SCREENING OF ASYMPTOMIC DIABETIC PATIENTS FOR CORONARY ARTERY DISEASE.WHY NOT?

Liana Maxa, PGY1

BACKGROUND: Coronary Artery Disease (CAD) is the leading cause of morbidity, mortality and medical costs of diabetes. The risk of Myocardial Infarction (MI) in diabetic patients is similar to that of patients without diabetes who have had previous MI and the rate of silent ischemia is higher than for the general population. National Cholesterol Education Program considers type 2 DM to be an independent CAD equivalent. We are investigating the role of stress test screening for CAD in the evaluation of asymptomatic diabetic patients with no CAD risk factors.  METHODS: Ovid and PubMed searches were done using “asymptomatic DM and CAD screening” as keywords. Selection criteria were randomized controlled prospective studies with reasonable number of subjects. Three studies were selected as well as two follow up studies.  RESULTS: Clinical trials reviewed showed some suggestive evidence that by following ADA guidelines an important number of patients with diabetes which could benefit from early screening for CAD could be missed. Studies also showed that the traditional risk factors don’t have significant predictive value in the prevention of CAD in asymptomatic diabetic patients  CONCLUSIONS: Current ADA recommendations for CAD screening in asymptomatic diabetic patients is based on level of evidence B and no reliable clinical trial data exists to support them. Which patients are at increased risk for adverse outcome, what are the screening tests to be considered and is it cost effective to screen for CAD in asymptomatic diabetic patients, are just some of the questions that should be addressed in future clinical trials.

 

 

EFFICACY AND SAFETY OF USE OF LONG-ACTING BETA AGONISTS (LABA) IN THE MANAGEMENT OF ASTHMA.

PRASAD, NAVIN, MD

BACKGROUND: Many studies have demonstrated greater efficacy of long-acting beta agonists (LABA) in improving pulmonary function, increasing symptom-free days over short-acting beta agonists (SABA). However, controversy continues about the association of chronic treatment with LABA with or without inhaled corticosteroids (ICS), with severe exacerbations and increased mortality in a small subgroup of patients.  CLNICAL QUESTION: Is the use of LABA safe in the management of asthma in adults?  METHODS: Literature was searched from databases of MEDLINE and Cochrane from 1966 to September 2008. Inclusion criteria was meta-analysis of parallel group and/or double blind randomized controlled trials with at least 3 months of treatment addressing the efficacy and impact of LABA on life-threatening events in the management of asthma.     RESULTS: Four studies reported that LABA significantly did better than SABA for  objective lung function measurements and also reduced day/night asthma symptoms. ICS were used as co-intervention in 46% to 70% in both LABA and SABA group in the above studies. Combined results of the Serevent Nationwide surveillance (SNS) study and Salmeterol Multicenter Asthma Research Trial (SMART) have shown that in patients who were not taking ICS there was a significant increase in risk of asthma-related death in LABA (salmeterol) group than in SABA (salbutamol) or placebo group, odds ratio 9.52 [95% CI:1.24, 73.09). The confidence interval for patients taking ICS was too wide to rule out an increase in asthma mortality in this group. A meta-analysis of 62 trials (29,201 participants) comparing the combination of LABA plus ICS  therapy and ICS alone found that combination therapy was associated with a decrease in the risk for severe exacerbations and no change in the risk of hospitalization. There were very few asthma- related deaths (3 deaths over 8,200 patient-years) and intubations. These events were too infrequent to establish LABA’s relative effect on these outcomes.  CONCLUSION: LABA should not be used as monotherapy because of significantly increased risk of asthma-related death. However, LABA in combination with ICS significantly reduces asthma exacerbation rates and it has important role in the management of asthma.

