syndrome (GBS) and acute transverse myelitis (ATM) and to recognize the value of early diagnosis and role of MRI in ATM.
Case: A 47-year-old male was transferred from an outlying facility with the diagnosis of GBS for plasmapheresis. He was unable to move his lower extremities on awakening on the morning of presentation, with one episode of difficulty urinating. He denied fever. GI symptoms, or vaccinations. Physical examination revealed lower extremity flaccid paralysis, absent reflexes, decreased light touch until T-6, but no hyperemic band and palpable bladder. CSF showed only slightly elavated proteins. MRI of the head was negative. MRI of the spine showed increased signal intensity and diffuse edema in the T3-T5 segments of the spinal cord, findings characteristic for ATM (sensitivity 60%). Steroids were started with complete resolution of symptoms.
Conclusions: GBS is a common generalized postinfectious polyradiculoneuropathy. Symptoms include weakness, paresthesias, and diminished/absent reflexes. History of viral, Cjejuni infection, or vaccinations may be obtained. ATM is comparatively rare, classically follows enterovirus infection, and can occur after Mycoplasma, EBV, CMV, and HSV. Urinary retention is common with ATM. ATM affects motor and sensory neurons, unlike GBS, which involves demyelination of peripheral nerves. GBS typically affects upper and lower extremities, has a high incidence of affecting diaphragmatic respiration, and typically does not present with a clearly defined sensory level. ATM often presents with a distinct sensory level; however, respiratory involvement only occurs if the lesion is high in cervical spine. ATM is treated with high-dose steroids; GBS with plasmapheresis. Steroids have little to no affect on progression or outcomes of GBS. This patient presented with classic clinical findings of ATM, which were supported by MRI. Understanding the clinical differences between the two and the value of MRI imaging in ATM is crucial for initiation of early and appropriate management to prevent complications and enhance the possibility of complete recovery.
MED-21. Hypercalcemia-Induced Pancreatitis as an Initial Presentation of Renal Non-Hodgkin Lymphoma.
Asma Ahsraf, MD, and Brajesh Bhatla, MD. UTHSCSA-RAHC, Harlingen, TX.
Background: Hypercalcemia is a rare but established cause of acute pancreatitis. This usually occurs in patients with hyperparathyroidism or known malignancy. Although pancreatitis has been the initial manifestation of cancer, this usually occurs with a solid tumor. This report describes an unusual case of pancreatitis as the initial presentation of renal non-Hodgkin lymphoma.
Case: A 74-year-old female with diabetes mellitus presented with history of fatigue, vomiting, poor appetite, and low-grade fevers. She had altered mental status and epigastric pain. Her laboratory values showed WBC 4.9, Hb 10, Hct 30, and plt 104. Her albumin was 2.5 mg/dL. Amylase and lipase were elevated at 249 IU/L and 596 IU/L. Serum calcium level was 13.7 mg/dL and corrected to 14.9 mg/dL. BUN was elevated at 53 and creatinine was 2.7. She was admitted with acute pancreatitis. Ultrasound of abdomen revealed a left renal mass presumed to be a tumor. CT scan of the abdomen and pelvis confirmed the renal mass and a large para-aortic mass, most likely adenopathy, in the retroperitoneum. CT-guided needle biopsy was consistent with renal non-Hodgkin lymphoma.
Conclusions: This case was very instructive. Although the most common cause of hypercalcemia in hospitalized patients in cancer, it is not the most common cause of pancreatitis. After evaluation, the presence of a renal mass, it was most probable that this patient had renal cell carcinoma. This would be consistent with this individual's severe hypercalcemia. The finding of a non-Hodgkin lymphoma underscores the biological variability of this malignancy but was at variance with the usual presentation. Although hypercalcemia is seen in up to 15% of patients with non-Hodgkin lymphoma, it has not been reported to be associated with pancreatitis. This case emphasizes the need to evaluate abnormalities (in this case the hypercalcemia) and to definitely make a diagnosis so that appropriate therapy can be instituted.
MED-22. Incidence and Risk Factors for Development of Post-Transplant Diabetes Mellitus in Renal Allograft Recipients: A Single-Center Experience.
Nidhi Munshi and Mohanram Narayanan. Scott and White Hospital, Temple, TX.
Background: The development of de novo diabetes mellitus (DM) is a serious complication of solid organ transplantation. The literature is replete with variable incidence of this complication, ranging between 15 and 30%. Various factors including increased body mass index (BMI), specific immunosuppressive agents, and, most recently, hepatitis C, have been implicated in the pathogenesis of this condition.
Objectives: To retrospectively evaluate the incidence and risk factors for development of post-transplant DM in a database of renal transplant recipients at Scott and White Hospital.
Methods: IRB approval was obtained for the study. A computerized database was used to identify all persons who underwent a renal transplant at this institution between January 1997 and September 2004. This analysis included 131 adult renal allograft recipients without known glucose metabolism abnormalities who were transplanted at this institution between January 1997 to September 2004. Post-transplant DM was defined as the requirement for oral hypoglycemic agents or insulin for at least 6 months after diagnosis. Patients were analyzed for incidence and risk factors for development of post-transplant DM. The variables that
were evaluated included age, sex, BMI, race, lipid profile, immunosuppressive agents, and hepatitis C. The risk factors were analyzed by the multiple logistic regression technique. Using the variable selection methods, a model was established to predict the incidence of post-transplant DM in renal transplant recipients. Analyses were performed with SAS 8.02 software, and P values < 0.05 were considered statistically significant.
Results: Fifteen percent of patients had post-transplant DM. Increased age (58 vs 51 years, P = 0.0054), increase in BMI after transplant (33.5 vs 28.7, P = 0.0122), increased triglycerides at the time of transplant (213 vs 165, P = < 0.0222), positive family history of DM (72 vs 21%, P = 0.0325), and prograf (90 vs 20%, P = 0.0241) were associated with development of de novo DM after renal transplantation.
Conclusions: Advanced age (odds ratio = 1.082), increased BMI after transplant (odds ratio = 1.133), and increased triglycerides (odds ratio = 1.005) are positively associated with the development of post-transplant DM. Patients with a positive family history of DM (odds ratio = 4.030) have a fourfold increase in the development of post-transplant DM. Patients on prograf (odds ratio = 3.901) also have a fourfold increase in the development of post-transplant DM. Cyclosporine was observed to have a negative relationship with prograf, so we can expect patients on cyclosporine to have a lower chance of developing post-transplant DM than patients not taking cyclosporine.
MED-23. Insulin Therapy: Normalization of Blood Glucose, Superiority of the Calculating Insulin Pump.
Brenda Hoover, RN, CDE, Veronica Piziak, MD, PhD, and Yasir Yaqub, MD. Scott and White, Texas A & M, HSC, Temple, TX.
Background: Insulin pump therapy provides a means of normalizing blood glucose levels with basal/bolus therapy. Although the diabetes team may determine the basal rate, bolus therapy is dependent on the patient's ability to count carbohydrates, determine a correction factor for elevated glucose, estimate the insulin on board (IOB) and calculate the proper bolus. This data analysis was performed to determine whether a pump with an internal calculator would improve HbA1c and reduce episodes of hypoglycemia and ketoacidosis in compliant pump users.
Methods: The data were obtained from the Scott and White Endocrinology Quality Assurance database. Twenty-three patients were compared when using a noncalculating insulin pump and after 3 months on the Smiths Medical Cozmo insulin pump with internal calculators for carbohydrate/insulin ratio, insulin sensitivity, and IOB. Data were analyzed using a t test. End points were improvement in HbA1c, number of hypoglycemic episodes, and occurrence of ketoacidosis.
Results: There was a statistically significant improvement in HbA1c for the group as a whole (P < 0.05). Serious hypoglycemia was eliminated, as was ketoacidosis. Data will be presented graphically.
Conclusions: Even compliant patients on insulin pump therapy benefit from a pump that eliminates errors in calculations. Particularly, the addition of the IOB feature helps to prevent hypoglycemia, because patients frequently forget to estimate the effect of preveiously administered insulin.
MED-25. Lemierre Syndrome Following a Subcutaneous Neck Abscess.
Nagapradeep Nagajothi and Kalpana Raghunathan. Rosalind Franklin University/The Chicago Medical School, North Chicago, IL.
Background: Lemierre syndrome is characterized by septic thrombophlebitis of the internal jugular vein, anaerobic septicemia, and metastatic abscesses, commonly to the lungs caused usually by an initial oropharyngeal infection. Lemierre syndrome has been reported as a complication of oropharyngeal infections, mastoiditis, and otitis media. This report describes a case of Lemierre syndrome after a neck abscess secondary to skin popping in a patient with history of drug abuse.
Methods and Results: A 41-year-old male came to the hospital with a right-sided neck abscess after skin-popping of heroin. The patient had an incision and drainage of the neck abscess. Immediately after incision and drainage, the patient had respiratory distress and needed endotracheal intubation. A CT scan of the chest was suggestive of multiple septic emboli. A transesophageal echocardiogram was negative for vegetations. A CT scan of the neck with contrast revealed thrombosis of the right internal jugular vein. A diagnosis of Lemierre syndrome was made. The patient was treated with clindamycin and cefepime for 4 weeks and made an uneventful recovery.
Conclusions: This is the first reported case of Lemierre syndrome as a complication of a subcutaneous neck abscess. This case also highlights the importance of considering Lemierre syndrome as a source of septic emboli, as treatment with antibiotics effective against anaerobic bacteria is vital in these cases.
MED-26. Massive Pulmonary Embolism Presenting as Ascites.
Ankur Sheth, Belayneh Abate Abejie, Savio Reddymasu, and Eden Suguitan. LSU Health Science Center, Shreveport, LA, and Overton Brooks VA Medical Center, Shreveport, LA.
Background: Massive pulmonary embolism can cause acute right heart failure with subsequent elevated systemic venous pressure manifesting as hepatomegaly, ascites, and pedal edema. However, ascites as a cardinal presenting manifestation of pulmonary embolism is extremely rare. Cardiac ascites accounts for less than 3% of total cases of ascites, the majority of which are secondary to left heart failure. This report describes an unusual case of massive pulmonary embolism presenting with ascites.
Case: A 57-year-old man with history of hepatitis C antibody-positive presented with a 2-week history of worsening abdominal distention and discomfort. On examination, his blood pressure was 100/68 mm Hg, pulse rate was 87 beats per minute, and respiratory rate was 18 breaths per minute. Abdominal examination was positive for ascites. Stigmata of chronic liver disease were absent, and there was no pedal edema. Laboratory studies showed WBC count of 5,100 per cmm, INR of 1.1, total bilirubin of 0.6 mg/dL, serum ascitic albumin gradient less than 1.1, and normal liver enzymes. CAT scan of the abdomen showed unremarkable liver and moderate ascites. Doppler ultrasound of the liver revealed patent venous system without any thrombosis. Echocardiogram of the heart revealed normal left ventricular systolic function with severely dilated and hypokinetic right ventricle and PASP of 65 mm Hg. Subsequent CAT scan of the chest revealed bilateral pulmonary artery emboli at the bifurcation. The patient was treated with intravenous t-PA and heparin.
Conclusions: Ascites should be considered as a possible presenting manifestation of pulmonary embolism. Physicians should keep cor pulmonale in mind when they evaluate patients with unexplained ascites.
MED-27. Military TB: An Old Scourage Revisited.
Maryam Saeed, Priyanka Nellori, MD, Ismail Jibrin, MD, and Kenneth Walsh, MD. Infectious Diseases, St. Agnes Healthcare, Baltimore, MD, and Johns Hopkins University, Baltimore, MD.
Background: Miliary tuberculosis is a difficult clinical diagnosis that requires early identification to ensure the best outcome. A rare disease in United States, if left untreated reaches a mortality rate of 100%. Its reported incidence is as low as 1% of all TB cases. The immune status of the patient might influence the diagnosis of miliary TB. This report describes a patient in an immunocompromised state in whom all initial screening for TB was negative but was found to have miliary tuberculosis.
Case: An 80-year-old black retired truck driver and ex-smoker with a history of treated prostate cancer and immunosuppressive therapy of a spinal mass presented with weakness, weight loss, and dry cough for a few weeks. Physical examination was benign except for wasting and decreased breath sounds in the left lower lobe. Chest x-ray revealed multiple small pulmonary nodules with the characteristic miliary pattern. Laboratory data, repeated acid fast bacilli smears from sputum, bronchoalveolar lavage, and pleural biopsy all proved to be negative, except for positive mycobacterium tuberculosis cultures, which were confirmed by DNA probe studies. Empiric antitubercular therapy was initiated with marked improvement in the patient's condition.
Conclusions: Miliary tuberculosis is the hematogenous dissemination of Mycobacterium tuberculosis and is an uncommon disease. The radiographic presentation can mimic malignancy. The importance of appropriate testing to diagnose this condition as early as possible is necessary due to its high mortality rate. Findings are smear-negative and culture-negative in 80% of patients because of hematogenous spread. In addition, immunosuppression leads to false-negative PPD results quite often. Therefore, strong clinical suspicion should guide initial empiric therapy pending cultures, to prevent fatalities. Therapy consists of the four-drug treatment with ethambutol, pyrazinamide, isoniazid, and rifampin for 2 months, followed by 6 months of isoniazid and rifampin alone.
MED-28. Mycoplasma pneumonia Associated with Hemolytic Anemia, Cold Agglutinins, and Recurrent Arterial Thrombi.
Eduardo Menjivar, MD, Michelle L. Wilson, DO, FACP, FABHP, Viswanath Kalapatapu, MD, Alfred P. Hand, MD, James Garber, MD, and Mike Ruiz, MD, Department of Internal Medicine Education, Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah, GA.
Background: This report describes an extremely rare case of an adult with Mycoplasma pneumoniae pneumonia who had development of recurrent arterial thrombosis.
Description: A 40-year-old white male came to our hospital and was diagnosed with M pneumoniae pneumonia (IgM titer 1:256); also, he had autoimmune hemolytic anemia due to cold agglutinins (titer of 1:512). Initial treatment included ceftriaxone, azithromycin, and enoxaparin as DVT prophylaxis. Four days after admission, he developed an acute abdomen and was brought to the OR. Four feet of ischemic small bowel was resected from the distal jejunum to 10 cm from the ileocecal valve. A follow-up angiogram revealed a superior mesenteric artery (SMA) thrombus with adequate collateral flow, a left popliteal artery thrombosis, and small bilateral renal cortical infarcts. The patient was returned to the OR and underwent an SMA and popliteal thrombectomy. The following day he redeveloped a left popliteal thrombosis, which required repeat thrombectomy. At this point he was started on plasmapheresis, coumadin, and prednisone. No further thrombotic events occurred. A workup for hypercoagulability was performed and was negative. Pathology samples revealed vasculitis in both the SMA and popliteal arteries. Based on the presence of a strong immunologic response (cold agglutinin titer; 1:512), this led us to conclude that this was an autoimmune mediated vasculitis. The patient recovered fully with no long-term sequela.
Discussion: Infections with M pneumoniae are well known to cause vascular abnormalities. Based on a negative hypercoagulability workup, nonrecurrence of thrombotic events after treatment, and in the absence of any structural abnormalities of the affected arteries, an autoimmune phenomenon with damage to the endothelium is thought to have played a role in underlying mechanism for thrombosis.
Conclusions: Such manifestations of Mycoplasma Pneumoniae can present a diagnostic and treatment challenge that clinicians need to be aware of.
MED-29. Paradoxical Bronchospasm: A Potentially Life-Threatening Adverse Effect of Albuterol.
Kalpana Raghunathan and Nagapradeep Nagajothi. Rosalind Franklin University/The Chicago Medical School, North Chicago, IL.
