2004 ACP Scientific Meeting Abstract Submissions
PERIPHERAL BUT NOT
Sinai Grace Hospital, Detroit Medical Center, Wayne State University and John D. Dingell VA Medical Center, Detroit, MI.
Introduction: The present study was designed to determine
if the ventilatory response to carbon dioxide (CO2)
in the presence of high or low oxygen (O2) levels are significantly
different in African Americans (AA) as compared to Caucasians (C) during
wakefulness.
Methods: Ten healthy African American (AA) and 9
healthy Caucasian (C) subjects completed 4 CO2 rebreathing
trials. Hyperventilation was completed before each rebreathing
trial to attain a partial pressure of CO2 (PETCO2)
between 22-25 mmHg. Thereafter, subjects were switched into a re-breathing bag
that contained an initial PETCO2 of 42 mmHg and a partial
pressure of O2 (PETO2) of either 50 mmHg (CP -
central + peripheral chemoreflex activation) (2
trials) or 140 mmHg (CC – central chemoreflex
activation) (2 trials). During the rebreathing trials
O2 levels were maintained while PETCO2
increased in a linear fashion.
Results: Age (AA vs. C - 38.9 ± 1.73 vs. 38.7 ± 2.5)
and body mass index (BMI) (AA vs. C - 27.3 ± 0.9 vs. 28.6 ± 1) was not
significantly different between the groups. The slope of the ventilatory response to increases in CO2 (i.e.
responsiveness) was greater in the AA as compared to the C group during the CP
(8.9 ± 1.3 vs. 6.2 ± 1.1 L/min/mmHg; p < 0.03), but not the CC rebreathing trials. The ventilatory
recruitment threshold (i.e. when ventilation begins to rise in a linear fashion
with increases in carbon dioxide) was not significantly different between the
groups during both the CP (AA vs. C - 40.7 ± 0.7 vs. 42.1 ± 0.8 mmHg) and CC
(AA vs. C - 46.8 ± 0.7 vs. 46.0 ± 0.8 mmHg) rebreathing
trials.
Conclusions: Activation of the peripheral chemoreflex leads to a greater ventilatory
response in AA as compared to C during wakefulness. This increase is due solely
to an increase in chemoreflex responsiveness and not
due to changes in the recruitment threshold.
PPAR-γ IS A POTENT INHIBITOR OF
NEUTROPHIL FUNCTION IN SEPSIS
Ghaffari M* (Associate), Reedy R, Smith I, Zeng
X, Newstead M, Rodriguez M, Standiford T, *Department of Internal
Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan, Department of Internal Medicine, Division of Pulmonary and
Critical Care Medicine, University of Michigan Medical Center, Ann Arbor,
Michigan.
Introduction: Sepsis results in a profound state of immunosuppression, which occurs in association with a
substantial impairment in leukocyte function. Peroxisome
proliferator-activated receptor-gamma (PPAR-g) is a ligand-dependent
transcription factor belonging to the nuclear hormone receptor superfamily. Importantly, activation of PPAR-g has been shown to negatively regulate
the activation of monocyte/macrophage populations.
However, the function of PPAR-g in regulating neutrophil function, and how PPAR-g expression in these cells may be altered in sepsis has not been
defined.
Hypothesis: PPAR-g is an important negative regulator of neutrophil
function, and activation of PPAR-g contributes to the dysfunction of the neutrophils
observed during the septic response.
Methods: Neutrophils
were isolated from healthy subjects and patients with sepsis. Expression of
PPAR-γ mRNA was defined by RT-PCR. Neutrophils
were treated with either endogenous (PGJ2) or
exogenous (Troglitazone) PPAR-γ agonists, then
effects on the neutrophil proinflammatory
cytokine production, migration, and apoptosis determined by ELISA, chemotaxis bioassay and single strained DNA analysis, respectively.
Results: Neutrophils
expressed minimal PPAR-γ mRNA at rest, but PPAR-γ message was induced
by cytokines released in sepsis, including TNF and IL-4. Treatment of neutrophil with PPAR-γ agonists dose-dependently
inhibited LPS induced cytokine production and FMLP-induced chemotaxis. Moreover, selected PPAR-γ agonists induced
neutrophil apoptosis at 24 hours. Finally we observed
constitutive expression of PPAR-γ mRNA in neutrophils
isolated from sepsis patients, but not neutrophils from healthy control
subjects.
Conclusion: PPAR-γ is a potent inhibitor of neutrophil function in vitro, and the expression and
activation of PPAR-γ in sepsis may contribute to the suppression of neutrophil function observed in sepsis .Modulating the
activity of PPAR-γ may serve as a potential therapeutic modality in the
management of sepsis immunosuppression.
PANCOAST SYNDROME AND
METHICILLIN RESISTANT STAPHYLOCOCCUS PNEUMONIA: AN UNCOMMON PRESENTATION.
Anjali Gupta MD
(Associate), Tabarak Qureshi
MD (Associate), Rose Andriacchi (Member),
Introduction: Staphylococcus aureus pneumonia is a common presentation. However, methicillin resistant staphylococcus aureus (MRSA) pneumonia presenting as Pancoast Syndrome is an uncommon presentation.