 

 

ANTIPSYCHOTICS FOR THE TREATMENT OF DELIRIUM

Sinan H. Sarsam, MD

Background: Delirium is found in up to 30 % of hospitalized patients, and is associated with increased morbidity and mortality, prolonged hospital stay, and subsequent deterioration in cognitive status. There are many interventions to prevent this disease, but when it occurs, management is supportive to control behaviors and may need use of psychotropic medications and benzodiazepines. Methods: A literature search of Medline, Pubmed, Ovid and Cochrane library was done to identify studies comparing different antipsychotics for the treatment of delirium. Eighteen clinical trials were identified, with three randomized trials. Agents studied included Haloperidol and atypical antipsychotics (risperidone, olanzapine, & quetiapine). Results: Han Study compared haloperidol & risperidone in the treatment of delirium. The result showed significant improvement in both groups (haloperidol 75%, risperidone 42%) (p<0.05). There was no significant difference between haloperidol and risperidone group (p>0.05). Hu Study compared olanzapine, haloperidol, and placebo in treatment of delirium. Result showed significant improvement with olanzapine(72.2%) & haloperidol (70.4%) which differed significantly from placebo (29.7%) (p<0.01). No significant difference in improvement between olanzapine & haloperidol groups (p>0.05). There was a faster response to olanzapine than haloperidol (p<0.001). A meta-analysis was done comparing Risperidone (Han) / Olanzapine (Hu) as treatment group v haloperidol as control group and showed no significant difference in management of delirium between both groups (p>0.05). Another meta-analysis compared several case studies, prospective & retrospective studies regarding the use of atypical antipsychotics for delirium treatment, and it suggests that atypical antipsychotics, with their similar rates of efficacy, and lower rate of extrapyramidal side effects, may be a viable option to traditional high-potency neuroleptics.  Conclusion: Haloperidol (<3.5mg/day), risperidone, and olanzapine are all equally effective in treating delirium, with few adverse effects. Parkinsonian side effects are common with haloperidol (>4.5mg/day), so patients requiring high doses can be treated with the atypical agents. Large size randomized trials on delirium need to be designed to compare atypical agents verses haloperidol.

 

 

ACUTE GRAFT VERSUS HOST DISEASE (aGVHD) AND CMV INFECTION OF THE GUT PRESENTING AS BOWEL PERFORATION IN CORD BLOOD TRANSPLANT.

Mustafa Abdul-Hussein MD. Sinai-Grace Hospital, Detroit medical Center, Zaid Al-Kadhimi MD. Karmanos Cancer Institute, Detroit, MI.

INTRODUCTION:  aGVHD is a common complication of hematopoietic stem cell transplantation.  It can involve the skin, liver, and gastrointestinal tract GIT.    Both aGVHD and its immunosuppressive therapy increase the risk for opportunistic infections like cytomegalovirus (CMV). Here we describe an unusual presentation of these two complications (aGVHD and CMV) in the form of colon perforation in a cord blood transplant patient.   We describe a 43 y/o African American lady, who was diagnosed in 2005 with non secretary multiple myeloma. The patient was treated with chemotherapy, followed by autologous hematopoietic stem cell transplant.  She relapsed within one year.  Since no HLA matched donor was found for her, she underwent a 4 out of 6 matched double cord blood transplant in June 2007.  The preparative regimen was Busulfan, Fludarabine and total body irradiation.  The total nucleated cell dose 3.58x10^7 cells/kg.  The patient was CMV+, and both of the cord units were CMV-.  Her GVHD prophylaxis regimen consisted of Tacrolimus and Mycophenolate.  Post transplant day 14, the patient engrafted and was started on steroids 2 mg/kg for erythematous skin rash (aGVHD grade III on biopsy).  Over the following two weeks the patient was having occasional nausea, epigastric discomfort and diarrhea, yet she continued to eat, drink, and walk a mile a day.  Her abdominal exam continued to be negative.  Since her skin aGVHD did not respond to the above therapy, she was enrolled on a clinical trial with mesenchymal stem cell infusions.  The trial required a routine body CT scans, which demonstrated free air under diaphragm.  Subsequently the patient underwent laparotomy, which revealed a cecal perforation.  It was repaired and the patient was left with an iliostomy.  Pathology report showed grade 3 aGVHD in addition to CMV colitis.  At the time of surgery her CMV PCR viral load rose to 4400 copies.  The patient’s GIT aGVHD responded slowly to more immune suppression, and her CMV infection responded to gancyclovir. The patient was discharged home 6 weeks later in good condition.  DISCUSSION: Cord blood transplants represent a significant clinical challenge.  In the context of sever GIT aGVHD, CMV infection, high dose steroid, bowel perforation with very little clinical findings becomes a potential complication. High suspicion and anticipation needs to be considered in these very complicated, yet potentially curable patients.

