Submitted Abstracts for 2003 ACP Scientific Meeting -
RENAL FAILURE AND MONOCLONAL GAMMAPATHY OF UNKNOWN SIGNIFICANCE.
O White, MD (Associate), S Marur, MD (Member), R Hillyer, MD,
Introduction:
MGUS is present in 1% of all adults and 3% of adults over age 70. Myeloma is distinguished from MGUS by findings of replacement of the bone marrow, bone destruction, and progression of renal failure and hypercalcemia. MGUS does not present with renal failure.
Case Report:
We present a case of a 73 year old African American man who presented to our emergency department with chest pain and shortness of breath. He was found to have pneumonia, but during work-up was also ruled out for myocardial infarction and pulmonary embolism (PE). He subsequently developed acute renal failure secondary to CT contrast when ruled out for PE, despite prophylactic measures, and his renal failure was refractory to subsequent management as well. Creatinine rose rapidly from baseline of 1.5 to 10.3 in 4 days, and he required hemodialysis for his acute renal failure (ARF) and intubation for respiratory failure. Once extubated, the patient underwent left renal biopsy which yielded results consistent with a myeloma kidney. Shortly thereafter, serum protein electrophoresis revealed a monoclonal gamma globulin band at a concentration of 1.13 g/dL. However, bone marrow biopsy was not consistent with a diagnosis of multiple myeloma.
Discussion:
The patient met criteria for a diagnosis of monoclonal gammopathy of undetermined significance (MGUS). MGUS is generally thought of as a benign condition with a benign course, but it is very noteworthy that the patient developed an unusual, refractory, irreversible, and rapidly progressive onset of ARF superimposed on CRF when given contrast for CT scan. MGUS supposedly has a benign clinical course, but it has not been precisely defined what MGUS truly is. It is considered by some to be a premyeloma state, in which the complications of myeloma are encountered after transformation into true myeloma has occurred. However, this patient was already having renal complications when he didn’t meet criteria for myeloma, and was even histologically diagnosed as having a myeloma kidney.
Conclusion:
This case seems to lend further credibility to the hypothesis that MGUS is a premyeloma state, in which some of the complications of myeloma may be encountered, and from which myeloma may arise from malignant transformation.
Submitted 2003 ACP Scientific Meeting in
Pulmonary blastomycosis may mimic pyogenic or fungal
infections, tuberculosis or malignancy. Cutaneous disease is the most common
hematogenous dissemination.
A 27 year old
immigrant Lebanese female, smoker, was referred to the Pulmonary Clinic with
complains of fever, night sweats, weight loss, cough and shortness of breath
for one month. Initial chest X-ray and CT of the chest revealed a large left
apical alveolar infiltrate. PPD was negative. Sputum gram stain and culture for
AFB (acid fast bacilli) were negative. Fiberoptic bronchoscopy with
transbronchial biopsy and BAL (bronchoalveolar lavage) was non-diagnostic.
Fluoroscopic guided transthoracic fine needle aspiration revealed necrotizing
granulomatous inflammation. No malignant cells or organisms (aerobic,
anaerobic, AFB or fungal) were noted on the BAL specimen or the biopsy specimens.
The patient completed a six months course of antituberculous treatment. The
repeated X-ray during treatment showed complete resolution of the left apical
infiltrate within two months. The patient developed a skin lesion on the left
cheek during treatment. The skin biopsy revealed noncaseating granulomas.
Fungal cultures from the skin lesion grew Blastomyces Dermatitidis. Patient was
started on Itraconazole.
Spontaneous resolution of symptomatic acute pneumonia caused
by Blastomyces Dermatitidis has been recognized in the literature. Our case is
one of the few reports of spontaneously resolved Blastomyces pneumonia followed
by secondary skin dissemination. Whether or not the lung lesion resolves
spontaneously, the infection commonly spreads hematogenously to other body
sites, and should be treated with Itraconazole, Fluconazole or Amphotericin B.
Submitted 2003 ACP Scientific Meeting in
MILLER-FISHER SYNDROME: AN ACUTE NEUROPATHY.
Tabarak A.
Qureshi, MD (Associate),
Objectives: The classical triad of ophthalmoplegia, ataxia and areflexia presenting as Miller Fisher Syndrome.
Case History: A 28-year-old Caucasian female with a preceding
diarrheal illness presented to the emergency center with a chief complaint of
diplopia. Initial physical examination revealed bilateral abducens nerve
palsies. The patient progressed to complete ophthalmoplegia. Muscle
strength testing revealed global weakness graded at 3/5. Muscle stretch
reflexes were absent. The patient demonstrated appendicular and gait
ataxia. Brain imaging with MRI was normal. Initial spinal fluid
analysis revealed normal protein and glucose without significant pleocytosis.
Further analysis of CSF demyelinating markers including myelin basic
protein, IgG synthesis rate, and oligoclonal bands proved unremarkable.
Tensilon test and Acetylcholine receptor antibodies were negative. Campylobacter
jejuni titer was normal. Antibody to GQ1b ganglioside was positive.
The patient was diagnosed with the Miller Fisher variant of
Guillain-Barre syndrome and was started on IVIG. Lack of improvement
prompted the transfer to a monitored ICU bed and the patient underwent five
plasmapheresis exchange transfusions. Her neurological status stabilized
and upon discharge from the hospital, the patient had minimal residual eye
weakness.
Discussion: In patients with
the triad of gait ataxia, ophthalmoplegia and areflexia, Miller Fisher syndrome
should be suspected. The presence of antibodies to the GQ1b ganglioside
favors this diagnosis.
Submitted 2003 ACP Scientific Meeting in
Primary malignant lymphoma in extraaxial fashion Prathyusha
Savarapu, M.D., Associate, Fadi Saab, M.D., Associate, Eisenberg Leopoldo,
M.D., F.A.C.P.
Introduction
Extraaxial primary malignant lymphoma is an extremely rare disorder. To our knowledge, this the first case report of lymphoma that is extradural in location.
Case Report
A sixty-one year old male presented with dizziness and increasing headaches. Part of the work up included MRI scan of brain which demonstrated a fairly large homogeneous enhancing extraaxial mass seen in the posterior interhemispheric fissure with extension into the bilateral parietal regions.
Symptoms persisted and the lesion clinically progressed which was confirmed by follow up MRI scan. Therefore, resection was performed and a gross tumor was removed noted to be in the extradural space. The histological and immuno-histo-chemical analysis revealed this to be a high grade non-hodgkin’s lymphoma of B-cell origin with positive CD20.