Case Report: A 47 year old African American female
with a history of T2 to T6 vertebral fusion after a MVA and an obsessive
compulsive disorder presented with severe back pain, Horner’s syndrome, and
numbness and tingling in her left arm. A
chest X-ray showed a left upper lobe mass. Laboratory analysis revealed a white
cell count of 14.7 K/CUMM. The patient was isolated and tuberculosis was ruled
out with three sputum samples negative for AFB, followed by a bronchoscopy and BAL. Tissue samples from the bronchoscopy showed an organizing pneumonia. Sputum and
blood cultures were positive for MRSA.
She was started on intravenous vancomycin and
a MRI was obtained. Results of the MRI showed a 3 cm x 4 cm mass in the left
upper lobe with encasement of the lower part of the brachial plexus.
Conclusion: Pancoast syndrome and methicillin resistant staphylococcus aureus pneumonia is a rare presentation. Extensive search of the English literature revealed one report similar to the case presented above. We report the second case.
GENETICS OF
THE HUMAN URIC ACID TRANSPORTER (hUAT)
B.N. Nandish, M.D., Sinai Grace Hospital, Detroit
Medical Center, Wayne State University, Detroit, MI. Michael S. Lipkowitz, M.D., Associate Professor, Mount Sinai School Of
Medicine, New York, NY.
INTRODUCTION: Elevated levels of uric acid have been associated with an
increased risk for gout, hypertension, cardiovascular disease, and renal
failure. Recent studies suggest that hyperuricemia
precedes and predicts the development of hypertension in adults and
adolescents. Molecular mechanisms for diminished excretions
of urate in theses disorders is not well
understood.
HYPOTHESIS: Data suggests galectin 9 is a functional
human homologue of the rat UAT. It also contains the putative channel forming transmembrane domain of UAT. Data clearly indicate that
mutations in individual ion transport proteins in renal tubule can result in
significant renal disease.
METHODS: Patients are from the NIH funded ancillary study of African-American
study of kidney disease who are expected to have hyperuricemia due at least in part to abnormal urate excretion. Genomic DNA are
extracted from peripheral blood leukocytes. Polymerase chain
reaction (PCR) for exon 1are done using a gradient cycler. PCR products are digested with restriction
enzyme MSPA1 followed by gel electrophoresis using ethylene bromide dye.
RESULTS: Results of PCR gel electrophoresis were analyzed for genotype GG and
mutation genotype GA. The mean uric acid levels in studies
done so far have shown marginal elevation of uric acid in genotype GA.
DISCUSSION: Confirmed mutations will be generated in hUAT
in expression vectors and for normal expression in cells. Localization of hUAT as a membrane protein will be done using the membrane biotinylation. Finally mutations detected are being cloned
into a bacterial expression vectors for generation of recombinant protein to
test for ion channel function in a lipid bilayer
system.
CONCLUSION: There is good reason to believe that UAT ion channel may be
responsible for alterations in uric acid excretion by the kidneys, seen in pathophysiologic states such as gout, hypertension and
familial hyperuricemia syndromes.
CASE REPORT
OF ORAL AMIODARONE INDUCED FULMINANT HEPATIC FAILURE.
Tannu Sahay,
MD, Associate, Samer El-Dirani,
MD, Associate, Jennifer Ui, MD, Arpita
Patel, PharmD, Thomas Piskorowski, DO, Department of Internal Medicine,
Sinai-Grace Hospital/Wayne State University, Detroit, Michigan..
CASE SUMMARY- Our patient is an 82-year-old male with no history of ethanol use
who came to the hospital with hypotension and a syncopal
episode related to hypovolemia that required intubation and mechanical ventilation. His past medical history was significant for
coronary artery disease with an EF of 20% and CABG performed approximately 9
years ago, tachy-brady syndrome for which he had a
pacemaker-AICD placed and end stage renal disease. Pacemaker interrogation did
not reveal any arrhythmic event. He had coagulopathy
(INR-3) but no clinical evidence of any overt bleeding. He had been on coumadin since the CABG.
Liver function tests were normal. The patient was successfully extubated the next day and was sent to the general medical
floor on hospital day number 3. His home
medications, including amiodarone
200 mg
DISCUSSION- Most cases of Amiodarone-induced hepatotoxicity are related to parenteral
administration, higher cumulative doses and prolonged duration of therapy. Our
patient is unique since he was on oral amiodarone for
no longer than 20 days. Amiodarone-induced hepatotoxicity is usually reversible with the withdrawal of
the medication.
CONCLUSION- Amiodarone-induced Hepatotoxicity
is a rare complication. However, it should be considered before addition of any
other hepatotoxic agent. Also, liver function studies should be followed
on a regular basis.
PNEUMOCYSTOSIS OF THE BRAIN PRESENTING AS RING ENHANCING LESIONS -
A RARE CLINICAL MANIFESTATION.
A Reddy, MD (Associate), B Sudhir, MD (Associate),
B Ismail, DPM, S.Marur, MD
(Member), L.Ganesan, MD; Department of Internal Medicine,
Sinai Grace Hospital/Wayne State University, Detroit, Michigan.
Introduction:
Pneumocystis carinii infection is predominantly
localized to the lungs. However, 0.5 to 2 % of persons with AIDS can present
with extra pulmonary Pneumocystitis. Among these,
involvement of CNS is the most uncommon presentation of Pneumocystis
carinii infection.
Case
Discussion:
A 42 Year old African American male with a past medical history of AIDS , Cryptococcal meningitis and seizure disorder, presented
with focal seizures of the right lower extremity followed by Todd’s paralysis.