 

 

LEFT VENTRICULAR MYXOMA DISCOVERED INCIDENTALLY IN A PATIENT PRESENTING WITH ACUTE ISCHEMIC STROKE

Mukhtar Al-Saadi, MD (Associate), Adriss Faraj, MD (Associate),, Dimitrios Apostolou, MD,  Ramegowda Rajagopal

Introduction: Myxoams are the most common primary cardiac tumors. They can occur in any chamber, yet only 3% in the left ventricle.  Although asymptomatic mxyoma have been recognized, most patient experience one or more effects from the classic triad of constitutional, embolic, and obstructive manifestations.  Case Reprot: We present a case of 48 year old woman with a history of hypertension and diabetes who presented to the emergency room with sudden onset of numbness of the right side of the face and right upper and lower extremities. Physical examination demonstrated normal vital signs and normal neurological examination except for right hemi sensory deficit to pin prick sensation. CT scan of the head showed no acute intracranial process.  Cardiac echocardiogram showed an echo dense mass of 1x1 cm that was highly mobile with an elongated stalk attached to the endocardial surface of the lateral wall of the left ventricle.  The mass was successfully removed surgically and the histology revealed a diagnosis of cardiac myxoma.  Discussion: Cardiac myxomas account for approximately half of benign cardiac tumors and are usually found in patients between 30 and 60 years old with a female predominance. Although most cases are isolated or sporadic, they can also be familial or complex.  75% of myxomas occur in the left atrium, 18% in the right atrium, 4% in the right ventricle, and only 3% in the left ventricle. They arise from the endocardial surface of the cardiac chamber attached with a stalk as friable, pedunculated, polypoid tumors. The clinical manifestations are some times the consequence of the location. Whether left ventricular myxomas are more likely to embolize due to the increased compressive force is undetermined. Surgical resection is the only acceptable treatment and should be performed promptly following diagnosis in view of the dangers of embolization and sudden death.

 

 

CASE REPORT: HYPERMAGNESEMIA

Camille Henson, D.O.

INTRODUCTION: Magnesium is a common ingredient in over-the counter (OTC) drug products, especially antacids, laxatives, and analgesics. Severe levels of serum magnesium greater than10.0 mEq/L are related to asystole, heart block, ventilator failure, stupor or coma and death. We report a case of hypermagnesemia resulting in cardiac arrest with an unusually high level not often reported, particularly with a survival and full recovery.  CASE REPORT: We report a 59 year old woman with a history of heart failure, hypertension, hypercholesterolemia, chronic kidney disease, diabetes and a prior admission for bradycardia who presented with symptoms of epigastric pain nausea and vomiting of 2 days duration. On presentation patient was bradycardic (HR33 ) with laboratory studies revealing hyperglycemia (glucose 807 ), acute renal failure (creatinine 3.2) and hyperkalemia (potassium 7.4). The patient’s bradyarrhythmia was attributed to hyperkalmia and improved after treatment. Ten hours later the patient developed acute mental status changes and became obtunded with respiratory depression. Repeat labs showed her magnesium to be critically high at 13.6 with normal serum potassium. She became bradycardic again (HR 30-40) and progressed on to cardiac arrest. The patient was revived, intubated with continuous transcutaneous pacing and transferred to the intensive care unit. Serum magnesium was repeated to rule out lab error. The second and third magnesium was reported as 18.8 and then 20.0 respectively. The patient underwent urgent hemodialysis and Mg decreased to 9.3 and 4.0 with two session of dialysis. On further questioning family reported large amounts (2 gallon bottles) of milk of magnesia empty in the home.  DISCUSSION: Physicians frequently neglect to consider hypermagnesemia in the differential diagnosis of most clinical presentations. In this case, hypermagnesemia resulted in a refractory hypotension, respiratory depression ultimately cardiac arrest. Hypermagnesemia is a rare electrolyte abnormality because the kidney is very proficient in excreting excess magnesium. However, it does occur primarily in two settings when renal function is impaired and/or a large magnesium load is given, intravenously, orally, or as an enema. The mechanism of hypermagnesemia-induced bradyarrhythmias is multifactorial, and includes sympathetic nervous system blockade, inhibition of cardiac myocytes potassium efflux and direct suppression of sino-atrial node activity. Although infrequent, this case illustrates that severe hypermagnesia may be the cause of severe arrhythmia and even cardiac arrest.