Background: Although albuterol is an effective bronchodilator, paradoxical bronchospasm is an adverse effect of albuterol that can be life-threatening.
Methods and Results: An 80-year-old male admitted for COPD exacerbation continued to remain tachypnoec in spite of frequent treatments with nebulized albuterol and ipratropium and was transferred to the Intensive Care Unit (ICU). In the ICU, he reported increased shortness of breath with the albuterol treatments. The patient was given nebulized levalbuterol. Within minutes after receiving the levalbuterol, the patient's dyspnea worsened dramatically. There was very poor air entry on auscultation and the patient was desaturating inspite of being on a nonrebreather mask. Subcutaneous epinephrine and intravenous methyl prednisolone were given immediately, and the patient responded very well. Albuterol was discontinued. The patient improved clinically and was discharged home 3 days later. He has been stable on ipratropium and salmeterol.
Conclusions: The mechanism for paradoxical bronchospasm secondary to albuterol has not been completely understood. Proposed mechanisms include bronchospasm secondary to the vehicle or preservative such as sulfites and benzalkonium chloride added to the albuterol and the presence of the S-isomer in racemic preparations of albuterol. This patient had bronchospastic response to nebulized levalbuterol, which does not contain the S-isomer of albuterol or preservatives. This is the first reported case of paradoxical bronchospasm to levalbuterol. Awareness of this adverse effect of albuterol can be lifesaving.
MED-30. Prescription Drug Dependence Among Healthcare Professionals.
Ronald J. Dougherty, MD, FAAFP, ASAM. Tully Hill Chemical Dependency Treatment Center, Tully, NY.
Background: Although the pharmaceutical market doubled its income to $145 billion between 1996 and 2000, the painkiller market tripled to $1.8 billion over the same period of time. During the same period of time, the incidence of reported first-time abuse of narcotics has also surged. The majority of these drugs are not new but been utilizing the pharmaceutical companies to promote their use. ER visits involving hydrocodone (Vicodin, Lortab) jumped from 6,100 incidents in 1992 to 14,000 in 1999. From 1965 to 2000, benzodiazapines, including Rohypnol, which is still illegal in the United States, jumped from a few hundred to 750,000.
Discussion: Drugs such as Xanax, generic formulations, increased from 16,500 to more than 20,500. During this same period of time, illegal drugs increased in higher numbers such as cocaine from 120,000 to 169,000 and heroin from 48,000 to 84,400. In 1998, roughly 1.6 million people in the United States used prescription narcotics nonmedically for the first time. This represents a fourfold increase from 1980. In 2000, roughly 2 million people in the United States used prescription narcotics nonmedically for the first time. Tully Hill Alcohol and Drug Treatment Center is a free-standing, inpatient facility located 15 miles south of Syracuse, NY. The facility provides detoxification, inpatient treatment, day treatment, and outpatient services to a population drawn primarily from within a 90-mile radius of this facility. Of the 1,324 admissions in 2001, 2002, and 2003, 117 were admitted for prescription drug dependence, primarily hydrocodone compound. Among the 117 admissions, there were 52 health care professionals. These included 10 pharmacists, 26 nurses, 8 dental professionals, 6 physicians, 1 veterinarian, and 1 OR technician. Of the 117, 61 were addicted to hydrocodone (Vicodin, Lortab), 27 to Oxycodone/OxyContin, 6 to morphine, 9 to Demerol, 6 to versed/fentanyl, 1 to Tylenol No. 4, and 1 to injectable Demerol/Roxanol. Of the group, all but two who became addicted to their particular opioid was a consequence of being treated for various pain syndromes. All but four had lost their licenses to practice their profession in New York State.
Conclusions: Of those who stayed in the program and stayed on the Naltrexone in conjunction with the 12-Step Program, all but two were still clean and sober 6 months to 1 year later.
MED-31. Pulmonary Nocardiosis as Initial Presentation of Acquired Immunodeficiency Syndrome (AIDS).
D. Sula, R. Dhawan, C. Liendo, and R. Penn. Section of Infectious Disease, Section of Pulmonary and Critical Care, Department of Medicine, Louisiana State University Health Sciences Center and Overton Brooks VA Medical Center, Shreveport, LA.
Case: A 48-year old, previously healthy male was evaluated for a 2-month history of anorexia, weakness, weight loss, productive cough, low grade fever, and night sweats. Four days before admission, he had episodes of hemoptysis, pleuritic chest pain and sore throat. He reported tuberculosis exposure 5 years ago without any evaluation. Pertinent physical findings revealed a temperature of 100.3[degrees]F, oral thrush, and bronchial breath sounds in the left lung. Chest radiograph showed consolidation in the left lower lung field and CT of the chest revealed mass-like opacification involving multiple segments of the left lower lobe. Sputum examination for acid-fast bacilli, tuberculin skin test, blood, and urine cultures were all negative. Bronchoscopy revealed Candida albicans pharyngitis. Transbronchial biopsy showed diffuse acute and chronic inflammation with early granulomas. Bronchial brushings revealed Gram-positive filamentous forms and a partial acid-fast stain yielded slender branching filaments identified as Nocardia asteroides. Cranial CT scan was negative. Elisa and Western blot HIV tests were positive, and the CD4 count was 77 cells/[mm.sup.3].
Conclusions: Nocardia are saprophytic, weakly acid-fast aerobic organisms belonging to the order of Actinomycetales. Infection is acquired through inhalation or percutaneous inoculation. It commonly affects immunocompromised patients, 17% of whom have hematological or solid organ malignancies, 13% are organ transplant recipients, and greater than 50% are receiving steroids. However, this infection has an incidence rate of only 0.19 to 2.0% in patients with HIV and is not an indicator disease in the current definition of AIDS. This may be partly due to the use of TMP-SMX for Pneumocystis jiroveci pneumonia prophylaxis in patients with CD4 count below 200 cells/[mm.sup.3]. As this case indicates, a primary diagnosis of Nocardiosis warrants further evaluation for immunosuppressive disorders, including HIV.
MED-32. Pure Red Cell Aplasia (PRCA) Associated with Nodal Marginal Zone Non-Hodghkin Lymphoma (NMZL) and Viral Hepatitis C.
Wilber Estrada, MD, and Jose Mendoza, MD. University of Virginia, Roanoke-Salem Program.
Background: Pure red cell aplasia (PRCA) is a rare condition that has been reported in association with malignancy, viral infections, autoimmune diseases, or idiopathic. However, PRCA in association with non-Hodgkin lymphoma (NHL), especially marginal zone lymphoma (NMZL), is uncommon. To the best of our knowledge, there has not been a case report on PRCA associated with NMZL. PRCA and NHL have been separately associated with hepatitis C viral infection (HCV), with very few cases reported in the medical literature. This report describes a patient with PRCA who had a positive antibody against HCV and recent diagnosis of NMZL.
Methods and Results: A 52-year-old black male presented with severe anemia and acute renal failure. Medical history reveled multiple medical problems and polysubstance abuse. His physical examination disclosed an obese black male with significant bilateral axillary and left supraclavicular mobile nodes, ranging in size from 2 X 2 to 4 X 5 cm. His laboratory data showed marked anemia with a Hct. Of 15.5%, absence of reticulocytes, and normal leukocyte and platelet count. SPEP showed oligoclonal bands characterized by IgG kappa light chain, Ig M kappa light chain, and a small IgA kappa light chain. Excisional biopsy was pursued, which showed marginal zone B-cell lymphoma, confirmed by immunohistochemical studies.
Conclusions: The presence of PRCA in patients with neoplasms other than thymoma is rare. The association between viral hepatitis C infection and PRCA is suggested by multiple case reports found in the medical literature. There also seems to be a link between viral hepatitis C infection and the development of certain types of MZL. A Pubmed search was performed and no link between NMZL and PRCA was found. This case suggests that hepatitis C viral infection may play a role in the development of PRCA in cases in which an association with a lymphoproliferative disorders exists.
MED-33. Pyoderma Gangrenosum in a Patient With Systemic Lupus Erythematosus, Negative Lupus Anticoagulant, and Autoimmune Hepatitis.
Joshua T. Evans, MD, Dwight I. Blair, MD, Edwin A. Smith, MD, and Faye N. Hant, MD. Medical University of South Carolina, Department of Internal Medicine, Charleston, SC.
Background: Lower extremity ulcers are very common and have a wide array of causes. Pyoderma gangrenosum (PG) is an idiopathic ulcerating condition often associated with underlying disease, including connective tissue disease. However, PG is uncommon and a confident diagnosis requires a high index of suspicion in the correct clinical context. This report describes the case of a 43-year-old female patient with systemic lupus erythematosus (SLE) and autoimmune hepatitis presenting with severe, advanced lower extremity ulcers.
Methods and Results: After extensive investigation, including vascular studies, laboratory tests, and skin biopsy, a diagnosis of PG was made. Her lesions progressed rapidly, requiring pulse dose steroids, cyclophosphamide, and split-thickness skin grafting. Approximately half of all cases of PG are associated with systemic illness, but reports of PG associated with SLE in the absence of the antiphospholipid antibody syndrome are sparse, as are reports of PG in patients with autoimmune hepatitis.
Conclusions: This report briefly reviews PG as a diagnosis of exclusion and discusses the studies necessary to exclude other causes of lower extremity ulcers that may present similarly.
MED-34. Recurrent DVT in a Patient with Inherited Thrombophilia.
Jennifer A. Dowalter, MD, and Kaveh Ehsanipoor, MD, FACP, FACE. Department of Internal Medicine Education, Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center in Savannah, GA.
Background: Inherited thrombophilia is a genetic tendency to recurrent venous thromboembolism that usually presents in young patients. The most frequent causes are factor V Leiden, prothrombin gene mutation, defects in protein S, protein C, antithrombin III, and certain dysfibrinogenemias.
Case Report: A 45-year-old white male, a type I diabetic, presented for diabetic management. History indicated recurrent DVT and superficial blood clots since 17 years old. No workup was done.
Methods and Results: His last DVT was treated with heparin, but he developed heparin-induced thrombocytopenia. He was currently on no therapy. Family history was positive for DVT. Protein C and S, anti-thrombin III activity, Factor V Leiden, prothrombin gene mutation, as well as anti-phospholipid antibodies were measured. Factor V Leiden was positive for R506Q mutation and protein S activity was low.
Discussion: The most common presentation of inherited thrombophilia is DVT. Pulmonary embolism is a common and feared complication of DVT; therefore patients should be evaluated for inherited thrombophilia. Factor V Leiden and prothrombin gene mutation account for 50 to 60% of inherited thrombophilia. The rest is accounted for by protein C, protein S, and antithrombin deficiency. A second thrombotic defect can occur among patients with any of the causes of familial thrombophilia, particularly factor V Leiden. Carriers of two defects are at a higher risk for thrombosis than those with single defect.
Conclusions: Recurrent DVT in a young patient with no known acquired risk factors warrants screening for inherited thrombophilia. Factor V Leiden is the most common defect, but combination of other defects is not uncommon. Patients with inherited thrombophilia with recurrent venous thrombosis need to be treated with anticoagulant, perhaps for life.
MED-35. Saw Palmetto-Induced Acute Hepatitis and Pancreatitis.
Jibrin Ismaila, Ayodele Erinle, and Zakari Aliyu. St. Agnes Hospital, Baltimore, MD, and National Institutes of Health, Bethesda, MD.
Background: Saw palmetto is a frequently used botanical agent in benign prostatic enlargement (BPH). Its safety and efficacy has not been fully determined. We report a case of a probable Saw palmetto-induced acute hepatitis and pancreatitis.
Case Report: A 55-year-old white male with a remote history of alcoholism, sober for greater than 15 years, and no history of cholelithiasis presented with severe nonradiating epigastric pain associated with nausea and vomiting. His only significant comorbidity is BPH for which he takes saw palmetto for about 4 years. Physical examination revealed normal vital signs, tender epigastrium without guarding or rebound tenderness. Cullen and Gray Turner signs were negative. Complete blood count and basic metabolic profile were normal. Additional laboratory values include a serum amylase: 2,152 mmol/L, lipase: 39,346 mmol/L, serum triglyceride: 38 mmol/, AST: 1265, ALP = 1,232, and ALP = 185. Urinalysis, toxicology screen, and cardiac enzymes were unremarkable. Abdominal ultrasound and magnetic resonance cholangiography revealed sludge without stones in the gallbladder or billiary tract. A hepatic indole diacetic acid scan was negative. The sSaw palmetto was held and he was treated accordingly. He improved remarkably with complete normalization of his serum enzymes by the fourth day of hospitalization. Two similar episodes of improvements followed by recurrence were noted with discontinuations and reinstitution of saw palmetto.
Conclusions: Medical drug-induced hepatitis is a relatively common phenomenon. This can be dose-dependent, allergic, or idiosyncratic in nature. The outcome of drug-induced hepatitis may be self-limiting or fatal. Herbal drug-induced hepatitis is, however, poorly defined due to the inadequate monitoring of these drugs and patients not volunteering information on the use of these agents. As the use of herbs, notably saw palmetto, increases, it is prudent to recognize its potential association with acute hepatitis and pancreatitis and counsel consumers accordingly.
MED-36. Sick Cell Syndrome.
Savio Reddymasu, Joan Blondin, and Mandeep Sing. LSUHSC, Shreveport, LA.
Background: A 64-year-old white female with diabetes and COPD was admitted to the ICU with bilateral pneumonia and hyponatremia.
Methods and Results: Laboratory work revealed a WBC count of 17,000 with 23% bands; sodium was 114 mEq/L; blood sugar was 491 mg/dL, BUN was 12 mg/dL, creatinine was 0.8 mg/dL, and anion gap was 15. Serum osmolality was 294 mOsm/kg. Calculated osmolality was 259, yielding an osmolar gap of 35 (normal <10); total protein was 7.5g/dL, serum ketones were negative; lactate was 0.5; total cholesterol was 136 mg/dL; and triglycerides were 137 mg/dLl. Methanol, ethanol, and paraldehyde levels were normal. The patient's osmolar gap and hyponatremia improved simultaneously as her clinical condition was treated, suggesting the diagnosis of sick cell syndrome. Osmolar gap is considered significant when the difference between the measured and calculated osmolarity is greater than 10 mOsm/kg. Common causes of increased osmolar gap are methnol, ethanol, paraldehyde, ketosis, hyperlipidemia, and paraprotenemia. In diabetics with high blood sugars, polyols could also contribute to increased osmolar gap. Some critically ill patients, as this one, have an unexplained osmolar gap thought to result from escape of osmotically active intracellular solutes into extracellular fluid secondary to increased membrane permeability. This may lead to "redistribution hyponatremia" and an increased osmolar gap. This concept has been called sick cell syndrome. This has been described in a variety of human diseases such as traumatic shock, diabetic ketoacidosis, lactic acidosis, and multiple organ failure. The nature of these solutes is unknown. Some animal studies identify these solutes as lactic acid, ketone bodies, or amino acids. Other studies have used the initial osmolar gap as a predictor of the severity of illness.
Conclusions: Correction of osmolar gap and hyponatremia simultaneously as the primary illness is treated is the hallmark of sick cell syndrome. Hence, calculating the osmolar gap in critically ill people may be helpful. Sick cell syndrome is suggested only when other causes for increased osmolar gap are excluded.
MED-37. Sickle Cell Crisis: Lesson of the Times.
A. Sequeira, D. Sula, J. Nijjar, C. Mitchell, and R. Penn. Section of Infectious Disease, Department of Medicine. Louisiana State University Medical Center, Shreveport, LA.