His medications included fluconazole, bactrim, zithromax, neurontin and HAART therapy. At presentation, he had an
initial viral load of 10,000 and a CD4 count of 255. CT Scan
with contrast showed multiple ring enhancing lesions at vertex. MRI with
contrast showed irregular thickened meninges in the
parietal region with multiple ring enhancing lesions bilaterally in the
parietal cortex. CSF was positive for Cryptococcal
antigen at a titer of 1:256. Serum titers were negative for Toxoplasma.
A stereotactic biopsy of the brain was performed with
a high clinical suspicion of cerebral lymphoma. The histo-pathology
report of the tissue was positive for Cryptococcus as well as Pneumocystis carinii. Chest X ray
was negative for Pneumocystis carinii
pneumonia. Treatment was started with amphoterecin-B
along with flucytosine and bactrim.
Patient developed anaphylactic reaction both to regular as well as lipophilic amphotericin-B and was
treated with high dose fluconazole.
Conclusion:
This is the first time this condition presented with ring enhancing lesions
coexisting with Cryptococcus infection in a patient with AIDS. There have been
two previous reports of cerebral Pneumocystosis which
were, however, diagnosed on autopsy. Recognition of this coexistence can be a
valuable consideration in patients with AIDS who present with ring enhancing
lesions on neuro-imaging.
Sterol and stanol ester based
margarines have a significant role in reducing plasma cholesterol levels.
Arvind Reddy,
M.D, M.P.H . Department of Medicine,
Research Question:
In normocholesterolemic
and mildly hypercholesterolemic individuals, do
sterol and stanol ester based margarines help in
lowering cholesterol levels when used alone or in adjunct with other
cholesterol lowering agents?
Data Source:
Experimental studies from the MEDLINE database from
1998 – 2003 using Pubmed and Ovid.
Study Selection:
Randomized trials included in this review were
identified by a MEDLINE search term "plant sterols."
Studies focusing on normal to mildly hypercholesterolemic
subjects who were not on any cholesterol lowering therapy except the NCEP step
1 diet were selected. A small group of studies involving subjects already on a
single lipid lowering drug were also selected.
Outcome Measures:
The data points chosen as outcome measures in these
studies were the plasma levels of total cholesterol, LDL cholesteorol
and HDL cholesterol.
Results:
The first randomized controlled study involving 224
subjects already on NCEP step 1 diet, showed that
sterol based margarines decreased total cholesterol by 7.1 % and LDL
cholesterol by as much as 10% at the end of the 5 week trial period with no
significant impact on HDL levels. In another study involving 100 subjects on
three different doses of sterol based margarines a dose dependent response was
observed with a decrease in total cholesterol by 4.9%, 5.9% and 6.8% and LDL
cholesterol by 6.7%, 8.5% and 9.9%. There was no significant change in HDL
levels. In another study involving 141 subjects comparing sterol and stanol ester based margarines, stanols
showed an increase in HDL cholesterol levels by 1.4% apart from lowering LDL
levels by about 13% at the end of the 90 day period. In the last study
involving 167 subjects, stanol ester based margarine
showed a reduction in LDL cholesterol by as much as 24% when used in adjunct to
intermediate dose of statins at the end of 8 weeks.
Conclusion:
Stanol and sterol ester based margarines
are very effective in reducing total and LDL cholesterol levels in normocholesterolemic and mildly hypercholesterolemic
individuals when used alone or in adjunct to statin
therapy. Stanol ester based margarines have an
additional benefit of raising HDL cholesterol levels when compared to sterol
ester based margarines.
ALTERNATIVE
METHODS OF BONE MINERAL DENSITY (BMD) ASSESSMENT.
Vibha Nayak, MD (Associate),
Dept. Of Medicine,
Question:
A 50 year old woman with a family history of hip fracture is
seen by you for routine physical examination and preventive care. You are
contemplating the use of peripheral bone densitometry in favor of a complete
bone mineral density assessment.
- What
methods are available?
- Which
sites have been evaluated?
- How
effective are they as compared to standard BMD assessment of the hip,
spine, and forearm?
Data sources:
Studies were identified by searching MEDLINE (1998 to 2003),
journal reviews and the following sources
National Osteoporosis Foundation(NOF)
Ovid-Cochrane
Pubmed
American Journal of Densitometry
British Journal of Radiology
Study selection:
Mulitple studies were conducted for comparison of Pheripheral densitometry and central densitometry.
All were prospective studies conducted over a period of 2 – 10
months.
Data extraction:
One investigator independently extracted data on patients,
interventions, and outcomes.
Main results:
As compared to
- The
sensitivity (T-Score < -2.5) and specificity (T-score>-2.5) of heel
ultrasound was 34 and 94 % respectively. The figures were 23% and 92% for
finger DXA. The sensitivity of both methods went up as the cut-off values
for diagnosis of osteoporosis was increased, however the discordance rates
increased correspondingly.
- RA had
the highest specificity (67%) followed by quantitative ultrasound(64%)
at a sensitivity level of 90% for
both.
- Applying
a calcaneal ultrasound in the detection of
osteoporosis but using a T-score threshold of < -1, the overall
sensitivity was 51% and specificity was 93% in detecting low bone mass at
the femoral neck .