 

 

MEASURES TO MINIMIZE MORBIDITY AND RECURRENT HOSPITAL ADMISSIONS DUE TO HEART FAILURE WITH ISCHEMIC ETIOLOGY

E.M. Malitha S. Hettiarachchi, MD. (Associate)

INTRODUCTION: Congestive Heart Failure (CHF) is the most common reason for hospital readmissions among adults in the United States, despite overwhelming clinical trial evidence on medications used, expert opinion, and national guidelines.   METHODOLOGY: A survey was done to find out recent research results on identifying factors that minimize morbidity and hospital readmissions due to CHF, using Medline, Cochrane, and Clinicaltrals.gov as data base. The inclusion criteria was Randomized Double Blinded Placebo controlled trials, prospective studies, and meta-analysis from 2000 to 2008. Three recent studies were finalized and reviewed in detail. RESULTS: A prospective study, OPTIMIZ- HF published in 2007 showed a significant reduction in post discharge mortality and hospital readmission by using Angiotensin Converting Enzyme Inhibitors (ACEI)/Angiotensin Receptor Blockers (ARB) and Beta Blockers (BB). BB use is not included in Joint Commission Performance Measures (JCPM) for heart failure. There is little or no association of other JCPM on heart failure disease out come. REMADHE (2008), a long-term randomized-prospective study showed that heart failure disease management program with repetitive education and telephone monitoring significantly improve quality of life and reduce readmissions and ER visits due to CHF. Meta-analysis (2004) of 18 randomized control trials showed that comprehensive discharge planning with post-discharge support, significantly reduce readmissions, medical costs, and improve quality of life.  CONCLUSION: Prescribing ACEI and BB at the hospital discharge, comprehensive discharge planning, and post discharge support with repetitive education and out-patient follow up are associated with reducing readmissions and medical costs due to CHF and improving quality of life.

 

 

TAKO-TSUBO CARDIOMYOPATHY WITHOUT CHEST PAIN- A CASE REPORT

Ayinde T. Bourne, DO

INTRODUCTION: Takotsubo cardiomyopathy is a rare syndrome consists of acute, transient, and extensive akinesia of the apical and mid-portions of the left ventricle, producing ballooning of the apex in the absence of significant coronary artery disease. The clinical presentation usually mimics symptoms, EKG changes, and cardiac enzyme changes of acute coronary syndrome.  CASE REPORT: This is a case of an 88 year old African American female presented with a tibio-fibular fracture after a fall and later developed Takotsubo Cardiomyopathy. During the hospital stay she had increased serum Troponin-I and ST elevation of the anterior precordial leads of the EKG. But she remained clinically asymptomatic and vitals showed transient hypertension and tachycardia followed by hypotension. Diagnosis of Acute ST Elevation Myocardial Infarction was made and cardiac catheterization was done: which showed angiographically patent coronary arteries. Left ventricular angiogram showed reduced Left Ventricular Ejection Fraction, (LVEF) apical akinesia, and Left Ventricular ballooning suggestive of Takotsubo Cardiomyopathy. Intravascular ultrasound showed no evidence of ruptured plaque. Patient was managed symptomatically and follow-up trans-thoracic echo cardiogram in three days showed improvement in apical akinesia and increased LVEF.   CONCLUSION: The exact etiology of this syndrome is still unclear and several mechanisms have proposed. Myocardial dysfunction mediated through catecholamine-induced damage is a widely accepted theory and could be the possible etiology of this patient. Although majority recovers completely without any complication, it is important to monitor for rare but life threatening complications such as cardiogenic shock and arrhythmias. It is important to consider this clinical entity as a differential diagnosis of acute coronary syndrome as it could be mistaken and treated differently.

