2005
Blebitis causing red eye in a patient with glaucoma
Vindya Achuthan MD† (Associate), Tom Obertynski* MD, Anju Gupta* MD, James Puklin* MD, Apurva Motivala* MD
Background: Red eye is a frequently encountered condition by primary care doctors both in the in-patient and ambulatory settings. While most cases can be easily managed, it is important that the astute physician recognizes cases which require immediate referral to a specialist to prevent vision loss.
Case Report: We report a 78 year old female who presented
with a red eye since 3 days. She denied any vision changes. Past medical
history included Glaucoma,
Discussion: In a patient with known glaucoma filtration surgery, primary care physicians should entertain the possibility of a bleb infection (blebitis) as a cause of red eye. The filtering bleb is a rather thin walled structure. In some cases the wall is extremely thin and intermittently even leaks fluid through it. This is not unusual in a person who has had a very successful glaucoma operation in the past. This requires immediate attention as, if blebitis occurs, it quickly can lead to endophthalmitis. Endophthalmitis commonly can cause severe loss of vision. Blebitis in our case, resulted in overfiltration, leading to hypotony and resulting in choroidal folds and retinal detachment.
MALIGNANT MESOTHELIOMA: A
Vindya Achuthan, MD (Associate),
Introduction: Malignant mesothelioma (MM) is a rare malignant tumor which arises from the mesothelial surfaces of pleura and peritoneum. The tumor is significant in view of its recognized association with occupational exposure to asbestos. Prolonged asbestos exposure is considered more significant rather than heavy exposure.
Case Report: A 54 year old retired assembly line worker with a history of COPD and 20 pack year smoking history presented with progressively worsening dyspnea of 2 weeks. He was tachypneic, tachycardic and hypoxic using accessory muscles, had decreased breath sounds on right lower lung field and diffuse crackles bilaterally. Patient had to be intubated in the ER for worsening dyspnea and hypoxia. Chest X-ray showed right sided pleural effusion. CT guided thoracentesis revealed bloody pleural fluid with lymphocytosis and mesothelial cells. Pleural biopsy showed areas of poorly differentiated malignant neoplasm with focal areas of necrosis and mitosis, epitheloid cells with pleomorphic nuclei intermixed with neoplastic spindle cells with elongated nuclei. This kind of mixed pattern is characteristic for mesothelioma. Staining was positive for cytokeratin and calretinin, which favored a diagnosis of mesothelioma. The patient is currently oxygen dependent and followed up as out patient, awaiting chemotherapy with cisplatin and alimta.
Discussion: We report a unique case of localized malignant mesothelioma presenting with dyspnea and unilateral pleural effusion in a patient with a risk of occupational exposure to asbestos. Lifetime risk of developing mesothelioma is 8-13 % in workers exposed to asbestos. The incidence of mesothelioma is expected to increase till 2020 and then decrease due to environmental legislation in place since 1990. There are almost 2500 new cases every year. Average survival time is one year. There are new emerging therapies that improve survival and provide palliation. It is therefore important that this serious condition be recognized as a differential diagnosis in patients presenting like ours.
Multiple Hydatid Cysts in the Heart
Bhavin Dalal, MD, (Associate); Ishani Dalal, MD; Pranav Dalal, MD; Umang Shah, MD; Suniel Dalal, MD; Kamal Nasser, MD
Introduction: Despite the rise in occurrence, echinococcosis
remains a very rare disease (<1 case per 1 million inhabitants) in the
continental
Case report: A 30 year old male came to the out patient
clinic with complaints of intermittent chest pain & palpitations. Physical
examination was normal except
Discussion: Cardiac involvement of hydatid cyst is rare
though, solitary hydatid cyst of heart is well documented. In our patient there
were multiple cysts in heart with predominance in RV and IVS. In spite of that he
was minimally symptomatic. Diagnosis of hydatid cyst in heart can be easily
made by 2D echo. CT scan or
Morgagni’s hernia as a cause of Hemodynamic instability – A rare entity!
Dalal B MD (Associate), Sinai-Grace Hospital / Detroit Medical Center, Wayne State University, Detroit, Michigan
Dhar S, MD, Dalal S MD, Desai N MD Department of Internal Medicine,Temple University Hospital, Philadelphia, PA
Introduction: The liver, bowel, or mesenteric fat may herniate directly through small congenital defects in the anterior diaphragm (i.e., Morgagni's foramina). We are reporting a case in which Morgagni’s hernia was responsible for hemodynamic instability and surgical emergency.
Case Report: A 63 year old man was transferred to the hospital with two episodes of hematemesis at boarding home. EGD revealed erosive esophagitis and a healing duodenal ulcer without an active source of bleeding. On the evening of day two, patient was restless and 2 mg of lorazepam was given intravenously. Subsequently he became lethargic and he was intubated for hypercapnic failure. On third day patient dropped his blood pressure tachycardia. He was aggressively hydrated without any significant response. Patient was started on dopamine drip. A thoracic radiograph revealed increased cardiac silhouette and some gaseous shadows in mediastinum. Subsequently a stat chest CT scan was performed which revealed a huge Morgagni’s hernia compressing the heart anteriorly and causing atelectasis of left lower lobe of lung. Patient was taken to operating room, where laparoscopic reduction of Morgagni’s hernia was performed with closure of defect.
Discussion: Morgagni’s hernia accounts for 2-4% of all diaphragmatic herniae. The majorities of hernias occurs on the right side and are asymptomatic. In our patient Morgagni’s hernia caused compression of heart from anteriorly and mimicked like a cardiac temponade. Surgical closure is required in all symptomatic patients.
Determinants of Central Apneas in Patients with Sleep-Disordered Breathing
Dalal Bhavin, MD, Ghabhsa Ahmed, MD, Badr Safwan, MD, Rowley James, MD
Detroit Medical Center, Wayne State University
Introduction: Research has shown that men are more susceptible to the development of central apneas compared to women under research conditions, suggesting that gender differences in the control of ventilation may explain the increased prevalence of sleep-disordered breathing (SDB) in men. It is unclear if this physiologic finding translates into a clinical finding of increased central apneas in men presenting for evaluation of SDB. Hypothesis: men are more likely than women to have an increased central apnea index on polysomnography.
Methods: Database review of 773 patients diagnosed with
sleep apnea (
Results: Group 1 patients were more likely to be male (60.4%
v. 37.0%). NC was larger in Group 1 patients (44.1±5.1 cm v. 41.9±5.1 cm, Group
2, p<0.001) but there was no difference in either age (48.0±14.9 yrs v.
50.1±13.0 yrs) or
Conclusions: Men are twice as likely to demonstrate central
apneas on polysomnography than women, consistent with the research finding of
an increased susceptibility to the development of central apnea. Central apneas
are also more likely in patients with increased overall
Solitary Plasmacytoma presenting as Spinal compressions syndrome
Jeevan C. Gowda M.D. Associate, Lourin Chahin M.D. Associate, Dr. Tanu Sahay M.D. Member
Case Presentation
We present the case of an 85-year-old African American Male
with a previous history of hypertension, congestive heart failure, and previous
tumor of the pituitary gland, which was surgical resected. He presents with a history of progressive
weakness over the past three days prior to admission. Patient was using his wife’s old walker to
ambulate when he lost all function of his lower extremities and called
Discussion
Though normally presenting with back pain, spinal cord
compression is one of the presentations of plasmacytoma. Treatment is surgical decompression followed
by Radiotherapy. The patient should be
monitored with serum and urine immunofixation every 4-6 months for the 1st year
and then annually, for Multiple Myeloma.
As well as Annual
ACQUIRED
Jayasree Grandhi, MD, Associate, Tannu Sahay, MD, Associate, Geetha Krishnamoorthy, MD, Member, Joel Appel, DO, FACP, Fellow
Department Of Medicine,
Introduction: Angioedema is characterized by extravasation of fluid into interstitial tissues. It can be mast cell mediated or complement mediated. The complement mediated can be hereditary or acquired. Acquired angioedema subtype is usually seen in the second or third decade of life and is usually due to an underlying disease. We report a case of acquired angioedema in a patient with Hodgkin’s disease.
Case Report: A 35-year-old African American female came with multiple episodes of angioedema and weight loss of 50 lbs for last four months. No previous documented cases of angioedema in her family were reported. Physical examination was normal except for angioedema of the upper lip. There was no evidence of lymphadenopathy. Chest x-ray and CT scan showed anterior mediastinal mass. Patient underwent resection of the mass. Pathology showed classic Hodgkin’s lymphoma, syncytial variant of nodular sclerosis type. Patient’s CT scan of abdomen, pelvis and bone marrow biopsy were negative. PET scan showed increased uptake in mediastinum. She was diagnosed to have stage 2B Hodgkin’s disease. Serum levels of C3, C4, and functional C1-esterase inhibitor were normal. Pt is being treated with ABVD chemotherapy.
Discussion: Acquired C1-inhibitor deficiency is well recognized in B-cell lymphoproliferative disorders with a prevalence of approximately 0.5%. The typical association of acquired angioedema is with non-Hodgkin’s lymphoma. Upon review of English literature, there was one reported case of acquired angioedema secondary to Hodgkin’s disease.
Conclusion: Patients with angioedema are often referred to an allergist to rule out an allergic cause. In most cases no allergic cause is identified and the cases are labeled as “idiopathic.” An adult onset angioedema without family history should raise the suspicion of other underlying diseases. The clinician should be aware of the possibility of Hodgkin’s disease as a cause of this paraneoplastic phenomenon.
