Section on Medicine. (Abstracts of Scientific Posters).

MED1-C. SAFETY AND EFFICACY OF GLARGINE ALONE TO CONTROL BLOOD GLUCOSE DURING A CONTINUOUS ENTERAL NUTRITION REGIMEN. George Ragsdale, MD, Department of Anesthesia; and Veronica Piziak, MD,PhD, Department of Medicine, Scott and White Clinic, and Texas A&M Health Science Center, Temple, TX.

Control of blood glucose level in patients with diabetes mellitus presents significant problems when enteral nutrition is required in chronic disease when patients are unable to consume adequate protein and carbohydrate. Many of these patients no longer require intravenous access, and thus insulin infusions, which are successful in controlling glucose level, are less desirable than the subcutaneous option. Presently used subcutaneous insulin regimens require multiple insulin injections, which are uncomfortable for the patients. We report the successful use of glargine peakless insulin as the sole routine insulin in a post-transplant patient receiving continuous enteral feeding requiring high-dose insulin supplementation because of an infection and steroid use. Insulin glargine (Lantus), a recombinant, long-acting human insulin has been recently approved to treat both type 1 and type 2 diabetes. It is a clear solution at acidic pH, but microprecipitates at neutral pH and slowly releases insulin. Mean onset is 1.5 hours, and the duration is 20.5 hours. A 49-year-old African American man with history of diabetic nephropathy and renal transplant presented with severe pain in his jaw and facial swelling a few days after undergoing dental surgery Upon presentation, there was necrotic tissue over his hard palate, and a diagnosis of mucormycosis of the sinuses and hard palate was made. Treatment with high-dose amphotericin B was started and the patient underwent multiple debridements. Continuous enteral feedings were started at 90 cc/hr, along with an insulin infusion with adequate control of blood sugars at 9 units/hour. When continuous intravenous access was no longer needed, the patient required subcutaneous insulin. Glargine was started, initially at 30 units each evening, and the insulin infusion decreased as the glargine was titrated to a final dosage of 140 units per day. Supplemental regular insulin every 6 hours was used during the titration process, after which the blood sugar levels were maintained consistentl y below 150 throughout the day with only one injection of glargine in the evening. Continuous feeding with use of glargine for glucose control provides a safe, efficient option. Glargine should be stopped 3 to 4 days before enteral feeding is discontinued, and the supplemental scale of regular insulin reinstituted.

MED2-C. SPONTANEOUS DISSECTION OF BILATERAL INTERNAL CAROTID ARTERIES. Sundar Venkatesh, MD, MSHS, and Abraham Joseph, MD. Rochester, NY

Spontaneous dissection of the internal carotid and vertebral arteries is a well known cause of ischemic stroke. It occurs more often in young and middle-aged patients. These dissections have their own pathognomonic clinical features, and, if identified early, it might be possible to prevent a lot of morbidity. A 55-year-old white man was admitted to hospital after having a generalized tonic-clonic seizure at home. A week before admission, he had complained of right-sided headache that was continous and throbbing. The headache was mostly in his right temporal and peri-orbital regions. He had numbness over his right ear. He also had ringing in his ears and loss of taste. He was treated for sinusitis, and was referred to ENT for work-up of tinnitus. On the day of presentation, the patient felt dizzy on waking in the morning, lost consciousness, and had a witnessed tonic-clonic seizure. The patient had amnesia of the whole episode later. He had no significant medical history, other than having an elevated blood p ressure that was noticed in the PMD's office the previous week. Physical examination showed a right-sided oculosympathetic palsy consisting of miosis and ptosis. Neurologic examination was otherwise unremarkable. MRI of the brain and MRA of the neck showed complete dissection of the right coronary artery, with an incomplete dissection of the left internal carotid artery. There was no evidence of any intracranial infarct or bleed. The patient was immediately anticoagulated using intravenous heparin and oral Coumadin. Repeated MRI/MRA done 10 months later showed that both internal carotid arteries were patent. Anticoagulation therapy was discontinued. This case illustrates that, in spite of complete blockage of one of the internal carotid arteries, with early diagnosis and adequate anticoagulation, ischemic events can be prevented. The prognosis in these cases is very good, and the risk of recurrent dissection in the same artery or a different artery is small, and diminishes with the passage of time.

