2005 National ACP Abstract Submissions
Multi-System Organ
Failure In Fifty Year Old African American Male With
Non-Typhoid Salmonella Serotype
Background: Salmonella are widely dispersed in nature, including
gastrointestinal tracts of domesticated and wild animals, reptiles, birds and
insects. Salmonella paratyphoid and
Case Report: A fifty (50) year old, African American Male with a history of
alcoholism and hepatitis c infection and hypertension presented to Sinai Grace
hospital Emergency Room with the chief complaint of three (3) to six (6) months
of increasing “yellowing” of the eyes and skin, two (2) to three (3) days of
generalized weakness, light-headedness, and decrease in oral intake, secondary
to nausea and vomiting. The initial
presentation revealed an ill appearing, jaundiced male in septic shock with
renal and liver failure. Patient was intubated and placed on mechanical ventilation. He
was transfused with fresh frozen plasma, packed red blood cells and
given vitamin K. Additional therapeutics
included aggressive hydration, broad spectrum antibiotics and steroids.
Antibiotics were changed to cover positive blood cultures that grew Salmonella
Dublin.
Discussion: The clinical manifestations of non-typhoid Salmonella infection
are varied. These variations include asymptomatic infection to clinically
manifested disease, which can present as enterocolitis,
vasculitides resulting in aneurysm, bacteremia, sepsis, localized infections or a chronic carrier
state. The majority of these infections
are associated with the food service establishments. This case is unique in
that there are no reports of Salmonella Dublin sepsis and multiorgan
involvement from 1966 to the present. World wide infections relating to nontyphi Salmonella are increasing, with most infections
secondary to under cooked poultry and eggs.
Conclusion: Although the exact nature of acquisition of infection for our
patient was not identified, it is imperative that high clinical suspicion of bacteremia, early pathogen identification and aggressive
therapeutics must be utilized in patients who present with sepsis and
underlying co-morbidity.
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.
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.
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
NON-FUNCTIONING ANAPLASTIC ADRENOCORTICAL
CARCINOMA PRESENTING AS CARCINOMATOSIS.
Raghukumar D. Thirumala M.D, Associate; Apurva Motivala M.D, Associate;
and Manesh Kottapuram M.D, Member.
Adrenocortical carcinoma is a rare, aggressive tumor usually affecting young
children and adults. Approximately 60% of tumors are hormone producing on
presentation. Non-functioning anaplastic tumors are
heralded by symptoms of local invasion by tumor or by metastasis. Most common
sites of metastasis are peritoneum, lung, liver and bone.
We present a
rare case of Non-functioning adrenocortical carcinoma
presenting as carcinomatosis. The patient is a
34-year-old female, who presented with headache, neck pain, difficulty walking
and tingling left arm of 2 days duration. No signs of neurological deficits or
excessive steroid secretion were present. Medical history was significant for
SLE, seizures secondary to lupus cerebritis, and
asthma. Examination was significant for orthostasis, guaiac positive stools, and staggering gait. Labs were
significant for a hemoglobin level of 2.5gm/ dl. Upper GI endoscopy
revealed two bleeding gastric masses. A work up for ataxia with a non-contrast
CT scan revealed a 2-3cm mass in the left occipital region. Subsequently, MRI
brain revealed mass occupying lesions in both the cerebellar
hemispheres with a 2cm lesion in the posterior left parietal area. CT thorax
revealed a large mass in the right paratracheal
region with mass effect on the airways and heart. CT abdomen revealed
heterogeneous mass in right adrenal gland with lymphadenopathy
in the porta and left paraaortic
region. USG of pelvis demonstrated enlargement of the ovaries with cystic
features. Autopsy revealed a large adrenal tumor with a large retroperitoneal hematoma and disseminated metastasis to the lungs, liver,
pancreas, ileum, gastric wall, peritoneum, ovaries, and brain. Immunohistochemical stains were negative for vimentin, S100, synaptophysin,
CK20 but positive for CK7, keratin, EMA and focally positive for HCG and PLAP,
consistent with epithelial tumors.
At present,
there is no pathognomic immunohistochemical
profile for adrenocortical carcinoma. Negative neuroendocrine tumor markers may rule out the possibility
of a malignant pheochromocytoma. This case highlights
certain key features in the diagnosis of adrenocortical
carcinoma. First, lack of specific immunohistochemical
profile fails to localize the primary site of the tumor. Second, carcinomatosis secondary to adrenocortical
carcinoma has rarely been reported.