Hemodynamic and Clinical Changes in Patients Following Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy
Irfan Hameed, MD, Associate, Amr Abbas, MD, Stacy Brewington, MD, Judy Boura, MS, William O’Neil, MD, Sinai Grace Hospital and William Beaumont Hospital, Michigan
Background:
Dynamic left ventricular outflow tract obstruction is an
important determinant of patient’s symptoms and prognosis. Relief of outflow
obstruction leads to positive clinical and hemodynamic effects. Alcohol Septal
Ablation (ASA) is a reliable alternative to surgical myomectomy in symptomatic
patients with Hypertrophic Cardiomyopathy (
Methods:
A retrospective analysis of 40 patients who underwent ASA
for
Results:
The mean age was 52 with 63% male. Median clinical follow up was 80 days and echocardiographic follow up was 46 days.
Clinically, a sustained improvement was noted in NYHA class, chest pain, palpitation, syncope, and use of medications. The majority of patients were NYHA class 3-4 at baseline (86%) and improved to class 1 (26%) at follow up, seventy percent of patients had no symptoms. Similarly, by echo an improvement in septal thickness (from 2.2 ± 0.6 to 1.6 ± 0.4 cm, P<0.0019), mitral regurgitation (from 96% to 58%, P< 0.039), and outflow gradient (from 74.0 ± 46 to 29 ± 33 mm Hg, P<0.0004) was noted.
Conclusion:
ASA leads to a hemodynamic and clinical improvement in
patients with
Hemodynamic and Clinical Changes in Patients Following Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy
Irfan Hameed, MD, Associate, Amr Abbas, MD, Stacy Brewington, MD, Judy Boura, MS, William O’Neil, MD, Sinai Grace Hospital and William Beaumont Hospital, Michigan
Background:
Dynamic left ventricular outflow tract obstruction is an
important determinant of patient’s symptoms and prognosis. Relief of outflow obstruction
leads to positive clinical and hemodynamic effects. Alcohol Septal Ablation
(ASA) is a reliable alternative to surgical myomectomy in symptomatic patients
with Hypertrophic Cardiomyopathy (
Methods:
A retrospective analysis of 40 patients who underwent ASA
for
Results:
The mean age was 52 with 63% male. Median clinical follow up was 80 days and echocardiographic follow up was 46 days.
Clinically, a sustained improvement was noted in NYHA class, chest pain, palpitation, syncope, and use of medications. The majority of patients were NYHA class 3-4 at baseline (86%) and improved to class 1 (26%) at follow up, seventy percent of patients had no symptoms. Similarly, by echo an improvement in septal thickness (from 2.2 ± 0.6 to 1.6 ± 0.4 cm, P<0.0019), mitral regurgitation (from 96% to 58%, P< 0.039), and outflow gradient (from 74.0 ± 46 to 29 ± 33 mm Hg, P<0.0004) was noted.
Conclusion:
ASA leads to a hemodynamic and clinical improvement in
patients with
Soft Tissue Amyloidoma in a Patient with Multiple Myeloma
Wahed Ishaqsei, MD; Amer Tfaili, MD; Kamal Nasser, MD; Leopoldo Eisenberg, MD
Introduction: Amyloidosis represents a heterogeneous group of disorders characterized by abnormal extra cellular deposition of insoluble fibrillar proteinacious material. Amyloidoma, which is an uncommon finding, is defined as localized nodular mass of amyloid deposit with or without systemic amyloidosis.
Case Report: We report a rare case of a 66-year-old woman who presented with right shoulder pain and limping due to left hip pain of few months’ duration and a 7-pound weight loss over 6 weeks prior to presentation. On exam there was tenderness to slight percussion over the left scapula, minimal tenderness to the chest wall, and slight discomfort to the right shoulder, both humeri proximally, and the left groin.
X-rays showed punched-out lesion of the proximal humerus and
pelvis consistent with multiple myeloma. Her hemoglobin was 10.2, creatinine
1.6 and 24-hour urine revealed 1226mg bence jones type protein. Bone marrow
revealed markedly increased number of atypical kappa restricted plasma cells,
with 47% plasma cells of total nucleated cells with normal karyotype. Patient
was treated on Zometa, Decadron, Thalidomide and procrit with clinical
improvement, but with persistence of left groin pain. An
Discussion: Only three reported cases of kappa-light chain Amyloidoma presenting simultaneously with multiple myeloma were found in the English literature. It is important to establish a differential diagnosis of amyloidoma in soft tissue tumor. The clinical presentation mimics other aggressive pathologic processes. The prognosis of amyloidoma is excellent, and cure can be expected by local resection when occurring primarily in a localized anatomic area and no recurrence has been described yet. The therapy of multiple myeloma as in our case, does not affect the course of amyloidoma.
Cortney V. Jones, MD; Kamal A. Nasser, MD; Gary W. Edelson, MD
Department of Medicine,
BACKGROUND: Carbohydrate Deficient Glycoprotein Syndrome (CDGS) is a rare autosomal recessive condition caused by incomplete glycosylation of plasma proteins. There are less than 200 documented cases of CDGS, with four described types, each caused by a specific enzyme deficiency.
CASE REPORT: An eighteen-year-old female with a history of
CDGS was referred to an endocrinologist regarding osteoporosis. She had mental
retardation, cerebellar hypoplasia, ataxia, pectus deformity, antithrombin
DISCUSSION: Skeletal abnormalities present in CDGS include: kyphoscoliosis, pectus carinatum, inverted nipples, ankle and hip contractures, and short stature. In our patient, primary ovarian failure led to decreased attained peak bone mass. The etiology of low bone mass was hypoestrogenism, lack of weight bearing exercise, and inadequate glycosylation of bone proteins. The only reasonable option to increase bone mass was human recombinant parathyroid hormone. Aledronate is indicated in patients with accelerated bone loss, and a hypercogulable state is a contraindication to estrogen therapy. Literature review confirmed the use of DXA technique for bone density assessment in CDGS; however, the use of teraperatide to increase bone mass was novel.
CONCLUSION: The inadequate glycosylation of plasma proteins has systemic effects. Until enzyme supplementation proves to be beneficial, the mainstay of therapy is supportive care. This entails a meticulous investigation of each organ system and should include bone density assessment.
Rarest of the Rare Tumor: Primary Leiomyosarcoma of the Sacrum
Rashad Khazi Syed, MD; Kaled Bazzi, MD; Kamal Nasser, MD; Susan Harold, MD
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.
INTRODUCTION: Primary leiomyosarcoma of the bone is regarded as a rare form of bone sarcoma and thus, few cases have been reported in literature. To our knowledge, this is the second case report of primary leiomyosarcoma involving the spine.
CASE REPORT: A 52 yr old African American female with history of leiomyosarcoma of the sacrum diagnosed and treated with chemotherapy and radiotherapy in 1999, presented to the hospital with complaints of back pain, weakness in her legs, saddle anesthesia, bladder and bowel incontinence. In the lower limb, there was decreased sensation to pinprick, decreased motor power, and positive babinski bilaterally. She was found to have recurrence few months prior to this admission and was started on chemotherapy. Cord compression was ruled out. Her bone scan did not show any other bone involvement and tissue was negative for C-Kit. Patient was started on gemcitabine, and analgesics. She received in-patient rehabilitation and was given the following options upon discharge: photon therapy, combined radiotherapy and chemotherapy, and sacrectomy.
DISCUSSION: Primary leiomyosarcoma of the bone (
Effects of Free Fatty Acid on Glomerular Mesangial Cell Viability and Extracellular Matrix Protein Expression
Diabetes and insulin resistance are marked by the presence
of hyperglycemia and high serum free fatty acids (
SULPHASALAZINE INDUCED PULMONARY TOXICITY
Rama Nadella, MD, Associate, Jayasree Grandhi, MD, Associate, Ahmed Ghabsha, MD, Associate, and , Rajika Munasinghe MD, Fellow, Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
INTRODUCTION: Sulphasalazine is widely used in the treatment of Inflammatory Bowel disease (IBD) and Rheumatoid arthritis (RA). Pulmonary toxicity due to Sulphasalazine is rare. The most common pulmonary complication is hypersensitivity pneumonitis with or without eosinophilia. Fibrosing alveolitis, bronchiolitis obliterans and non-cardiogenic pulmonary edema are also reported. Differentiating Sulphasalazine induced lung toxicity from pulmonary manifestations of IBD can be difficult.
CASE REPORT: A 60 year old female with past medical history of ulcerative colitis, was admitted to the hospital with progressive difficulty in breathing, chest pain, fever, 13 pound weight loss over one month and failure to respond to multiple trials of antibiotics. She was on Sulphasalazine 500mg four times a day. She had bilateral inspiratory crackles and chest X-ray showed lower lobe infiltrates. The possibilities of tuberculosis, malignancy and interstitial pneumonitis secondary to active IBD were considered and excluded by transbronchial biopsy, bronchio-alveolar lavage and colonoscopy with biopsy. Lung biopsy results showed non-specific interstitial pneumonitis. Discontinuation of Sulphasalazine resulted in a relapse of her IBD and treatment with steroids and 5-amino salicylic acid (5-ASA) was initiated. Her symptoms and infiltrates on chest X-ray resolved in 6-8 weeks.
DISCUSSION: Pulmonary toxicity of Sulphasalazine is attributed to Sulphapyridine and can occur within one to six months of exposure and even up to six years later. IBD can itself cause lung manifestations such as pulmonary vasculitis, chronic bronchitis, and bronchiectasis and bronchiolitis obliterans. The rapid resolution of symptoms in this patient after Sulphasalazine withdrawal and treatment with steroids is consistent with the diagnosis of delayed hypersensitivity reaction due to Sulphasalazine. The definite way to establish causality is to re-challenge with Sulphasalazine. However, due to prior case reports of fatal pulmonary toxicity associated with Sulphasalazine and the availability of safer 5-ASA agents as alternative therapy for IBD, re-challenge with Sulphasalazine was not attempted.