Case: A 25-year-old black female with sickle cell disease was admitted with a 1-day history of pains around her knees and elbows, typical of prior episodes of pain crisis. She denied having sore throat, fever, chills, headache, or sick contacts. Physical examination was remarkable for an afebrile patient with diffuse tenderness around her elbows and knees with no evidence of erythema, effusion, or synovitis. The next day, she developed a fever of 103[degrees]F and a leukocytosis (19,000/[micro]L) that persisted. Evaluation revealed a normal chest radiograph, repeatedly negative blood and urine cultures, negative bone scan, and a negative throat swab for streptococci. Transthoracic echocardiogram did not reveal vegetations. Doppler ultrasound of the lower extremities failed to reveal thrombosis. She had no response to broad spectrum antibiotics. Further evaluation revealed that she had not been vaccinated against influenza, and the number of documented influenza cases was increasing in the community. Throat gargle specimen was positive for influenza virus type B. She was placed in respiratory isolation, and antibiotics were stopped. Over the next 2 weeks, she became normothermic and her pain crisis resolved.
Conclusions: Infections are known to precipitate a crisis in sickle cell patients. These patients are routinely vaccinated against certain bacterial and viral agents to decrease morbidity. Our literature search leads us to believe that this is the first reported case of influenza virus precipitating a crisis in an adult sickle cell patient. In addition, this patient did not have the classic presentation of influenza. The pain crisis may have masked the manifestations of influenza and delayed its diagnosis. This case emphasizes that influenza should always be considered early in the work up during the flu season to prevent unwarranted use of antibiotics and costly diagnostic testing.
MED-39. Sulfonylurea-Induced Factitious Hypoglycemia.
Brian Purdie, MD, and Than Win, MBBS, FACP, Department of Internal Medicine Education, Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah, GA.
Background: Factitious hypoglycemia is caused by surreptitious use of insulin or insulin secretagogues. We report a case of hypoglycemia due to factitious use of a sulfonylurea, glyburide.
Case Report: A 42-year-old ex-dialysis technician with history of depression presented to the emergency department for the third time in 4 weeks for headache, shaking, sweating, and near syncope for 2 days. Physical examination was normal. Her plasma glucose was 49 mg/dL and documented as low as 27 mg/dL. Plasma glucose levels from recent weeks were normal. Aggressive intravenous fluids were required to keep plasma glucose levels within normal limits during her initial 48 hours of hospitalization, with a gradual return to euglycemia. The patient was not diabetic but had abused insulin from a relative 5 years ago. However, she denied ever doing it again this time. Plasma insulin was 242 uU/mL (< 17) and C-peptide was 19.3 ng/mL (0.08 to 3.1), with simultaneous blood sugar of 37 mg/dL. CT scan of pancreas was normal. Once blood glucose level was normal, the patient had normal fasting blood sugar, plasma insulin, and C-peptide level after a 12-hour fast. Serum sulfonylurea screen returned positive for glyburide, at 0.12 [micro]g/mL (0.08).
Discussion: Major differential diagnoses were insulinoma and surreptitious use of insulin secretagogues. Plasma insulin in insulinoma is usually less than 100 [micro]U/mL. Very high plasma insulin and positive sulfonylurea screen confirmed surreptitious use of sulfonylurea.
Conclusions: This case illustrates surreptitious use of insulin secretagogues to induce hypoglycemia. Screening for sulfonylurea should be performed at admission, especially in patients with very high plasma insulin level. It might otherwise lead to unnecessary, expansive and potentially invasive workup for insulinoma and other rare causes of hypoglycemia. Should the patient have had surreptitious use of newer secretagogues such as repaglinide and meglitinide, it would have required additional laboratory testing.
MED-40. Temperate Pyomyositis in an Immunocompetent Patient.
Ashok K. Kondur, MD, and Sumanth R. Daram, MD. Department of Internal Medicine, Jasonville Medical Center, Terre Haute, IN, the Department of Internal Medicine, Saint Joseph Regional Medical Center, Milwaukee, WI, and Medical College of Wisconsin, Milwaukee, WI.
Background: Pyomyositis is an abscess-forming bacterial infection of skeletal muscle. It is more common in the tropics [tropical pyomyositis] but now seen with increasing incidence in temperate countries including the United States [temperate pyomyositis]. We describe the case of a 36-year-old intravenous drug user in whom acute Staphylococcal pyomyositis developed in the absence of HIV infection and other predisposing factors.
Case History: The patient was admitted to the hospital with a 5-day history of fever and severe right sided low back pain. Physical examination was remarkable for tenderness in the right paraspinal area corresponding to the L2-S1 vertebrae. Plain films of the lumbosacral spine were unremarkable. Magnetic resonance imaging of the lumbosacral spine revealed inflammation and muscle edema, a finding highly suggestive of the initial stage of pyomyositis. Blood cultures grew methicillin-sensitive Staphylococcus aureus. Intravenous nafcillin therapy was instituted.
Discussion: Pyomyositis is very uncommon in the United States, with only about 100 cases being reported until the early 1990s. Pyomyositis is rare but well documented in injection drug users. The cause of pyomyositis remains unclear. This disease may give rise to obscure, nonspecific, or misleading signs and symptoms. The diagnosis of pyomyositis requires a high degree of clinical suspicion. Therefore, pyomyositis should be considered and evaluated with computerized tomographic or magnetic resonacc imaging of the affected area in injection drug users presenting with muscle pain, fever, and swelling.
Conclusions: Physicians need to recognize this potentially life-threatening but easily curable disease.
MED-41. Veillonella, an Uncommon Pathogen Involved in Vertebral Osteomyelitis.
Farhan Aslam and Ayoub Mirza MD. Geisinger Medical Center, Danville, PA.
Objectives: Vertebral osteomyleitis is primarily a disease of adults usually after 50 years of age. Common causative organisms are Staphyloccocus aureus, group B streptococci, and Gram-negative bacilli. Veillonella is an anaerobic Gram-negative cocci that is part of normal flora of mouth, nasopharynx, and intestine. It is usually isolated in polymicrobial anaerobic infection but rarely a sole cause of infections. This report describes a case of vertebral osteomyelitis caused by Veillonella.
Case Information: A 72-year-old female was admitted to our tertiary care center with 4 months history of fever and progressively increasing midline lower back pain, associated with numbness and tingling in left lower extremity. Physical examination revealed normal vital signs, significant spinal tenderness at the level of L1-2 vertebral area. Neurological examination of bilateral lower extremities was intact and straight leg rising test was negative. White cell count was elevated. The patient was empirically treated with intravenous ceftrioxone. The patient subsequently underwent surgery with L1-2 anterior lumbar corpectomy and 1 week later posterior spinal fusion. Vertebral tissue culture grew moderate veillonella species sensitive to metronidazole. Antibiotic therapy was changed to metronidazole. She continued to feel better with good pain control and without any fever and chills and was discharged home on 8 weeks therapy of metronidazole.
Discussion: Veillonella species are group of small anaerobic Gram-negative cocci that are part of normal flora of the mouth, nasophararynx, and the intestine. It is usually isolated in polymicrobial anaerobic infection but rarely a sole cause of infections. Vertebral osteomyelitis is usually caused by Gram-positive cocci and Gram-negative bacilli. Veillonella as the sole cause of vertebral osteomyelitis is rare. In this patient, it was the only isolated organism from vertebral tissue culture.
Conclusions: This case demonstrates that in treating vertebral osteomyelitis, empirical antibiotic therapy should cover atypical organisms such as veillonella.
MED-42. Water Aerobics to Immobility: A Case of Acute-Onset Anterior Spinal Artery Syndrome.
Lola Famakinwa, MD, Ganesh D. Kini, MD, PhD, Jeri M. Lantz, MD, R. Allen Blackwood, MD, and Bashir K. Ahmad, MD. Department of Internal Medicine, University of Virginia Roanoke-Salem Program, Roanoke, VA, and the Roanoke Neurological Center, Roanoke, VA.
Background: a 73-year-old white woman presented with lower extremity weakness, inability to ambulate, and incontinence of bladder and bowel of few hours' duration, after bending over to pick up an object from the floor. Before this, patient was in excellent health, participating in water aerobics 3 times weekly. Initial symptoms included tingling in her legs. Within hours, this progressed to flaccid paralysis of lower extremities, urinary and bowel incontinence, loss of temperature sense. Position and vibration sense were preserved.
Data: MRI thoracic spine showed abnormal signal intensity in the distal spinal cord at T10 to T12, which was suspicious for an infarct. CBC, BMP, PTT, and INR were normal. Lipid panel revealed elevated LDL. Other workup included transthoracic echocardiogram, abdominal ultrasound, lumbar puncture for cell count, cytology, lyme titer, CRP, antiphospholipid antibodies and Factor V Liden, which were all unremarkable. Exact cause for this syndrome in this patient was not confirmed, but common possible causes were excluded. She was started on decadron 10 mg IV bolus and then 4 mg IV every 6 hours, aspirin, and plavix. Aggressive physical therapy was also initiated. She showed some improvement in muscle strength 7 days after initial presentation but continued to be incontinent of stool and urine.
Conclusions: Prognosis for complete recovery was discussed with her. Details of this case including discussion of this syndrome will be presented.
Section on Neurology
NEURO-2. Longitudinal Myelopathy Associated with Sero-Negative Systemic Lupus Erythematosus: Clinical and Radiological Features.
R. Thiagarajan and M. Sundaram. Department of Neurology, University of Mississippi Medical Center.
Background: Acute myelopathy is a rare complication of systemic lupus erythematosus (SLE). Three patients with myelopathy as the initial SLE manifestation are described. They presented with acute paraparesis and urinary incontinence with cervical sensory level. Antinuclear antibody titers ranged from 1:80 to 1:320. Cerebrospinal fluid analysis showed increased protein and mononuclear pleocytosis in two cases and was normal in the third patient. Extensive workup for other neurological and systemic causes was negative. MRI of the spine showed increased signal intensity in T2-weighted images, cord swelling, and contrast-enhancement involving several cervical and thoracic segments ("longitudinal myelitis"). All three patients received high-dose intravenous corticosteroids, two received additional IVIG, and one was given azathioprine. Although the MRI abnormalities improved, the clinical outcome was uniformly poor and all patients remain totally paraplegic at follow-up. One patient initially showed improvement but had several relapses during follow-up.
Conclusions: Acute myelopathy associated with sero-negative SLE carries a poor prognosis and does not appear to respond to immunosuppressive therapies.
NEURO-3. Neuroleptic Malignant Syndrome (NMS) or Lethal Catatonia? Two Shots, One Arrow: Benzodiazepines.
Supriya Mannepalli, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga. TN.
Objectives: To appreciate similarities/differences between NMS and lethal catatonia and to recognize the common link in their treatment with benzodiazepines.
Case: A 35-year-old female with history of schizoaffective disorder transferred from a psychiatric facility unresponsive after a period of acute psychotic excitement was studied. Medications included geodon, depot prolexin, and seroquel. She was hyperthermic, tachycardic, tachypneic, and diaphoretic, with increased muscle rigidity. Laboratory values showed elevated CPK, prolactin, leukocytosis, increased CSF protein and negative cultures, and CT/MRI/EEG negative. The patient was treated with dantrolene, bromocriptine, with minimal change. On day 9, ativan 2 mg was given. In 10 minutes, the patient was alert/oriented. Scheduled ativan was continued. The patient was ambulating in 6 days.
Discussion: There has been a long-standing discussion of whether NMS is an iatrogenic type of lethal catatonia or a separate entity. Catatonia is characterized by negativism, mutism, stereotypy, posturing, and muscular rigidity. Although the use of antipsychotics has nearly eradicated lethal catatonia, it has led to the emergence of NMS. NMS usually presents with severe muscle rigidity and alterations in mental status.
Conclusions: Lethal catatonia has a prodrome of psychotic excitement progressing to fever, waxing muscular rigidity, and exhaustion. The cardinal difference in these syndromes is in their treatment: Lethal catatonia requires introduction of neuroleptics, NMS requires their discontinuation as well as treatment with bromocriptine, amantidine, and dantrolene. However, benzodiazepines can be used in both syndromes. Therefore, in situations when differentiating between NMS and lethal catatonia is difficult, introducing benzodiazepines in addition to other modalities of treatment at the onset of treatment is recommended.
Section on Occupational and Environmental Medicine
OEM-1. No Poinsettia This Christmas.
Tripura Mantha Bala, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.
Objectives: To educate health personnel regarding the cross reactivity between latex allergy and Poinsettia plant.
Case: A 50-year-old white female was admitted to the hospital during December 2004 for evaluation of syncope. She had history of latex allergy and continued to be in a latex-free environment during hospitalization. On her second day of hospitalization, her friend brought her a basket of Poinsettia. The next morning she developed diffuse macular rash more prominent on the right side of neck and arm. She also had itching and received a benadryl injection. She was not on any medication that could explain the rash. Because of her history of latex allergy, each object of the room was investigated, and an important fact about the cross-reactivity of latex and Poinsettia was learned. The plant was removed, and her symptoms improved.
Discussion: Poinsettia is widely used as an ornamental plant during Christmas season. The usual color is the red. Other colors are pink, white, or marbled. Poinsettias are native to Mexico. They were introduced into the United States in 1825 by Joel Poinsett. They are part of the Euphorbiaceae family, similar to natural rubber latex. Many plants in this family ooze a milky sap. There are at least two cross-reactive proteins in Poinsettia extracts that correspond to proteins in natural rubber latex. The prevalence of Poinsettia allergy is 40% of latex allergy individuals.
Conclusions: Latex-allergic individuals should be cautious with contact with Poinsettia plants, especially if the plants are crushed or damaged, since the exposure may result in severe allergic reaction.
OEM-2. Physician Wellness and Stress Management.
Shannon B. Moss, PhD, Patrick O. Smith, PhD, and W. Mel Flowers, Jr, MD. Departments of Family Medicine and Radiology. The University of Mississippi Medical Center and The Mississippi Professionals Health Committee of the Mississippi State Medical Association.
Background: Physicians are susceptible to stress and to substance abuse.
Discussion: Most states have professional health programs that address physician impairment. These programs are becoming proactive in education and prevention and are emphasizing health and wellness. Physicians are two times more likely to commit suicide than the general population. Suicide is the most common cause of death for young physicians. This educational exhibit addresses warning signs of physician impairment and sources of stress in the practice of medicine.
Conclusions: Sources of physicians' stress include the situational stressors sleep deprivation and difficult patients, personal stressors such as financial strain and family demands, and professional stressors such as career planning and increasing professional responsibilities. Physicians will do a better job attending to their patients' health care needs if they first take care of their own. Practicing wellness means being alert to early signs of impairment and engaging in positive behaviors. These include exercise, adequate sleep, healthy diet, self-care, time management, developing a social network, and observing proper hygiene. Practicing wellness also means effective time management, prioritization of goals, reducing multitasking at home, practicing assertive communication, and knowing when to say no. Leisure activities can be helpful. The physician should locate sources of stress, problem-solve, and attempt to implement change. Proper stress management also means seeking help when there are symptoms of impairment.
OEM-3. Sex, Drugs, Power, and the Practice of Medicine.
Gregory E. Skipper, MD, FASAM, and W. Mel Flowers, Jr, MD. FACR. Alabama Physician Health Program and Mississippi Professionals Health Program.
Background: The Alabama Physician Health Program (APHP) and the Mississippi Professionals Health Program (MPHP) promote early identification and assistance for physicians who may have a condition that could cause
impairment. These problems include mental or emotional illness, stress, depression, anxiety, substance abuse or dependence, inappropriate prescribing, ethical violations, age-related disorders, sexual boundary issues, and disruptive behavior.