 

 

FAMILY HISTORY OF PREMATURE CORONARY ARTERY DISEASE: QUANLITATION OF APOLIPOROTEINS

Suchitra Kamineni MD, Rajika Munnasinghe MD

INTRODUCTION: Family history of premature coronary artery disease (CAD) is a major risk factor for CAD.The risk in first degree relatives is 3 times more than the general population. Low density lipoprotein (LDL) is predictor of CAD risk but not a best circulatory marker. Results of several studies have shown that apolipoprotein B (apoB) in atherogenic particles LDL, VLDL and IDL, apolipoprotein A-I (apoA-I) in anti-atherogenic particles the HDL types are better predictors of risk of coronary artery disease. We review this evidence and address their importance in clinical practice. METHODS: Literature review from Ovid Medline,pub med from 1993-2007 were reviewed. Prospective studies like Quebec cardiovascular study and AMORIS (apolipoprotein –related mortality risk study) on general population were reviewed. There were no prospective studies conducted in adult population with strong family history of premature CAD as an individual risk factor available looking for Apo B and Apo A1 , so we reviewed retrospective studies done in children and adolescents with familial history of CAD. Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS) and Long term Intervention with Pravastastin in Ischemic Disease (LIPID) trail were also reviewed. RESULTS : Quebec cardiovascular study, a sample of 2155 Canadian men followed for a period of 5 years for clinical signs of ischemic heart disease (IHD) showed  plasma apoB concentrations  strongly  associatiated with onset of IHD. AMORIS study, a total of 1,75,553 individuals from Sweden were followed for an average of 5.5 years showed, apoB, apoA-I and apoB/apoA-I ratio were all highly significant predictors of myocardial ischemia in both sexes. Crossectional studies done in children with family history of CAD showed apoAI and ApoB are better predictors of premature CAD. AFCAPS and LIPID trails showed plasma apo B levels are better predictors of statin therapy than change in LDL levels. CONCLUSION: Apolipoproteins are better predictors of CAD than traditional lipid parameters. The tests for measuring apo B and apo A I are widely internationally standardized, automated and doesn’t require any fasting sample. However prospective studies in target population with family history premature CAD are required before any recommendations to be made.

 

 

Lung Malignancy Disguised as Aspergillosis

Thien H. Van, MD, Department of Internal Medicine Sinai Grace Hospital, Wayne State Univ. /Detroit Medical Center

INTRODUCTION:  While Aspergillus species is ubiquitous and exposures to their spores are frequent, disease due to tissue invasion with these fungi is uncommon and occurs primarily in immunocompromised host.  The infrequency of this in immunocompetent patients with an underlying lung malignancy makes it a formidable diagnostic challenge.   CASE REPORT:  A 59-year-old African American male with a past medical history significant for peripheral vascular disease (PVD), prostate cancer status post prostatectomy presented to the emergency department with left leg pain.  DVT was suspected and venous Doppler was done (negative).  A chest radiograph showed a 5 cm area in the left hilar region.  This was followed up with a PE protocol chest CT.  The CT showed a left hilar mass, mediastinal lymphadenopathy and a 2.6 mm nodular opacity in the right lung base.  He was also admitted for constant left leg pain with intermittent claudication.  Vascular surgery was consulted to manage his PVD while interventional radiology (IR) was consulted for an FNA of the hilar mass.  The final pathology report showed aspergillosis with acute inflammatory cells and lymphocytes/histiocytes.  Infectious disease was consulted and the patient was started on liposomal amphotericin B for 14 days, followed by voriconazole for 28 days with a total duration of 6 weeks.  Patient was also consented for an HIV test which was found to be negative.  Approximately 3 months after discharge, patient returned with chief complaint of one month once daily hemoptysis.  Patient denied all associated symptoms except for night sweats.  He denied any sick contact or travel outside the U.S.  He was admitted for hemoptysis and refractory systemic aspergillosis.  Pulmonary performed a bronchoscopy showing left upper lobe bronchial washing of non-malignant cells.  Thoracic surgery performed an exploratory thoracotomy with upper lobectomy and anterior mediastinal biopsy.  Patient was eventually transferred to surgical ICU unit for recovery revealing a biphasic lung carcinosarcoma.   DISCUSSION:  This case illustrates how a common fungal infection normally in an immunocompromised person can be masked and complicated by a rare lung malignancy in an immunocompetent person.  Recognition of aspergillosis in healthy individuals without any risk factors or immunosuppression is critical for future treatments of this disease alone and superimposed by other systemic malignancies.  There is an association between bronchogenic carcinoma and secondary aspergillosis especially in patients with NSC carcinoma.