SULPHASALAZINE INDUCED PULMONARY TOXICITY
Rama Nadella, MD, Associate, Jayasree Grandhi, MD, Associate, Ahmed Ghabsha, MD, Associate, and , Rajika Munasinghe MD, Fellow, Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
INTRODUCTION: Sulphasalazine is widely used in the treatment of Inflammatory Bowel disease (IBD) and Rheumatoid arthritis (RA). Pulmonary toxicity due to Sulphasalazine is rare. The most common pulmonary complication is hypersensitivity pneumonitis with or without eosinophilia. Fibrosing alveolitis, bronchiolitis obliterans and non-cardiogenic pulmonary edema are also reported. Differentiating Sulphasalazine induced lung toxicity from pulmonary manifestations of IBD can be difficult.
CASE REPORT: A 60 year old female with past medical history of ulcerative colitis, was admitted to the hospital with progressive difficulty in breathing, chest pain, fever, 13 pound weight loss over one month and failure to respond to multiple trials of antibiotics. She was on Sulphasalazine 500mg four times a day. She had bilateral inspiratory crackles and chest X-ray showed lower lobe infiltrates. The possibilities of tuberculosis, malignancy and interstitial pneumonitis secondary to active IBD were considered and excluded by transbronchial biopsy, bronchio-alveolar lavage and colonoscopy with biopsy. Lung biopsy results showed non-specific interstitial pneumonitis. Discontinuation of Sulphasalazine resulted in a relapse of her IBD and treatment with steroids and 5-amino salicylic acid (5-ASA) was initiated. Her symptoms and infiltrates on chest X-ray resolved in 6-8 weeks.
DISCUSSION: Pulmonary toxicity of Sulphasalazine is attributed to Sulphapyridine and can occur within one to six months of exposure and even up to six years later. IBD can itself cause lung manifestations such as pulmonary vasculitis, chronic bronchitis, and bronchiectasis and bronchiolitis obliterans. The rapid resolution of symptoms in this patient after Sulphasalazine withdrawal and treatment with steroids is consistent with the diagnosis of delayed hypersensitivity reaction due to Sulphasalazine. The definite way to establish causality is to re-challenge with Sulphasalazine. However, due to prior case reports of fatal pulmonary toxicity associated with Sulphasalazine and the availability of safer 5-ASA agents as alternative therapy for IBD, re-challenge with Sulphasalazine was not attempted.
EFFICACY OF NON-PHARMACOLOGICAL MODALITIES TO TREAT DEMENTIA
Rama Nadella, M.D., Associate, Dept of Internal Medicine, Sinai Grace Hospital, Wayne State University, Detroit
BACKGROUND : Gingko biloba (Gingko) has been used medicinally for over one thousand years. Ginkgo represents one of the most studied and commonly used herbal remedies for Dementia. Vitamin E has been tried in the treatment of Demetia as it is an anti-oxidant scavenging toxic free radicals.
STUDY SELECTION : Gingko: Randomized controlled trial by Le Bars (N-309) and Metaanalysis conducted by Le Bars using only well conducted randomized trials since 1989 (Eg: Le Bars, Kanowski, Maurer and Hofferberth analyses) were studied to see whether Gingko works over Placebo in cognitive disorders, and if it works, how safe is it in treatment of Dementia.
Vitamin E: Sano 1996 is a double blind randomized trial (N-341), which showed effect of a-tocopherol compared with Placebo in the treatment of Alzheimers disease.
OUTCOME MEASURES:
Gingko => Outcome evaluation was done at 12, 26 and 52 weeks, wherein higher the score poorer the function.
1. ADAS – Cog (to assess memory, language and orientation)
2.GERRI (to assess daily living and social behavior)
3.CGIC (to assess general psychopathology)
Vitamin E => Survival time to the first of four end points :
1. Death 2. Institutionalization
3.Severity of Dementia 4. Loss of 2 out of 3 basic activities of daily living.
RESULTS:
Gingko: The primary outcome measures were analyzed using intent-to-treat analysis showing a significant improvement in ADAS-Cog score and GERRI score with a p-value < 0.05. No difference was seen in CGIC score.
Vitamin E: There appeared some benefit from Vitamin E with fewer participants reaching end point (only 58%), showing a Peto odds ratio of 0.49 (95% CI 0.25 – 0.96). Moreover, there were excess of falls in Vitamin E group compared to Placebo.
CONCLUSION: Gingko is safe and appears capable of improving cognitive performance and social functioning of Demented patients for 6 months to 1 Year.There is insufficient evidence of efficacy of Vitamin E in the treatment of dementia.
SEVERE SYMPTOMATIC HYPOCALCEMIA DUE TO VITAMIN D DEFICIENCY PRESENTING AS TETANY.
Padmaja Naidu, MD, Associate, Wahed Ishaqsei, MD, Associate, Rajika Munasinghe, MD, Fellow, Dept. of Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan
Introduction: Vitamin D deficiency is increasingly recognized as an important cause of osteomalacia, osteoporosis and fracture in adult patients with limited exposure to sunlight and reduced dietary intake of Vitamin D. Most patients are asymptomatic except for an increased risk of fracture. Severe symptomatic hypocalcemia is rare. Patients with Vitamin D deficiency should be evaluated for additional predisposing conditions when they present with severe hypocalcemia.
Case Report: We present a 54 year old female with who presented to our emergency department with involuntary jerks in all four extremities. She had a past medical history of chronic renal failure secondary to obstructive nephropathy from bladder cancer treated by cystectomy and urostomy, history of partial gastrectomy for peptic ulcer disease, diabetes mellitus, breast cancer and osteoporosis. She was significantly debilitated from her multiple medical conditions and reported only very limited exposure to sunlight. She was found to have severe hypocalcemia ( calcium 4.3 mg/dL) and renal insufficiency (creatinine 2.9 mg/dL). She also had elevated serum parathyroid hormone levels (PTH 187 pg/ml) along with low 25 OH Vitamin D levels(<5ng/ml). The serum, 1,25(OH) Vitamin D was normal (25 pg/ml).
Discussion: Severe hypocalcemia with tetany is a rare complication of Vitamin D deficiency and is usually associated with the concurrent presence of other risk factors. Our patient had previously undergone a partial gastrectomy, which contributes to malabsorption of fat and fat solvable Vitamins such as Vitamin D. She also had renal insufficiency although the normal levels of serum 1,25(OH) Vitamin D, suggest that renal conversion of 25(OH) Vitamin D to 1,25(OH) Vitamin D was probably not affected to a significant extent. The combined presence of Vitamin D malabsorption and inadequate sunlight exposure contributed to the severity of hypovitaminosis D and resulting hypocalcemia in our patient. It is important to recognize patients at risk of Vitamin D deficiency and institute adequate dietary supplement of calcium and Vitamin D to prevent serious skeletal and metabolic complications.
IMPACT OF LONG TERM USE OF INHALED CORTICOSTEROIDS ON BONE MINERAL DENSITY
Padmaja Naidu, MD, Associate, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan
Research Question:
Does long term use of inhaled corticosteroid decrease bone mineral density?
Data Source:
Pubmed, Ovid Medline 1966 to 2004 July 01
Study Selection: Randomised trials were identified by Medline search term “Inhalation Steroids” and “Bone mineral density”. One Meta-analysis and two randomized controlled trials were selected for study, out of 143 search results found. Out of these three, only the meta-analysis was accepted for present study as other two had incomplete follow up of patients. In the meta analysis selected, published and unpublished articles were identified using Medline and Embase databases.
Data Extraction: Studies reporting BMD among adult asthma and COPD patients using Inhaled steroids(ICS) and non-ICS controls were identified. Studies selected for review included at least 1 year of follow up. Two independent reviewers evaluated studies, data from those meeting specified inclusion criteria were abstracted for inclusion in the meta-analysis.
Results: In the meta-analysis, 266 studies were reviewed, out of which fourteen(5.3%) met specified inclusion criteria. Sufficient data was available to perform meta-analysis on 3 measures for ICS using patients (lumbar, femoral neck and major trochanter BMD) and one measure(lumbar BMD) for non-ICS using controls. Using current National Asthma Education and Prevention Program definitions, the majority of studies (12 of 14) included patients receiving moderate to high doses of ICSs. Among ICS users, annual changes from baseline in lumbar, femoral neck and major trochanter BMD(-0.23%, -0.17%, and +1.46% respectively) were not statistically significant for subgroups of patients with asthma or COPD. Mean change in lumbar BMD were also not significantly different from controls(-0.02%). Further annual changes in lumbar BMD were not significantly different for subgroups of patients with asthma or COPD.
Conclusions: Long term use of ICSs in patients with asthma or COPD was not associated with statistically significant changes in BMD.
Levofloxacin Induced Recurrent Torsades de Pointes
Kamal Nasser, MD; Amer Tfaili, MD; Jennifer Maples, PharmD; Lawrence MacDonald, MD, FACP
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.
INTRODUCTION: Torsades de pointes (Tdp) represents a type of polymorphic ventricular tachycardia associated with the long QT syndrome. Antiarrythmics, antihistamines, macrolide antibiotics, and psychotropics are the major drug classes associated with Tdp. We are reporting a case of levofloxacin-induced recurrent episodes of Tdp in a young female with ESRD and CHF.
CASE REPORT: A 37 year old Caucasian female came with an infected indwelling hemodialysis catheter. She received one dose of levofloxacin 500mg intravenously (IV) in ED and another dose two days later. Because of sepsis and respiratory failure, the patient was transferred to the intensive care unit on mechanical ventilation. Within nine hours of the last levofloxacin dose, she had recurrent episodes of Tdp in association with prolongation of the QTc interval from 395 ms at presentation to 525 ms at onset of the first Tdp. Each episode required immediate nonsynchronized electric defibrillation. IV magnesium sulfate was given and levofloxacin was discontinued, but these episodes persisted. Serum levofloxacin concentration was 3 then 1.2 mcg/ml at 6 and 12 days respectively (therapeutic range 0.6 – 6.4 mcg/ml). After the addition of isoproterenol, Tdp episodes became self terminating and less frequent with normalization of the QTc interval. Patient was discharged 25 days later in stable condition with a levofloxacin level of < 0.5 mcg/ml, and QTc of 398 ms.