MED3-C. AN ATYPICAL PRESENTATION OF FUNGAL LARYNGITIS. Steve Gore, MD, Roger Wood, MD, and Michael Forgione, MD. Wilford Hall Medical Center, Lackland AFB, TX.

Primary mycotic infections involving the larynx are relatively rare, and, when found, are usually present in immunocompromised hosts. We present a case of an individual that was found to have a 1 x 1-cm fungate laryngeal lesion with superficial organisms consistent with Candida species. Furthermore, this individual had no documented evidence of conditions predisposing him to an immunosuppressive state. A 63-year-old man with at medical history of prostate cancer, hypothyroidism, hypertension, and hyperlipidemia presented with a six-month history of hoarseness, left-sided neck pain, dysphagia, weight loss, and progressive shortness of breath. Social history revealed tobacco and ethanol use. Physical examination was unremarkable. Laboratory studies were within normal limits. Direct laryngoscopy revealed a 1-cm exophytic lesion centered over the right arytenoid. The lesion was resected and pathologic examination revealed squamous hyperkeratosis with superficial fungal organisms consistent with Candida species. P atient had complete resolution of symptoms after resection and antifungal treatment. Candida albicans is a common inhabitant of the oropharynx, and in the immunocompetent host, is not ordinarily a pathogen. Although infrequent, there have been multiple case reports of laryngeal infection with Candida in the immunosuppressed host. Clinical presentation generally includes hoarseness, dysphagia, and cough. Gross inspection reveals thick, whitish areas resembling a pseudomembrane. Symptoms resolve with anti-fungals and/or removal of the lesions. Primary fungal infections of the larynx are rare, but when present, are usually found in immunosuppressed patients and have a typical pseudomembrane or pachyderma morphology. However, as presented above, it can uncommonly be found in an immunocompetent individual and have the morphology and clinical presentation suggestive of malignancy. These findings call for caution in diagnosis and management decisions in order to avoid overly aggressive or inappropriate therapy.

MED4-C. SALSALATE-INDUCED ABNORMALITIES OF THYROID FUNCTION TESTS: A LABORATORY ENTITY MIMICKING HYPOTHYROIDISM OF CENTRAL ORIGIN. Ritu Chahil, MD, Ahmed Bahatheq Phar, MD, and Ali Iranmanesh, MD. UVA School of Medicine, Roanoke-Salem Program in Internal Medicine and Psychiatry, Salem, VA.

Competitive binding of certain drugs, such as Salicylates and dilantin, to thyroid- binding proteins are reported to alter circulating total thyroid hormone concentrations. This entity appears to be more prevalent after salsalate administration, and is characterized by a state of euthyroidism associated with decreased serum concentration of total thyroxine, relative or absolute decreases in calculated free thyroxine index (FTI). and normal circulating concentrations of TSH. While not clinically significant per se, this laboratory constellation is of special consideration in the differential diagnosis of hypothyroidism of hypothalamic or pituitary origin. The key to this diagnostic dilemma is normalization of thyroid function tests while not taking salsalate, which is well documented in the 9 cases depicted in a group of 77 patients receiving this compound (prevalence, 12 %). In conclusion, consumption of drugs such as salsalate should be considered in the differential diagnosis of suppressed FTI in associatio n with normal TSH. To obviate the need for unwarranted and relatively expensive work-up for secondary hypothyroidism, reassessment of thyroid function tests off the drug should be performed prior to any other diagnostic approaches.

MED5-C. SOFA SCORE AS PREDICTOR OF MORBIDITY AND MORTALITIY OF HIV-POSITIVE PATIENTS IN ICU. Faria Farhat, MD, and Vinod Mody, MD. Department of Medicine/Infectious Diseases, Howard University, Washington, DC.