 

 

ONCHROBACTRUM ANTHROPI BACTEREMIA

Saba Khokhar, MD (PGY-3), J. Salinas, MD (PGY-3), Thien Van, MD (PGY-1), Department of Internal Medicine Sinai Grace Hospital, Wayne State Univ. /Detroit Medical Center

INTRODUCTION: Onchrobactrum anthropi is a rare gram-negative organism widely distributed in aquatic environment identified as a source of infection in indwelling catheters and hospital apparatus in immunocompromised patients. It is however, an infrequent pathogen recently reported in immunocompetent hosts as well. Most cases resolve with removal of the catheter with or without antibiotic treatment. CASE REPORT: A 71 year-old Caucasian male with past medical history of hypertension was admitted to the hospital for multiple fractures status post fall, rhabdomyolysis and acute kidney injury. His hospital course was hemodynamically stable but required ventilatory support. Further workup was negative for HIV or any malignancy. Bronchoscopy findings showed marked inflammatory and mucoid secretions. Blood and catheter tip cultures returned positive for Ochrobactrum anthropi. Workup for HIV and malignancy were ruled out. DISCUSSION/CONCLUSION: Ochrobactrum anthropi is an aerobic, gram-negative, oxidase positive pathogen.  It is a rare cause of nosocomial infection. It has been implicated as a cause of intravenous line infection especially in immunocompromised patients but recent cases have been reported in immunocompetent hosts as well. It is reported to be a low virulent organism with resolution of infection by removal of the infected line and/or antibiotic treatment. The antibiotic susceptibility of our isolate was consistent with a few other published case reports.   Ochrobactrum anthropi are resistant to penicillins and cephalosporins with susceptibility to TMP-SMX and imipenem. Our patient was treated with bactrim and went onto full recovery with resolution of the  infection.

 

 

Unprepared CT Colonoscopy, a New Colorectal Cancer Screening Modality.

Mustafa Abdul-Hussein MD., Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.

Background – Colorectal cancer is the second most common cause of cancer death in the United States, approximately 150,000 new cases are diagnosed each year in the United States. Annually approximately 50,000 Americans die of colorectal cancer. Screening is cost effective in reducing the morbidity and mortality associated with colon cancer.  Methods – A literature search of MEDLINE, Pub med, and Cochrane library was undertaken to identify studies comparing different screening modalities. Prospective nonrandomized clinical trials that compared the prepared conventional colonoscopy (CC) with the unprepared CT (virtual) colonoscopy (CTC) in adult patients with average risk for colon cancer.    Results – Three well done studies by Iannaccone R. et al (Gastroenterology 2004 Nov; 127(5):1300-11), Callstrom, M, R. et al (Radiology 2001; 219:693-698) and Abraham H. Dachman. Et al (Abdominal imaging 2007 Feb; 32(1):96-104) met the selection criteria of the patients` age (> 35), a family history of CRC, no history of IBD, bowel obstruction, colorectal surgery or acute diverticulitis. Iannaccone study provided excellent results for the detection of colorectal polyp’s &#8805;8 mm (average sensitivity, 95.5%; average sensitivity for neoplastic polyp’s &#8805;8 mm, 100%). Even when the cutoff size is reduced to polyps &#8805;6 mm, CTC maintains an average sensitivity of 86%, a value that approaches that of optical colonoscopy and is in the upper range reported in the literature for CTC as performed with standard bowel cleansing .In Callstrom study, reviewers correctly identified 80% and 100% of patients with polyps 1 cm or larger in the 48-hour seven-dose group, which had the highest average stool labeling score throughout the colon. These sensitivities compare favorably with reported sensitivities of 85%–100% in the prepared colon Whereas Abraham showed that a truly unprepped strategy that leaves significant residual stool, even if well tagged, is not desirable, because it was harder to interpret and lead to polyp missing.   Conclusions: A low-dose multidetector CTC without cathartic bowel preparation provides excellent results for the detection of colorectal ca. Sensitivity for polyp detection in patients with adequate stool labeling approaches the sensitivity for polyp detection in prepared colons, but further studies is warranted.