Conclusion:
More studies are needed to examine the efficacy and
benefits of peripheral
densitometry methods over DXA. As seen previously peripheral densitometry has a low
sensitivity. Hence, it does not have
much of a role in
screening for low BMD. These devices are not an equitable replacement for
central DXA in screening for osteoporosis.
One strategy, however, might be to use DXA as a initial screener and once osteoporosis is detected and treatment initiated, subsequent follow up can be done by peripheral methods.
COPAXONE
INDUCED PLEURAL EFFUSION AND HILAR LYMPHADENOPATHY
V. Nayak,
MD, Associate, D. Obeid, MD, Associate, L. MacDonald, MD,
Copaxone or Glatiramer
Acetate is an immunomodulatory agent used in the
treatment of Multiple Sclerosis (MS).
The drug has been shown in controlled clinical trials to reduce the
frequency of relapses in MRI-defined disease activity and burden in relapsing
–remitting MS. Most common side effects in patients on copaxone
include injection site reactions, vasodilatation, depression, dizziness, dyspnea, and urticaria. This case
report is to demonstrate the manifestation of pleural effusion and hilar lymphadenopathy secondary
to copaxone.
We report a 28 year old African-american female who is a nursing home resident with history
of MS maintained on copaxone 20 mg SC once daily
since March 2003 who was admitted to the hospital in August 2003 with a one
week history of progressively worsening shortness of breath. She was found to
have a right pleural effusion as well as hilar lymphadenopathy.
Additionally, soft tissue fullness was now evident in the subcarinal region that may have represented additional
lymph nodes. The pleural effusion was found to be exudative
with a predominance of macrophages. The possibilities of Tuberculosis,
malignancy, granulomatous diseases and infections
were considered. A thoracoscopic biopsy was done
which showed focal perivascular chronic inflammation
mainly composed of lymphocytes. No atypical cells or granulomata
were identified. Therefore, we concluded that these findings are drug-induced
secondary to Copaxone.
Copaxone has been shown to cause lymphadenopathy, mainly localized to draining lymph nodes.
Biopsy findings on reported nodes in the literature were similar to that found in
our patient. However, we present this case to demonstrate unilateral pleural
effusion and hilar lymphadenopthy
as a hitherto undocumented manifestation of copaxone.
DOES
GENISTEIN HAVE A SYNERGISTIC THERAPEUTIC EFFECT WHEN USED WITH CISPLATIN IN
TREATING HEAD AND NECK CANCER CELL LINE?
Tawhida Khatoon, MD, Associate, Fazlul Sarkar, PhD, Sinai-Grace
Hospital and Wayne State University,
Detroit, Michigan.
Approximately
40,000 cases of Squamous Cell Carcinoma of the head and neck are
diagnosed every year in the
11,000
patients die of this disease every year. These patients are at increased risk
of developing second primaries involving their upper aerodigestive
tracts. Cisplatin is one of the main stay of
treatment along with radiation.
We were looking for a new compound that is non-toxic that may be used as an effective chemotherapeutic agent for cancers of the head and neck in addition to Cisplatin. Genistein is a drug that is being used in phase I trial of breast cancer treatment.
Prior research by Alhasan, Ensley and Sarkar has
demonstrated strong molecular evidence of the antitumor
activity of Genistein in highly nondifferentiated
squamous cell carcinoma (HNSCC) cells by inducing
cell cycle arrest and apoptosis in such cells. My research hypothesis is that
addition of Genistein to Cisplatin
will significantly enhance the therapeutic response of Cisplatin.
HN12 cells were cultured in
special media. Cells were treated with Genistein and Cisplatin separately and in combination for various lengths
of time, namely 24, 48 and 72 hours. Viable cell growth was determined by the standard MTT
reduction assay. Cell apoptosis was determined by
the cell death detection Elisa kit. The results revealed that either compound alone killed less than 50% of the viable cells
proving HN12 cell line to be a rather resistant cell line. However, in
combination using longer incubation periods, there was evidence of minimal
enhancement of the therapeutic effects Cisplatin.
Therefore, the combination of Cisplatin and Genistein did not prove to be synergistic in their
therapeutic benefits in the HNSCC cells. Nonetheless, there was some
cell-killing achieved by Genistein alone with longer
incubation periods.
This may provide Genistein
with a role in chemoprevention of second primaries pending further research.
SYNDROME OF INAPPROPRIATE SECRETION OF
ANTI-DIURETIC HORMONE (SIADH) CAUSED BY ADENOCARCINOMA OF THE
R Kotihal, MD, Associate, M Ghaffari,
MD, Associate, and O
SIADH has many
etiologies including ectopic production of
anti-diuretic hormone (ADH) by lung cancer or other neoplasms,
eutopic release by various diseases or drugs, and
exogenous administration of ADH or its analogues. Among neoplastic
producers of ectopic ADH, we know pulmonary tumors,
sarcomas, breast tumors and brain tumors are common.
We report a rare
case of adenocarcinoma of the colon with the classic
features of SIADH. A 76-year-old-man who complained of abdominal pain and
constipation, had guaiac positive stools. At the time
of admission, he was found to be hyponatremic with a
normal blood pressure and euvolemia. Laboratory
examination showed serum sodium of 124 mEq/L, plasma osmolality 257 mosm/kg, urine
sodium 83 mEq/L and urine osmolality of 268 mosm/kg. The
liver function tests, cortisol levels, TSH and
imaging studies of the head and the lungs were found to be normal. The hyponatremia was too early to be caused by the facial
trauma, which occurred one hour prior to the admission. Colonoscopy revealed a
mass at the rectosigmoid junction with more than 90%
obstruction. Partial colectomy was performed and
pathologic analysis of the mass revealed a moderately differentiated adenocarcinoma. Three days following the surgery, an
initially difficult to correct hyponatremia was found
to be within the normal range.