Our study evaluated organ dysfunction trends in critically ill HIV-positive patients as a predictor of outcome and determined the usefulness of sequential organ failure assessment (SOFA) score for prediction of mortality in HIV-positive patients admitted to the ICU. We performed a prospective, observational study of patients admitted to MICU at HUH from November 1, 2001, through March 1, 2002. Based on the data we have analyzed so far, the initial high SOFA score correlates well with mortality in HIV-positive patients. Statistics are currently being analyzed. Organ dysfunction is associated with high rates of ICU morbidity and mortality. It accounts for large part of ICU resources. SOFA score can assess organ dysfunction over time, and become useful in evaluating morbidity and mortality, and appropriate allocation of resources.

MED6-C. TEMPORAL ARTERITIS AND POLYMYALGIA RHEUMATICA PRESENTING AS FEVER OF UNKNOWN ORIGIN. Fatema Azam, MD, and Nurcan Ilksoy, MD. Atlanta, GA.

The patient was a 62-year-old white man with chief complaint of fevers up to 102[degrees]F, weakness, night sweats, and weight loss for two months. He also had diffuse bilateral joint pain with wrist and knee swelling. He reported severe morning and late evening stiffness lasting more than one hour and involving the above-mentioned joints, and also the shoulders. He also reports ten days of proximal muscle weakness involving primarily the thighs. PMH was significant for A-Fib, high cholesterol, and recently diagnosed Raynaud's syndrome. Physical examination was negative for any source of the recurrent fevers. His PCP started antibiotic therapy, but the patient continued to have fevers. Further work-up included negative blood cultures, urine culture, and chest/sinus x-ray films. He had normal CPKs, LFTs, TTE, and whole body CT and UGI. Other tests results included: ESR=70 mm/hr, RF (+), ANA (-). The differential diagnosis at this point included: giant cell arteritis, polyarteritis nodosa, polymyalgia rheumatic a, and cryoglobulinemia/hepatitis. Treatment with prednisone 20 mg PO TID was begun (since GCA was a consideration) and a temporal artery biopsy was performed. Biopsy results: arterial vasculitis with multinucleated giant cells compatible with giant cell arteritis. The patient's symptoms improved while taking high-dose steroids, especially the weakness, stiffness, and fatigue. The patient had no further fevers or chills. This is an unusual case of giant cell arteritis and polymyalgia rheumatica. The patient's symptom of stiffness that resolves with steroids is classic for PMR; however, he had no symptoms or physical examination findings suggestive of GCA. GCA is a vasculitis involving large and medium-sized arteries that occurs in patients age 50 years and older, more commonly in women of northern European heritage. This same population is subject to having a higher incidence of PMR. GCA and PMR may be part of the same disease entity, as they both occur in the same patient population and often in the same ind ividual. Symptoms of PMR may precede GCA by weeks or months, and may follow treatment of GCA when the corticosteroid dose is reduced below 10 to 15 mg of prednisone/day. There have been case reports of GCA or PMR following influenza vaccination in the current medical literature, among other syndromes including Guillan-Barre, SLE, and RA. Therefore, in cases of fever of unknown origin where every test ordered is inconclusive, GCA should be considered, given its high rate of morbidity if left untreated.

MED7-C. AUTOMATED TRANSIENT ISCHEMIC DILATATION (TID): AN UNRELIABLE INDEX OF MYOCARDIAL ISCHEMIA. H. Gull, A. Singh, D. Dang, and B. Greenspan. University of Missouri-Columbia, Columbia, MO.