Discussion: Education helps achieve our goals. Leaders of the two state programs have collaborated to produce this poster presentation, which explores some of these problems and points the way for a physician or colleague to receive confidential, effective, and compassionate assistance whenever it is needed. In this poster presentation, there is specific emphasis on sexual boundary issues, substance abuse and addiction, power discrepancies, and disruptive behavior.
Conclusions: The APHP and the MPHP belong to The Federation of State Physician Health Programs (FSPHP). The FSPHP has member physician health programs in every state in America, and these programs offer similar services. Physicians can be evaluated and treated without risk to their medical career. The success rate is very high. The APHP and the MPHP furnish advocacy to the Alabama Board of Medical Examiners and to the Mississippi State Board of Medical Licensure and advocate to malpractice companies, health insurers, colleagues, and employers. State Physicians Health Programs stand ready to help solve some difficult problems.
OEM-4. Study of the Past Helps Diagnose the Present and Prevent the Future.
Jasmine Shah, MD, and Mukta Panda, MD.
Objectives: To recognize the importance of occupational history and to understand the spectrum of asbestosis and its relation to coronary artery disease.
Case: A 57-year-old male, a welder for 26 years, presented with 1-year progressive shortness of breath, cough with clear sputum, and right pleuritic pain. He had a PCI with stent placement 4 weeks prior without improvement. Examination revealed bilateral diminished basal breath sounds with crackles. CXR showed multiple pleural-based opacities. Chest CT showed multiple pleural-based nodules with soft tissue calcified densities, bibasilar interstitial lung disease, no pleural effusion, and coronary artery calcification, findings confirmed on a prone HRCT suggesting asbestosis given his occupational exposure.
Discussion: Asbestosis caused by exposure to asbestos fibers has a varied spectrum of disease: benign pleural effusion, plaques, interstitial fibrosis, normal font for bronchogenic carcinoma, and malignant mesothelioma. Asbestos is widely used because of its pliability and extreme heat resistance. There is 10 to 40 years of latency between first exposure and symptoms. Asbestos fibers induce a local inflammatory reaction stimulating fibrosis. Diagnosis requires a history of exposure, adequate latency, and interstitial fibrosis. Asbestos bodies or fibers seen on BAL are only suggestive of exposure, not disease. There is some evidence that asbestos exposure increases fibrinogen levels and causes increased relative risk of CAD. Also, there is evidence that welders have a higher incidence of CAD than the general US population when adjusted for smoking and age. There is no definitive treatment.
Conclusions: Preventive and supportive measures are emphasized. Mainstay includes stopping exposure and smoking cessation for asbestosis and CAD prevention.
OEM-5. Substance Use Disorders in Medical Professionals.
W. Mel Flowers, Jr, MD. The Mississippi Professionals Health Committee of the Mississippi State Medical Association.
Background: Substance abuse and dependence are common in physicians (about a 15% lifetime prevalence).
Discussion: Early detection is important. The individual physician should be interested because chemical dependency may affect his patients, his colleagues, or even himself. Even when affected people experience withdrawal symptoms, they nearly always deny the problem, leaving it up to coworkers, friends, or relatives to recognize the symptoms and to take the first steps toward encouraging treatment. Although 15% to 30% of people who are hospitalized suffer from alcoholism or alcohol dependence, physicians often fail to screen for the problem. In one study, alcohol problems were detected by the physician in less than half of patients who had them. This poster presentation explores definitions of substance abuse and addiction and the reasons for using addictive substances. Key points emphasized are that substance use disorders in physicians are similar to those in the general population. Benzodiazepines and opioid usage are higher in physicians. Identification of the problem may be difficult or delayed.
Conclusions: Treatment outcomes are often better in physicians than in the general population. Treatment is usually very effective, and help is readily available. The Mississippi Professionals Health Committee (MPHC) is a standing, constituent committee of the Mississippi State Medical Association (MSMA). It is contractually associated with the Mississippi State Board of Medical Licensure (MSBML) through a formal Memorandum of Understanding. Along with its dental advisors, MPHC also serves the Mississippi State Board of Dental Examiners (MBDE) through a separate Memorandum of Understanding. The concept of a state professionals health program sponsored by the medical association, supported by the dental association and approved by the respective boards is a solid one and has met with success around the country. The MPHP is prepared to help medical students, residents, and all Mississippi physicians recover from chemical dependency.
OEM-6. The Disruptive Physician.
W. Mel Flowers, Jr, MD, and Gary D. Carr, MD. Mississippi Professionals Health Committee, Mississippi State Medical Association, Jackson, MS.
Background: The disruptive physician has a pattern of being unable or unwilling to function with others to such an extent that his or her behavior, through word or action, has the potential to interfere with quality health care. Characteristic behaviors include anger, abuse, disparagement, and blaming others. Some behaviors, such as physical assault, may be severe enough to warrant immediate action.
Discussion: Typically, the behavior is refractory to the usual medical staff interventions. A policy established by the medical staff should be approved as medical staff bylaws. The majority of disruptive physicians can be helped through effective diagnosis, treatment, and monitoring. The best first step is for a senior member of the medical staff and a colleague to informally discuss the problem with the physician. The next appropriate referral may be to a medical staff wellness or assistance committee, where confidential discussions can take place and help can be offered. It is recommended that a referral to the Mississippi Professionals Health Program (MPHP) be made before any actual disciplinary action. A disciplinary hearing is indicated if the disruptive acts continue and/or the physician is un-cooperative. The MPHC can become formally involved when the medical staff has exhausted all due process provisions of its bylaws and stands ready to suspend privileges and desires the assistance of the MPHP. The MPHP encourages medical staffs to extend a medical leave of absence for any indicated treatment. This approach is consistent with the intent of Joint Commission on Accreditation of Healthcare Organizations. The MPHP can facilitate evaluation, treatment if warranted, support, monitoring, and supervised re-entry. Only in extreme cases is the physician so self destructive that the Mississippi State Board of Medical Licensure must become involved.
Conclusions: Effectively addressed in a systematic fashion, rehabilitation of the disruptive physician can occur, the public is protected, and everybody wins!
Section on Otolaryngology--Head and Neck Surgery
OHNS-2. Inverted Papilloma: Case Studies and Evolution in Management.
K. Chritopher McMains, Stilianos E. Kountakis, and Edward S. Porubsky. Department of Otolaryngology/HNS, University of Texas Health Science Center, San Antonio, TX, and the Department of Otolaryngology/HNS, Medical College of Georgia, Augusta, GA.
Background: Inverted papilloma is a pathologically benign process that involves thickened epithelium invading into the underlying stroma. Inverted papilloma represents the most common neoplastic cause of unilateral nasal mass and has a tendency to recur. It most commonly originates on the lateral nasal wall; however, it may originate from any site within the sinonasal cavities and may be multifocal. Inverted papilloma act in a locally destructive fashion and transform into squamous cell cancer in approximately 10% of cases. Endoscopic surgical techniques provide alternative to traditional surgical techniques.
Description/methods: Pathological processes contributing to the formation of Inverted Papillomata are reviewed. Evolution of surgical management is reviewed, notable cases are presented, and endoscopic surgery is demonstrated. Frontiers of surgery and adjunctive therapy are explored.
Summary/Clinical relevance: Unilateral nasal masses should always raise suspicion of malignancy. Epistaxis in the context of a unilateral nasal mass suggests inverted papilloma. As technology continues to advance, new technologies find applications to treat disease with less morbidity. Endoscopic medial maxillectomy offers the opportunity to completely treat inverted papilloma with less morbidity than open techniques.
Conclusions: Surgery remains the mainstay of treatment for inverted papilloma; however, endoscopic techniques provide an alternative to open medial maxillectomy with the potential for decreased morbidity and equal control rates. Anti-inflammatory medications may prove important adjunctive treatment for recurrent inverted papilloma and in primary treatment of nonresectable disease.
OHNS-3. Pediatric Elective Surgery Utilization and Payer Mix Under TennCare Managed Competition.
Christopher J. Hall, MD, Jerome W. Thompson, MD, MBA, James Bailey, MD. University of Tennessee, Department of Otolaryngology. Memphis, TN, and University of Tennessee Medical Group, Department of Medicine, Division of General Internal Medicine, Memphis, TN.
Background: Managed care decreases reimbursement for surgical referral care and may decrease access for elective procedures. This study seeks to determine the impact of Medicaid managed competition on elective pediatric otolaryngology surgery.
Design and Setting: Payer mix was analyzed for tonsillectomy and adenoidectomy (T and A) and bilateral myringotomy with ventilation tube insertion (BM and VT) charges for an 8-year period surrounding TennCare implementation. The payer mix for hospital gross charges was analyzed for the same period as a control.
Results: After TennCare implementation, hospital gross charges shifted toward increased TennCare/Medicaid and decreased commercial insurance; whereas charges for the two elective procedures shifted toward increased commercial insurance and decreased TennCare/Medicaid.
Conclusions: Otolaryngologists may have avoided impending losses under TennCare, through indirect cost shifting. Numbers of T and A and BM and VT procedures performed on Tenncare/Medicaid patients remained constant, whereas numbers of these procedures performed on commercially insured patients increased.
OHNS-4. Samter Triad: Asthma of the Nose.
K. Christopher McMains. Department of Otolaryngology/HNS, University of Texas Health Science Center, San Antonio, TX.
Background: The association between asthma and rhinosinusitis is well established. One theory regarding the underlying basis for the association of asthma with nasal polyposis and aspirin sensitivity suggests that these conditions represent organ specific manifestations of the same dysfunction of respiratory epithelium. The suggested mechanism is diversion of arachidonic acid metabolism to the lipoxygenase pathway by blocking cyclooxygenase activity. The resulting overload of Leukotrienes is thought to manifest in the clinical constellations seen in asthma and chronic rhinosinusitis with nasal polyposis.
Description: This presentation is a review of relevant literature describing clinical evidence and biochemical mechanisms at work in each of these processes. Additionally, literature describing available treatment approaches including medical management, immunotherapy, endoscopic sinus surgery, and aspirin desensitization is reviewed.
Summary/Clinical Relevance: Evidence supports the theory that asthma and nasal polyposis associated with aspirin sensitivity are related inflammatory conditions of the common respiratory epithelium. Aspirin sensitivity does not correlate with asthma severity. Patients with Samter triad who fail maximum medical management derive benefit from endoscopic sinus surgery; however, they may require revision surgery more often than asthmatic rhinosinusitis patients not sensitive to aspirin. Adjunctive aspirin desensitization decreases need for revision FESS in patients with Samter triad.
Conclusions: Inflammation control is the key to long-term management of patients with Samter's triad. Medical management, immunotherapy, endoscopic sinus surgery, and aspirin desensitization each have a role in long-term management in patients with Samter triad.
Section on Oncology
ONC-1. Assessing the Need for a Geriatric Assessment Clinic in a Major Cancer Center: A Successful Interdisciplinary Partnership Among Geriatrics and Oncology.
Thu-Tam T. Huynh, MD, and Sandra E. Sanchez-Reilly, MD. University of Texas Health Science Center, South Texas Veterans Health Care System, GRECC, San Antonio, TX.
Background: Sixty percent of new cancers are diagnosed in patients older than 65 years, accounting for greater than 70% of cancer deaths with few experts in geriatric oncology (GO). Cancer-clinical trials enroll few elderly patients (13%). Geriatric minority population is growing, particularly Hispanics (HP), the largest US minority. Cancer screening and GO care access are concerning in elderly HP.
Objectives: To identify populations with common cancers at a major cancer center, establishing the need for culturally competent GO clinic. The Cancer Treatment and Research Center (CTRC) is affiliated with the University of Texas Health Science Center and is one of two NCI-designated centers in Texas. CTRC is in San Antonio, where 56% of its population are HP.
Methods: Chart review of data pertinent to subject's demographics and first-encounter cancer diagnoses (1996 to 2004).
Results: There were 89,960 subjects, 47% age greater than 60 years; 49% female, 61% white, 29% HP, 3% black. Predominant malignancy diagnoses are (1) prostate cancer; 84% subjects greater than 60 (43%: 60 to 69, 48%: 70 to 79, 9%: age greater than 80); (2) lung cancer: 68% subjects greater than 60 (49%: 60 to 69, 41%: 70 to 79, 10%: age greater than 80); (3) colorectal cancer: 53% subjects greater than 60(51%: 60 to 69, 38%: 70 to 79, 11%: age greater than 80); and (4) breast cancer: 37% subjects greater than 60(54%: 60 to 69, 35%: 70 to 79, 11%: age greater than 80).
Conclusions: Elderly patients suffer the most from common cancers. A comprehensive interdisciplinary approach is essential to address elderly needs. GO clinic is an ideal setting to screen and optimize elderly for appropriate treatment, improve function, and enhance trial participation, 29% patients were HP. A GO clinic has started at this institution, aiming to be culturally competent for HP elderly. Further research is planned to evaluate clinical outcomes/future benefits.
ONC-2. Descriptive Analysis of Changing Toxicity Profiles for 30- and 100-Day Mortality After Matched Related Donor (MRD) Allogeneic (ALLO) Hematopoietic Stem Cell Transplantation (HSCT) Using PO-Versus IV Busulfan (BU)-Based Conditioning Regimens.
Scott W. Cole, MD, Sameer Gupta, MBBS, Donna E. Salzman, MD, Khaleel Ashraf, MD, Charu Aggarwal, MBBS, and William P. Vaughan, MD. Bone Marrow Transplantation Program, University of Alabama at Birmingham, Birmingham, AL.
Background: BU-based preparative regimens in ALLO MRD HSCT for hematological malignancies have been used at UAB since 3/92. Before 3/99, 135 patients were treated with PO BU in BU/Cy2, BU/Cy/VP16, and BU/Fludara preparative regimens (PO group). Between 3/99 and 5/04, 97 patients received IV BU with pharmacokinetic (PK)-guided dosing in one of the same three regimens (IV group).
Methods and Results: The distribution of diagnoses was similar in the two groups. The female/male ratio was also similar in the two groups. The patients in the IV group were older (>45 years) (63/97 vs 57/135, P = 0.0006, 2), had a slightly higher ASBMT relapse risk score, a higher ratio of ASBMT HR CML patients, and more patients with less than 10/10 match. Despite the higher risk for both relapse and transplant-related mortality in the IV group, the 30- and 100-day mortality was similar for the two groups (4% and 31% for IV BU: 8% and 28% for PO BU). Defining cause of death as the initiating event or organ failure, death due to Hepatic Veno-Occlusive Disease (HVOD) was eliminated with the use of PK-directed IV BU (0/21 vs 8/34, P = 0.014, 2). GVHD/immunodeficiency and cardiopulmonary toxicity were not increased in the higher-risk IV group, but these two causes remained significant and together accounted for 67% of the overall non relapse mortality in the combined population. However, death due to progression of primary disease was greater in the IV group (9/30 vs 4/38, P = 0.04, 2), reflecting their greater ASBMT relapse risk.
Conclusions: Because of elimination of HVOD and no increase in other causes of nonrelapse mortality, higher-risk patients can be transplanted without an increase in the 30 or 100-day mortality.
ONC-3. High-Grade Spindle Cell Carcinoma of the Left Cheek Treated with Primary Chemoirradiation.
Melisa G. Boersma, MD, Join Y. Luh, MD, Melissa Joyner, MD, Elizabeth Kurian, MD, Frank Miller, MD, and David H. Hussey, MD. University of Texas Health Science Center, San Antonio, TX.
Background: Approximately 15% of all soft tissue sarcomas present in the head and neck, and these represent approximately 1% of all tumors of the head and neck. Although their natural history is similar to sarcomas in other locations of the body, the anatomical constraints make surgical resection with adequate margins virtually impossible in this area.