DISCUSSION: Levofloxacin is renally cleared, with 80-90% of the dose excreted unchanged in the urine. Its half-life extends from approximately 6 hours in patients with normal renal function to greater than 35 - 72 hours in patients with ESRD, and it is not removed to any significant extent by hemodialysis. Only two cases of levofloxacin-induced Tdp have been reported in the literature none of which was recurrent. The persistently elevated concentration of the drug 6 and 12 days following the last dose of levofloxacin might explain the recurrence of Tdp.
CONCLUSION: Caution has been advised with the use of levofloxacin in patients with risk factors for Tdp such as heart disease, electrolyte disturbances, and concomitant use of other QT-prolonging drugs. This case calls for more caution to be exercised when these patients also have ESRD due to the longer levofloxacin half-life which could render a possible Tdp recurrent.
POST TRANSPLANT GLOMERULOPATHY IN HEPATITIS C POSITIVE
PATIENTS WITH RENAL ALLOGRAFTS
Vibha Nayak, MD, Abdolreza Haririan, MD, Jose-Marie El-Amm, MD, Department of Medicine,Sinai-Grace Hospital/Harper Hospital, Detroit Medical Center, Wayne State University, Michigan.
Little is known about risk factors for development of post transplant glomerulonephritis (GN) in Hep C+ kidney transplant (KT) recipients. The records of 41 Hep C + patients transplanted between 9/98 and 5/04 and followed for 2 yrs (median) were reviewed. The induction and maintenance agents used in conjunction with Mycophenolate Mofetil were steroids,Calcineurin Inhibitors(CI),Sirolimus and Interleukin-2 receptor antibodies(IL-2R). Transplant glomerulopathy in 2 pts, was not considered a GN variant. Association between GN and different variables were examined using x2 or t-test, as appropriate. P<0.05 was considered as significant. Patient characteristics were their age, race, sex, number of years on hemodialysis, presence of coronaty artery disease, delayed graft function(DGF), Donor Hep C status, the use of steroids, calcineurin inhibitors, interleukin-2 receptor antibodies, and sirolimus.
Five pts (12%) developed membranoproliferative/membranous GN (MPGN/MGN) and 9 (22%)developed focal segmental glomerulosclerosis(FSGS). Fourteen pts (34%) experienced acute rejection (AR). Donor Hep C status, DGF, and CI use were not associated with GN. We observed that post transplant GN occurs in one-third of Hep C+ KT recipients, with FSGS accounting for two-thirds of these cases in our predominantly African-American population. There was an association between use of maintenance steroid and IL-2R antibody induction with development of FSGS, and also between Sirolimus use and AR with development of MPGN/MGN.
Scleroderma Renal Crises in Pregnancy
Asmita Patel, MD, Associate, Amer Tfaili, MD, Associate, Ramesh Kotihal, MD, Associate, Kamal Nasser, MD, Member, Department of Internal Medicine,
Sinai-Grace Hospital/Detroit Medical Center, Wayne State University, Detroit, Michigan.
Introduction: Scleroderma is an uncommon systemic disease, which affects 1 to 2 per 100,000 individuals in the USA. Scleroderma renal crisis (SRC) develops in 10 to 15% of patients with early diffuse cutaneous scleroderma. In the pregnant patients, however, it is difficult to distinguish hypertensive crisis due to SRC from that secondary to eclampsia.
Case Report: A 32 year-old pregnant African-American female with gestational age of 35 weeks, and past medical history of diffuse cutaneous scleroderma, diagnosed one year prior to presentation, presented to the emergency department (ED) with two witnessed tonic-clonic seizures and elevated blood pressure. Patient was diagnosed with eclampsia and managed with intravenous magnesium sulfate and hydralazine followed by an emergent cesarean section. Postpartum, her renal function progressively worsened and blood pressure remained uncontrolled. This was attributed to eclampsia, and the blood pressure was managed with esmolol and hydralazine. An ACE inhibitor was also added to this treatment regimen. Patient’s renal function continued to deteriorate with a rise in creatinine levels from 1.8 to 3.3 mg/dl. ACE inhibitor was withheld, which was followed by further elevation in creatinine levels to 9.8 mg/dl along with anuria. This deterioration in renal function was thought to be due to SRC and ACE inhibitor was reintroduced at that time. Hemodialysis was eventually initiated for signs of volume overload. Patient was discharged home in a stable condition.
Discussion: In pregnant patients, it is difficult to distinguish hypertensive crisis due to SRC from eclampsia. The cutaneous manifestations of scleroderma help this distinction to a certain extent. Liver function tests, which are usually normal in SRC and elevated in eclampsia, and the fast deterioration of renal function in SRC could also be helpful clues. In patients with scleroderma who develop eclampsia, therapy with ACE inhibitors, particularly captopril, has been shown to improve survival and shorten the duration of dialysis (1-year survival: 15% without and 76% with ACE inhibitors). ACE inhibitors should be promptly initiated and maintained in the postpartum period. Despite initiation of ACE inhibitor therapy, poor outcome is associated with an uncontrolled blood pressure, congestive heart failure, and initial serum creatinine more than 3.0 mg/dl.
Scleroderma Renal Crises in Pregnancy
Asmita Patel, MD, Associate, Amer Tfaili, MD, Associate, Ramesh Kotihal, MD, Associate, Kamal Nasser, MD, Member, Department of Internal Medicine,
Introduction: Scleroderma is an uncommon systemic disease,
which affects 1 to 2 per 100,000 individuals in the
Case Report: A 32 year-old pregnant African-American female with gestational age of 35 weeks, and past medical history of diffuse cutaneous scleroderma, diagnosed one year prior to presentation, presented to the emergency department (ED) with two witnessed tonic-clonic seizures and elevated blood pressure. Patient was diagnosed with eclampsia and managed with intravenous magnesium sulfate and hydralazine followed by an emergent cesarean section. Postpartum, her renal function progressively worsened and blood pressure remained uncontrolled. This was attributed to eclampsia, and the blood pressure was managed with esmolol and hydralazine. An ACE inhibitor was also added to this treatment regimen. Patient’s renal function continued to deteriorate with a rise in creatinine levels from 1.8 to 3.3 mg/dl. ACE inhibitor was withheld, which was followed by further elevation in creatinine levels to 9.8 mg/dl along with anuria. This deterioration in renal function was thought to be due to SRC and ACE inhibitor was reintroduced at that time. Hemodialysis was eventually initiated for signs of volume overload. Patient was discharged home in a stable condition.
Discussion: In pregnant patients, it is difficult to distinguish hypertensive crisis due to SRC from eclampsia. The cutaneous manifestations of scleroderma help this distinction to a certain extent. Liver function tests, which are usually normal in SRC and elevated in eclampsia, and the fast deterioration of renal function in SRC could also be helpful clues. In patients with scleroderma who develop eclampsia, therapy with ACE inhibitors, particularly captopril, has been shown to improve survival and shorten the duration of dialysis (1-year survival: 15% without and 76% with ACE inhibitors). ACE inhibitors should be promptly initiated and maintained in the postpartum period. Despite initiation of ACE inhibitor therapy, poor outcome is associated with an uncontrolled blood pressure, congestive heart failure, and initial serum creatinine more than 3.0 mg/dl.
A rare case of orbital wall metastasis from prostate cancer
1 Asmita Patel, MD, Associate, 2 Kenneth Pienta, MD, Fellow,
1 Department of Internal Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan, 2 Department of Urology/Oncology, University of Michigan, Ann Arbor, Michigan.
Introduction: Prostate cancer is the second most common
malignancy in males in the
Case Report: A 66-year-old Caucasian male was diagnosed with prostate cancer seven years prior to this presentation, when he underwent a prostatectomy for acute urinary retention, and outlet obstruction. Bone scan had showed a left tabular and lumbar vertebral lesion. Patient was believed to have metastatic disease, and was treated with radiation therapy. Five years later, a repeat bone scan revealed multiple lesions, notably a right periorbital lesion. Combined androgen blockade therapy was started. He discontinued his hormonal therapy after a total of six months, and did not seek follow-up care.
During this presentation, patient had diminished visual
acuity, right eye pain and difficulty in depth perception. There were no other
painful sites, neurological changes or constitutional symptoms. Patient had
developed proptosis, and orbital nerve compression was suspected.
Discussion: Metastases of prostate carcinoma to the orbit
are rare. Cancer of breast and lung, lymphomas, and leukemia are amongst the
commonest primary neoplasms known to metastasize to the orbit. The mean age at
the onset of symptoms is greater for patients with orbital metastasis secondary
to prostate cancer as compared to those with other orbital metastases (70.1
versus. 53.6 years). Prostate metastases to the orbit frequently present as
osteoblastic lesions, whereas other orbital tumors present as osteolytic
lesions or soft-tissue masses. Clinical history, high resolution CT scan,
.
Surgical management of a lung abscess : A Review
Question: After failure of optimal antibiotic therapy in patients with a lung abscess, what are the benefits of surgical intervention?
Data Sources: Data was collected by searching Medline, Pubmed, and Cochrane library from 1980 to 2004, using the search terms "lung abscess" and "pulmonary abscess". Different modes of surgical interventions available were reviewed.
Methods: A retrospective analysis of the patients who underwent lobectomy was studied. A review of literature also revealed four case series, which studied various modes and efficacy of surgical management of lung abscess. The outcome measures studied in these case series included the cure rate, rapidity of recovery, and residual defects. No randomized control trials were found.