TID of the left ventricle (LV) during stress testing has been associated with a high prevalence of multivessel critical coronary artery disease (CAD). Recent advent of the software AutoQuant (AQ) provides automated calculation of TID, which, although reported to be highly specific for detection of severe and extensive CAD, is of questionable reliability when compared with clinical and angiographic data. In this study, the occurrence and significance of automated TID of LV during stress testing was evaluated using dual isotope protocol. Myocardial perfusion stress scintigraphy (MPSS) following treadmill exercise or adenosine was performed in 49 adult patients utilizing thallium-201 for rest and Tc-99m tetrofosmin for stress imaging. MPSS results were interpreted by two experienced nuclear medicine physicians. TID was calculated automatically by AQ. Abnormal TID was defined as > 1.22, using the previously published limits for normal. Thirty-one patients were considered to have low likelihood of CAD based on the ir risk factor analysis. Eighteen patients were considered to have high likelihood of CAD, with complaints of angina and multiple risk factors, including history of CAD. Of 31 patients with low likelihood of CAD, 27 (87%) were found to have normal MPSS with no reversible ischemia and normal wall motion. TID was abnormal in 20 of 27 patients (74%), ranging from 1.26 to 1.60. In 18 patients with high likelihood of CAD, 5 were found to have severe 2- to 3-vessel CAD on angiograms, with TID ranging from 1.32 to 1.56. Six of 15 patients had noncritical CAD on angiograms, or normal MPSS with TID ranging from 1.04 tol.42. Automated TID was found to be present irrespective of the amount and severity of ischemia, and had a false-positive rate exceeding 74% in patients with a low likelihood of CAD and normal MPSS. The automatic measurement of LV TID during dual tracer MPSS is an unreliable predictor of myocardial ischemia and should not be used for interpreting MPSS, as it is associated with an unacceptably high false- positive rate.

MED8-C. METFORMIN-INDUCED HEPATOTOXICITY CPT Scott T. McNear, MC USA, CPT Beth A. Steinberger, MC USA, MAJ R.K. Fincher, MC USA. Dwight David Eisenhower Army Medical Center, Fort Gordon, GA.

Metformin hydrochloride is one of the biguanides that was introduced as an oral hypoglycemic in the 1950s for the management of non-insulin-dependent diabetes. The drug was voluntarily removed from the market some 20 years later due to reports that the phenformin was associated with an increased risk of lactic acidosis and subsequent cardiac morbidity and mortality. In the 1990s, metformin was reintroduced as an effective antihyperglycemic agent. The incidence of drug-induced lactic acidosis is very low, and is most likely in patients with renal insufficiency, since 90% of the medication is renally. excreted. As reported in the literature, only 3 cases of metformin-associated hepatotoxicity have been reported. Two of those cases involved the administration of other medications that could be hepatotoxic. This is the third described case of hepatotoxicity solely attributable to metformin reported in the English literature. The patient is a 55-year-old white man with non-insulin-clependent diabetes due to prolon ged use of prednisone for Grohn's disease, who began therapy with metfonnin, 500 mg/day, in mid-June. The patient became jaundiced with icteric sciera in July. Laboratory tests initially indicated intrahepatic cholestasis. Metformin therapy was discontinued. The patient's liver function continued to increase. His INR was elevated to 1.45; his bilirubin reached a maximum of 15.8 mg/dL; conjugated bilirubin, 7.7 mg/dL; and amino-transferases remained persistendy high. Viral titers did not indicate an infectious process, radiographic studies were within normal limits, and the patient denied any high-risk behavior. A liver biopsy showed marked intrahepatic bile stasis and spotty, mild hepatocellular necroinflammatory injury, consistent with drug-induced etiology. As the patient's clinical picture did not worsen, he was released after biopsy and followed up as an outpatient. The patient's liver function was continually monitored, with gradual decrease in laboratory values and complete resolution of values by 4 months.

MED9-C. ANGINA PECTORIS UNMASKED BY THYROID REPLACEMENT THERAPY. Jonathan MacCabe, MD, and Judith Kinzy, MD. University of Tennessee Medical Center at Knoxville, Knoxville, TN.