Case: A 50-year-old female presented with a rapidly enlarging mass in the left cheek at the end of September 2004. After a non-diagnostic workup by an oral surgeon, she was referred to ENT, and a biopsy was performed on 12/08/04, which confirmed poorly differentiated spindle cell malignancy consistent with high-grade sarcoma (grade 3). MRI demonstrated an infiltrative lesion involving the soft tissues and bony structures of the left face, 6.5 X 4 cm in maximal axial dimension. Superiorly, the mass extended into the infratemporal fossa, invaded through the medial wall of the left maxillary sinus, into the nasal cavity, and abutted the left orbital floor. Her clinical stage was stage IV (T2b, Nx, M0). Due to the size, location, and histology, it was determined that adequate surgical margins were unattainable, and primary chemoirradiation was offered. On physical examination, the patient was observed to have trismus, lateral displacement of the left oral commissure, and extension of the mass into the oral cavity. She had no cervical or supraclavicular hymphadenopathy. Her vision and extraocular muscles were intact, but she reported left eye and sinus pain, sensation of nasal mass, and obstruction of the left nare. She was treated with conventional external beam irradiation to a total dose of 7,100 cGy, and received cisplatin on days 1. 22, and 43 of radiation. She had an excellent response to therapy. At the completion of treatment, the tumor was clinically confined to the left cheek and measured 2.5 X 3 cm. ENT evaluation for surgical salvage is pending.
Discussion: High-grade spindle cell sarcomas are very rare malignancies. They have been reported in the bone and in dedifferentiated renal cell carcinoma. To the best of our knowledge, this may be the first reported case of a non-osteosarcoma, non-MFH-type high-grade spindle cell sarcoma in the head and neck. Based on the relatively decreased responsiveness of poorly differentiated high-grade sarcomas to radiation, the rapid and consistent response of this patient's tumor to chemoirradiation was unexpected.
Conclusions: High-grade spindle sarcomas are rare, and presentation of these tumors in the head and neck are even less common. Despite their relatively decreased radioresponsiveness, chemoirradiation can dramatically improve likelihood of surgical respectability in even the most challenging instances.
ONC-4. Lung Cancer Survival Predictions Utilizing Artificial Intelligence.
Daniel S. Smith and Stephen L. Smith, MD. Mayo Clinic, Jacksonville, FL.
Background: Predicting cancer survival is something commonly asked of the treating physician. Utilizing artificial intelligence via an artificial neural network to assist in this prediction has not been performed for lung cancer patients to date.
Methods: An Artificial Neural Network (ANN) was constructed in the C++ programing language to analyze 22 variables gathered from the records of 100 patients. These patients were diagnosed with lung cancer at the Mayo Clinic between 1993 to 2003 and have died. A three-layered ANN system was constructed and interfaced with Excel for easy program control. The data was inputted into the neural network which was then configured and initiated. The network was subsequently called upon to make survival predictions.
Results: The average deviation in these 100 patients between the predicted and actual survival was 341 days. In 35 of the 100 patients, the deviation was less than 100 days. The group with the largest deviation was those patients who underwent surgical treatment as this was a relatively small number of patients with diverse results.
Conclusions: An Artificial Neural network can accurately predict survival in patients diagnosed with lung cancer. Even better accuracy of these predictions could be obtained by training the ANN with a larger group of patients particularly in those patients where surgical resection is feasible.
ONC-5. Peri-Rectal Pain and Constipation in a Female with Pancreatic Adenocarcinoma: A Case Report of a Blumer Shelf Metastasis.
Samuel J. Wang, MD, PhD, Monica Mita, MD, Join Y. Luh, MD, Alexander Miller, MD, Kyriakos Papadopoulos, MD, and Charles R. Thomas, Jr, MD. Department of Radiation Oncology, Department of Surgical Oncology, and Department of Medical Oncology, University of Texas Health Science Center, San Antonio, TX, and the Institute for Drug Development, Cancer Therapy and Research Center. San Antonio, TX.
Background: Cancer of the pancreas is the fourth leading cause of cancer-related death in the United States. The prognosis of pancreatic cancer is poor; 5-year survival after pancreaticoduodenectomy is only about 25 to 30% for node-negative and 10% for node-positive tumors. Physical findings in patients with disseminated cancer may include palpable hepatic metastases, left supraclavicular adenopathy (Virchow node), periumbilical lymphadenopathy (Sister Mary Joseph nodes), and the finding of drop metastases in the pelvis encircling the perirectal region (Blumer shelf). A rare case of a patient with previously treated pancreatic cancer with metastasis to the rectum is presented.
Methods and Results: A 73-year-old female was originally diagnosed with pancreatic cancer in October of 2002. She then received chemotherapy with gemcitabine from November 2002 until November of 2004. Her CA19-9 had been stable until August of 2004 when it began to rise from 800 to above 2,000 in November of 2004. CT scan of the abdomen in October 2004 showed no obvious malignancy. By the end of December of 2004, she began complaining of perianal pain and constipation. The pain was worse with bowel movements and with standing. Physical examination revealed a large firm mass along the anterior rectal wall approximately 5 cm from the anal verge. A CT scan of the abdomen and pelvis showed a soft tissue fullness at the junction of the head and uncinate process of the pancreas but no definite mass. She underwent colonoscopy on January 23, 2005, which showed mass in the rectum 5 cm up from the anal verge, which extended for approximately 5 cm in length. Biopsy of this mass showed adenocarcinoma, which stained positive for CK-7 and CK-20, similar to her pancreatic primary. She proceeded to receive 4,500 cGy of three-field pelvic radiation therapy with concomitant oral capecitabine chemotherapy (825 mg/[m.sup.2] BID), which she completed on March 14, 2005. She completed her chemoradiation treatment but she did develop grade 3 diarrhea shortly after the completion of her radiotherapy, requiring antimotility medications and IV hydration.
Conclusions: Blumer shelf was first described by the pathologist Dr. George Blumer in 1909, where he described the palpable shelf as "a neglected rectal sign of value in the diagnosis and prognosis of obscure malignant and inflammatory disease within the abdomen." Despite being described nearly 100 years ago, current oncology and surgery textbooks only briefly mention this unusual finding; literature is also scant. The incidence and prognostic importance of Blumer's shelf in patients with pancreatic cancer are unknown and deserves further study. This appears to be the first case report of a patient with Blumer shelf metastasis from a pancreatic primary.
Section on Ophthalmology
OPH-1. Contact Lens Wear After Radial Keratotomy.
Kali Bliss Cole, MD, MPH, and Carol Rosenstiel, OD. Callahan Eye Foundation, University of Alabama, Birmingham, AL.
Background: Radial keratotomy (RK) was developed in the Soviet Union and became a common surgery worldwide in the 1970s. It was the most commonly performed refractive procedure in the late 1970s to 1980s.
Discussion: RK is a safe procedure with rapid results. However, there are also significant drawbacks, including the theoretical risk of wound rupture with blunt trauma, significant glare, irregular astigmatism, progressive changes in vision over years after surgery, and diurnal variation of refraction. Many complications can be overcome with the use of contact lenses such as the rigid gas permeable lens, soft lens/rigid gas lens piggyback system, Soft-Perm lens, and the silicone-hydrogel lens.
Case Report: A 45-year-old white female presented 18 years after RK, complaining of fluctuating vision throughout the day. She was found to have approximately 1.00 diopter difference between her morning and evening refractions. She could not tolerate contact lenses secondary to recurrent corneal abrasions and decrease in vision from lens decentration. The patient was then switched to the piggyback system with a higher Dk Acuvue advance lens as a base with RGP lens. Her treatment is ongoing in that she is interested in surgical options for correction. Currently, her limited options include custom surface ablation when it is available versus conductive keratoplasty, which she is presently considering.
Conclusions: Treating patients who have had RK can be a dilemma for clinicians, as they can present many years later with challenging complications. Treatment options appear to be limited and some come with adverse effects. Soft contact lenses have been shown to be associated with neovascularization of the cornea. Similarly, the hybrid Soft-Perm lens is not recommended for use following RK because of the material's low gas exchange. On the other hand, the silicone hydrogels, because of the ultra-high oxygen flux, have almost completely eliminated the incidence of hypoxia.
Section on Orthopaedic and Trauma Surgery
ORT-1. Nitric Oxide Donor Improves Wound Healing in Diabetic Mice.
Eric M. Stehly, MD, Victor L. Sylvia, PhD, David D. Dean, PhD, and Adam Bruggeman, MS. The University of Texas Health Science Center at San Antonio, Department of Orthopaedic Surgery, San Antonio, TX.
Background: Diabetic patients are at risk for developing chronic wounds, particularly on the lower extremities where the condition is commonly called the diabetic foot. Chronic foot wounds are a leading cause of admission to hospital among diabetic patients and are responsible for 50 to 70% of all nontraumatic amputations. The severe tissue destruction associated with diabetic ulcers suggests a number of factors in their etiology, particularly matrix metalloproteinases (MMPs). The nonhealing diabetic foot wound displays pathologically elevated MMP activity. Total MMP activity is elevated 30-fold in chronic wound fluid from diabetic patients compared with acute wounds from other patients, predominantly due to elevated MMP-2 and MMP-9 levels. Nitric oxide has been shown to be significantly reduced in chronic ulcers and impaired healing of diabetic wounds is thought to be related to diminished nitric oxide production. The mechanism by which low nitric oxide impairs wound healing and high nitric oxide promotes wound healing are unknown.
Conclusions: Our hypothesis is that nitric oxide downregulates MMP expression in diabetic wounds. In this study, we treated diabetic fibroblasts in vitro and diabetic wounds in vivo with nitric oxide donor or inhibitor compounds and measured changes in MMP expression. The nitric oxide donor (S-nitroso-N-acetylpenicillamine, SNAP) and the inhibitor (N-nitro-L-arginine methyl ester, L-NAME) were used and MMP expression was examined by real-time PCR. We examined the effects of these compounds on wound healing by assessing wound area and rate of wound closure between different experimental treatment groups and between control and diabetic mice. Results demonstrated that the nitric oxide donor compound SNAP significantly lowers MMP-9 expression in human diabetic skin fibroblasts, and accelerates skin wound healing in a diabetic mouse model. The ability to control MMP-induced tissue destruction with nitric oxide could provide a novel and effective means of controlling the devastating complications of diabetes on wound healing.
Section on Pathology
PAT-2. Increased Long-term Survival in Tricuspid Atresia: A Case Report and Review of the Literature.
Jolie R. Rodriguez, MD, Carole W. Boudreaux, MD, and Clara V. Massey. MD. Department of Pathology, University of South Alabama, Mobile, AL.
Background: Tricuspid atresia is a rare congenital heart disease, with an incidence of 118 per one million births. Originally associated with a uniformly poor long-term prognosis, recent advances in cardiology and cardiovascular surgery have greatly extended the survival of patients with tricuspid atresia. This report presents the autopsy findings of a 24 year-old female with tricuspid atresia and a hypoplastic right ventricle.
Methods and results: Early in life, the patient had several corrective procedures, including a right shunt placement and a Fontan repair. More recently, she had begun experiencing atrial arrhythmias; she also developed a right atrial thrombus and had been maintained on anticoagulation
therapy. The patient presented to our institution with symptoms of pneumonia, and complaints of palpitations. Despite aggressive medical management for refractory atrial arrhythmias and pulmonary hypertension, her condition rapidly deteriorated and she died soon after admission. At postmortem examination, in addition to her cardiac anomaly, the patient also had marked chronic passive liver congestion with centrilobular necrosis consistent with congestive heart failure. Microscopic examination revealed bilateral atypical pneumonia with hyaline membrane formation and patchy acute bronchopneumonia.
Conclusions: This case highlights the medical course of a new and rapidly expanding population of patients: adults living with complex congenital heart disease.
PAT-3. Neonaticide: A Rare Entity?
P. Clark, S. Thomas, J. Pestaner, and M.G.F. Gilliland. Brody School of Medicine at East Carolina University, Department of Pathology and Laboratory Medicine, Greenville, NC.
Background: Neonaticide, defined as the deliberate killing of a baby soon after birth, is an important medical entity that involves multiple medical specialties. Reportedly, such cases remain unrecognized and underreported. As a regional medical examiners office, all unnatural deaths are reported to our office and a review of such cases provides insight into why neonaticide is considered unrecognized and underreported.
Material and Methods: A retrospective review of our case files retrieved three neonatal deaths where the circumstances warranted consideration of neonaticide, but ultimately such a conclusion could not always be shown to a reasonable degree of medical certainty.
Results: Case 1 involved the skeletonized remains of a neonate in which providing the necessary medical parameters could not be done. Case 2 involved a term twin gestation from a 14-year-old in whom delivery occurred at home in the bathroom. Anatomic findings of one neonate identified significant blunt force injuries and evidence of a live birth while the other neonate had no significant injuries or evidence of a live birth. Case 3 involved a 23-year-old mother with a history of cocaine use who delivered at home in the bathroom. The mother admitted to using cocaine but did not seek medical attention for several hours after the delivery.
Discussion: Of the three cases, only the second case is being pursued legally as a case of neonaticide. The other two had evidentiary challenges based on the investigation and autopsy. The inherent difficulties of these cases may provide some insight as to why they are considered underreported due to the fact that it is difficult to obtain the necessary medicolegal evidence to prove.
Conclusions: Neonaticide cases are complex death investigations, and concluding that a case involves deliberate neglect and murder is not a simple task.
Section on Pediatric and Adolescent Medicine
PED-1. Implementing a Health Literacy Intervention in a Pediatric Clinic.
Leah Trevino, Virginia S. Mika, MPH, and Pamela Wood, MD. University of Texas Health Science Center at San Antonio, TX.
Background: The National Adult Literacy Survey (NALS) showed 45% of the adult population in the United States has limited literacy skills, and about one fourth is functionally illiterate. Poor health literacy has been associated with poorer health outcomes, increased medication errors, and increased hospital visits. However, there is very limited data about the effects of parental health literacy on children's health. Parents must understand medical information for their children in order to follow recommended medical advice "Ask Me 3" promotes three simple but important questions that parents should ask their health care provider in every health care interaction: (1) What is my main problem? (2) What do I need to do? (3) Why is it important for me to do this?
Design and Methods: Ask Me 3 was implemented in a large, urban pediatric clinic in a hospital setting. Before implementation, we conducted 100 surveys with parents, composed of questions on satisfaction of care, recognition, and use of Ask Me 3, demographics, acculturation, and administered the Short Test of Functional Health Literacy in Adults (STOFHLA). For postimplementation, we will conduct 500 surveys containing the same questions plus the addition of provider responsiveness to Ask Me 3 questions.
Results: To date, 100 preimplementation surveys have been completed. By the end of July 2005, we will have completed the 500 postimplementation surveys. We will also conduct in-depth interviews with parents who used and did not use Ask Me 3. Health care providers will also be asked about their responsiveness to the program.
Conclusions: Although our quantitative data from the pre implementation survey demonstrated the parents had adequate literacy skills and satisfaction of care from their health care providers, we hope to show increased qualitative data on the recognition and use of Ask Me 3.
Section on Plastic and Reconstructive Surgery
PRS-1. Finger Tip Reconstruction by Division of Lateral Band.
Richard A. Heimburger, MD, FACS. Division of Plastsic Surgery, St. Louis University, St. Louis, MO.
Background: After several frustrating attempts to cover amputated finger tips by traditional V to Y advancement flaps. I went to the anatomic laboratory to evaluate and develop a simple reproducible method to cover exposed bone of finger tips.