A review of
literature revealed only two other cases of adenocarcinoma
of the colon presenting with SIADH. We report the third such case.
SIADH can be a paraneoplastic manifestation of colon carcinoma and this
case underlines hyponatremia as one of the presenting
symptoms of a colonic malignancy. After having ruled out the obvious causes of
SIADH, a diagnostic colonoscopy could be included in the search for ectopic causes.
ANTIPLATELET THERAPY FOR SECONDARY PREVENTION OF CORONARY ARTERY
DISEASE.
Question: In
patients undergoing thrombolysis for treatment of
myocardial infarction, what is the optimal antiplatelet
therapy regimen for secondary prevention of myocardial infarction (MI)?
Data sources:
Studies were identified by searching MEDLINE (1966 to 2003), Cochrane Library,
and Web of Science database.
Study Selection:
Double-blinded randomized trials comparing an antiplatelet
regimen with a control regimen or with another antiplatelet
regimen, in patients with MI treated with pharmacological thrombolysis..
Data Extraction:
Data was extracted from 12 trials comparing the efficacy of antiplatelet
regimens in patients with history of MI and 15 trials comparing antiplatelet regimens in patients with acute MI. The
occurrence of reinfarction (fatal and non-fatal) and
the composite outcome of vascular death, MI and stroke were studied.
Results: In
patients with ST-elevation MI, therapy with aspirin or clopidogrel
was found to have equivalent effects on the prevention of reinfarction.
In patients with a non ST-elevation MI receiving therapy with aspirin and clopidogrel, the relative risk of MI was 0.77 and the
relative risk for the composite outcomes of MI, stroke or vascular death was
0.80 (p <0.001) as compared to those receiving aspirin only.
Conclusion:
Optimal anitplatelet therapy for secondary prevention
of coronary artery disease in patients with ST elevation MI consists of aspirin
life long or clopidogrel life long in case of aspirin
allergy, aspirin intolerance or aspirin resistance. In patients with non-ST
elevation MI, therapy with aspirin life long combined with clopidogrel for the first 9 to 12 months provides
maximum benefit. In non-ST elevation MI patients in whom aspirin cannot be
used, therapy with clopidogrel life long should be
used.
A RARE CASE OF POTT’S PUFFY
TUMOR DUE TO GROUP C STREPTOCOCCAL INFECTION. Jayasree Grandhi, MD, Associate, Adeel Ijaz, MD, Associate, Sinai-Grace Hospital, Wayne State
University, Detroit, Michigan.
Introduction: Pott’s puffy tumor is a subperiosteal
abscess of the frontal bone associated with underlying frontal bone osteomyelitis, causing swelling and edema over the
forehead. We describe a 38-year-old man with a Pott’s
puffy tumor due to streptococcus C that was successfully treated with
antibiotics and surgery.
Case Report: A
38-year-old male with HIV came with pain and swelling over the forehead and
both eyes. Patient had similar complaints one month ago and was diagnosed with preseptal orbital cellulitis and
treated with ampicillin-sulbactam. He gave a history
of chronic sinusitis for 2 years without any regular treatment. On examination,
there was an eythematous, tender, fluctuant swelling
over the forehead and eyes. He had bilateral frontal, maxillary, ethmoid sinus tenderness, intact visual acuity and no
evidence of opthalmoplegia. His CD4 count was 650 and
CT and MRI imaging showed preseptal orbital
cellulites, extensive pan sinusitis, frontal bone osteomyelitis,
destruction of anterior wall of the right frontal sinus and a right frontal
scalp abscess. Aspiration of the fluid grew streptococcus C. The patient was
treated with ampicillin-sulbactam and underwent early
surgical drainage with bilateral ethmoidectomy and
revision of the frontal bone.
Discussion: Pott’s puffy tumor is usually a complication of chronic
sinusitis rarely seen at present time due to the widespread availability of
antibiotics. Suppurative complications such as
epidural, subdural and intracerebral
abscesses are common, therefore early recognition is very important. A review
of 23 cases showed that it is mostly seen in children, with only 8 cases
reported in adults, none of them were caused by streptococcus C.
Conclusion: Pott’s puffy tumor is most common in children; it should be
included in the differential diagnosis of a swelling on the forehead in adults.
Surgical drainage and antibiotic therapy remains standard of therapy.
ROLE
OF SURGERY IN THE MANAGEMENT OF CHRONIC RHINOSINUSITIS. Jayasree Grandhi , MD Sinai-Grace Hospital Wayne State University Detroit , Michigan
Research
Question: A 30 year old female has chronic sinusitis with recurrent episodes of
acute exacerbations in spite of being treated with antihistamines, nasal
steroid sprays, decongestants and antibiotics for acute exacerbations. What are
the various surgical options available? What are the indications for surgery?
How effective is surgery for the short and long term relief of symptoms in
patients with chronic rhinosinusitis?