SIGNET RING CELL CARCINOMA OF UNKNOWN PRIMARY WITH DIC: A
CASE REVIEW
Amer Tfaili MD, Associate, Darshana Tawde MD, Associate,
A 62-year-old
African American female was hospitalized with a 1-month history of weight loss
and a recent history of abdominal pain. Physical examination revealed a
distended tender abdomen with ascites but without any
jaundice. There was cyanosis of the 3rd and the 4th toes
bilaterally. Laboratory evaluation revealed the presence of DIC. Alkaline phosphatase, CEA and CA 19-9 levels were significantly
elevated.
Paracentesis revealed signet cell adenocarcinoma. CT
of the abdomen and pelvis showed dilatation of the intra hepatic ducts, common
bile duct and the pancreatic duct without any evidence of cholelithiasis.
An ERCP done 1 year earlier for pancreatitis had
shown the same dilatation, which was considered a normal variant then. MRI of
the abdomen with MRCP failed to show any hepatobiliary
or pancreatic mass. EGD and colonoscopy were negative for malignancy and a bone
scan did not show bony metastasis.
The patient
refused chemotherapy and died a month later after a cardiopulmonary arrest. The
family refused an autopsy.
Our literature
review revealed 2 cases of signet ring cell carcinoma of unknown primary, one
of which was found to have a 0.8 cm carcinoma of the Ampulla
of Vater on autopsy. Treatment with chemotherapy has
been shown to improve DIC, decrease tumor burden and prolong survival in these
patients. Hence chemotherapy should be offered to such patients. The diagnosis
of signet ring cell carcinoma of the gastrointestinal tract by endoscopy remains a diagnostic challenge.
Our patient
presented such a challenge. This is a rare case of signet ring cell carcinoma
of unknown primary presenting with DIC and a greatly elevated alkaline phosphatase level with no evidence of obstructive hepatobiliary or pancreatic disease.
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.
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.
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.
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.
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.
ATYPICAL
CLINICAL COURSE OF LOCALIZED REACTIVE LYMPHOID HYPERPLASIA OF THE SPLEEN
(SPLENIC LYMPHOID HAMARTOMA): A CASE REPORT.
Introduction:
Localized reactive lymphoid hyperplasia (lymphoid hamartoma)
is a rare lesion of the spleen. Most of the patients are asymptomatic but a
small group of patients present with a wide range of clinical manifestations.
Case
report: A 24-year-old Caucasian male of Italian descent presented with severe microcytic anemia and thrombocytosis
of a chronic nature with symptoms of tiredness, fatigue and syncope eventually
requiring transfusions. The patient admitted to using anabolic steroids for
body building. Diagnostic studies demonstrated a normal bone marrow with
adequate iron stores, elevated ESR, fibrinogen, and CRP levels and an
unexpected IgA deficiency. Familial hemoglobinopathy was excluded by hemoglobin electrophoresis
of available family members. Panendoscopy of the
gastrointestinal tract was negative for bleeding but revealed esophagitis due to C. Albicans
and gastritis due to H pylori. CT scan demonstrated splenomegaly
with a 3.6 x 3.8 cm mass that increased in size over a 2-month interval.
Diagnostic and therapeutic splenectomy was performed
revealing localized reactive lymphoid hyperplasia of the spleen consistent with
a lymphoid hamartoma with negative cytogenetics and polyclonal flow cytometry.
Follow up surprisingly demonstrated normalization of all hematological
parameters with no additional therapy.
Conclusion:
In our literature review of splenic lymphoid hamartoma, we did not find a previously described
association with severe microcytic anemia.
Additionally, no case reports of elevated ESR, fibrinogen or C-reactive protein
were found except in association with Hodgkin’s disease. Lymphoid harmartomas are usually seen in children with most patients
being asymptomatic although a few present with hypersplenism.
Histopathology is important in differentiating splenic
lymphoid hamartoma from lymphoma, inflammatory psuedotumor of the spleen and red-pulp hamartomas
(splenic hamartoma due to
malformed vascular elements). This case reports illustrates several important
clinical features of lymphoid splenic harmatomas that have not been reported previously and the
potential for a complete and sustained response to splenectomy.
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.
DECREASING
RENAL FUNCTION AS A PREDICTOR OF INCIDENT CARDIOVASCULAR DISEASE IN
DIABETICS
Oronde White, MD, Errol Crook, MD, Sinai-Grace Hospital,
Wayne State University School of Medicine and John D. Dingel
VAMC, Detroit, MI.
Objective: Chronic kidney disease (CKD) has been
recognized as a cardiovascular disease (CVD) risk factor. However, whether
progression of established CKD further increases risk for CVD is not clear. In this study we examined the effects of
declining renal function in diabetics as a predictor of incident CVD.