Conclusions: I found that by dividing the lateral band, I could mobilize the entire lateral aspect and advance an axial neurovascular flap to restore normal sensation with well vascularized and padded soft tissue and place the scar high laterally away from the pinch. I have used this procedure to restore over 100 avulsed fingertips over the past 20 years, and will demonstrate this technique with cadaver dissections, drawings, and case examples with detailed follow-up.
PRS-2. Volunteer Surgical Missions in Transition.
Richard A. Heimburger, MD, FACS. Saint Louis University, Division of Plastic Surgery, St. Louis, MO.
Background: We live in a rapidly changing world. Plastic surgical volunteer programs under the international programs of the American Plastic Surgery Education Foundation have changed to keep up with the changing times and situations.
Discussion: Many mission hospitals have been built around the world in the last century by Christian churches and other organizations. They are now struggling to provide specialty care such as plastic surgery on either short or long-term basis. Though attitudes, technology, and politics change in a shrinking world, some basic principles persist, which we summarize as the four Cs: (1) Concern, compassionate and caring; (2) Cooperation, interdependent collaboration among concerned physicians, governments, and churches; (3) Communication, vastly improved over the past century; (4) Continuation, both before and after visits by a surgical team.
Conclusions: American plastic surgery teams have been going overseas to provide volunteer surgical care in underdeveloped countries for many years. Many have developed very sophisticated programs to finance, train and provide specialty care, primarily for cleft lip, palate, and other birth defects and are publicized as Interplast, Rotoplast, Operation Smile, Operation Kids, Physicians for Peace, Christian Medical and Dental Association, to name only a few. The next most common problems we see are victims of trauma; particularly burn scar contractures, which are very deforming and disabling. We currently are advocating the establishment of burn units to improve initial care and minimize burn contractures. My personal surgical practice has taken me from Vanderbilt to Augusta, Georgia, then to Galveston and San Antonio, Texas, and finally to Columbia, Missouri, and St. Louis. My overseas volunteer plastic surgery mission work include Presbyterian Medical Center in Chon-Ju, Korea, San Juan de Dios Hospital for Children in Lima, Peru, and most recently establishing a children's burn unit at the Christian Medical College in Vellore, India. I will contrast our current medical mission work with my father's early medical missionary work eighty years ago in Shandung Province in northeast China at Cheeloo University, where he built and administered two leprosy hospitals. This interesting contrast will be illustrated with pictures, slides and stories.
Section on Psychiatry
PSN-2. Case Report: Gatifloxacin-Induced Hallucinations in a 19-Year-Old Male.
CPT Marie Adams, USA, and CAPT Hamid Tavakoli, USAF. Life Skills Support Center/Wilford Hall Medical Center, Lackland AFB, TX, and Consultation-Liaison Psychiatry, Wilford Hall Medical Center/Lackland AFB, TX.
Background: The fluoroquinolones are routinely used for antimicrobial therapy. They as well as other anti-infectious medications are an under-recognized cause of drug induced mental status changes.
Discussion: A review of the literature for acute psychiatric changes due to the fluoroquinolone class of antibiotics yielded few case reports, with ciprofloxacin being the primary agent most discussed. The CNS side effects of the fluoroquinolones (ie, mainly ciprofloxacin) such as seizures and hallucinations have also been reported as being rare. A MEDLINE search for the past 10 years yielded no case reports on adverse psychiatric effects for gatifloxacin (Tequin), a newer member of the fluoroquinolones. We report a case, the first in the psychiatric literature, of an uncomplicated and clear-cut case involving gatifloxacin induced hallucinations in a healthy 19 year-old male.
Section on Radiology
RAD-1. 5.5-Year Treatment Success and Survival of Patients Treated with Percutaneous Interventional Magnetic Resonance Image Guided and Monitored Renal Cell Carcinoma Cryoablation.
P.E. Sewell, P.J. Gressett, D.B. Shingleton, H. Mangum, J. Boyd, and J. Patel. Department of Radiology. University of Mississippi Medical Center, Jackson MS.
Background: The purpose of this investigation was to examine treatment success and survival of 114 patients treated with percutaneous interventional magnetic resonance image (IMRI) guided cryoablation of renal cell carcinoma over the last 5.5 years.
Discussion: One hundred fourteen patients with 137 tumors underwent percutaneous cryoablation of renal cell carcinoma under MRI guidance. Most patients were selected for this procedure due to single kidneys, multiple tumors, bilateral tumors, or renal insufficiency. Factors such as blood creatinine level, urine output, and radiologic appearance were investigated. Data regarding complications, the need for, and number of retreatments were correlated with tumor location and size. Tumor stage, tumor number per patient, and survival were also examined. Eighty tumors were ablated with a single procedure. Fifteen patients with 18 tumors required a second cryoablation procedure, 2 patients with 5 tumors required a third cryoablation, and 3 patients with 11 patients required a fourth cryoablation. One hundred one patients were classified as no evidence of disease (NED). Sixteen patients have residual disease or had residual disease at the time of death. Ten patients died, but only 3 were disease related. Adjusted tumor-related survival was 97%. Observed overall survival was 86%. Follow-up ranged from 1 to 106 months, with a mean of 39.2 months from time of diagnosis. Complications were limited to one incision abscess, treated successfully with incision and drainage and antibiotics. One patient required a single unit of packed red blood cells due to a limited retroperitoneal bleed. Gross hematuria was evident in approximately 5% and cleared within 24 hours.
Conclusions: In our large population, a 97.4% adjusted survival with a mean follow-up of 39.2 months and the low morbidity of this procedure suggest it is an excellent nephron sparing alternative to traditional surgical resection for treating renal cell carcinoma.
RAD-2. A Gut Feeling.
Angie Creel, Jeffrey Kent, Daphne Logan, Amy Quattlebaum, Mike Ketchum, BS, RT (R), and Kristi Moore, RT (R) (CT). School of Radiologic Technology, University of Mississippi Medical Center, Jackson, MS.
Background: Patient management by members of the radiological team is facilitated if there is knowledge of the radiological appearance, nomenclature, and features of common diseases likely to be encountered in the practice of radiology and radiologic technology.
Methods and Results: The image archives of the University of Mississippi Department of Radiology were searched to find twelve examples of classic presentations of gastrointestinal disorders. These were collected, documented, annotated, and set up in a format featuring a brief discussion and an important teaching point for each of the examples given. The radiographic findings in achalasia, esophageal varices, adenocarcinoma of the stomach, leiomyoma arising from the muscular layer of the stomach wall, intussusception, ascariasis, volvulus, lymphomatous polyposis, diverticulitis, Crohn disease, schistosomiasis, and AIDS are demonstrated.
Conclusions: After studying these examples, the learner should be able to recognize similar presentations when the disorders are next encountered. Knowledge gained will improve the ability of medical personnel to manage and care for patients with these conditions.
RAD-3. Clinical and Radiological Presentations of Blastomycosis.
W. Mel Flowers, Jr, MD, George Benashvili, MD, Jonathan Fratkin, MD, and Stanley Chapman, MD. Departments of Radiology and Pathology and the Division of Infectious Diseases, Department of Medicine, The University of Mississippi Medical Center (UMC), Jackson, MS.
Background: In this exhibit, we present the radiological and clinical findings in blastomycosis.
Discussion: Acute, self-limited blastomycosis is seldom recognized clinically. Symptomatic infection (50% of cases) usually presents as a flu-like illness with fever, chills, productive cough, myalgia, arthralgia, and pleuritic chest pain. Most often, the infection has an insidious onset and is chronic. Some patients have rapidly progressive infections, and adult respiratory distress syndrome may develop. Mortality rate in these patients is greater than 50%. Blastomycosis is caused by inhalation of mold conidia (spores) of blastomyces dermatitidis. These convert to yeasts and invade the lungs, occasionally spreading hematogenously to the skin or focal sites in other tissues. The lungs are the primary site of involvement. Pulmonary disease is present in over 90% of patients and may present as a pulmonary infiltrate, a hilar mass, a solitary pulmonary nodule, a military infiltrate, or with cavitation or atelectasis. Carcinoma of the lung and tuberculosis should be considered in the differential diagnoses. Blastomcyes dermatitidis may disseminate from the lungs to other areas of the body. The skin is the most frequent site of spread. Bone is the second most frequent site of spread from the lungs and occurs in about 25% of patients with systemic disease. Sometimes areas overlying bone lesions are swollen, warm, and tender. Some patients develop chronic pulmonary infection or disseminated infection (affecting the skin, bones, and genitourinary tract). Blastomycosis causes central nervous system disease in about 4% of patients. In extrapulmonary disseminated blastomycosis, hematogenous spread may lead to focal infection in skin, prostate, epididymis, testis, kidneys, vertebrae, ends of long bones, subcutaneous tissues, brain, oral or nasal mucosa, thyroid, lymph nodes, bone marrow, and other tissues.
Conclusions: Acute, self-limited blastomycosis is seldom recognized clinically. The chronic disseminated form produces clinical and radiographic findings that should be diagnostic.
RAD-4. CT of Chest and Abdomen: What to Order, When to Order.
Shailendra Chopra, MD, MRCP, FRCR. Department of Radiology, Lexington Clinic, Lexington, KY.
Background: With the development of multidetector row CT, CT scanning has become an accurate method for rapidly diagnosing many conditions of the chest and abdomen.
Discussion: By changing the way a CT scan is performed, different types of information can be obtained. Due to their different patho-physiologic attributes, different groups of thoracic and abdominal diseases lend themselves to optimum evaluation by different protocols. Therefore, each CT examination must be tailored to solve the clinical problem in a given patient. To facilitate the daily workflow, protocols of CT technique have been developed that are optimized for different indications. These protocols are designed to get maximum useful information for the indications that they are designed to evaluate. The multitude of protocols makes it confusing for the nonradiologist to decide which protocol is the most appropriate for her patient. Choosing the wrong protocol can mean inadequate patient workup, additional radiation exposure and increased cost of care. Although the ultimate choice of protocol rests with the radiologist, the referring physician must be familiar with the available protocols to order CT scans appropriately. This poster aims to summarize the available CT protocols for the evaluation of thoracic and abdominal conditions. The rationale behind using different protocols is illustrated. Indications for each protocol are succinctly laid out with illustrative examples of the information provided by CT in each case.
Conclusions: After viewing this poster, a physician should have more information to decide what CT protocol is appropriate for his or her patient.
RAD-5. Fetus In Fetu.
Ramesh Patel, MD, and Henry Giles. MD, University of Mississippi Medical Center, Jackson, MS.
Background: Fetus in fetu is a rare form of monozygotic, diamniotic twinning in which the abnormal twin resides as a parasitic fetiform mass within the body of the other twin. The condition results from an unequal division of totipotential cells of a blastocyst with inclusion of the smaller cellular mass within the more mature embryo, which otherwise developes normally.
Discussion: Most of the patients are children, and the majority of them present with abdominal complaints or mass. The parasitic twin has also been found in the skull, the sacrum, the scrotum and in the mouth. Most of the parasitic twins show variable organogenesis.
Conclusions: Radiographic studies, including computerized tomography, magnetic resonance scans, ultrasonography, and plain radiography help make a specific preoprative diagnosis, in most of the cases. Rarely, more than one parasitic mass has been found at surgery. Such a case is described with with discussion of the diagnostic findings seen on the radiographic studies.
RAD-6. Fibrosing Mediastinitis: A Benign Disease with Protean Radiologic and Clinical Manifestations.
Narayan Sundaram, AB, Ramesh Patel, MD, FACR, and Henry Giles MD.
Background: Fibrosing mediastinitis (also known as sclerosing mediastinitis) is a rare, benign disease of poorly understood underlying cause and pathophysiologic mechanism. Although it is a benign disease, in many cases its clinical manifestations can be severe.
Discussion: Although a number of etiologic agents are postulated to be the causative agents, none of them have been befinitely proven to be so. Among the reported cases are tuberculosis, aspergillosis, mucormycosis, blastomycosis and cryptococcosis. It has also been reported in association with autoimmune diseases such as Behect disease, rhumatic fever, rhumatoid arthritis and systemic lupus. Hodgkin disease, trauma, certain drugs such as methysergide and malignancy have also been implicated as etiologic factors. It can also occur in association with other fibroinlfammatory disorders such as retroperitoneal fibrosis, sclerosing cholangitis, Riedel thyroiditis, and pseudotumor of the orbit.
Conclusions: Most of the cases in the United States, especially in the Mississippi Valley, are thought to be secondary to Histoplasma capsulatum infection. Ongoing immune reaction resulting in deposition of acellular collagen followed by fibrosis is thought to be the underlying pathophysiologic mechanism. The clinical manifestations can be severe due to involvement of the vital cardiovascular, respiratory and nervous structures in the mediastinum. A variety of radiologic findings can be seen on plain radiographs, computerized tomography and magnetic resonance scans. Cases with different clinical and radiologic findings are described.
RAD-7. Fractures and Dislocations of the Wrist: A Radiologic Review.
Vanessa M. Zayas, MD, Carol Becker, MD, and Christian Scheuermann, MD, LSU Health Sciences Center, Department of Radiology, New Orleans, LA.
Background: The wrist is one of the most commonly injured joints as seen daily in numerous Emergency Rooms across the country. This poster will try to summarize some of the important derangements and related complications occurring in this complex joint.
Discussion: The carpus is a link joint, with the lunate acting as a potential unstable segment between the distal row and radius. The scaphoid functions as a bridge, providing stability to an otherwise unstable intercalated segment. Dislocations are all stages of the same injury and are caused by hyperextension of the wrist. They are classified as scapholunate dissociation, perilunate dislocation, midcarpal dislocation and lunate dislocation. The complication unique to dislocations of the wrist is late instability (DISI and VISI).
Conclusions: Fractures occur in isolation or in combination with other fractures or dislocations. The scaphoid is the most commonly fractured carpal bone, followed in order by the triquetrum, lunate, and capitate. Intercarpal dislocations and ligamentous injuries are frequently associated with displaced fractures. The complications most frequently encountered after fractures are arthritis, nonunion and avascular necrosis.
RAD-8. Idiopathic Transient Osteopenia: An Enigmatic Clinical and Radiologic Entity.
Narayan Sundaram, AB, and Ramesh Patel, MD. Vanderbilt University, Nashville, TN, and University of Mississippi Medical Center, Jackson, MS.
Background: Idiopathic transient osteopenia (transient osteoporosis) is a rare clinical entity charecterized by severe joint pain of sudden onset that may last for several weeks to months. The pain can be debilitating and may be exaggerated by weight bearing and joint motion.
Discussion: Most of the patients are healthy, active middle-aged men. The hip is the most frequently affected joint. The knee, ankle, or foot can also be affected. Although a single joint is involved at presentation the other joints can be sequentially involved, sometimes after long intervals. In women, the condition is almost exclusivily found during pregnancy. Due to unusual clinical presentation and discordant radiological findings many patients are misdiagnosed and end up having surgical interventions.
Conclusions: Awareness of the clinical entity coupled with appropriate radiologic studies would lead one to make an accurate diagnosis of this rare, self-limiting condition that only requires pain control for treatment. Clinical presentations and radiologic findings on plain films, nuclide scans. CT, and magnetic resonance scans are described.
RAD-9. Infantile Hypophosphatasia: In Utero Sonographic and Postnatal Radiographic Features.
Ramesh Patel, MD, and Henry Giles, MD. University of Mississippi Medical Center. Jackson, MS.
Background: Hypophosphatasia, first recognized by Rathbun in 1948, is a rare, inherited metabolic disease caused by decreased tissue-nonspecific alkaline phosphatase (TNSALP) and defective bone mineralization. It varies widely in its clinical presentation and severety. It has been subdivided into five catagories known as perinatal, infantile, childhood, adult and odontohypophosphatasia.