The association between hyperthyroidism and angina pectoris has long been recognized. At one time, thyroid ablation was even explored as a treatment for angina pectoris. More recently, the risks associated with thyroid replacement therapy in patients with known coronary disease have been described. We present a case of angina pectoris that was unmasked by thyroid replacement A 56-year-old nonsmoking woman with a history of hyperlipidemia was found to have an elevated TSH level. She was prescribed a low dose of levothyroid and, approximately two weeks after beginning the medication, she presented to the clinic with a new complaint of exertional chest pain and dyspnea. The EKG was normal. There was no history of coronary disease, nor was there any family history of coronary disease. She was advised to stop her thyroid replacement therapy, and she was scheduled for an exercise stress test. During the test, she experienced severe chest pain that was relieved with nitroglycerine. A subsequent coronary angiogram re vealed severe three-vessel coronary disease, and she was referred for urgent coronary artery bypass grafting. This case demonstrates the ability of hypothyroidism to mask the symptoms of severe coronary disease. Patients may become symptomatic as they return to a euthyroid state. All patients who are considered for thyroid replacement therapy should be carefully questioned about risk factors for coronary disease and warned about the possibility of anginal symptoms prior to the initiation of treatment.

MED 10-C. EFFECTS OF BROMOCRIPTINE MONOTHERAPY. Oladipo Adeolu Adeniyi, MBBS (MD equivalent), and George Lawrence, MD. Baltimore, MD.

We present the case 25-year-old black man with a history of hyperprolactinemia diagnosed two years prior when he presented with erectile faliure and gynecomastia. He had no prior significant medical history and was taking no medications. He had a prolactin level of 46 ng/mL, with subnormal testosterone level of 148 ng/dL and free testosterone level of 4.5ng/dL. Thyroid function tests, FSH, LH, and estradiol levels were normal. He had a normal karyotype. Brain MRI showed no evidence of pituitary or hypothalamic lesions. Bone density DEXA scan showed mild osteopenia of left femoral neck; however, there was no evidence of osteoporosis. A diagnosis of idiopathic hyperprolactinemia was made. Treatment with bromocriptine, 2.5 mg/day, was started. Over an eighteen-month follow-up period, his prolactin level remained elevated in the 35 to 48 ng/mL range, with persistent gynecomastia. He had marked improvement in erectile function, however, and his testosterone level had returned to normal. Idiopathic hyperprolactinem ia (IH) is the presence of elevated serum prolactin level in a patient without any demonstrable pituitary problem, central nervous system disease, or any other recognizable cause of increased prolactin level (PRL). It is a rare cause of male erectile dysfunction that responds to dopaminergic agonist treatment with or without a decrease in the serum PRL toward normal. It is a diagnosis of exclusion. All other recorgnizable causes of increased PRL, including hypothalamopituitary disease, medications like the neuroleptics, primary hypothyroidism, and neurosarcoidosis must be excluded. It is an unusual disorder and causes male erectile dysfunction in less than 1% of cases. The natural history of IH is benign, predisposing to pituitary adenoma in less than 3% of cases. Chronic IH is also a recognized cause of osteopenia and osteoporosis because of its estrogen-lowering effect, therefore warranting prophylactic treatment and preventive measures, even in asymptomatic patients. Some studies have shown that IH may pla y a role in promotion of bone loss. Our findings support the hypothesis that bromocriptine therapy improves erectile dysfunction associated with hyperprolactinemia by a direct dopaminergic stimulatory effect on the erectile mechanism in addition to its inhibitory action on prolactin secretion. Bromocriptine monotherapy is effective in treating hypogonadism and erectile dysfunction in over 90% of cases.

MED11-C. AN UNUSUAL CASE OF VERTEBRAL ARTERY DISSECTION. Tarik Haddad, MD, Loveen Puthumana, MD, and Peter Sloane, MD. Union Memorial Hospital, Baltimore MD.