Completion of the work up for lymphoma included a PET scan of the whole body which showed two small foci in right and left axilla with abnormal FDG (Fluorodeoxyglucose) uptake. SUV (Standard Uptake Value) was between 2.3 to 2.6 suspicious for malignancy. Therapy was instituted with CHOP Rituxan followed by radiation to the primary site.
Discussion
Primary malignant lymphoma is usually a B-cell lymphoma that arises within and is limited to CNS. Primary CNS lymphoma is mostly seen in immunodeficient patients particularly AIDS. Despite its three fold increased incidence in immunocompetent host, it remains a rare tumor. This particular case is unique as it is the first reported case of extraaxial lymphoma located extradurally.
Submitted 2003 ACP Scientific Meeting in
CASE REPORT OF ADENOCARCINOMA OF THE RETE TESTIS,
Tannu Sahay, M.D.,
Associate,
Adenocarcinoma of the rete testis is extremely rare with
only a few sporadic cases being reported since it was first described in
1945. It is a highly malignant tumor
mainly presenting as a scrotal mass with diffuse enlargement of the testes.
Tumors are diagnosed based on their distinctive histology. Recent reports have implicated HBME1 and thrombomodulin as positive markers.
We report a 53 year old Asian male diagnosed with adenocarcinoma of the rete testis The patient had wide spread metastasis to the liver, lung, retroperitoneal and mediastinal lymph nodes. A radical orchiectomy was performed with retroperitoneal lymph node dissection .The patient received multiple chemotherapeutic agents with no evidence of disease regression. These included cisplatin, carboplatin, gemcitabine, capecitabine, etoposide, and paclitaxel. He is currently on phase 1 trial with DX-8951F, a camptothecan analog.
Only limited data is currently available on the appropriate the treatment for this tumor type.
Submitted 2003 ACP Scientific Meeting in
ABSTRACT INHIBITION
OF NUCLEAR FACTOR kB ACTIVATION IN BREAST CANCER BY GENISTEIN
Tannu Sahay, M.D., Associate,
Introduction- Genistein is an isoflavanoid present in soybean, which has been shown to inactivate Akt/NF-kB pathway ultimately leading to apoptotic cell death
Hypothesis- It has been shown that the activation of NF-kB leads to aggressive tumor growth and chemo-resistance. We therefore hypothesized that the cancer cells pre-treated with genistein would have greater cell killing compared to conventional chemotherapeutic agents.
Methods- We investigated the chemo-sensitizing effect of genistein for cisplatin in breast cancer MDA-MB-231 cells using the apoptosis assay and the gel electrophoresis mobility shift assay. Different drug concentration and combinations over different time intervals were tested.
Result- We found that apoptotic indices were greater in genistein pre-treated cells compared to either genistein or cisplatin alone. We were also able to demonstrate the down-regulation of NF-kB by genistein. Cisplatin-induced activation of NF-kB was abrogated in cells pre-treated with genistein
Discussion- Data from our laboratory showed that the transfection of cells by Akt cDNA leads to the activation of NF-kB directly, suggesting a molecular cross talk between Akt and NF-kB. The results supported our hypothesis of the chemosensitizing effects of genistein.
Conclusion- The inhibition of Akt/NF-kB pathway by genistein could be a novel approach for the treatment of breast cancer in the future.
Submitted 2003 ACP Scientific Meeting in
IDIOPATHIC
HYPEREOSINOPHILIC SYNDROME OF THE HEART.
F Omar MD (Associate), D Obeid MD (Associate), G
Krishnamorthy MD (Member).
Idiopathic Hypereosinophilic Syndrome (Loeffler’s syndrome) is a rare disease characterized by eosinophilia associated with signs and symptoms of end organ dysfunction. Most commonly it affects the heart, skin, nervous system, lung and spleen.
Here we present a case of Loeffler’s syndrome with a cardiac presentation.
The patient is a 30 year old male presented with atypical chest pain. He had normal physical exam but stress test showed a partially reversible apical defect. He had high eosinophil count unexplained by any other etiologies. Cardiac catheterization showed normal coronaries; 2-D echo showed increased endomyocardial echodensity at the apex which suggested Loffler’s syndrome. Biopsy of the Myocardium revealed eosinophilic infiltrates thus confirming the diagnosis of Loeffler’s syndrome of the heart. The patient was started on Steroids and experienced significant clinical improvement.
It is very important to diagnose Loeffler’s syndrome as early as possible because starting treatment early will decrease mortality and morbidity especially in younger male patients.
Submitted 2003 ACP Scientific Meeting in
IMPACT
OF INTERMITTENT HYPOXIA ON CENTRAL AND PERIPHERAL CHEMOREFLEX COMPONENTS. J.H.
Mateika MD, C. Mendello MD, D.A. Obeid MD (Associate), M.S. Badr MD.
Introduction: We examined whether facilitation of ventilation after intermittent hypoxia (IH) was due to adaptations in one or more of the central and/or peripheral chemoreflex components {i.e. basal ventilation (ventilation below the chemoreflex threshold), central and peripheral chemoreflex threshold and sensitivity}.
Methods: Six healthy subjects completed 4 modified hypercapnic rebreathing trials under iso-oxic conditions before and 20 minutes after exposure to IH. Two rebreathing trials were completed while the partial pressure of oxygen (PETO2) was maintained at 50 mmHg (H50 - central + peripheral chemoreflex response combined) and 2 were completed with the PETO2 maintained at 140 mmHg (H140 - central chemoreflex alone). The IH protocol consisted of 8-4 minute trials of isocapnic hypoxia (8 % oxygen) separated by 5 minute recovery periods.
Results: Ventilation at a PETCO2 of 45 mmHg was significantly greater during the H50 rebreathing trials after IH. This occurred because basal ventilation was significantly greater (p<0.05) for the H50 (11.51 ± 1.19 vs. 16.66 ± 2.32) but not the H140 (11.81 ± 1.7 vs. 13.49 ± 2.53) trials after IH. Moreover, the central + peripheral chemoreflex sensitivity (H50) (8.51 ± 0.79 vs. 11.60 ± 1.80) was enhanced after IH but not central chemoreflex sensitivity (H140) (6.31 ± 0.75 vs. 7.14 ± 1.14) alone. No change in central and peripheral chemoreflex thresholds occurred after IH.
Conclusions: Ventilation is facilitated both below and above the peripheral chemoreflex threshold after exposure to IH. This enhancement might be due to an increase in peripheral chemoreflex sensitivity.
Submitted 2003 ACP Scientific Meeting in
FOCAL
SEGMENTAL GLOMERULOSCLEROSIS A CASE REPORT OF (P) FOCAL SEGMENTAL
GLOMERULOSCLEROSIS COMPLICATING IN A PATIENT WITH LUPUS NEPHRITIS.