Results: The cure rate with lobectomy was 81% and mortality was reduced to 14%. Patients with percutaneous mode of drainage also had comparable cure rates, but had slower resolution requiring up to 30 days. The mean duration of hospital stay was 10 days with percutaneous drainage, compared to 21 days with lobectomy.
SPONTANEOUS KIDNEY RUPTURE IN A DIALYSIS PATIENT
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Wayne State University, Detroit, MI.
INTRODUCTION: Spontaneous subcapsular or perinephric bleeding of the kidney is an uncommon clinical scenario. Acquired cystic kidney disease (ACKD) is one of the rare causes of such bleeding. It is frequently oligosymptomatic and thus needs a high level of suspicion for the diagnosis. We present a case of ACKD complicated by perinephric hemorrhage.
CASE REPORT: A 62 year-old male with past medical history of ESRD on hemodialysis (HD), hypertension and hepatitis C was transferred from his dialysis center due to sudden onset of a right sided flank pain during HD. The pain was dull aching, severe 10/10 in intensity, non-radiating and not associated with any aggravating or relieving factors. The patient usually made little urine daily and had noticed a reddish discoloration of his urine one day prior to admission. He denied any fever or chills, history of trauma, kidney stones or bleeding diathesis. On admission, the patient was hemodynamically stable and had minimal right flank tenderness. The rest of his exam was non-revealing. His hemoglobin was 14.9mg/dl and hematocrit was 44.6 %. A computed tomography of his abdomen and pelvis revealed multiple cysts in both kidneys and a perinephric infiltration around the posterior aspect of the right kidney suggestive of a retroperitoneal hemorrhage. The patient was admitted to the medical floor and the urology service was consulted. His condition was closely monitored for any signs of extension of the retroperitoneal bleeding with serial hemoglobin concentrations and renal ultrasound imaging. The bleeding proved to be stable so the patient was managed conservatively and later discharged home in stable condition to follow-up with the urologist as an outpatient.
CONCLUSION: ACKD is a complication of long standing ESRD and is almost the rule after 10 years of HD independent of the cause of the renal failure. Intracystic or retroperitoneal bleeding is one of the main complications in addition to neoplastic transformation in these patients. Early diagnosis of such a bleed with an imaging study is essential to prevent a life-threatening bleeding. Non-massive bleeding in a hemodynamically stable patient is managed conservatively and nephrectomy is indicated for severe hematomas and in cases where malignancy is suspected.
Orthostatic Hypotension; is it a sign of post concussion syndrome?
S. Rajaguru, M.D (Associate), A. Reddy M.D (Associate), S.
Marur MD (Member), Department of Medicine,
Background: Patients sustaining mild traumatic brain
injuries often report physical, cognitive, and emotional or behavioral symptoms
referred to as post concussion syndrome (
Case report: A 35-year-old African American male with no significant past medical history presented to Sinai Grace emergency department for new onset seizures after sustaining a closed head injury from “pistol whipping”. He developed seizure activity in the emergency department as well. Initial presentation revealed a 2.5 cm laceration to the border of his parieto-occipital area with hematoma on the inferior aspect of his left occipital area. During the hospital stay, the patient continued to have seizure, headache, anxiety, and symptomatic orthostatic hypotension, which did not respond to IV fluid boluses. Further, the orthostasis did resolved with fludrocortisone treatment.
Discussion: The most commonly reported post concussion symptoms are headache, dizziness, decreased concentration, memory impairments, irritability, fatigue, visual disturbances, sensitivity to noise, judgment impairments, depression, and anxiety. However the occurrence of autonomic dysfunctions like orthostatic hypotension following head trauma in the absence of other causes such as hypovolemia is not documented thus far.
Conclusion: Here we would like to announce the first reported case of autonomic dysfunction presenting as orthostatic hypotension with post concussion syndrome.
Efficacy of Trnscutaneous Pacing in Asystole.
S. Rajaguru MD (Associate), S. Marur MD (Member) Department
of Medicine,
Background: Asystole is the absence of electrical activity
in the myocardium. Confirmation of the rhythm is crucial in the management of
Asystole. Transcutaneous pacing (
Method: Extensive literature search was carried out on the studies done on asystole from 1980 onwards. Ovid and Pub med search were done using asystole and transcutaneous pacing as keywords. Selection criteria were randomized controlled prospective studies with reasonable number of population. Six studies were selected based on the selection criteria.
Results: Three out of these studies were done in pre-hospital settings. Two studies were conducted in the emergency department and the other study was carried out in in-hospital. All the studies done in pre-hospital setting came to a similar conclusion.
Conclusion: Out of hospital studies concluded that
transcutaneous pacing does not improve the survival of the patient with
asystolyic cardiac arrest. In-hospital studies basically concluded that
Discussion: Asystole occurs due to several underlying
conditions. However, the studies done so far have not taken etiology in to
consideration. Here we suggest designing a retrospective study conducting on
inpatients that develop asystolic cardiac arrest and received
A Rare Case of Uremic Enteropathy
M. Reddy, MD, K. Majekodunmi, MD, M. Sklar, MD
Background: Since the advent of hemodialysis, the long-term complications of uremia have been reduced. But there are rare instances of complications even on patients undergoing Hemodialysis. Among the many organ systems affected by uremia, gastrointestinal tract (GI) tract is most profoundly affected. Some of the clinical manifestations include anorexia, nausea, vomiting, metallic taste in mouth and some times bloody diarrhea1, 2. Studies done prior to the start of dialysis had shown changes in mucosa and submucosa including hemorrhage, ulceration, and pseudomembranous lesions in End Stage Renal Disease (ESRD) patients3, 4.
Clinical Vignette: We report a rare case of a 33 yr old female with ESRD on hemodialysis for 9 yrs who was not shown to have any changes in the GI tract on Esophagogastroduedunoscopy (EGD) and colonoscopy did show remarkable changes in the small intestine on capsule endoscopy. The patient came to the hospital with complaints of nausea, vomiting and severe diarrhea associated with hematochezia for 24-hrs. The patient had developed ESRD secondary to lupus between ages 18-21, also had other co-morbidities like hypertension, hyperlipidemia, multiple graft placements for hemodialysis, as well as had a renal transplant in Feb 2004. Physical exam was unremarkable except for the presence of vascular grafts. Labs showed a WBC count of 4.5, Hb 10.6, platelets of 151,000, Potassium 5.1, BUN 66 and Cr 11.6. Colonoscopy showed small internal hemorrhoids with a tortuous and redundant colon. EGD showed esophagitis, esophageal ulcers, and non-bleeding erythematous gastropathy with mild nodularity. The living non-related renal transplant did not show any signs of rejection or immune complex mediated process on biopsy. The patient was then scheduled for a capsule endoscopy, which showed multiple sites of hemorrhagic, polypoid folds. The mucosa had a mosaic pattern with absence of villi. These findings were suggestive of enteropathy most probably related to uremia.
Discussion: There has been evidence of motility disorders of the esophagus as a result of ESRD induced neuropathy5, and hemorrhagic gastritis and hemorrhagic duodenitis6. There have not been enough studies to look at the remainder of the small intestine to note chronic changes as a result of ESRD. Our case here represents changes occurring in the small intestine as a result of ESRD. In ESRD patients with iron deficiency anemia with negative EGD and colonoscopy need to further investigation by other means such as capsule endoscopy.
Wireless capsule endoscopy offers an optimal approach for evaluating patients with obscure gastrointestinal bleed. Wireless capsule endoscopy is as or more sensitive than other methods for the diagnosis of small bowel sources of blood loss including push enteroscopy. Its main advantages are that it is noninvasive and permits examination of the entire small bowel, which is not always possible during enteroscopy. Further work however needs to be done to utilize this device in tissue sampling.
Hypothyroidism: A possible risk factor for Hepatocellular Carcinoma
Arvind Reddy, MD,
Background:
Hepatocellular Carcinoma (
We conducted a case control study at the Mayo Clinic,
Methods
Subjects were consecutive patients diagnosed with
Data were abstracted from the medical records using
structured forms designed for the purpose of the study. Hypothyroidism was
defined as
We used multivariate logistic regression to model the
relationship between history of hypothyroidism and etiology of
Results
Out of the 160
Conclusion
We conclude that hypothyroidism may have a role to play in
hepatocarcinogenesis and should be further investigated as a potential
etiologic agent. If established, it can play an important role in preventive
medicine as a reversible cause for
Role of Diet in Gout
M Reddy, MD
Background: Gout is a chronic crystal induced arthropathy with an incidence of 20-35/100,000. Hyperuricemia leading to the gouty attacks is controlled by the use of drugs to decrease the production or increase excretion of uric acid. A 21 percent increase in the risk of having gout has been associated with the intake of food having high purine content.
Methods: Several studies were analyzed from OVID Medline. Two trials were selected for this study as they were comparing clinical outcomes versus measuring metabolite levels. The first is a Prospective clinical trial involving 13 patients, the second is a Prospective cohort study involving 47,150 patients in the Health Professionals Follow-up study. Pearson’s Correlation analyses and Relative Risks were used for analysis of the data.
Results: In the first study there was a significant
(p=0.002) reduction in number of Gouty attacks from 2.1 attacks per month to
0.6 in patients on a low purine diet for 16 weeks. In the second study it was
shown that there was a 21% increased risk of gout with each additional serving
of meat a day, and a 7% increased risk with one additional weekly serving of seafood.
In this study they also showed that there was no increased risk with purine
rich vegetable intake. In both these studies there was a significant decrease
in incidence of gouty attacks with reduction of
Conclusions: There is convincing evidence about the
reduction in the incidence of gouty attacks with reduced consumption of alcohol
and a reduction in
HEMOLYTIC ANEMIA AFTER MITRAL VALVE REPAIR
Department of Internal Medicine, Sinai-Grace Hospital/Detroit Medical Center, Wayne State University, Detroit, Michigan.