Methods: The charts of all diabetic patients seen in
the Wayne State University Nephrology clinic in 2001 and 2002 were reviewed and
data on basic demographics, blood pressure, renal function, medications, and
both prevalent and incident cardiovascular disease was extracted. Combined hear disease (CHD) was defined as
CHF and Coronary Heart disease, and CVD was defined as CHD & stroke. Stable renal function was defined as remaining
in the same CKD stage (according to the classification of the National Kidney Foundation)
over the course of follow-up, and unstable kidney function was defined as
deterioration by 1 or more stages.
Estimated GFR (eGFR) was calculated using the
abbreviated Modification of Diet in Renal Disease formula. Statistical analysis was performed using the StatView program.
Differences between continuous variables were determined by t-tests, and
between nominal variables by Chi-Square analysis. The initial relationship regarding progression
of kidney disease and incident CVD was done by Chi-Square analysis. Logistic Regression was used to adjust for
the effects of other factors on incident CVD risk.
Results: 337 patients were included (85% African
American, 216 women, 217 stable CKD).
Patients with unstable CKD had significantly higher rates of incident
CVD than stable patients (19.2% vs. 29.7%, stable vs. unstable, respectively
(chi 2, p = 0.039)). Similar
results were seen for CHD. Logistic
regression revealed 57.4 %
and 71% increased risk of CVD (p = 0.034) & CHD (p = 0.015)
respectively. Prevalent CAD, CHF, diabetic extrarenal
microvascular complications, follow-up time, # BP
meds on follow-up, and smoking status were significantly related to incident
CHD & CVD. When controlling for
these factors in stepwise logistic regression, unstable CKD was still
significantly associated with increased risk of incident of CHD (p = 0.0126)
but not CVD. However, the continous variable of change in eGFR
was significantly related to incident CHD and CVD after adjustment for the
above factors.
Conclusions: Diabetic patients with progression of kidney
disease are at higher risk for CVD events.
Any patient with progression of CKD, especially diabetics, should be
closely monitored for cardiovascular complications.
Myelodysplastic Syndrome
(MDS) and Pregnancy- Still an Enigma
Tannu Sahay,MD (associate), Saad Usmani,MD (associate), Leopoldo Eisenberg, MD (member), Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
Introduction
MDS is a hematological disorder with ineffective hematopoesis commonly seen in elderly patients with a median age at onset in the seventh decade. There are only rare cases of MDS reported amongst young pregnant patients. We report a case of such a patient.
Our patient is a 27-year-old G2 P1 Caucasian female who was referred at 30th week of gestation for further work-up of a macrocytic anemia and thrombocytopenia. Her past medical and obstetric history was significant only for a spontaneous vaginal delivery at age 24 with no family history of any hematological disorder. Physical examination showed significant pallor, no icterus, petechiae or splenomegaly. Her CBC revealed an Hb-9.5; Hct-28.1; MCV-110; RBC count-2.92; RDW-15.4; platelets-59,000. The peripheral smear showed polychromasia, teardrop cells, macro-ovalocytes, pseudo-Peulger-Heut anomaly, occasional Dohle bodies, thrombocytopenia with few large platelets and spherocytes. Bone marrow examination that showed a hypocellular marrow (20-30% cellularity), macronormoblastic erythrocytogenesis with few dysplastic forms, 31% sideroblasts, decreased storage iron, decreased myeloid leukogenesis with orderly maturation and 0.9%myeloblasts. The M:E ratio was 1.5:1. No karyotypic abnormality was noted.
Discussion
MDS is an extremely rare condition to present in pregnant females. With extensive search of English literature, we could only find 6 reported such cases. All were Caucasian females in the ages between 30 to 42 years. Only two were in FAB class RAEB and the rest in RA. 4 of the 6 cases underwent leukemic transformations following diagnoses. Karyotypic abnormality was noted in only one patient with Iso (17) q abnormality. The association of MDS with pregnancy was thought to be coincidental by most authors. One of the patients underwent therapeutic abortion and no other adverse outcomes were reported. Survivals amongst these patients were from 1 month to as long as 5 years. There was no consensus regarding the treatment of MDS in these studies. But we did come across a Japanese case (not available for review) of successful treatment with steroids.
Conclusion
Association of MDS during pregnancy should be recognized. Issues related to multiple transfusions, pregnancy outcome, severe anemia and IUGR might present with potential difficulties in the management of these patients. There are reasons be believe that there may be an increasing incidence of MDS in pregnant females especially with an ongoing trend towards childbirth in older females.