B.N. Nandish, M.D. (Associate), S Marur, M.D. (Member),
and I Omar, M.D.
BACKGROUND
Lupus Nephritis is a well-known complication of SLE. We are reporting a case of focal segmental glomerulosclerosis (FSGS) in lupus nephritis.
FSGS is a difficult category of glomerular disease to diagnose pathologically and to treat. Many patients with FSGS progress into end stage renal disease. FSGS accounts for about one third of cases of nephrotic syndrome in adults. Occurrence of FSGS in the setting of SLE with lupus nephritis is not common.
CASE REPORT
This is a 20-year-old African American woman, with a diagnosis of SLE. She has a history of nephrotic syndrome, presumed to be secondary to lupus nephritis. The patient also has arthritis, erythematous rash with photosensitivity, and acute psychosis. Patient denied any IV drug abuse. Her medications included prednisone and plaquenil. The patient presented with a fever, headache, abdominal pain, and a skin rash. Her physical exam revealed a macular rash on her face, patchy alopecia, cervical lymphadenopathy, and right upper quadrant abdominal tenderness. On investigation, a 24-hour urine for protein revealed nephrotic range proteinuria. Her other lab results included BUN 11, Serum Creatinine 1. Anticardiolipin screen was positive (IgG and IgM). ANA, Anti-dsDNA and Anti-ssDNA were also positive. Complements CH50, C3, and C4 were elevated. Kidney biopsy was suggestive of FSGS immune complex mediated, and mesangial proliferative glomerulonephritis with rare subepithelial and subendothelial deposits consistent with lupus nephritis, WHO class IIb.
FSGS is difficult to treat and
progresses to ESRD rapidly. Even
cyclophospamide and cyclosporine have no role in management of steroid
resistant FSGS. Renal transplantation is
also complicated by recurrence of FSGS in the allograft. In most cases of SLE, renal dysfunction is
mostly secondary to lupus nephritis. If
clinical and pathological evidence appear to be discordant, an alternative or
contributing renal process should be entertained. This case illustrates the difficulties and
challenges seen in treating patients of FSGS.
We discuss the role of kidney biopsy in diagnosis and management of FSGS
and the difficulties of renal transplant in patients with ESRD secondary to
FSGS.
Concomitant
Lupus Nephritis and FSGS is uncommon.
When Lupus Nephritis is resistant to standard therapy, other diagnoses
should be considered.
Submitted 2003 ACP Scientific Meeting in
CLINICAL PRESENTATION OF MYOSITIS OSSIFICANS. Kalyani Mehta, MD, Associate, Violeta Botea, MD, Associate, Gary W. Edelson, MD, Fellow, Sinai-Grace Hospital, Wayne State University-Detroit, Michigan.
Introduction: Myositis Ossificans is a disorder defined by ectopic bone formation in soft tissues mostly following trauma, neurologic injury, surgery, or burns.
Case report: A
55-year-old white male presented with left shoulder pain. At the age of 39, he
had developed multiple painful calcifications bilaterally in the hips and knees
as well as in an abdominal surgical scar during a 140-day hospitalization
following an appendectomy complicated by sepsis, ARDS and cardiopulmonary
arrest. He was diagnosed with myositis ossificans in hips, knees and abdominal
surgical scar and most of these lesions have been surgically removed. He denies any other trauma or extra calcium
intake. Physical examination revealed a
well-nourished male with no thyromegaly or thyroid nodularity. He had a 3 cm tender hard mass in the left
supraclavicular area. Laboratory studies revealed total serum calcium of 9.0
mg/dl (8.5-10.5), and alkaline phosphatase was 30.5 (
Discussion: Myositis Ossificans has been reported mainly in children, following trauma or burns and was associated with pain only early in the course. Our patient developed the condition in his adulthood, without a clear trigger and developed painful lesions throughout the course. The molecular basis as well as specific treatment of this disorder remains to be explored.
Submitted 2003 ACP Scientific Meeting in
K Majekodunmi, MD (Associate), R M Ghurani, MD (Associate), W Hafeez, MD
(Member)
Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
West Nile Virus (WNV) is a mosquito-borne Flavivirus that
primarily affects birds with humans and horses being incidental hosts. The
virus is indigenous to
We present our case series of all
Our results reflect a total of 14 confirmed cases of West Nile Virus
encephalitis. The patients’ mean age was 59years. 57% of the cases were females
with an average length of stay of 8.8 days in the hospital. All were
WNV is expanding its geographical range into the western
parts of the
Submitted 2003 ACP Scientific Meeting in
ARRHYTHMOGENIC RIGHT
VENTRICULAR CARDIOMYOPATHY/ DYSPLASIA: PRESENTING AS SHOCK, ACUTE RENAL FAILURE
AND TRANSIENT MESENTERIC ISCHEMIA.
Manesh Kottapuram, M.D. (Associate), Barry Lesser, M.D., F.C.C.P. (Member), Department of Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Arrhythmogenic right ventricular (RV) Cardiomyopathy/Dysplasia (ARVC/D) is a rare myocardial disease affecting primarily the RV and characterized histologically by the gradual replacement of cardiomyocytes by fibro-fatty tissue. It can diffusely involve the whole myocardium and culminate in biventricular heart failure, arrhythmias and sudden death in young patients.
We present a forty-five year old African-American man
brought to the emergency room (ER) with complaints of fever, abdominal pain,
vomiting and bloody diarrhea of four days duration. He was a smoker and there was no significant
past or family medical history. At admission,
he was hypothermic (93oF), tachycardic (130/minute), tachypneic
(40/minute) and hypotensive (50/palpable).
He appeared drowsy, dehydrated and had diffusely tender abdomen with
decreased bowel sounds. His stool was
positive for occult blood. Initial labs
were significant for Na+ 127, Cl- 82, HCO3-
12 (mmol/L); BUN 70, Creatinine 8.7 (mg/dL); WBC 10.6 (bands 3.8) K/mm3;
ALT 162, AST 257 (U/L), and lactic acid 4.9 mmol/L. Electrocardiogram was significant for sinus
tachycardia and abdominal x-ray showed small bowel wall edema with ileus. He remained hypotensive despite intravenous
fluids, vasopressors and broad spectrum antibiotics.
ARVC/D is typically seen in young men as an autosomal
dominant trait with multiple factors facilitating gene expression. Physicians should consider this condition in
young subjects with cardiac arrhythmias or unexplained cardiomyopathy.
Treatment includes class I antiarrhytmic drugs, beta blockers, amiodarone,
radiofrequency ablation and patients with high risk of sudden death should
receive an implantable cardioverter/defibrillator.