Background: Rhinosinusitis is a common medical complaint in primary care practice affecting approximately 33 million Americans annually. Patients continue to have symptoms of chronic sinusitis in spite of being on maximal medical therapy. Functional endoscopic sinus surgery (FESS) is the most commonly performed surgery now based on the theory that the manifestations of chronic sinusitis can be reversed if optimal conditions for ventilation and drainage are reestablished.
Data Source: Observational cohort studies from the MEDLINE database from 1994 to 2003 were identified using Pubmed and Ovid search engines.
Study Selection: Studies were identified from MEDLINE search using the term surgery in chronic sinusitis. Studies focusing on the subjective and objective assessment of symptoms pre and postoperatively were selected. Studies, which assessed both short and long term symptom relief, were also included.
Outcome Measures: The endpoints chosen as outcome measures were subjective assessment of symptoms using VAS (visual analog score), objective assessment of symptoms improvement using different methods and medication usage both short term and long term.
Results: We did not find any well-designed randomized trails on this subject although several observational cohort studies were identified. These observational cohort studies have shown a significant improvement in subjective symptoms (p value<0.05). There was an improvement in symptoms that were assessed objectively, but it was not statistically significant. The improvement in symptoms was maintained even 7 years after surgery. The degree of medication use has also been reduced significantly following surgery.
Conclusion: Medical management is still first line of therapy in patients with chronic rhinosinusitis. Based on observational cohort studies, improvement in symptoms, particularly subjective symptoms, can be expected from surgery in patients who fail to respond adequately to medical therapy.
CASE REPORT OF ISOLATED
HYPOPARATHYROIDISM
Introduction: Hypoparathyroidism
is a state of inadequate parathyroid hormone (PTH) secretion where ionized
calcium in the extra cellular fluid decreases. The causes of primary hypoparathyroidism are diverse representing disruptions of
one or more steps in development and maintenance of PTH secretion.
Case Report: We describe a case of 68 yr old
middle-eastern female who came in with tingling of her fingers and toes, hand
tremors, palpitations and muscle cramps of her legs for the past 3 years. Past
medical history was strikingly negative for any neck surgery or irradiation of
neck. Physical examination was significantly positive for chvostek’s
and trousseau’s sign. Labs: Ca 4.5, P 6.5, Mg l.4. Albumin, activated vita D3,
24 hr urine Ca , TSH, prolactin and cortisol levels were all within normal limits but PTH was
inappropriately low <5pg/ml (Normal PTH 11-65 pg/ml ). Patient was diagnosed with primary isolated hypoparathyroidism.
Patient was started on calcium and vitamin D replacement therapy and was
told to wear an alert bracelet. She follows up regularly and continues to do
well.
Discussion: Primary hypoparathyroidism
can be due to wide variety of causes. It is most commonly due to damage or
removal of parathyroid glands during neck surgery like thyroidectomy
or following removal of parathyroid adenoma for primary hyperparathyroidism or
following neck irradiation. It can be seen as a part of autoimmune polyglandular syndrome, which is characterized by the
presence of at least two of the following: candidiasis,
hypoparathyroidism and Addison’s disease. Parathyroid
deficiency can occur form developmental defects like DiGeorge syndrome or as a result of damage from heavy
metals, granulomatous diseases. A very rare cause of hypoparathyroidism is primary isolated hypoparathyroidism
where it is seen as isolated entity and not due to any of the causes as
mentioned above the cause of which is exactly not known. Our patient was also
thus diagnosed with isolated hypoparathyroidism.
Conclusion: The most common cause of hypoparathyroidism is acquired like post surgical. Isolated
hypoparathyroidism is a diagnosis of exclusion and is
a rare entity. It should be as a part of differential diagnosis in a patient
coming with hypocalcaemia secondary to hypoparathyroidism.
The index of suspicion should be high in patients who have not had any neck
surgery or irradiation. In our literary search we could not find any case
reports in
Cryptococcal Pneumonia Mimicking as Pneumocystis Carnii Pneumonia in
a patient with AIDS. Jayasree Grandhi, MD, Associate, Apuva Motivala, MD, Associate,
Wasif Hafeez, MD, Fellow, Sinai-Grace Hospital, Wayne State University,
Detroit, Michigan.
Introduction:
The most common pulmonary complication of AIDS is pneumocystis
carnii pneumonia (PCP). However, other opportunistic
infections like cryptococcus neoformans
and mycobacterium avium intracellulare
(MAI) can present with diffuse pulmonary involvement and mimic PCP. We report a
patient with disseminated cryptococcosis whose
initial clinical presentation was indistinguishable from PCP.
Case Report: A
30 yr old homosexual male with AIDS and with
multiple previous admissions for PCP came with difficulty in breathing, pleuritic chest pain and diarrhea of 1 week duration. He
was on highly active antiretroviral therapy (HAART), azithromycin
for MAI prophylaxis but was noncompliant with bactrim
for PCP prophylaxis. He was slightly tachypneic with inspiratory rhonchi in bilateral
lung fields with oxygen saturation of 92-95% on 2 liters of oxygen. Initial
labs were WBC 21.9, CD4 count 0, HIV viral load 175,000 and chest X-ray showed
bilateral perihilar interstitial infiltrates. He was
treated for presumed PCP pneumonia. On day 2 patient became very tachypneic, desaturated and was intubated for impending respiratory failure. Cardiac arrest
ensued and despite vigorous attempts at resuscitation, the patient died.