A previously healthy 39-year-old athlete presented to the emergency department after waking up from sleep feeling diaphoretic and dizzy. This was followed by right facial numbness, slurred speech, vertigo, nausea, and vomiting. Four days prior to admission, in preparation for a triathlon competition, he had biked 120 miles. The day prior to admission he developed mild posterior neck pain. The physical exam was significant for right horizontal nystagmus, right facial palsy, absent gag reflex, and right-sided hemiparesis with a positive Babinski sign. The patient was admitted to the ICU, and over the course of a few hours he was placed on mechanical ventilation for respiratory distress. MRA showed a right medullary infarction. MRA revealed abnormal tapering and termination of the right vertebral artery, consistent with vertebral artery dissection. Vertebral artery dissection is an important cause of stroke, especially in young people. Vertebral artery dissection can occur spontaneously or after mechanical stret ch associated with hyperextension or rotation of the neck. Cases have been reported after yoga, chiropractic manipulation, coughing, or even sneezing, and present with an occipital headache and neck pain following a relatively minor head or neck injury. CNS sequelae can start from minutes to weeks after the incident. Most dissections heal spontaneously. Prevention of thromboembolic complications with immediate intravenous heparin administration, followed by warfarin therapy for 3 to 6 months is the standard of treatment. The reported rate of death is less than 5%. Eighty-eight percent of patients have a good functional recovery. Literature search shows only one other documented case of vertebral artery dissection directly related to bicycling. When healthy young patients present with stroke in the setting of a possible hyperextension neck injury, physicians should have a high index of suspicion of vertebral artery dissection. Most patients with vertebral artery dissection will show significant functional improvement.

MED12-C. SPLENIC ARTERY PSEUDOANEURYSM: A RARE CAUSE OF UPPER GASTROINTESTINAL HEMORRHAGE. Syed Quadri, MD, Ihab Shehadeh, MD, Giti Rostami,MD, Sangeeta Agrawal, MD. VA Medical Center and Wright State University School of Medicine, Dayton, OH.

Visceral artery aneurysms are rare but important cause of upper gastrointestinal hemorrhage. The splenic artery is the most common site of visceral artery aneurysms. Pseudo-aneurysms of the splenic artery are less common than true splenic artery aneurysms, and are frequently associated with chronic pancreatitis. A 51-year-old diabetic man was admitted to hospital with complaints of syncope, diffuse abdominal pain, and hematemesis. Five years earlier he had undergone splenectomy with distal pancreatectomy for repair of a bleeding splenic artery aneurysm resulting from blunt abdominal trauma. On admission, the patient was pale and tachycardic, with a systolic blood pressure of 90 mm Hg. Abdominal examination revealed midline scar and mild epigastric tenderness. There were no palpable masses or abdominal bruits. The remainder of the physical examination was unremarkable. Nasogastric aspirate showed bright red blood. Laboratory examination showed a hemoglobin level of 7.9 g/dL, hematocrit value of 22.9%, and a no rmal mean corpuscular volume. The coagulation studies were normal. Abdominal series were unremarkable. An emergent upper endoscopy showed the stomach to be full of blood clots. Upper endoscopy repeated the next day showed a sub-mucosal mass on the posterior aspect of the gastric fundus with a large blood clot adherent to it. A computerized tomography (CT) scan of the abdomen was obtained, which revealed a large pseudoaneurysm with mass effect upon the stomach. Abdominal angiography showed the pseudoaneurysm to be coming off the stump of the splenic artery. Transcatheter coil embolization was done with vascular coils. Angiography and abdominal CT were repeated and confirmed complete occlusion of the pseudoaneurysm. The patient was discharged from hospital in a stable condition. We report a rare case of pseudoaneurysm arising from the stump of the splenic artery, which was managed successfully with selective angiography and coil embolization

MED13-C. ANALYSIS OF INITIAL SITE OF CARE DECISIONS FOR LOW-RISK COMMUNITY-ACQUIRED PNEUMONIA PATIENTS: CLINICAL AND PATIENTS PERSPECTIVES. Zakari Y. Aliyu, MD, MPH. Department of Internal Medicine, St. Agnes Hospital, Baltimore, MD.