Submitted 2003 ACP Scientific Meeting in
NEISSERIA MENINGITIDES PNEUMONIA
DIAGNOSED BY CT-GUIDED THORACOCENTESIS OF ASSOCIATED EMPYEMA
Manish Kesliker, MD MS (Associate), Kashif Qureshi, MD
(Associate), Atul Singh, MD (Member), Shazia Essan, MD (Member), Latha Ganesan,
MD (Member).
Background: Neisseria meningitides infection in humans is usually associated with meningitis and septicemia with skin manifestations. While infections of the lower respiratory tract with N meningitidis have been documented in the past, they remain exceedingly rare, but may be due to the fact that isolation is difficult. Despite presence of bacteremia, many patients do not develop meningitis and its associated complications.
Case Report: A 62 year old African American female developed fever and chills, shortness of breath and tachypnea. CT-thorax revealed right middle and lower lobe infiltrate with loculated effusions of right hemithorax. Patient was treated for presumed community acquired pneumonia with IV Ceftriaxone. Loculated pleural fluid was aspirated by CT-guided thoracocentesis confirmed empyema which grew gram-negative diplococci, later identified as Neisseria meningitidis. Subsequent blood cultures collected on admission later revealed the same. Patient was treated with Penicillin G 4 million units IV every four hours and prophylactic antibiotics were provided to immediate family contacts. Patient continued to experience respiratory distress and was transferred to MICU for impending respiratory failure. Pigtail catheters were placed for drainage of empyema and patient responded well over three weeks. Patient was later discharged home with few lasting complications.
Discussion: Pneumonia caused by Nessieria meningitides is rare, with 58 cases described from 1974 to 2000. The difficulty of diagnosis and recognition of rare manifestations of meningococcal infection because of risk of spread to contacts including health care professionals and other patients is discussed.
Submitted 2003 ACP Scientific Meeting in
HPV-16 AND SCHISTOSOMIASIS-CAUSED BLADDER CANCER.
Ahmed Kaseb, MD 1,
Associate, David Kurnit, MD,PhD 2 and Kun Yong, MD 2. Sinai-
Introduction:
Schistosomiasis afflicts over 200 million people in the world. Using quantitative PCR (QPCR) system we were able to detect HPV-16 in tumor, serum and some urine specimens from patients with this disorder. In distinction, only 1/29 french bladder cancers not caused by schistosomiasis were associated with HPV-16 infection.
Materials and Methods:
We collaborated with the
National Cancer Institute in
Results:
With this more sensitive
anlysis, we found that more than two thirds of the tumor specimens (17/22) were
positive for HPV-16 as identified by sequencing later on. Especially usefully, we found that serum was
often more positive than tumor (20/22).
Urine sediments were positive in only 9 cases. We found five cases where the tumor was
negative or very weakly positive and the serum was positive. In three of these cases, the urine sediment
was positive meaning that the bladder tumor is actually present as micro
satellites or that a more sensitive technique is needed to detect the
virus. Compared with our previous
analysis of non-schistosomiasis bladder cancers from
Conclusion:
HPV-16 infection is one of the predisopsing factors for schistosmiasis-caused bladder cancer. This is the first time to apply the QPCR technique to detect the virus in specimens from patients with this disorder with the serum ones identified as the most sensitive among them. This now establishes the potential of screening serum for HPV-16 as a rapid and sensitive means of searching for a predisposing factor for bladder cancer in these patients.
Submitted 2003 ACP Scientific Meeting in
Expression of B2 subunit mutants
alters localization of L-type calcium channels in rat adult cardiomyocytes
Sinoj K John MD (Associate) Sabine
Telemaque-Potts MD, Terrie Grain MD, Jeffrey T Potts MD, James D Marsh MD. Sinai-Grace Hospital, Wayne-State University,
Detroit, Michigan, Internal Medicine - Cardiology, Wayne-State University,
Detroit, Michigan.
Introduction:
The a1C
subunit of the L-type
calcium channel is the pore-forming subunit of the channel, allowing calcium
entry into cardiomyocytes and other cells. The intracellular b2a subunit acts as a
chaperone and interacts with the intracellular loop of the a1C subunit. We tested the hypothesis that overexpession of mutated b subunits could alter
membrane localization and ultimately channel function.
Methods:
Isolated rat adult cardiomyocytes were
infected with adenovirus constructs. The GFP-fusion constructs encoded either
the full-length b2a subunit (GFP-Full) or
putative dominant-negative mutants of the beta interaction domain (BID) portion
of the subunit (GFP-BID: BID only; GFP-N-BID: N-terminal + BID), under CMV
promoter control. After 24 hr, cells were fixed and visualized by
epifluorescence microscopy using standard methods.
Results:
Analysis of 5 independent cell isolations
showed that GFP or GFP-BID are localized to the cytosol of the myocyte. In
GFP-N-BID-infected myocytes, a distinct punctate pattern of protein expression
was observed in all infected cells, without cell membrane localization. In
cells infected with the full-length b2a subunit
adenovirus (GFP-Full), the fluorescence was exclusively visible at the cell
membrane.
Conclusion:
These results suggest that beta subunit decoys
can alter localization of the L-type calcium channel to the sarcolemma, which
could result in reduced contractile performance.
Submitted 2003 ACP Scientific Meeting in
ACUTE PANCREATITIS
SECONDARY TO ACUTE AORTIC DISSECTION
A Ijaz MD (Associate),
Sinai-Grace Hospital/Wayne State University-Detroit,
INTRODUCTION:
Acute pancreatitis is an intense inflammation of the pancreas with variable involvement of the regional tissues or remote organ systems. Etiology in around 85% of the cases is gall stones or alcoholism. A rare but documented cause of acute pancreatitis is hypoperfusion of thepancreas.
CASE:
We describe a 50 year old male with a history of hypertension, end stage renal disease on hemodialysis and no alcohol consumption, who presented with abdominal pain and vomiting. At the time of his presentation, his blood pressure was 180/118, with labs revealing an amylase of 1109 and lipase of 5599. A diagnosis of acute pancreatitis and hypertensive urgency was made and patient was admitted to general medical floor. His acute pancreatitis started resolving and an abdominal ultrasound was subsequently done which was suggestive of an acute aortic dissection showing an intimal flap with flow in both lumens and no gall stones. Patient was transferred to MICU and a CT scan of the thorax and abdomen with IV contrast was performed revealing an acute aortic dissection from the arch of the aorta to the abdominal aorta just inferior to superior mesenteric artery origin. The patient was managed medically.
DISCUSSION:
Regional and systemic hypoperfusion is an important factor in acute pancreatitis which in this case was brought on by the acute dissecting aneurysm of the aorta. The cause of pancreatitis in such a case is a result of pancreatic ischemia which leads to the release of oxygen free radicals, activation of polymorphonuclear lymphocytes, failure of micro vascular perfusion, cellular acidosis and disturbance of intracellular homeostasis causing ischemia induced acute pancreatitis. The management of ischemic pancreatitis is similar to that of acute pancreatitis of any etiology.