Meanwhile, bronchoscopic alveolar lavage
(BAL) was performed which showed budding yeasts with halos around them,
suggestive of C. neoformans. Autopsy revealed
disseminated cryptococcosis.
Conclusion: C. neoformans must be high in the differential diagnosis of
diffuse interstitial pneumonia in patients with AIDS. Since cryptococcal
infection is potentially treatable with antifungal agents, an early
microbiological diagnosis is essential. Early aggressive investigations aimed
at definitive diagnosis like serum cryptococcal
antigen titer and identification of Cryptococcus in BAL washings will give
strong support in planning therapy.
ROLE
OF SURGERY IN REFRACTORY EPILEPSY.
Kavitha Potluri, MD, Associate, Department of Medicine, Sinai-Grace
Hospital, Wayne State University, Detroit, Michigan.
Question: What surgical options including implantable devices have been
evaluated for the treatment of refractory seizures? What are the known benefits and risks of such
procedures?
Background: The prevalence of epilepsy in
Data Sources: Medline and Cochrane
databases were searched for all English language papers on treatment options
available for drug resistant epilepsy.
Study Selection : Randomized double blind control trails
with a P-value of <0.05 and those that are statistically significant have
been selected. There is only one study conducted thus far on the role of
surgery in epilepsy and two studies regarding vagal
nerve stimulation.
Study Details: For the role of surgery in refractory epilepsy, 80 patients
who had drug refractory epilepsy were randomly assigned to medical and surgical
groups (original article in 2002 NEJM: Author: WEIBE at al )
and all the patients were followed for one year. The primary outcome was
freedom from seizures that impair awareness and secondary outcome was reduction
in severity of seizures and improvement in quality of life. For VNS, two active
control trails of high versus low vagal nerve
stimulation have been conducted (VNS Study in 1995 and Handsforth
Study in 1998). The outcomes measured were 50% reduction in seizures and
adverse effects of vagal nerve stimulation.
Main Results: In the study conducted by Weibe at
al, the cumulative benefits from the various surgical options available for
refractory epilepsy far exceeded than medical management. There was major
reduction in all primary and secondary outcomes with a p-value of <0.001 in the surgical
group with very few adverse effects. Similarly, in the VNS studies, > 50%
reduction in seizure frequency was noted for partial onset seizures in the high
stimulation group with few side-effects when compared to the control group.
Conclusion: In the treatment of drug resistant epilepsy, surgery and vagal nerve stimulation are effective alternative options
available. Further studies comparing surgery and VNS ,
the optimal time to consider surgery in refractory seizures and the role of VNS
in obesity, depression and pain need to be done.
RUPTURE OF ABDOMINAL AORTA ANEURYSM IN A
24 YEAR OLD FEMALE WITH CYSTIC MEDIAL NECROSIS.
K Potluri, MD (Associate), S
Department of Medicine and Department of
Pathology*,
Abdominal Aortic
Aneurysm is a disease that is rarely manifested before the age of fifty-five.
The most common cause is atherosclerosis.
We present a 24
year old African American female, who came to the emergency room with sudden
onset of abdominal pain, low back pain and vomiting. Physical examination
revealed diffuse abdominal tenderness.
CT Scan of the abdomen reported, a large infrarenal pseudoaneurysm and
rupture of the abdominal aorta with extensive retroperitoneal hemorrhage.
Patient was in shock and underwent an emergency resection of the abdominal
aorta aneurysm with a bypass graft. Intra-operative findings revealed a nine
centimeter infrarenal aortic “blow out” rupture.
Although the post-operative period was complicated, the patient survived this
event. The pathology of the aorta revealed extensive myxoid
degeneration and cystic medial necrosis.
Aortic aneurysms
in patients younger than 40 years are most often associated with cystic medial
necrosis. The thoracic aorta is more commonly involved.
Very few cases
of the abdominal aorta aneurysm rupture secondary to cystic medial necrosis
have been reported. Cystic medial
necrosis may occur as an isolated abnormality or as part of a systemic
connective tissue disease such as Marfans
syndrome or Ehlers Danlos syndrome. This patient had some features
of Marfans but failed to meet all the criteria of Marfans. There was no family history of aneurysms. Our
patient could have idiopathic cystic medial necrosis or a partial expression of
the Marfan syndrome with a possibility of a new missense mutation.
Regardless of
the diagnosis, prophylactic treatment and prevention of further complications
associated with cystic medial necrosis is important. Awareness of the broad
spectrum of manifestations in myxoid degeneration
disorders needs to be increased among practitioners, to lower the threshold of
suspicion necessary for referral to a specialist center.
Cryptococcal Pneumonia Mimicking as Pneumocystis Carnii Pneumonia in
a patient with AIDS. Jayasree Grandhi, MD, Associate, Apuva Motivala, MD, Associate,
Wasif Hafeez, MD, Fellow, Sinai-Grace Hospital, Wayne State University,
Detroit, Michigan.
Introduction: The
most common pulmonary complication of AIDS is pneumocystis
carnii pneumonia (PCP). However, other opportunistic
infections like cryptococcus neoformans
and mycobacterium avium intracellulare
(MAI) can present with diffuse pulmonary involvement and mimic PCP. We report a
patient with disseminated cryptococcosis whose
initial clinical presentation was indistinguishable from PCP.