Discussion: The different clinical forms have different modes of presentation, history and inheritance. Alkaline phosphatase exists as four isomeres, each with its own gene locus. Three of the isomeres are tissue specific, one each for germ cell, placental, and intestinal alkaline phosphatase. The fourth isomere is known as tissue-non-specific alkaline phosphatase (TNSALP) and is found in the bones, liver, kidneys, and other tissues.
Conclusions: The perinatal form of hypophosphatasia is considered to be lethal. The infantile form has a mortality rate of 50%. Since in the affected fetus the bone formation and mineralization is poor, this condition can be suspected and diagnosed on prenatal sonograms. Prenatal diagnosis of this condition would help to form proper prognosis. Postnatal radiographs and chemical studies can confirmthe diagnosis. In the presented case, prenatal sonographic and postnatal radiographic findings are described.
RAD-10. Intracranal Blastomycosis.
W. Mel Flowers, Jr, MD, George Benashvili, MD, Jonathan Fratkin, MD, Elizabeth R. Flowers, MD, and Stanley Chapman, MD. Departments of Radiology and Pathology and the Division of Infectious Diseases, Department of Medicine. The University of Mississippi Medical Center (UMC), Jackson, MS.
Background: Blastomycosis is a disease caused by Blastomyces dermatiditus, a fungus that exists as spores in the soil, enters the body through the lungs, and becomes a budding yeast at body temperature. The yeast form is not ordinarily passed from person to person.
Discussion: Involvement of the central nervous system (CNS) occurs in 3.6% of infected patients (>35% with AIDS) by hematogenous spread. Intracranial infection can present as acute or chronic meningitis, single or multiple cerebral abscesses, mass lesions, and obstructive hydrocephalus. Case 1 was a 21-year-old white male, admitted to UMC in November 2002 with cutaneous lesions and a miliary infiltrate on chest x-ray. MRI examination of the brain was normal except for a cystic lesion of the right posterior scalp. He was diagnosed with disseminated blastomycosis, treated, and recovered. His chest x-ray returned to normal. In March 2003, he presented with acute neurologic deterioration, coma, and obstructive hydrocephalus. Magnetic resonance imaging (MRI) of the brain revealed a 2.3 X 2.2 X 2 cm irregular enhancing lesion in the region of the quadrigeminal plate. The lesion was resected. Follow-up MRI of the brain showed no residual mass. He was given a definitive shunt and improved. Case 2 was a 42-year-old black male with a medical history of pulmonary blastomycosis who presented in June 2003 complaining of headache for about 2 months. He had decreased peripheral vision, intermittent numbness of the foot, and gait disturbance. CT and MRI scans demonstrated left occipitoparietal and right temperoparietal abscesses. Pathological examination of revealed blastomycosis. He was treated with intravenous antifungal therapy. Follow-up MRI studies revealed significant and progressive improvement.
Conclusions: We recently treated two cases of pathologically diagnosed CNS blasomycosis. In this report, we present our cases with special emphasis on gross morphologic characteristics observed at CT and MRI imaging.
RAD-11. Lithokelyphopedion: Imaging Features.
Ramesh Patel, MD, and Henry Giles, MD. University of Mississippi Medical Center, Jackson, MS.
Background: Lithokelyphos can be considered to be a variant of lithopedion (litho = stone: pedion = child). Lithopedion results from an extrauterine, abdominal pregnancy that results in fetal death and calcification.
Discussion: Lithopedion is extremely rare. Its incidence is estimated to be about 1.5 to 1.8 in more than 1 million pregnancies. Due to improved prenatal care and diagnosis, the incidence of lithopedion is thought to be on the decline despite an increase in the incidence of pelvic inflammatory disease and tubal pregnancies. Lithokelyphos is a variant of lithopedion in which only the fetal membranes are calcified (litho = stone: kelyphos = shell). Another variant is lithokelyphopedion in which both the fetus and the covering membranes show calcifications.
Conclusions: Radiologic studies including abdominal radiographs, CT, and abdominal sonography helped to make an accurate diagnosis of lithokelyphopedion in an elderly woman who had complains of vague abdominal pain. The radiologic findings are described and discussed.
RAD-12. Osteomyelitis: Review and Correlation of Imaging Findings Using Different Radiologic Modalities.
Vanessa Zayas, MD, Myles Digby, MD, and Cynthia Hanemann, MD. LSU Health Sciences Center, Radiology Department, New Orleans, LA.
Background: Osteomyelitis is a common condition encountered in our everyday practices that can represent both a diagnostic and therapeutic challenge. Early and accurate radiographic diagnosis is imperative so that the primary physicians can institute prompt treatment to prevent complications.
Discussion: Osteomyelitis is an infection of the bone and marrow. Manifestations are varied and depend on several factors including location, patient age, precipitating event, and infecting organism. Radiographic findings of osteomyelitis (including sequestrum, involcrum, cloaca, sinus tract, and bone abscess) and septic arthritis are usually delayed after the clinical onset of infection.
Conclusions: Early and accurate diagnosis of osteomyelitis requires knowledge of the numerous radiographic manifestations. The usual features of osteomyelitis seen on conventional radiography (CR) are soft-tissue swelling, periosteal reaction, cortical erosion/destruction, and osteolysis. Nuclear medicine Tc-99m-labeled methylene diphosphonate (MDP) dynamic bone scans may be used in the differential diagnosis of cellulitis and osteomyelitis and can detect bone tracer uptake days or weeks before osseous changes are apparent on CR. These findings in skeletal scintigraphy are not specific for osteomyelitis and thus Indium-111 labeled WBC scans have been used in combination with Tc-99m MDP scans, as this tracer localizes in areas of infection and not in areas of remodeling or reactive bone. The primary applications of CT and magnetic resonance imaging (MRI) in the evaluation of bone infection are the delineation of the osseous and overlying soft tissue extent of the disease. CT can also be used for monitoring percutaneous aspiration and biopsy procedures. Despite the various appearances within the musculoskeletal system, the changes seen in osteomyelitis must be well known to the radiologist on all imaging modalities. Using cases from our radiology department database, we present, review, and correlate the imaging characteristics of osteomyelitis in CR, nuclear medicine, CT, and MRI.
RAD-13. Portal Venous Gas on Real-Time Sonography: A Pathognomonic Sign?
Ramesh Patel, MD, Tom Hogan, RDMS, and Henry Giles, MD. University of Mississippi Medical Center, Jackson, MS.
Background: Presence of portal venous gas in a patient usually indicates an acute surgical abdomen and poor prognosis. This is because in many of these cases the presence of portal venous gas is secondary to bowl infarction and necrosis or an overwhelming infection of the bowl. However, portal venous gas can also be seen in association with a number of relatively benign conditions that may not require surgical intervention and can be managed conservatively.
Discussion: Portal venous gas is usually documented on radiographic studies such as plain radiographs and CT scans. With increased availability of ultrasound equipment coupled with better resolution and increasing experience of the sonographers, hepatic sonography as an initial examination is being used to evaluate for presence portal venous gas. Visuilization of streaming bubbles of gas within the portal system on real-time sonography is a unique sign to unequivocally diagnose this condition since no other condition has been reported to simulate gas bubbles in the portal system. Hence, this seems to be a pathognomonic sign. After documentation of this sign, an abdominal CT scan may be appropriately tailored to evaluate the intra-abdominal organs to plan further therapy.
Conclusions: A pediatric case with documentaion of portal vevous gas on real-time sonography secondary to a nonsurgical bowl distension that was conservatively managed is discussed.
RAD-14. Radiological Manifestations of Langerhans Cell Histiocytosis.
Joseph F. Navoy, MD, and W. Mel. Flowers, Jr, MD. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.
Background: Langerhans cell histiocytosis (LCH) is a disease of unknown cause thought to be due to a disorder of immune regulation, which is characterized by abnormal proliferation of histiocytes, and includes the syndromes previously known as Letterer-Siwe, Hand-Schuller-Christian, and Eosinophilic Granuloma.
Discussion: Letterer-Siwe syndrome was described in infants as an acutely disseminated, rapidly progressive disease affecting primarily the soft tissues with minimal or no bone involvement. Hand-Schuller-Christian syndrome included chronic disseminated disease of young children with variable degrees of soft tissue involvement and multiple bone lesions. Eosinophilic granuloma was described as occurring in older children, usually presenting as a solitary bone lesion. Disseminated disease causes weakness, weight loss, fever, loss of appetite, and failure to thrive. LCH can involve multiple organ systems including bone, skin, lymph nodes, respiratory, reticuloendothelial, and central nervous system. LCH is classified in some centers as unifocal-unisystem, multifocal-unisystem, and multifocal-multisystem. Plain films may show round or oval lytic lesions in the skull, long bones, pelvis, ribs, and spine. Pathological fractures may occur. There may be only diffuse osteopenia. Computed tomography may reveal involvement of the mastoids and petrous ridges of the temporal bone. Magnetic resonance imaging can show early marrow involvement. Multifocal bone lesions may be associated with pain, tenderness, soft tissue swelling, and limitation of motion. Solitary bone lesions may be asymptomatic or painful. Extraskeletal lesions include interstitial and cystic pulmonary changes which may be complicated by pneumothorax.
Conclusions: The prognosis depends on the patient's age, the extent of disease, and the degree of organ dysfunction. Patients with unifocal LCH generally have an excellent prognosis. LCH produces a variety of radiographic findings in multiple organ systems. Knowledge of these findings can improve diagnosis and management. Our exhibit features numerous radiographic findings of this fascinating disease.
RAD-15. Radiologist Wellness and Stress Management.
Shannon B. Moss, PhD, Patrick O. Smith, PhD, and W. Mel. Flowers, Jr, MD. Departments of Family Medicine and Radiology, The University of Mississippi Medical Center, and The Mississippi Professionals Health Committee of the Mississippi State Medical Association.
Background: Radiologists, like other physicians, are susceptible to stress and to substance abuse. Most states have professional health programs that address physician impairment.
Discussion: These programs are becoming proactive in education and prevention and are emphasizing health and wellness. Physicians will do a better job attending to their patients' health care needs if they first take care of their own. This educational exhibit addresses warning signs of radiologist impairment, rates of substance abuse among radiologists, and sources of stress in radiology. Practicing wellness means being alert to early signs of impairment and engaging in positive behaviors. These include exercise, adequate sleep, healthy diet, self-care, time management, developing a social network, observing proper hygiene, and seeking help when there are symptoms of declining mental or physical health.
Conclusions: The radiologist should locate sources of stress, problem-solve, and attempt to implement change.
RAD-16. Scintigraphic Findings in Amiodarone-Induced Thyrotoxicosis (AIT).
Aju Thomas, MD, and Amolak Singh, MD. Department of Radiology, University of Missouri Health Care, Columbia, MO.
Background: Hyperthyroidism and markedly decreased thyroid uptake is most commonly due to thyroiditis but may occur due to iodine-induced hyperthyroidism caused by iodinated contrast or Amiodarone.
Discussion: The incidence of AIT is 3% among patients treated with amiodarone in the United States and 10% in iodine deficient regions. About 37% of the amiodarone's mass is organic iodine; 10% is released as free iodine. AIT may resolve spontaneously in 20% of the cases; in others, the disease may not resolve even if amiodarone is stopped. Antithyroid drugs, lithium, and beta-blockers have been used with variable success. Thyroidectomy is an effective treatment for AIT but may have high incidence of perioperative morbidity and mortality. Thyroid scintigraphy can be helpful when interpreted in light of clinical and laboratory findings.
Case: A 78-year-old female presented with hyperthyroidism after taking amiodarone for nearly 5 years for atrial fibrillation. The patient had no clinical signs suggestive of Graves disease or thyroiditis. The patient also denied any history of radiographic study with iodinated contrast. I-123 thyroid uptake and scan performed in June 2003 showed markedly decreased 24-hour uptake of 2.5% and poor visualization on scan. A follow-up study performed in January 2005 showed interval slight increase in the thyroid uptake to 5.4%. The amiodarone had been discontinued for 1 month. Another study performed 2 months after discontinuing amiodarone showed similar findings and the uptake of 2.75%. During the entire time, the TSH level was persistently low; less than 0.03 mU/mL. The thyroid hormone levels were within normal limits or borderline elevated. The hyperthyroid symptoms were controlled with beta-blockers.
Conclusions: In patients with hyperthyroidism and low radioiodine thyroid uptake, AIT should be considered when history and clinical grounds exclude thyroiditis and contrast-induced hyperthyroidism. Thyroid scintigraphy helps in excluding condition that can be treated with radioiodine ablation.
RAD-17. Setting Up Large Poster Presentations in PowerPoint[R].
W. Mel Flowers, Jr, William A. Buhner II, and Renea Hays. Departments of Radiology and Biomedical Illustration Services, University of Mississippi Medical Center, Jackson, MS.
Background: Features inherent in PowerPoint[R] allow production of a single large slide that can be printed as a full sized poster for display.
Discussion: The creator of this poster has full control of the design, layout, and content of the presentation and can adjust and readjust the height, width, position, and composition of the exhibit elements during stages of production until an entirely satisfactory finished poster is ready for printing. Starting with a single PowerPoint[R] slide as a background, the size of the poster is set in the Page Setup dialogue box (Choose File/Page Setup from the Menu Bar). This allows sizes up to 56 inches wide. Posters larger this can be set up half-size, with doubling of the dimensions during printing. After the large background slide has been created, the Insert/Picture and the Insert/Textbox features on the Menu Bar are used to add text and image content, just as in any ordinary PowerPoint[R] presentation. Pictures and text can be moved, enlarged, and freely edited. The Insert/Object feature allows pasting of one or many smaller PowerPoint[R] slides onto the larger background slide. Even smaller versions of entire exhibit posters can be added to the display. PowerPoint[R] tools to make ovals, boxes, lines, and arrows add considerable design flexibility. Size, color, and placement of these objects can be easily modified.
Conclusions: The production of an exhibit is much more efficient when this method is used.
RAD-18. Supra-renal Abdominal Aortic Mycotic Pseudoaneurysm Associated with Vertebral Osteomyelitis: Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) Findings.
Jaime Boudreaux, MD, Philip E. Cranston, MD, and W. Mel Flowers, Jr, MD, Department of Radiology, University of Mississippi Medical Center (UMMC), Jackson, MS.
Background: A mycotic aneurysm (MA) of an artery is an infected pseudoaneurysm. Though the term mycotic literally means pertaining to a disease caused by a fungus, the vast majority of MA are due to bacterial infections.
Discussion: MA account for approximately 3% of all abdominal aneurysms. Infected aneurysms of the suprarenal abdominal aorta with adjacent abscess and vertebral osteomyelitis are uncommon. We report the CT and MRI findings in a case of MA of the supra-renal abdominal aorta above the superior mesenteric artery with adjacent vertebral osteomyelitis and abscess at the left paraspinal/diaphragmatic crus region. There is a dramatic change between an initial and a follow-up CT scan.
Case: An 82-year-old white female was initially admitted to UMMC with a urinary tract infection and methicillin-sensitive Staphylococcus aureus bacteremia (MSSA). She was treated with antibiotics and became asymptomatic. CT scanning during that admission revealed a normal-size abdominal aorta with calcific plaque. The following month, the MSSA bacteremia reoccurred and intravenous antibiotics were started. An MRI scan was performed at an outside hospital for back pain and showed a paraspinous abscess and discitis at the T12-L1 level. Percutaneous drainage was performed and cultures grew out MSSA. She was referred to our institution for treatment, and further evaluation of para-spinal abscess and osteomyelitis when a repeat MRI showed abscess progression and vertebral destruction. MRI scanning of the lumbar spine at UMMC confirmed osteomyelitis and a para-spinal mass. CT demonstrated a large mycotic pseudoaneurysm involving the supra-renal aorta.