Submitted 2003 ACP Scientific Meeting in
In Vitro study of the effect of Gossypol in
combination with Docetaxel on two different human adrenocortical carcinoma cell
lines.
haleh Haerian, MD, Associate, Sinai-Grace Hospital, Detroit Medical Center/Wayne State University-Detroit; Recardo Benitez, MD; David E. Schteingart, MD,The University of Michigan-Ann Arbor.
Introduction: Adrenocortical carcinomas, ACC, are rare but highly malignant tumors with poor prognosis. Several treatment strategies have resulted in temporarily and partial tumor regression but very few cases have attained long survival. The absence of an effective therapeutic regimen for ACC, suffices the need for more studies with new drugs. Gossypol is a lipid soluble polyphenolic compound isolated from cottonseed oil, which has been extensively tested in clinical trials as a male contraceptive agent and found to be well tolerated. One proposed mechanism of action for gossypol is stimulation of apoptosis in human tumor cells by inhibition of the anti-apoptotic activity of certain proteins (e.g., Bcl-XL). Docetaxel is an effective chemotherapeutic agent used in breast and non-small cell lung cancers. It inhibits mitosis and induces apoptosis in cancer cells. In view of a potential clinical use, we assessed the antiproliferative and possible synergistic effect of these drugs in ACC cell lines.
Methods: We used two different cell lines: RL-251 with high expression of Bcl-XL, and H295R without Bcl-XL expression. We tested eight different concentrations of each drugs separately and their combination. We used Sulforhodamine B assay (SRB) to measure the inhibition of cell proliferation.
Results: Gossypol induced a dose-dependent inhibition of cell proliferation in both H295R (IC50=0.71mM), and RL-251 (IC50=1.5mM) cell lines. Docetaxel also induced a dose-dependent inhibition of cell proliferation in both H295R (IC50=0.015mM), and RL-251 (IC50=0.0003mM) cell lines. Addition of 1mM of Gossypol to Docetaxel decreases the IC50 value for both cell lines to less than 0.0001mM.
Discussion: Gossypol has a potent, dose dependant inhibitory effect on both H295R and RL251 cell lines. The greater effect of Gossypol on H295R in comparison to RL-251 is against the proposed mechanism of action of Gossypol through Bcl-XL. Docetaxel is also a very potent inhibitor of our cell lines. The combination of Gossypol plus Docetaxel is more effective than Docetaxel alone.
Conclusion: The results suggest a potential role for these drugs in the treatment of patients with ACC could be considered.
Submitted 2003 ACP Scientific Meeting in
First case report of Eosinophilic Peritonitis in a patient with intraperitoneal catheter prior to the initiation of peritoneal dialysis.
Mehrdad Ghaffari, MD (Associate); Haleh Haerian, MD (Associate); Latha Ganesan, MD (Member), Sinai-Grace Hospital / Wayne State Universiy – Detroit, Michigan.
Background: Eosinophilic Peritonitis, EP, is a rare but benign complication of continuous ambulatory peritoneal dialysis, CAPD, that tends to resolve spontaneously. EP is defined by presence of more than100 eosinophil per milliliter of peritoneal fluid in patients with clinical symptoms of peritonitis.
Case Report: A 55-year-old African American woman developed end-stage renal disease secondary to diabetes mellitus in 1995. She had been on hemodialysis since then. In Aug 2002, a Tenckhoff peritoneal catheter was placed. In Sept 2002, while she was still on hemodialysis, she presented to our emergency room complaining of severe abdominal pain, nausea, and vomiting. On physical examination, she was found to have moderate abdominal tenderness without rebound or rigidity. Her catheter site appeared clean without any signs of infection. Peritoneal fluid aspirated from her catheter was cloudy and had 3650/CUMM nucleated cell with 76% eosinophil and with a normal serum eosinophil count. Fluid gram stain and cultures including fungal and mycobacterial were negative. Based on the above-mentioned results, a diagnosis of EP was made and she was treated with oral prednisone. She responded well within a week. Her peritoneal dialysis was started subsequently without any complication thus far.
Discussion: EP is a rare complication of CAPD. Among the cases reported in the literature, all of them occurred after the initiation of peritoneal dialysis. Here we report the first case of EP developed prior to the initiation of CAPD. The development of EP prior to CAPD may indicate the pathogenesis linked to the catheter itself and not the CAPD.
Submitted 2003 ACP Scientific Meeting in
COMPARISON OF ACUTE
VENTRICULAR DEFIBRILLATION THRESHOLDS UTILIZING BINARY SEARCH VS. SEQUENTIAL
STEP-UP PROTOCOL
Siddhartha Annamraju, M.D. (Associate), Randy
Lieberman, M.D., Marc Meissner, M.D., Venkata Sagi, M.D., Detroit Medical
Center/ Wayne State University
Paul DeGroot, Sr. Staff Scientist / Fellow,
Tachyarrythmia Research Medtronic, Inc
Introduction: Determination of defibrillation threshold
(DFT) at the time of ICD (Implantable Cardioverter-Defibrillator) implant
enables programming the ICD to an energy less than full output. This decreases
capacitor charge time and episode duration and conserves battery energy.
However, accepted DFT protocols such as Binary Search (BS) or Step-Down methods
require multiple VF (ventricular defibrillation) inductions. Fewer VF
inductions and an appropriate determination of DFT are clinically desirable. We
hypothesized that the DFT can be determined by a single VF induction utilizing
a Step-Up (SU) protocol.
Methods: After informed consent was obtained, paired
DFTs were determined in patients undergoing initial ICD implant for approved
indications using an active Can + transvenous RV lead system. In the SU
protocol, energies of 3-6-10-12-15-18 joules were delivered sequentially after
a single VF induction until VF was terminated. SU DFT was defined as the energy
that terminated VF. DFT was also measured using BS protocol starting at 12 J
with 6 J and then 3 J steps. VF not terminated by highest protocol energy was
shocked externally and a DFT of 24 J assigned.
Results: 25 patients were enrolled. Age – 54 ± 15
years, EF 25 ± 9 % and CAD 65%. SU DFT and BS DFT were identical in 15/25
patients. In 5 patients, SU DFT was 3 J < BS DFT. In 5 patients, SU DFT was
3 J > BS DFT. On a second repeated VF
episode, SU DFT was identical to the first in 21/25 patients.