Case Report: A 30 yr old homosexual male with AIDS and with
multiple previous admissions for PCP came with difficulty in breathing, pleuritic chest pain and diarrhea of 1 week duration. He
was on highly active antiretroviral therapy (HAART), azithromycin
for MAI prophylaxis but was noncompliant with bactrim
for PCP prophylaxis. He was slightly tachypneic with inspiratory rhonchi in bilateral
lung fields with oxygen saturation of 92-95% on 2 liters of oxygen. Initial
labs were WBC 21.9, CD4 count 0, HIV viral load 175,000 and chest X-ray showed
bilateral perihilar interstitial infiltrates. He was
treated for presumed PCP pneumonia. On day 2 patient became very tachypneic, desaturated and was intubated for impending respiratory failure. Cardiac arrest
ensued and despite vigorous attempts at resuscitation, the patient died.
Meanwhile, bronchoscopic alveolar lavage
(BAL) was performed which showed budding yeasts with halos around them,
suggestive of C. neoformans. Autopsy revealed
disseminated cryptococcosis.
Conclusion: C.
neoformans must be high in the differential diagnosis
of diffuse interstitial pneumonia in patients with AIDS. Since cryptococcal infection is potentially treatable with
antifungal agents, an early microbiological diagnosis is essential. Early
aggressive investigations aimed at definitive diagnosis like serum cryptococcal antigen titer and identification of Cryptococcus
in BAL washings will give strong support in planning therapy.
MIXED SMALL /LARGE CELL CARCINOMAS OF THE
LUNG, THERAPEUTIC AND PROGNOSTIC IMPLICATIONS. Bazzi,Kaled, MD. Associate, Marius Vidinas,
MD, Associate and
Lung cancer is currently the most common cause of cancer
mortality in the
We report the case of a 67 year-old Hispanic female with a 5 pack-year history of smoking who presented with a dry cough of 4 months that failed to respond to several courses of oral antibiotics. The patient also reported a weight loss of 15 pounds over the same time period associated with dysphagia to solid foods and a progressive weakness of the lower extremities. Three days prior to presentation the patient had developed urinary and fecal incontinence. Diagnostic evaluation showed a lung mass on chest X-ray and MRI of the spine demonstrated multiple metatstatic foci involving the vertebral bodies at various levels with signs of spinal cord compression. Bronchoscopy with biopsy of the lung revealed a mixed small/large cell lung cancer. Palliative treatment with radiation therapy was initiated but the patient deceased two weeks later from complications of her cancer and septic shock.
Mixed histology small cell/large cell carcinoma constitutes about 4-6% of all small cell cancers and is considered a distinct variant with clinical, therapeutic and prognostic implications. The distribution of the mixed elements can be heterogeneous and the definitive pathological features evident only after resection of the tumor or at autopsy. Although this case illustrates a small cell/large cell mixed cancer, mixed histology of small cell with squamous and/or adenocarcinoma have also been described. Interestingly, metastases from these tumors may consist of mixed elements or limited to the small cell or non-small cell component alone. When treated with aggressive chemotherapy protocols for small cell cancer, patients with mixed small cell/large cell cancer have lower partial or complete response rates (58% vs 91%), and shorter survival rates (median 6 vs. 10.5 months) than patients with pure small cell cancer.
NEUROLOGIC SYMPTOMS AS THE INITIAL MANIFESTATION OF LEGIONELLA PNEUMONIA, A CASE SERIES. Irfan Hameed, MD, Associate, Wasif Hafeez, MD fellow, Sinai-Grace Hosptial, Wayne State University, Detroit, Michigan.
Infection with Legionella pneumophilia manifests as pneumonia in 90% of cases and can also manifest with neurologic findings ranging from headache to lethargy to frank encepholopathy. We describe a series of three cases of Legionella pneumonia that presented with prominent neurologic symptoms at our institution over a span of just five months. In all three patients, Legionella antigen was present in their urine.
Case 1: A 55 year-old man presented with a seizure, productive cough, RUL infiltrate, acute renal failure, temperature of 105o, WBC = 22,000 and CPK=32,000. Septic shock and respiratory failure ensued requiring ICU admission. He was treated with azithromycin and rifampin and eventually discharged to the rehabilitation service after a 42 day stay in the ICU.
Case 2: A 44 year-old man presented with delirium and had been having influenza-like symptoms for seven days. LUL infiltrate, acute renal failure, CPK = 15,000 and leukopenia were also present on admission. Septic shock with respiratory failure ensued. He was discharged to the rehabilitation service after a 57-day stay in the ICU.
Case 3:A 32 year-old man presented with obtundation progressing to coma. Bilateral infiltrates, WBC = 31,000 and coagulapathy were also present. Septic shock and respiratory failure ensued. Blood culture yielded pneumoccoccus. Despite aggressive antibiotic treatment the patient died on the 5th hospital day.
These three cases illustrate the propensity of Legionella infection to cause severe neurologic symptoms as compared to other causes of pneumonia. Patients who do present initially with predominantly CNS symptoms, in general, have more complications and are more likely to develop multiorgan involvement. The neurologic involvement may precede the pulmonary involvement and has been reported to develop in the absence of pulmonary disease. Encephalopathy, delirium, profound coma, hallucinations, cerebellar dysfunction, hemiparesis, quadraplegia, chorea, seizures and cranial nerve palsies have all been reported. Therefore, Legionella infection should be considered in all patients presenting with neurologic symptoms in the setting of pneumonia. Timely testing to confirm the diagnosis and appropriate treatment may be life saving.