Patients with community acquired pneumonia (CAP) and a pneumonia severity index (PSI) score lower than seventy are at low risk for complications and are candidates for outpatient therapy. Variations in the initial site of care (inpatient vs outpatient) exist. Limited information exists regarding the clinical and socio-demographic predictors for hospitalization of these patients. Clinical outcomes data and information on patient satisfaction with the site of care decisions are also limited. A structured questionnaire was administered to 214 patients evaluated at our institution's emergency department with a diagnosis of CAP (PSI <70, 61% hospitalized, 39% managed as outpatients) between January 2000 and January 2001, to assess their clinical outcomes and levels of satisfaction with the site of care decisions. A retrospective chart review of both groups was also done to compare clinical and socio-demographic parameters in the two groups. No differences were observed in the levels of satisfaction with the site o f care decisions or outcomes between the two groups (P > .05). Fifty percent of patients in both groups reported lack of adequate involvement in the initial site of care decisions. Women, African Americans, and medically insured patients were more likely to be admitted (P < .001); higher temperature and pulse rates were also observed in the admitted group (P < .01). An understanding of the association between the socio-demographic and clinical variables with admission decisions for low risk CAP would increase the quality of care delivered to these patients. It is important to determine patients' satisfaction with site of care decisions and to incorporate them into clinical decisions.

MED14-C. HYPOPITUITARISM ASSOCIATED WITH AN ENLARGING SELLAR MASS DUE TO MENINGIOMA OF INTRA- AND EXTRASELLAR ORIGIN. Suzanne E Strong, DO, and Ali Iranmanesh, MD. UVA School of Medicine, Roanoke-Salem Program in Internal Medicine, Salem, VA.

Hypopituitarism is usually caused by the mass effect of lesions originating from the pituitary gland, a craniopharyngioma, or destruction of the hypophyseal tissue by hemorrhage, surgery, and/or irradiation. The present case is a 63-year-old man who originally presented at the age of 59 years with chest discomfort and 20 pounds of weight loss over a period of 2 months prior to his hospital admission. The work-up at this time was significant for suppressed serum concentrations of TSH at 0.04 mIU/mL (normal, 0.35-5.5 mIU/mL) in the presence of a normal free thyroxine index at 1.6 (normal, 1-4). The association of thyroid function abnormality with decreased circulating concentrations of testosterone (58 ng/dL; normal, 241-827 ng/dL), FSH (0.6 mIU/mL; normal, 0.9-15 mIU/mL), LH (0.2 mIU/mL; normal, 1.5-9.3 mIU/mL), and AM cortisol (5 mg/dL; normal, 7-25 mg/dL) with normal plasma ACTH (12 pg/mL; normal, 0-46 pg/mL) concentration suggested multi-axis endocrine failure of a central origin. Serum concentration of pro lactin was normal at 12.1 ng/mL (normal, 2.1-17.7 ng/mL). At this point, patient was subjected to a MRI of the sella, which showed a pituitary mass measuring 1.3 cm. Replacement doses of levothyroxine, hydrocortisone, and testosterone were given, with significant improvement in his general medical condition. Follow-up care included an MRI in April of 2000, which disclosed a substantial increase in the size of the enhancing pituitary mass, measuring 2.7 cm, with sellar expansion, erosion of the dorsum sella, and suprasellar extension with possible compression of the optic chiasma. These findings prompted a referral to the neuro-surgery service, and eventual transnasal, trans-sphenoidal partial resection of a very vascular pituitary lesion. The tumor had extra- and intrasellar origin, and was histopathologically diagnosed as meningioma. In summary, this is a rare case of extra- and intrasellar meningioma presenting as a nonsecreting pituitary adenoma with hypopituitarism.

Retrospectively, the relatively rapid growth of the tumor (2-fold increase in size over a 3-year period), and attention to subtle MRI differences (as described in the literature) could have assisted in identifying the incriminating etiology, and led to a more appropriate choice of surgery (ie, trancranial).