Introduction: Microangiopathic hemolytic anemia is commonly seen after mitral valve replacement. But it is an uncommon complication of mitral valve repair and when it happens it is considered a failure of the valve repair. We present a case of hemolysis after mitral valve repair.
Case Report: A 54-year-old male with prior history of
Discussion and Conclusion: This case is a unique
presentation of early mitral valve repair failure. In the English literature 65
such cases have been reported showing development of hemolysis within 3-4
months. The mechanism of hemolysis in our case was attributed to fragmentation
of
Role of Oral Hypoglycemic agents in Diabetes Mellitus type 2 patients after Diabetic ketoacidosis
Zainab Shahid, MD (Associate), Saad Z Usmani, MD (Associate)
Department of Internal Medicine, Sinai-Grace Hospital/Detroit Medical Center, Wayne State University, Detroit, Michigan.
Introduction: It is a general practice to send patients home on insulin regimen after an episode of diabetic ketoacidosis (DKA) with eventual switchover to oral hypoglycemics.
Clinical Question: What is the evidence for the use of Oral hypoglycemics in Diabetes mellitus type 2 status post-diabetic ketoacidosis?
Methods: Literature search was conducted utilizing Medline Ovid(1966-2004), Medline PubMed and Cochrane library with DKA, oral hypoglycemics and type 2 diabetes mellitus used as key words. Only double-blinded randomized controlled trials were to be selected.
Results: Only one relevant study meeting the above criteria observed use of oral hypoglycemics in African American patients who presented with severe hyperglycemia and DKA. The study revealed that over a period of sixteen months, use of low dose sulfonylurea decreased the recurrence of hyperglycemia signifinicantly (p= 0.03), in patients post DKA from 60% to 14% when comparing with patients on diet alone. Assessment of beta-cell function showed improvement in basal and stimulated C peptide levels in patients with history of DKA and became comparable to patients with severe hyperglycemia (P<0.01).
Conclusions: This study was conducted on a select subset of the population and provided evidence that oral hypoglycemics decrease the incidence of hyperglycemic episodes post DKA. . It should be remembered that DKA occurs because of transient and reversible glucotoxicity of islets cell in patients with type two DM. Experts practices reveal a pattern of gradual transition of insulin to oral hypoglycemics , starting with secretogouges than adding other hypoglycemic agents with tapering of insulin over a period of time. Clear guidelines are strongly required. More randomized control studies are recommended to study the efficacy of different oral hypoglycemics agents against insulin in patients post DKA.
A Rare Presentation of Granulocytic Sarcoma as Isolated Cervical Adenopathy.
Srikanth Tamma MD (Associate), Arvind Reddy MD (Associate),
Introduction: Granulocytic Sarcoma, also known as Chloroma, is a rare extramedullary solid tumor composed of malignant immature cells of the granulocytic series. It is often misdiagnosed as it can be confused with lymphoma. It has unique cytologic features independent of the site of the tumor.
Case Report: Our
patient is a 55-year-old African American gentleman with a known history of
metastatic prostate cancer and pancreatitis, who presented to the emergency
department with abdominal pain, nausea and vomiting. On neck exam, he was found
to have 4 masses which were hard, mobile, painless, each measuring
approximately 3x4 cm. Lungs were clear. Abdominal exam revealed distension,
positive bowel sounds, and diffuse tenderness without guarding or rebound.
Discussion and Conclusion: Granulocytic sarcoma is a rare extramedullary solid tumor composed of malignant immature cells of the granulocytic series. It usually occurs in patients with acute myelogenous leukemia. Isolated chloromas, in the absence of acute myelogenous leukemia, are rare. The diagnosis of granulocytic sarcoma is difficult in the absence of abnormality in the peripheral blood or bone marrow. Hence histopathologic findings should be evaluated before a diagnosis of malignant lymphoma is pronounced. Granulocytic sarcoma has poor prognosis. One study showed that administration of intensive chemotherapy similar to that used to treat acute nonlymphoblastic leukemia, is associated with a significantly lower probability of developing acute myeloid leukemia and prolongs survival.
A Rare Presentation of Granulocytic Sarcoma as Isolated Cervical Adenopathy.
Srikanth Tamma MD (Associate), Arvind Reddy MD (Associate),
Introduction: Granulocytic Sarcoma, also known as Chloroma, is a rare extramedullary solid tumor composed of malignant immature cells of the granulocytic series. It is often misdiagnosed as it can be confused with lymphoma. It has unique cytologic features independent of the site of the tumor.
Case Report: Our patient
is a 55-year-old African American gentleman with a known history of metastatic
prostate cancer and pancreatitis, who presented to the emergency department
with abdominal pain, nausea and vomiting. On neck exam, he was found to have 4
masses which were hard, mobile, painless, each measuring approximately 3x4 cm.
Lungs were clear. Abdominal exam revealed distension, positive bowel sounds,
and diffuse tenderness without guarding or rebound.
Discussion and Conclusion: Granulocytic sarcoma is a rare extramedullary solid tumor composed of malignant immature cells of the granulocytic series. It usually occurs in patients with acute myelogenous leukemia. Isolated chloromas, in the absence of acute myelogenous leukemia, are rare. The diagnosis of granulocytic sarcoma is difficult in the absence of abnormality in the peripheral blood or bone marrow. Hence histopathologic findings should be evaluated before a diagnosis of malignant lymphoma is pronounced. Granulocytic sarcoma has poor prognosis. One study showed that administration of intensive chemotherapy similar to that used to treat acute nonlymphoblastic leukemia, is associated with a significantly lower probability of developing acute myeloid leukemia and prolongs survival.
Upper Extremity Deep Vein Thrombosis : An Evidence-Based Review of
Risk Factors, Manifestations, Diagnosis, Sequelae and Treatment Options.
Srikanth Tamma MD (Associate). Department of Internal
Medicine,
Introduction: Upper extremity deep vein thrombosis (UEDVT) is defined as thrombosis of the subclavian, axillary, brachial or internal jugular veins. It accounts for nearly 2% of all cases of DVT. There has been a steady increase in the incidence of UEDVT with increasing use of central venous catheters and better diagnostic techniques.
Data Source: Observational studies and review articles were identified using Medline, Ovid and Pubmed databases.
Study Selection: Multiple studies were selected to look at the complications and complication rates of UEDVT. All were retrospective study designs. Review articles were selected to look at the treatment options available based on expert opinion. No randomized controlled trials were found.
Results: Edema or swelling of the involved upper extremity was the predominant manifestation of UEDVT in majority of the subjects. This was followed by pain, erythema, tenderness and palpable cord in decreasing order of frequency. More than 70% cases were associated with the use of central venous catheters. Nearly half of the cases were associated with some kind of malignancy. About a fourth of patients diagnosed ended up with complications pulmonary embolism or post-thrombotic sequelae. Anticoagulation, limb elevation and use of compression arm sleeve is the mainstay of therapy for UEDVT. Mechanical thrombolytic therapy is considered if the patient is severely symptomatic. Other treatment options such as catheter directed thrombolysis, balloon angioplasty, suction thrombectomy, vein stenting, thoracic outlet decompression and use of superior vena caval filters have also been cited in the literature.
Conclusion: Edema of the upper extremity in a patient with central venous catheter should prompt a physician to exclude UEDVT with a venous duplex.
Further Research: Prospective studies of a larger number of patients with central venous catheters are needed. A meta-analysis of such studies would better characterize the problem. After taking ethical aspects into consideration, randomized controlled trials should be conducted to come up with a good treatment algorithm for patients diagnosed with UEDVT.
Upper Extremity Deep Vein Thrombosis : An Evidence-Based Review of
Risk Factors, Manifestations, Diagnosis, Sequelae and Treatment Options.
Srikanth Tamma MD (Associate), Department of Internal Medicine, Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
Introduction: Upper extremity deep vein thrombosis (UEDVT) is defined as thrombosis of the subclavian, axillary, brachial or internal jugular veins. It accounts for nearly 2% of all cases of DVT. There has been a steady increase in the incidence of UEDVT with increasing use of central venous catheters and better diagnostic techniques.
Data Source: Observational studies and review articles were identified using Medline, Ovid and Pubmed databases.
Study Selection: Multiple studies were selected to look at the complications and complication rates of UEDVT. All were retrospective study designs. Review articles were selected to look at the treatment options available based on expert opinion. No randomized controlled trials were found.
Results: Edema or swelling of the involved upper extremity was the predominant manifestation of UEDVT in majority of the subjects. This was followed by pain, erythema, tenderness and palpable cord in decreasing order of frequency. More than 70% cases were associated with the use of central venous catheters. Nearly half of the cases were associated with some kind of malignancy. About a fourth of patients diagnosed ended up with complications pulmonary embolism or post-thrombotic sequelae. Anticoagulation, limb elevation and use of compression arm sleeve is the mainstay of therapy for UEDVT. Mechanical thrombolytic therapy is considered if the patient is severely symptomatic. Other treatment options such as catheter directed thrombolysis, balloon angioplasty, suction thrombectomy, vein stenting, thoracic outlet decompression and use of superior vena caval filters have also been cited in the literature.
Conclusions: Edema of the upper extremity in a patient with central venous catheter should prompt a physician to exclude UEDVT with a venous duplex.
Further Research: Prospective studies of a larger number of patients with central venous catheters are needed. A meta-analysis of such studies would better characterize the problem. After taking ethical aspects into consideration, randomized controlled trials should be conducted to come up with a good treatment algorithm for patients diagnosed with UEDVT.
Alpha Fetoprotein Producing Lung Adenocarcinoma
Amer Tfaili, MD; Ahmed Ghabsha, MD; Husain Saleh, MD; Kamal Nasser, MD
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.