Conclusions: SU DFT highly correlates with BS DFT and is highly reproducible. SU
protocol reduces the number of VF inductions needed to determine DFT. SU
protocol reduces total time in VF compared to the BS protocol. Further clinical
research is required to verify the suitability of determining DFT and
programming ICDs based on a single VF induction via SU protocol.
Submitted 2003 ACP Scientific Meeting in
case report of ATYPICAL PRESENTATION OF SEVERE LEGIONNAIRE’S DISEASE
A Abdussalam, MD (Associate); D Obeid, MD (Associate); Wasif Hafeez, MD (Member) – Department of Medicine, Sinai-Grace Hospital, Wayne State University – Detroit, Michigan.
Introduction
Legionella infection ranks among
the three or four most common causes of community-acquired pneumonia. The
diagnosis must be considered whenever the etiology of a pneumonia is in
question. Rarely, Legionnaire’s disease is complicated by rhabdomyolysis and
subsequent acute renal failure.
Case Report
54 year old African-american female with history of hypertension, tobacco/ethanol/cocaine use was admitted with 3 days history of mental status changes. She had no respiratory symptoms upon admission. Temperature 104, pulse 100/min., RR 30 /min., no focal neurological signs, CT head with and without contrast showed suspicious low density areas adjacent to the right sylvian fissure, basil ganglia, and right thalamic region, EEG did not show any focal activity. CXR showed right lung infiltrate, Na=128, Creatinine=0.9, WBC=15000, platelet=155000. CSF showed 6 nucleated cells, protein 62mg/100ml and glucose 91mg/100ml. Patient received ceftriaxone and azithromycin for CAP. Two days later creatinine went up to 3.5. BUN to 49, Calcium dropped to 5.8, Phosphorus=5.5, CPK = 128,858 and AST=1348. Urine myoglobin=200. Multiple cultures of blood urine and cerebrospinal fluid for bacteria, fungi and viruses were negative. Urinary assay for L.pneumophilia antigen serogroup 1 was positive.
Patient went into respiratory failure soon after admission and was ventilated for 4 days, she had full recovery of her renal, respiratory and neurological function, and was sent home 3 weeks after admission.
Discussion
Legionnaire‘s disease is a multisystem disease; it ranks forth among the organisms causing CAP. It typically presents with cough, chills, fever, dyspnea, headache, myalgia/arthralgia, diarrhea, nausea/vomiting, neurological abnormalities and chest pain. Rarely, Legionnaire’s disease is complicated by rhabdomyolysis with subsequent acute renal failure. Pathogenesis of rhabdomyolysis and encephalitis in Legionnaire’s disease remains speculative.
Submitted 2003 ACP Scientific Meeting in
TISSUE TRANSGLUTAMINASE EXPRESSION IN
MYOCARDIAL INFARCTION AND ITS INDUCTION BY CYTOKINES.
Muhammad Tariq Akbar, MD, Associate, (Dept of
Medicine,
Introduction
Myocardial infarction is associated with an
inflammatory response leading to extracellular matrix accumulation in the
injured area. Cross-linking of matrix proteins leads to maturation of the scar.
Extracellular matrix cross-linking enzymes (such as Tissue Transglutaminase)
may be induced in the infarcted heart for this purpose. Tissue transglutaminase
(TTG) catalyses the formation of lysine bonds (isopeptide bonds) between
peptide bound glutamine residues and the primary amine group of various
proteins. The covalent linking reaction increases the resistance of proteins to
chemical, enzymatic and physical disruption. TTG has been demonstrated to play
a role in the stabilization of the basement membrane and adhesion of cells,
which are important processes in wound healing and angiogenesis.
Methods
Healthy mongrel dogs were used for the study.
Coronary artery occlustion was achieved by a hydraulic occluder (previously
implanted). After one hour of occlusion the reperfusion intervals ranged from 1
hr to 28 days after which the dogs were sacrificed and heart tissue was removed
for immunohistochemical analysis and Northern Hybridization. The primary
antibodies used for immunohistochemistry included, anti-tissue transglutaminase
antibody, mouse anti-CD 31 antibody, anti-isopeptide antibody, anti Collagen
type III antibody and anti alpha smooth muscle antibody. RNA was isolated from
the myocardial tissue segments and Northern Hybridization was performed.
Endothelial cell isolation and stimulation was achieved using canine jugular
veins. These cells were stimulated with TNF-alpha, IL-1, TGF and PDGF. At the
end of the experiment the endothelial cells were used for RNA extraction and
Northern Hybridisation.
Results
TTG is expressed in ring structures at the
borders of healing infarcts. Theses structures also exhibit positivity for
mouse anti-CD-31 antibody (marker for endothelium) and anti alpha smooth muscle
antibody (marker for pericyte coated vessels). TTG mRNA is induced in healing
infarcts after 24h-28 days of reperfusion, with maximal expression around 7
days. TTG protein is localized in microvascular endothelial cells and the
connective tissue in the border zone of healing infarcts. During scar
maturation, many pericyte-coated neovessels show TTG and isopeptide expression.
TNF-alpha and PDGF induce TTG mRNA synthesis in canine endothelial cells.
Conclusion
TTG expression in healing infarcts is
consistent with a specialized role for this enzyme in regulating maturation of
the infarct neovasculature, through cross-linking of the endothelial basement
membrane. In addition, expression of TTG in the infarct border zone may
contribute to the formation of a "barrier" containing proteolysis-resistant
matrix, limiting expansion of the inflammatory process into normal areas.
Submitted 2003 ACP Scientific Meeting in
Lourin Chahin, MD, Associate, Apurva Motivala, MD,
Associate, Atul Singh, MD, Member, Marc Meissner, MD FACC, Dept. of
Medicine, Sinai-Grace Hospital, Wayne State University - Detroit, Michigan.
Case Report
We describe a 20-year-old African-American male presenting with severe symptoms of congestive heart failure (CHF) following an upper respiratory infection. Physical examination revealed respiratory distress, bilateral rales, summation gallop and mitral regurgitation murmer. 2D-echocardiography revealed left ventricular ejection fraction of 20%, global hypokinesis, mitral and tricuspid regurgitation. He was discharged after good response to pharmacologic therapy.
Hypertension, alcohol, toxins, illicit drugs were excluded as etiologies. His presentation was felt to be due to post-viral myocarditis/cardiomyopathy. Thus, we requested Coxsackie blood titers. B5 titers returned as 1:320.
The patient returned 2 weeks later with CHF exacerbation. Telemetry tracings variously revealed unsustained atrial tachycardia, AV- block (Wenckebach, high-grade, 4-second ventricular asystole), and rapid unsustained ventricular tachycardia (VT).