Conclusions: CT is the most important imaging study for the evaluation of mycotic aneurysms (MA). Serial CT scans will show the characteristic rapid development and progression. CT is especially valuable for investigating associated spinal osteomyelitis. The role of computerized tomograpic angiography (CTA) with coronal and sagittal reformatting and three-dimensional reconstruction is increasing.
RAD-19. The Explosive Incidence of Adenocarcinoma of the Esophagus: Relationships to Gastro-esophageal Reflux Disease (GERD), Barrett Esophagus, Obesity, and Pharmaceuticals.
Robert D. Halpert, MD, and W. Mel. Flowers, Jr, MD. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.
Background: Before the early 1970s, carcinomas of the esophagus were primarily squamous cell carcinomas arising from the squamous epithelium of the esophagus. Adenocarcinomas were unusual and accounted for only about 5% of the cases. They were often attributed to the nearby gastroesophageal junction extending into the esophagus. Since that time, the incidence of adenocarcinoma has exploded, with a 350% increase.
Discussion: This exhibit explores the possible reasons for this dramatic change. There is an increasing incidence of Barrett metaplasia. In 1950, when British surgeon Norman Barrett first described this entity, it was considered an oddity of questionable significance. Now, a half-century later, it is recognized as the most serious complication of GERD, which is chronically present in 20 to 25% of the population and is increasing. Malignant conversion is 40 to 125 times greater than in the general population. The risk is about 10%. It follows that the increased incidence of GERD is related to the increased incidence of Barrett esophagus, which is related to the increased incidence of adenocarcinoma. Most research has concentrated on detection, treatment and surveillance of Barrett metaplasia. Relatively little effort has been expended in exploring the issue as to why the incidence of GERD has increased.
Conclusions: Did society's endemic obesity problem contribute to the rise in this disease? The literature suggests it is probable, but the obesity issue and the anti-fast food campaign leave many unanswered questions. Multiple new medications to treat a variety of diseases were developed in the latter half of the 20th century. Many of these have the untoward effect of diminishing lower esophageal sphincter function. Did the widespread use of these medications contribute to this rise in this disease? The evidence suggests the possibility but is still inconclusive. More research is needed.
RAD-20. Transmesenteric Internal Hernia: Case Report.
Mitchell T. Godbee, MD, Kenneth L. Rall, MD, and Brinda Rao, MD. Department of Radiology, University of Missouri HealthCare, Columbia, MO.
Background: Transmesenteric hernias are a subtype of internal hernia that has interesting imaging findings.
Discussion: We present a case of transmesenteric internal hernia with x-ray and CT correlation in a male who presented with abdominal distention and intermittent pain.
RAD-21. Using Windows[R] Movie Maker[R] to Make Radiological Computed Tomography (CT) and Magnetic Resonance (MR) Video Scrolls for PowerPoint[R] Presentations.
W. Mel Flowers, Jr, MD, FACR. Department of Radiology, The University of Mississippi Medical Center, Jackson, MS.
Background: PowerPoint[R] presentations are now the preferred method of presenting information at radiology teaching conferences and national and regional radiological meetings.
Discussion: Present-day tomographic scanners produce hundreds of individual images that are usually examined by scrolling or paging thru the image series Once the series is available as a collection of .jpg images in a personal computer, a video scroll can be produced from these images and inserted as a video movie into a PowerPoint[R] presentation. This can be done with resources included in Windows XP[R] without the need to purchase additional software. DICOM images are captured and moved into .jpeg files into a personal computer (PC). Windows Movie Maker can be opened in Windows XP[R] by selecting Start, All Programs, Accessories, Entertainment, Windows Movie Maker. Open Import File Text Box, Select Tasks, Movie Tasks, Capture Video, import pictures. The Import File Text Box Appears. The first images of the series appear in the collection pane. Set the frame duration: select tools, select options. The Options Text Box opens. Set picture duration to 0.125 seconds. Click OK. Select all the images in the series. Drag and drop them into the timeline. Save the movie. Open PowerPoint. Select a new slide. Select insert, movies and sounds, movie from file. Browse--find the folder that contains the video then select and import the video. In summary, scroll videos of MR and CT series can be made for insertion in Powerpoint[R] XP using Windows[R] MovieMaker. No additional expensive programs are required. Videos can be combined with still pictures to accentuate and label abnormalities, and to point to the abnormalities with flashing arrows.
Conclusions: A video scroll can be produced from CT and MR images and inserted as a video movie into a PowerPoint[R] presentation. This can be done with resources included in Windows XP[R].
Section on Rheumatology
RHE-1. A Young Patient with Recurrent Pneumonitis: The Common Presentation of a Rare Disease.
Vrishali Dalvi, MD, Louis Lovett, FACP, and Emilio Gonzales, FACP. Atlanta Medical Center, Atlanta, GA.
Background: Lymphocytic interstitial penumonitis is a rare lymphoproliferative disorder characterized by polyclonal proliferation of mature lymphocytes in the lung. The cause is unknown, but it is often associated with autoimmune diseases, particularly Sjogren's syndrome. Early identification and immunosuppressive therapy may help prevent major complications such as progression to pulmonary fibrosis and transformation to lymphoma.
Case: We present a 26-year-old patient referred to our hospital for evaluation of recurrent cough and shortness of breath. Despite multiple therapeutic antibiotic trials given by the primary care physician on basis of radiological findings, the patient failed to respond. On presentation to AMC, the patient had moderate respiratory distress with diffuse crackles as well as axillary and inguinal lymphadenopathy. Room air Pa[O.sub.2] was 61 mm Hg, and chest CT showed diffuse alveolar infiltrates. Lung biopsy showed polyclonal lymphocyte proliferation, and a diagnosis of lymphocytic interstitial pneumonitis (LIP) was made.
Discussion: The patient showed an excellent response to corticosteroid treatment. Outpatient workup for diseases associated with LIP revealed Sjogren syndrome. The patient was treated with hydroxychloroquine and azathioprine; she remains asymptomatic and has resumed full-time employment. LIP was first described in 1966; 40 to 75% cases are idiopathic. Sjogren disease accounts for 25% of all adult cases of LIP, whereas HIV is the main association in children. There is a higher risk of progression to lymphoma in Sjogren disease. LIP is steroid responsive, but it is not known if early treatment can prevent progression to lymphoma. Early recognition and treatment of LIP will, however, prevent progression to pulmonary fibrosis in majority of cases.
Conclusions: This case demonstrates the importance of considering noninfectious causes in the differential diagnosis of recurrent pneumonia, especially with multiple therapeutic failures. Early recognition may alter the course and prognosis of the disease.
RHE-2. Case Report of Adult-Onset Still Disease.
Stephen Bagg, BA, and Leonard Serebro, MD. FACR. Medical University of South Carolina, College of Medicine. Charleston, SC, and Ochsner Clinic Foundation, New Orleans, LA.
Background: A 57-year-old black female without a significant medical history presented to the clinic with complaints of joint pains and fever. Physical examination showed tenderness and swelling of the MCPs, PIPs, and wrists bilaterally. She also had decreased abduction of the right shoulder, and her left knee was tender. She had several soft cervical and inguinal lymph nodes.
Discussion: Laboratory studies showed a negative ANA, negative CCP, negative HIV, extremely increased CRP at 31 mg/dL (nl 0.3 to 0.8), and a markedly elevated WBC count of 25,000. Infection and malignancy were ruled out by extensive testing including cultures, lab tests, and multiple imaging procedures. The patient was started on Celebrex 200 mg bid, Ultram 50 mg prn, and prednisone 10 mg, with no response in symptoms or CRP. We suspected adult Still disease and ordered a ferritin level, which was extremely elevated at 3738 ng/dL (nl 10 to 200). Her LDH was mildly elevated. High dose prednisone at 40 mg per day resulted in clinical improvement and normalization of CRP after several weeks.
Conclusions: Adult-onset Still disease is a disease of unknown cause characterized by arthritis, fever, a salmon-colored rash, and other systemic manifestations. A diagnosis of Still disease can be made using Yamaguchi criteria; his four major criteria consist of arthritis, fever, rash, and elevated leukocyte count. Minor criteria include sore throat, lymphadenopathy, increased liver tests, negative ANA, and rheumatoid factor. Diagnosis requires five criteria with at least two majors. Other potential causes, such as infection, must be excluded. Adult Still disease causes marked elevation of ferritin and acute phase reactants. Our patient met the criteria, with three major criteria: arthritis, fever, and elevated leukocyte count; and three minor criteria: negative ANA and rheumatoid factors, lymphadenopathy, and elevated LDH. Adult Still disease should be considered in a patient with arthritis and fever when other connective tissue diseases, infection, and malignancy have been ruled out.
RHE-3. Cytoxan Use in a Pregnant Female with Lupus Nephritis.
Stephen Bagg, BA, and Leonard Serebro, MD, FACR. Medical University of South Carolina, College of Medicine, Charleston, SC, and Ochsner Clinic, New Orleans, LA.
Background: A 31-year-old Chinese female with SLE by American College of Rheumatology criteria with history of arthritis, photosensitive rash, pleurisy, positive ANA 1:2500, positive DNA 1:5120, and a serum creatinine level of 1.5 presented to clinic. She was taking plaquanil 200 mg/day and prednisone 10 mg/day when she developed an SLE flare with arthritis, rash, proteinuria, and red cell casts.
Discussion: The prednisone was increased to 60 mg/day, and a kidney biopsy showed class Ill focal proliferative glomerulonephritis with moderately severe activity and chronicity indices. The patient was started on IV cytoxan per NIH protocol. Ten days after receiving the first dose, she presented with herpes zoster, causing severe pain in the left ophthalmic distribution. She was hospitalized and given IV acyclovir. Two weeks later, she was found to be pregnant (3 months by ultrasound). The patient was offered termination of pregnancy due to the potential teratogenicity of the cytoxan and acyclovir, but she declined. She was continued on 60 mg of prednisone and plaquanil. Due to deteriorating renal function, her nephrologist decided to administer monthly cytoxan for six total injections.
Conclusions: Subsequently, her renal function improved, and her prednisone dose was tapered to 30 mg daily. She delivered a low-birth-weight baby at 34 weeks, and the baby had no fetal abnormalities. After 5 years of follow-up, the baby had no apparent physical or mental sequelae from the cytoxan administration during pregnancy. It is generally believed that immunosuppressive drugs such as cytoxan are contraindicated in pregnancy due to the potential of fetal harm. The outcome in our patient suggests that when the clinical situation is grave with impending renal failure, such therapy may be warranted and can be given with proper counseling on the potential risks and is supported by case reports from the transplant literature.
Section on Surgery
SUR-1. Acute Pulmonary Edema Secondary to Release of A Chronic Traumatic Pericardial Effusion.
Andrei Gursky, MD, Darryl S. Weiman, MD, JD, and James W. Pate, MD. University of Tennessee College of Medicine, Division of Thoracic Surgery, Memphis, TN.
Background: Pericardial effusions with tamponade may present a clinical challenge for the cardiothoracic surgeon. We present a case of acute pulmonary edema secondary to the rapid release fo a chronic traumatic pericardial effusion that resulted in the death of the patient.
Methods and Results: A 19-year-old female was invloved in a motor vehicle accident 8 weeks before her presentation. Her initial injuries included a cerebral contusion, rib fractures with bilateral pulmonary contusions, and a grade Ill liver laceration. She required bilateral tube thoracostomies. Prolonged intubation eventually resulted in a tracheostomy. She improved and was discharged. She presented at follow-up with increasing fatigue and shortness of breath. A CT scan revealed a large pericardial effusion and and enlarged extrapericardial inferio vena cava. On presentation to the thoracic service, her pulse was 110 to 120 bpm, blood pressure was 120/80, and there was no pulsus paradoxas. She had slightly audible heart tones, mild jugular venous distention, and clear breath sounds. In the emergency department, her blood pressure fell to 90 systoloc with increasing tachycardia. She was brought to the operating room for a pericardial window. Attempts to pass an endotracheal tube were unsuccussful due to a subglottic stenosis at the previous tracheostomy site. The procedure was done by using mask anesthesia. A 1,600-mL pericardial effusion was drained through a subxyphoid approach. Hemodynamics normalized with the drainage. Arterial blood gases and oxygen saturations remained normal during the procedure. While preparing for transfer, the patient's oxygen saturation fell into the high 70s and respirations became labored. Mask ventilation became unacceptable, and attempt to pass an endotracheal tube failed. An emergent redo tracheostomy was done. The patient continued to be difficult to oxygenate and ventilate due to copious amount of pulmonary edema fluid, which had to be continuously cleared from the tracheostomy tube and ventilator circuit. Bilateral chest tubes were placed with minimal results. She failed further resuscitative efforts.
Conclusions: Review of pertinenet literature revealed few other cases of acute pulmonary edema with rapid release of pericardial effusion. Multiple mechanisms that have been proposed are complex. A rapid increase in right and left end-diastolic volumes occur with release of the effusion. This abrupt increase in venous return to the heart and increased afterload that is present with tamponade causes acute decompensation of cardiac function. This is usually pronounced with patients with preoperative myocardial dysfunction, multiple comorbidities, and longstanding disease. This physiologic derangement with our patients prolonged lack of adequate oxygenation probably caused a further elevation of pulmonary artery pressures resulting in a more pronounced right heart decompensation that should have been overcome. Rapid intubation, which did not occur in our case, may have been necessary to salvage the situation.
SUR-3. The Pinch-An-Inch Test for Appendicitis.
Gerald York II, MD, MAJ, MC, US Army, Devin Rickett, MD, CAPT, MC, USAF, Phil Albaneze, MD, CPT, MC, US Army, Michael D. Jones, MD, CPT, MC, US Army, Bradley Woods, MD, MAJ, MC, US Army, and Bruce D. Adams, MD, LTC, MC, US Army. Department of Radiology, Department of Emergency Medicine, and Department of Surgery, Brooke Army Medical Center, San Antonio, TX, and Department of Surgery, 228th Combat Support Hospital, San Antonio, TX.
Background: Rebound tenderness, a widely used physical examination test for patients with suspected appendicitis, can be quite uncomfortable for the patient. Accordingly, some standard references no longer advise its using it on patients with abdominal pain. We have developed a new alternative test for peritonitis that, in our experience, produces less discomfort for patients. We colloquially termed this peritoneal sign the "pinch-an-inch" test. To the best of our knowledge others have not described it.
Methods: To perform the pinch-an-inch, grasp a fold of abdominal skin over McBurney point and elevate it away from the peritoneum. Then let the skin recoil back briskly against the peritoneum. If the patient experiences increased pain when the skin fold strikes the peritoneum, the test is positive and peritonitis is likely present.
Case Reports: We describe two patients who presented with mild abdominal pain that subsequently were found to have appendicitis. In both patients, classic peritoneal signs were absent, and only the pinch-an-inch test was positive on presentation. Initial CT findings were negative as well in one of the patients. Both patients tolerated the pinch-an-inch test well and felt it was more comfortable than classic rebound tenderness.
Discussion: Delayed treatment of acute appendicitis can lead to significant morbidity. Despite (and perhaps because of) recent technological advances in radiological imaging, the prompt diagnosis of acute appendicitis can be difficult.
Conclusions: The experienced physician's bedside clinical examination remains the most critical component for rapidly identifying those patients with surgical disease. Although rebound tenderness is a widely used examination technique for detecting peritonitis, it is quite uncomfortable and can be inaccurate despite serial examinations. Therefore, research efforts should be directed to developing and validating improved bedside assessments of peritonitis.