INTRODUCTION: The elevation of serum
CASE REPORT: A 68 year old African American woman with
history of smoking, presented to the hospital with right sided weakness and
bloody sputum. Physical exam was significant for right upper and lower
extremities weakness and dullness in the left chest posteriorly. Chest X-ray
showed a large mass (8 cm) in the region of superior segment of the left lower
lobe. CT of the brain showed several lesions in the left hemisphere. Blood
tests were significant for markedly elevated serum alpha fetoprotein (
DISCUSSION:
Amiodarone Induced Angioedema
Amer Tfaili, MD; Kamal Nasser, MD; Kavitha Potluri, MD; Muhammad Karim, MD
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Wayne State University, Detroit, MI.
INTRODUCTION: Amiodarone is a class
CASE REPORT: The patient is a 71 year-old Afro-American
female with a medical history complicated by diabetes,
DISCUSSION: Amiodarone is well known to cause thyroid dysfunction owing to its high iodine content. Other well-described side effects include the potentially fatal pulmonary fibrosis, cardiac conduction blocks, hepatotoxicity, corneal microdeposits and optic neuropathy to name a few. Skin manifestations of amiodarone toxicity include photosensitivity that affects 10% of patients and skin discoloration but allergic skin reactions are rare. Angioedema is a serious condition the can lead to respiratory failure and is potentially fatal. It could be inherited or acquired with medication use representing one of the major causes of the latter. Amiodarone has not been classically recognized as a cause of drug-induced angioedema. This case, added to those described in the literature, should encourage the clinician to consider amiodarone as a possible culprit in cases of angioedema.
Predictive Ability of Lymphocytic Bronchitis (LB) in Lung Transplant Recipients
V. Lama, R. Thirumala, J. Mumford, S. Murray, A. Chang, G. Toews, M. Peters-Golden and F.J. Martinez. University of Michigan, Ann Arbor, MI and Sinai-Grace Hospital/ Wayne State University, Detroit, MI.
LB is considered a probable risk factor for development of
bronchiolitis obliterans syndrome (
Methods: Transbronchial biopsies (TBBx) were used to
diagnose LB.
Results: The median follow-up time was 5.4 years (95% CI,
4.6, 6.9). The median time from transplantation to stage 1
Conclusion: LB is a significant risk factor for development
of
Primary Cardiac Lymphoma Presenting as Pulmonary Embolism
Anna Trostinskaia MD Associate, Joel Appel DO FACP, Manish Kesliker MS MD Associate,Geetha Krishnamoorthy MD Member
Department of Internal Medicine, Sinai-Grace Hospital, Wayne State University
Primary Cardiac Lymphoma (
We report case of a 65-year-old African American male who presented with complains of shortness of breath, easy fatigability, and intense right scapular pain of sudden onset. His previous medical history was remarkable for hypertension, smoking for 40 years, and 40 pounds weight loss during the past 6 months. He appeared well nourished, in no acute distress, HR 108, BP 151/73, and RR 20. He had bilateral crackles in middle to lower lung fields, muffled heart sounds, systolic murmur on left sternal border in 3-4 intercostal spaces, pedal edema without organomegaly or lymphadenopathy. Lab findings were unremarkable. Patient’s symptoms prompted chest CT with contrast which gave initial impression of pulmonary embolus but on further examination appeared to be a large intracardiac mass confirmed with echocardiography as well.
Open heart biopsy showed right atrial and ventricular tumor with cardiomegaly, tricuspid valve involvement, and constrictive pericarditis. Further workup also revealed ascitis, splenomegaly, renal cyst, cholelithiasis. Immunohistochemistry demonstrated a high grade diffuse large B -cell lymphoma. Bone marrow biopsy indicated no lymphoma cells. The diagnosis of Primary heart non-Hodgkin’s Lymphoma Stage II B was entertained. After 2 courses of chemotherapy
CHOP and Rituximab patient achieved marked reduction of the tumor mass and is in a good health without signs of heart failure.
To our knowledge this is the first case of
Angio-immunoblastic T-cell Lymphoma in evolution- a case report.
Saad Z.Usmani, MD (associate); T.Sahay, MD (associate) L.Eisenberg, MD, FACP.
Sinai-Grace Hospital/Wayne State University
Introduction: Angio-immunoblastic T-cell lymphoma (AITL), a rare disease which constitutes of 1-2% of the Non-Hodgkin’s Lymphomas, presents in middle-aged and elderly individuals. Evidence indicates that an abnormal immune reaction to an infectious agent is a possible etiology. This creates an oligoclonal phase leading eventually to malignant monoclonal proliferation. Such a case is being presented.
Case Report: 59-year-old Caucasian female presented with high-grade fever and diffuse lymphadenoapthy. Extensive in-hospital work-up for fever of unknown origin including lymph node biopsy yielded negative results. Patient became asymptomatic for 4 weeks but then the symptoms recurred with more pronounced lymphadenoapthy. Lab results showed normocytic normochromic anemia, thrombocytosis and normal WBC count with variable eosinophilia. CT scan documented diffuse lymphadenoapthy. A second lymph node biopsy was done which revealed florid changes strongly suggesting AITL. Flowcytometry confirmed the diagnosis. The patient was treated with HyperCVAD achieving complete remission after the first cycle. Patient developed sepsis during the second cycle and expired within 4 months of diagnosis.
Discussion and Conclusion: This case is unique due to the waxing and waning pattern of lymphadenoapthy leading to AITL. Review of the current literature does not dictate any definite therapy. The prognosis and natural course of AITL is poor with classic chemotherapy protocol. Physicians should be wary of aggressive lymphomas presenting with diffuse lymphadenoapthy and fever when infections have been ruled out.
Can Pneumcoccus Cause Post-Infectious Glomerulonephritis in Adults
Saad Usmani, MD (Associate), Ramesh Kotihal, MD (Associate), Donald Wheeler, MD, Kamal Nasser, MD (Associate).
Department of Internal Medicine, Sinai Grace Hospital/Wayne State University, Detroit, MI.
Introduction: Post-infectious glomerulonephritis is commonly seen as a complication of infection with nephritogenic strains of Group A Streptococci. Presentation in adult population is declining in developed countries. We present the second case of post-infectious glomerulonephritis caused by streptococcus pneumonia in an adult.
Case Report: A 55-year male presented with a one-week history of worsening bilateral leg edema, oliguria and hematuria. Prior to this presentation, patient had recovered from pneumoccocal pneumonia with positive blood cultures. Initial lab results showed normocytic anemia and acute renal failure. Urine analysis showed hematuria and subnephrotic proteinuria. Patient became anuric requiring hemodialysis. Work-up for acute nephritic syndrome showed negative serological studies. Complement studies revealed normal C3 and C4 with low CH50. Renal biopsy showed immune-complex mediated crescenteric glomerulonephritis. Patient received pulse dose steroids for 5 days, which was followed by oral steroids. This therapy led to improvement of urinary output, and he was off dialysis on discharge.
Discussion and Conclusion: This is a very rare and unusual
presentation of post-infectious glomerulonephritis in adults attributed to
pneumococcal pneumonia. Only one adult case and few pediatric cases have been
reported in English literature. In the present case, other possible etiologies
of nephritic syndrome were ruled out, with negative ANCA, Anti-GBM,
Antistreptolysin O (
Successful treatment of Primary Pulmonary Angiosarcoma with Gemcitabine and Taxotere.
Saad Usmani 1, MD (Associate), David Reisman 2, MD (Member)
1Sinai-Grace Hospital/Wayne State University, Detroit, Michigan; 2University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan.
Introduction: Angiosarcomas account for about 1% of all soft tissue sarcomas. Metastatic involvement of the lung is by far more common than primary involvement. We present a very rare case of primary pulmonary angiosarcoma that was treated successfully with chemotherapy.
Case Report: A 56-year-old Caucasian man presented with hemoptysis. CT scan showed a left upper lobe mass which on bronchoscopic biopsy showed undifferentiated high-grade sarcoma. Immunostaining was negative. The patient underwent left upper lobe resection and was found to have N2 nodal involvement, making him Stage IIIA. Pre-radiation CT and PET scan showed interval development of bone metastases in bilateral scapula, pelvis, and lower thoracic and upper lumbar spine. The left scapula was biopsied and pathology of the tumor was consistent with an epitheliod angiosarcoma. The patient received 2 weeks of radiotherapy to the lower back .It was followed by chemotherapy with six cycles of gemcitabine and docetaxel therapy. Patient achieved complete response following therapy. Follow-up Positron emission tomography (PET) scans have been negative for 10 months.
Discussion & Conclusion: Primary pulmonary angiosarcomas are very rare tumors, with only 9 reported cases in the English literature. Currently there are no treatment protocols for this tumor due to few cases. The present case is the first instance of primary pulmonary angiosarcoma responding to gemcitabine and docetaxel combination with a sustained complete response for 10 months. This chemotherapeutic regimen may be used successfully for similar cases in the future.
MYELOID SARCOMA PRESENTING AS A PELVIC MASS WITH BILATERAL
HYDRONEPHROSIS - A
SAAD USMANI, MD (ASSOCIATE); KAMAL NASSER, MD (ASSOCIATE); HUSAIN SALEH, MD; JOEL APPEL, MD, FACP.
DEPARTMENT OF MEDICIEN, SINAI-GRACE HOSPITAL, DETROIT MEDICAL CENTER, WAYNE STATE UNIVERSITY, DETROIT, MI.