A dual-chamber implantable defibrillator (ICD) system was placed, to allow safe optimization of medical therapy (eg. use of beta blockers in face of above-noted AV-block), and to protect against sudden death, to which such patients are very vulnerable. Subsequent ICD testing revealed elevated defibrillation thresholds (DFTs), and the system was modified: generator change and addition of defibrillation-pacing lead placed in a posterolateral coronary vein via the coronary sinus. This resulted in successful biventricular pacing and good DFTs.
Conclusion
This case highlights several interesting points: wide range of brady- and tachy-arrhythmias in a young man with Coxsackie cardiomyopathy; technical feasibility and potential therapeutic value of biventricular 3-lead ICD system capable of improving CHF symptoms and protecting against sudden death.
Submitted 2003 ACP Scientific Meeting in
DETERMINANTS
OF REACHING BLOOD PRESSURE GOAL IN DIABETICS WITH RENAL DISEASE
Bharathi Gavini, M.D., Associate, Sinai-Grace
Hospital, and Errol D. Crook, M.D.,
Wayne State University – Detroit, Michigan.
Introduction: Diabetic Nephropathy is the number one
cause of end stage renal disease in the
Objective: We
sought to determine factors associated with reaching BP targets in diabetics.
Methods: The
charts of 146 diabetic patients seen in the WSU faculty
Nephrology clinic between
Results: The cohort was mostly African American (122), female (93), obese (mean BMI = 34.0), with moderate to severe renal insufficiency (mean serum creatinine = 2.42). The mean duration of diabetes was 15.7 years and over 90% of patients had hypertension (HTN) at presentation (duration = 13.7 yrs). The mean BP at presentations was 160/83.2 mm Hg. Fifteen patients were at BP goal at presentation. Of the 146 patients with follow-up 47 reached BP goal. The only factor that was significantly correlated with reaching BP goal was initial BP. The following factors did not predict who reached BP goal: BMI, age, gender, amount of proteinuria at initial visit, creatinine at initial visit, estimated GFR, duration of HTN, the number of BP meds at presentation or during follow-up, duration of diabetes, and duration of dyslipidemia. Compared to ACE inhibitors, the presence of a calcium channel blocker (CCB) in the regimen was associated with a longer time to reaching BP goal that appeared related to more advanced renal disease in those on CCB.
Conclusion: While
it is challenging, it is possible to achieve the aggressive BP goals set for
diabetics. Those with highest initial BP
are the most difficult to get to goal.
Submitted 2003 ACP Scientific Meeting in
MATURATION OF THE MICROVASCULATURE IN HEALING MYOCARDIAL
INFARCTS: A POTENTIAL ROLE FOR PDGF.
1KAMAL
1Department of Internal Medicine, Sinai-Grace
Hospital, Detroit Medical Center/Wayne State University, Detroit MI, and 2Section
of Cardiovascular Sciences, DeBakey Heart Center, Baylor College of Medicine,
Houston TX.
Background: The microvasculature in healing wounds undergoes dynamic changes leading to formation of mature pericyte-coated vessels. Platelet Derived Growth Factor (PDGF) is crucial for the formation of a pericyte coat in the developing embryonic vasculature. We hypothesize an important role for PDGF in vascular maturation of infarct neovessels, critically regulating healing.
Aims: To investigate the dynamic changes in the infarct microvasculature and the phenotypic characteristics of smooth muscle cells and fibroblasts in canine and murine models of experimental myocardial infarction, and to study the role of PDGF in maturation of the infarct neovasculature.
Methodology: We used established canine and murine models of experimental myocardial infarction. Hearts were processed and used for histological studies. Isolated canine jugular vein endothelial cells were used for in vitro experiments.
Results: The proliferative stage of infarct healing is characterized by myofibroblast accumulation and a high number of capillaries critical for sustaining metabolism. In both canine and murine models, infarct maturation is associated with a decreasing capillary density and an increasing number of pericyte coated vessels (p<0.01, 7d reperfusion vs 28 days reperfusion). The muscular coat of infarct vessels stains for a-Smooth Muscle Actin (a-SMAc) and calponin. Only a subset of the vessels exhibits expression of desmin and smoothelin, markers of mature contractile smooth muscle cells. PDGF is highly expressed in infarct neovessels. In addition, PDGF Receptor b is markedly upregulated in pericyte-like cells infiltrating the infarcted myocardium. PDGF receptor a synthesis is found in a subset of myofibroblasts and endothelial cells. Purified PDGF and recombinant PDGF-AA and –BB significantly induce mRNA expression of the matrix cross-linking enzyme tissue transglutaminase (tTG) in canine endothelial cells.
Conclusion: The infarct microvasculature undergoes dynamic changes leading to formation of mature pericyte-coated vessels. PDGF may play an important role in maturation of the infarct vasculature through regulation of vascular pericyte coating and by inducing endothelial expression of the cross-linking enzyme tTG, promoting endothelial basement membrane maturation. Further experiments using neutralizing antibodies in mice undergoing infarction protocols will determine the role of PDGF in healing infarcts.
Submitted 2003 ACP Scientific Meeting in
ACUTE INTERSTITIAL NEPHRITIS
SECONDARY TO OMEPRAZOLE.
Apurva Motivala MD, Associate,
Robert Michaels MD, Irfan Omar MD
Dept. of Internal Medicine, Sinai-Grace Hospital/ Wayne State University –
Detroit, Michigan.
We describe a 75 year old male who presented with acute on chronic renal
insufficiency (creatinine increased from
1.5 to 3.7 over six months) . He had a history of hypertension, gout, chronic
hypertensive nephropathy, benign prostatic hypertrophy and gastro-esophageal
reflux disease (GERD). The patient was on amlodipine, colchicine and sucralfate
and omeprazole (recently initiated). His blood pressure was well controlled and
no abdominal was auscultated. The leukocyte count was 11,000/mm3 without
eosinophilia Urinalysis showed 10-20 leukocytes per high powered field but no
proteinuria or nitrates, The patient was subsequently worked up for his acute
renal failure : renal ultrasound, C3, C4 , ANCA , ANA, serum protein and immunoelectrophoresis,
sedimentation rate, rheumatoid factor, recent captopril renogram and 24 hour
urine protein were normal. A renal biopsy confirmed acute interstitial
nephritis (AIN) and background gouty nephropathy. Omeprazole was discontinued
and oral steroids initiated followed by a resolution of the acute renal
failure. A diagnosis of omeprazole induced AIN was made because of the temporal
relation between its initiation and development of AIN confirmed by
biopsy.
Acute interstitial nephritis accounts for 15 % of
all lesions in renal biopsies performed for evaluation of acute renal failure.