MED15-C. BUPROPION SR VERSUS PLACEBO: COMPARISON OF DEPRESSIVE SYMPTOMS AND WEIGHT LOSS IN OBESE PATIENTS WITH A HISTORY OF MAJOR DEPRESSION. Paul S. Bradley, MD, Barbara Haight, PharmD, Brenda Jamerson, PharmD, Vicki Foster, MSPH, Nathalie Richard, MS, and Alan Metz, MD.

The purpose of this study was to compare the efficacy of bupropion SR versus placebo in the treatment of depressive symptoms and in the facilitation of weight loss in obese adults with current depressive symptoms and a history of major depression. Obese adults with depressive symptoms (but not meeting DSM-IV criteria for a current depressive disorder) were randomized to receive bupropion SR (300-400 mg/day) or placebo in combination with a 500-calorie deficit diet for 26 weeks. At each visit, weight and Beck Depression Inventory (BDI) scores were obtained. A prospective analysis of patients with a self-reported history of major depression was conducted. Ninety-two of the 422 randomized patients reported a history of major depression (50 bupropion SR 42 placebo). Significantly more bupropion SR patients (52%) than placebo patients (28%) achieved [greater than or equal to] 50% reduction in BDI at week 26, a trend that began at week 4 and continued throughout the study (P < .05). Mean weight loss was also signif icantly greater for those taking bupropion SR- versus placebo-treated patients from week 2 through week 26 (4.8 kg vs 1.6 kg, respectively) (P < .001). Bupropion SR was significantly more effective than placebo in reducing depressive symptoms and facilitating weight loss in obese patients with a history of major depression and current depressive symptoms.

MED17-C. ASSOCIATION OF GRAVES' DISEASE WITH LOW-OUTPUT CARDIAC FAILURE: QUESTION OF CAUSE-AND-EFFECT PHENOMENON. Jennifer John, MD, Imran Haque, MD, and Ali Iranmanesh, MD. University of Virginia School of Medicine, Roanoke-Salem Program in Internal Medicine, Salem, VX

While uncommon, hyperthyroidism can cause congestive heart failure, usually of high-output nature. The present case is a 50-year-old man who was admitted to the hospital with edema of lower extremities, scrotum, and abdomen; shortness of breath with exertion; orthopnea; and 10 pounds of weight loss. Based on medical history and subtle eye findings, hyperthyroidism was suspected and documented by elevated free thyroxine index (FTI) at 5.6 (normal, 1-4), and suppressed TSH level of < 0.03 mIU/mL (normal, 0.35-5.5 mIU/mL). To this end, high values of TSH-receptor antibody of 51 (positive,> 15) confirmed the diagnosis of Graves' disease. In addition, assessment of cardiovascular and pulmonary systems disclosed a normal-sized heart with bilateral pleural effusion on chest x-ray films; atrial fibrillation with rapid ventricular rate on EKG; global hypokinesis and ejection fraction estimated at 10% by echocardiogram; elevated pulmonary capillary wedge pressure; increased sight-sided and pulmonary artery pressures; a nd low cardiac output by cardiac catheterization. Patient was started on PTU with significant improvement in the thyroid function tests after one day of treatment (FTI, 3.9; TSH 0.03 mIU/mL). However, pulmonary condition deteriorated, with increasing hypoxemia and hypercapnia and blood gases suggestive of respiratory acidosis, which required artificial ventilation. Other work-up included sampling of the pleural fluid, which was of transudative type. Nutritional supplementation was initiated due to a prior history of alcoholism, as well as clinical and laboratory evidence (low circulating concentrations of albumin and cholesterol) of malnutrition. This, along with treatment of thyrotoxicosis, management of CHF, and drainage of about one litter of pleural effusion, resulted in significant improvement in the patient's clinical condition and eventual discharge from the hospital and in a stable condition. In summary, Graves' disease in this patient was accompanied by CHF, respiratory failure, and malnutrition. Whi le hyperthyroid state could have contributed to the severity of cardiac failure, due to the presence of low ejection fraction and global cardiac hypokinesia, it is unlikely to be the primary cause.