INTRODUCTION:
Myeloid sarcoma (MS), historically known as chloroma or
granulocytic sarcoma, is a very rare disease. It is an extramedullary
accumulation of myeloblasts that either presents with acute myeloid leukemia (
CASE REPORT:
51-year-old previously healthy post-menopausal female presented with ascites, worsening bilateral lower extremity edema and decreasing urinary output for three weeks. Lab results showed normocytic anemia, hyperkalemia and acute renal failure (ARF). She was started on hemodialysis and workup of acute renal failure was initiated. Transabdominal and transvaginal ultrasounds showed bilateral hydronephrosis and a large pelvic mass displacing the uterus. CT Scan of thorax, abdomen and pelvis showed mediastinal lymphadenoapthy in addition to the above findings. Retrograde pyelogram and bilateral ureteral stenting were done but renal function did not improve. Fine needle aspiration results of the pelvic mass were suspicious for hematopoietic malignancy with inconclusive immunostaining. An exploratory laparotomy and pelvic mass biopsy were done for a definitive diagnosis. Histopathology showed fibroadipose tissue with diffuse neoplastic cell infiltration and immunostaining was positive for leukocyte common antigen (LCA) and myeloperoxidase. Bone marrow biopsy revealed 63% myeloblasts. These findings were found to be consistent with myeloid sarcoma. Chemotherapy was started but the patient developed pancytopenia, septicemia, and acute respiratory distress. Patient expired on seventeenth day of induction therapy.
DISCUSSION & CONCLUSION:
Myeloid sarcomas rarely have their initial presentation in the lower urinary tract. We came across only four cases in English literature that presented with ARF. Two cases had tumors originating from the prostate, one from the urinary bladder and one from the uterine cervix. To our knowledge, this case is the first description of pelvic myeloid sarcoma presenting with ARF and bilateral hydronephrosis not originating from urogenital system. Physicians should consider possible hematological malignancies in patients with similar presentation.
Warfarin Anticoagulant Therapy for Vascular Access Patency in Hemodialysis
Usmani SZ, MD (Associate), Shahid Z, MD (Associate)
Sinai-Grace Hospital/Wayne State University, Detroit, Michigan
Introduction: Unlike other established indications for its use, warfarin to prevent AV graft clotting in hemodialysis patients is controversial with no clear guidelines.
Clinical Question: What is the evidence and efficacy of Warfarin in preventing AV graft clotting in patients with ESRD on HD with no known hypercoagulable states?
Methods: A literature search was done looking for double-blinded randomized controlled trials using keywords AV grafts, hemodialysis and warfarin. The search was conducted on Medline Ovid, Medline PubMed and Cochrane library.
Results: We came across only one study on use of low-intensity warfarin for vascular patency in ESRD patients which showed that 73% patients allocated to Warfarin and 61% in the placebo group experienced graft loss (p=0.21; odds ratio in favor of placebo 1.76; 95% confidence interval 0.72 to 4.34). 5 patients in the Warfarin group had 6 major bleeding events as compared to none in the placebo (one-tailed Fisher exact test, p=0.03)
Conclusions: Based on the evidence provided by this study, it can be said that the use of warfarin anticoagulation in end-stage renal disease population for prevention of thrombotic complications of AV access should be avoided due to increased risk of major bleeding events. There is a need for further studies on this topic to reach a decision on which agent(s) to use for anticoagulation purposes in these patients.
Kallmann syndrome in a female – an approach to treatment.
Gaurav Vashishta, MD; Zainab Shahid, MD; Gary W Edelson, MD; Kamal Nasser, MD
Deprtment of Internal Medicine, Sinai Grace Hospital, Detroit, MI
Kallmann syndrome is characterized by hypogonadotropic hypogonadism manifesting as delayed puberty associated with anosmia. It usually goes undiagnosed till late teens and is more common in males. Management of this disorder in females presents unique challenges.
Our patient is an 18-year-old caucasian lady who was
diagnosed with Kallmann syndrome at age 15 and followed as an outpatient. She
was seen initially for delayed puberty and short stature, found to have
hyposmia. She had low
Kallmann syndrome is a rare disorder with a strong
predilection for the male sex. Sporadic cases form the majority of cases, but X
linked, autosomal dominant and recessive forms have been described. Treatment
modalities for male patients include testosterone to attain sexual maturity,
and hCG, with
A
A.Virk, MD; K.Potluri, MD; K.Nasser, MD.
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.
INTRODUCTION: Peritonitis is one of the main reasons for morbidity and treatment failure in chronic Peritoneal Dialysis (PD) patients, aerobic gram-positive and gram-negative being the most common organisms. The incidence of peritonitis has progressively declined since the 1980’s and during the past decade, approximately 1 episode every 24 patient-treatment-months was routinely observed.
CASE REPORT: A 57 year old female with past medical history of ESRD, on PD for almost 4 yrs, presented in March, 2004 with abdominal pain, nausea and vomiting of one day duration. She was on temporary hemodialysis (HD) for one week prior to admission as her PD catheter was replaced due to malfunction. On examination, she was febrile with diffuse abdominal tenderness and the PD catheter site looked clean. Peritoneal fluid analysis showed 19,100 nucleated cells with cultures growing few Alcaligenes Xylosoxidans, sensitive to multiple antibiotics. The patient was started back on PD in hospital and discharged home on antibiotics. Few weeks later, she presented with similar complaints of fever and abdominal pain. Repeat fluid analysis revealed 1,830 nucleated cells with cultures positive for numerous Alcaligenes, sensitive to only a few antibiotics. She was started on temporary HD and PD catheter was removed. In September 2004, another attempt to start the patient back on PD failed due to recurrent peritonitis.
DISCUSSION: Our literature review revealed only 5 reported cases of PD associated peritonitis caused solely by Alcaligenes xylosoxidans. Alcaligenes is a motile, gram negative rod, easily confused with Pseudomonas and causes serious infections in immunocompromised hosts. It is associated with high mortality rate because of its virulence and resistance to multiple antibiotics. In addition to appropriate antimicrobial therapy, removal of the catheter is almost mandatory as this organism is adherent to plastic material. One aspect of our literature review and case report deals with the recurrent nature of peritonitis caused by Alcaligenes and whether patients should be allowed to return to PD after recovery.
ROLE OF IV STEROIDS IN ADULTS WITH BACTERIAL MENINGITIS
Amneet Virk MD,
Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
Introduction: In childhood bacterial meningitis, adjuvant corticosteroids reduce risk of severe hearing loss by 58% and have been shown to help in reducing mortality and neurological sequelae. The aim of this project is to study the role of IV steroids in adult bacterial meningitis.
Methods: A comprehensive literature review was done using Ovid Medline and Cochrane Library databases. Keywords used were meningitis, bacterial meningitis, adult meningitis, dexamethasone, steroids. The results of relevant articles were then compared.
Results: Of the few relevant studies, this project reviews mainly two, one of which is a meta-analysis and the other is a multicenter randomized conrolled trial. The meta-analysis showed an absolute risk reduction in mortality of 10% in the steroid group when compared to the placebo group. Subanalysis for causative organism showed a statistically significant favorable relative risk of mortality in steroid group compared to placebo group in pneumococcal meningitis (RR=0.5;p=0.001). Even though the beneficial effect of steroids on neurological sequelae showed borderline statistical significance, including the subanalysis for causative organisms, the point estimates were below one in all groups. In the prospective multicenter randomized controlled trial, adjunctive treatment with dexamethasone reduced the risks of both an unfavorable outcome (RR=0.59;p=0.03) and death (RR=0.48;p=0.04) significantly. Overall treatment with dexamethasone did not result in an increased risk of adverse events.
Conclusion: IV dexamethasone has beneficial effect on mortality and unfavorable outcomes in adults with bacterial meningitis. A dose of 10mg IV dexamethasone Q6hrs can be given before or along with the antibiotics. Even though it does not increase adverse events, further studies on congnitive evaluation are needed.
Methylobacterium Mesophilicum Causing Infectious Endocarditis
Durga Yerasuri, MD; Amer Tfaili, MD; Kamal Nasser, MD; Mark Wolf, MD
Department of Internal Medicine, Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.
INTRODUCTION: Methylobacterium mesophilicum is a methylotropic gram-negative rod with natural habitat in vegetation, sewage and soil. This bacterium has been increasingly reported as a cause of sepsis and line infections in immunocompromised patients. We report a case of sepsis and infective endocarditis with methylobacterium mesophilicum in a 68 year old woman with ESRD. To date this is the first case of infectious endocarditis caused by methylobacterium mesophilicum.
CASE REPORT: A 68 year old women with history of Hepatitis C and ESRD, receiving dialysis through a permacatheter presented with fever and chills. Patient had multiple admissions in the past with infected vascular accesses due to klebsiella and stenotrophomonas maltophila. On this admission, patient had a temperature of 101.4 and a WBC count of 12000. She was started on vancomycin and tobramycin empirically pending blood cultures. Blood cultures grew methylobacterum mesophilicum susceptible to tobramycin and ciprofloxacin. Echocardiogram showed mitral valve vegetations. The permacatheter was removed and vancomycin was replaced by ciprofloxacin. Patient later became afebrile and subsequent blood cultures showed no growth.
DISCUSSION: Methylobacterium mesophilicum is increasingly reported as a cause of
bacteremia in immunocompromised patients. Most of the
reported infections were nosocomial. Exposure to soil and vegetation was
reported in some cases. Infections included infected hemodialysis access catheters,
pneumonias, septic arthritis, osteomyelitis, keratitis, uveitis, encephalitis,
and peritonitis. The bacteria were successfully isolated from blood, sputum,
bronchial collections, synovial fluid, bone marrow, corneal scrapings,
CONCLUSION: With the newer effective treatments for cancers and AIDS and with the increased use of central veins as vascular access in chronic debilitated patients, the incidence of rare opportunistic infections has increased. The increased use of endoscopic procedures and contamination of these instruments with resistant organisms is also a concern. This presents a challenge to the physicians and diagnostic laboratories to look for unusual opportunistic infections.