The most common drugs associated with AIN are penicillins, cephalosporins,
sulfonamides and non steriodal anti-inflammatory agents. We hereby report the
22nd case of omeprazole induced AIN in the literature. Acute
interstitial nephritis is an increasingly recognized side effect of the
commonly used proton pump inhibitor, omeprazole, of which the internist needs
to be aware.
Submitted 2003 ACP Scientific Meeting in
CRYPTOCOCCAL MENINGITIS IN A NON-HIV PATIENT
Mohamed Iqbal P.
Rouf, MD, Associate, Latha Ganesan, MD, Member,
Department of Internal Medicine, Sinai-Grace
Hospital, Detroit Medical Center/Wayne State University, Detroit, Michigan.
Introduction
Cryptococcal
meningitis is one of the most common fungal meningitis in both
immunocompromised hosts and non-immunocompromised hosts.
Case Report
Here,
we present a case of a 47-year-old male with known end-stage renal failure,
diabetes mellitus and hepatitis C, admitted with a history of change in mental
status in the form of drowsiness, decreased appetite, weight loss and
progressive deconditioning over a period of 4 months. On the day of admission,
the patient was found to be unresponsive at home. On examination patient was comatose,
pulse-67beats/min, blood pressure-100/68mmHg, respiratory rate-12breaths/min.
Neurological exam revealed unequal, unreactive pupil and absent corneal and gag
reflexes. Examination of other systems were normal. His laboratory data revealed normal CBC,
sodium, potassium, chloride and bicarbonate. He had BUN of 59mg/dl, creatnine
of 7.7mg/dl, phosphorus of 6.2mg/dl, blood glucose19mg/dl. His liver enzymes, bilirubin, lactic acid, serum
acetone levels were all normal. . Urine analysis showed proteinuria, positive
leukocyte esterase, RBCs and more than 100 WBCs. Chest x-ray was normal and computed
tomography scan of the head showed hydrocephalus. Urine drug screen was
negative. Based on the above, the
patient was treated initially as hypoglycemic encephalopathy. Since there was no significant improvement in
the patient’s mental status, and urine culture was growing cryptococcus, lumbar
puncture was done. CSF study showed WBC- 145, neutrophil 88%, cryptococcal
antigen was 1:128. His HIV serology was negative. He was initially treated with amphotericin B
and 5 flucytosine but ultimately treated
with supportive measures as per his family’s wish. He died two weeks later.
Conclusion
This
case illustrates the importance of
recognizing cryptococcal
meningitis in non-HIV patients with chronic meningitis. In this patient, Diabetes Mellitus and renal
failure could be the risk factors for impaired immunity.
Submitted 2003 ACP Scientific Meeting in
THE
ROLE OF FINE PARTICULATE AIR POLLUTION AND ELEVATION OF CIRCULATING ASYMMETRIC DIMETHYLARGININE (ADMA) LEVELS
Sanjay Rajagopalan, MD1, Robert D. Brook, MD1, Gerald
J. Keeler, PhD1, J. Timothy Dvonch, PhD1, Frank J.
Marsik, PhD1, Masako Morishita, PhD1, Jeff R. Brook, PhD2,
Lou D’Alecy, PhD1, Apurva Motivala, MD (Associate)3,
Edward J. Timm4, James Wagner4, and Jack R. Harkema, DVM
PhD4 – 1The University of Michigan, Ann Arbor, 2University
of Toronto, Canada, 3Sinai-Grace Hospital/Wayne State University,
Detroit, 4Michigan State University, East Lansing.
Background and Aim: The health effects of fine
ambient particulate matter (PM2.5) and its potential impact on vascular
endothelial function have not been thoroughly investigated. As endothelial
dysfunction plays an important role in atherosclerosis and cardiovascular
disease, we examined the effects of concentrated fine ambient particles (CAPs)
on the plasma levels of asymmetric dimethylarginine (ADMA) in a pilot study.
ADMA is an endogenous inhibitor of nitric oxide synthase that is associated
with impaired vascular function and an increased risk of cardiovascular events.
Methods: A mobile air research laboratory (AirCARE 1),
equipped with whole body inhalation chambers and a Harvard type ambient fine
particle concentrator, was used in the study. AirCARE 1 was designed and
constructed collaboratively by
Results: Plasma concentrations of ADMA were significantly
elevated in the rats exposed to CAPs versus those exposed to FA (1.49 ± 0.18 vs
1.29 ± 0.26 *M, p*0.05 by 1 tailed t-test).
Conclusion: Fine particulate air pollution exposure at high
concentrations triggers an acute increase in circulating ADMA level. This could
potentially cause impaired vascular endothelial function and enhance the risk
for cardiovascular disease.
Submitted 2003 ACP Scientific Meeting in
CHOLECYSTITIS AND PANCREATITIS ASSOCIATED WITH EDWARDSIELLA
TARDA SEPSIS IN AN IMMUNOCOMPROMISED
HOST
Edwardsiella tarda is a gram-negative bacteria that causes zoonotic infections but rarely causes human disease. There are approximately 300 reported cases of Edwardsiella tarda sepsis in the literature. We report the first case of Edwardsiella tarda sepsis associated with acute myelocytic leukemia.
A 50-year-old African American male with acute myelocytic leukemia, who presented with abdominal pain, chills and fever for two weeks. He was febrile with epigastric and right hypochondrial tenderness. Laboratory studies showed neutropenia with excess blasts, elevated amylase, lipase, alkaline phosphatase and bilirubin. Hence, patient was admitted for relapse of acute myelocytic leukemia with febrile neutropenia, acute pancreatitis and acute cholecystitis. Imaging studies did not reveal any gallstones. Blood cultures were positive for Edwardsiella tarda. Patient responded well to antibiotics with resolution of his symptoms.
Edwardsiella tarda is a zoonotic bacteria that infrequently causes gastroenteritis in humans. Extra-intestinal manifestations are rare and include septicemia, wound infection myonecrois, cholecystitis and pancreatitis. Human disease is more common in the immunocompromised. Human infection is acquired through contact with or ingestion of infected fish. Our patient had a significant history of recreational fishing and had eaten his catch a few days prior to the onset of his symptoms. He was also at a higher risk for infection because of immunosupression from acute leukemia.
Submitted 2003 ACP Scientific Meeting in
MASSIVE RIGHT
VENTRICULAR THROMBUS PRESENTING AS ACUTE ABDOMEN
Manesh Kottapuram, MD (Associate); Shazia Essani, MD (Member) Department of Internal Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Acute cor pulmonale due to massive right ventricular thrombus presenting as acute abdomen is a rare event.
We present a 21 year old caucasian woman who presented to the emergency room with sudden onset of abdominal pain and shortness of breath. Pain was continuous and generalized but mainly in the left upper and lower quadrant.