 

 

Multidrug Resistant Klebsiella Pneumoniae Infection.

Abdul-Hussein MD , Wasif Hafeez MD, Sinai-Grace Hospital, Detroit Medical Center, Detroit, MI.

Introduction: The importance of the carbapenem class of antibiotics is that they have activity against gram-negative organisms with chromosomal cephalosporinases and extended-spectrum beta-lactamases. Resistance to carbapenems has been uncommon until now. Recently, infections due to Klebsiella pneumoniae resistant to carbapenems (KPC) have been reported in the northeastern United States. We report 2 cases of KPC that occurred in southeastern Michigan. Case Report:  Case 1: A 78-year-old man who was admitted to hospital on August 21, 2008 with left hip pain. He was subsequently diagnosed with extensive acute left lower limb DVT. He developed multiple complications including phlegmasia cerulean dolens and acute compartment syndrome. Despite multiple fasciotomies, he developed muscle necrosis requiring extensive surgical debridement. Tissue cultures grew multiple organisms including: Citropacter, E.coli, Acinetobacter, E.faecium and Pseudomonas. The patient failed antibiotic treatment, had continued necrosis and finally required a left hip disarticulation He developed a new fever with tachycardia. Blood cultures were drawn on October 24, 2008 which grew a gram-negative bacilli later identified as Klebsiella pneumoniae that was found to be a carbapenemase producer resistant to all antibiotics except to tigecycline and gentamicin. Therapy with tigecycline and gentamicin was begun and the patient improved. His follow-up blood cultures became negative.  Case 2: An 86-year-old man who is a nursing home resident presented with shortness of breath. In the ED, he was found in to be in respiratory distress with PaO2 of 65% and hypotensive. The patient was intubated and vasopressors were started. Blood cultures were drawn and the patient initially started on cefepime and vancomycin. Blood cultures grew a gram-negative bacillus later identified as Klebsiella pneumoniae which was a carbapenemase producer and was resistant to all antibiotics except gentamicin and tigeccycline. His antibiotic therapy was changed to tigecycline and his follow-up blood cultures were negative but the patient eventually expired on 10/28/08.      Conclusion: KPC is an emerging pathogen adding to a growing list of antibiotic resistant organisms. It poses a significant challenge to clinicians caring for patients infected with these organisms. Identification of KPC in many microbology labs has not been perfected and once identified, these organisms pose treatment and infection control challenges. Mortality of KPC infection is high, reported at 47% in the literature.

 

 

TRANSCATHETER CLOSURE VERSUS MEDICAL MANAGEMENT IN PATIENTS WITH PATENT FORAMEN OVALE (PFO) AND CRYPTOGENIC STROKE: A SYSTEMIC REVIEW

Ahmad Kadhim, MD

There are 200,000 cryptogenic strokes per year in the United States. The prevalence of PFO in patient with cryptogenic stroke is 40-56%. Previous meta analysis studies have suggested a strong relationship between cryptogenic strokes and patent foramen ovale. In the United States, 98,000-120,000 strokes per year could be attributed to PFO. The optimal strategy to prevent recurrent presumed paradoxical emboli in patients with PFO is unknown. The purpose of this study is to synthesize the current knowledge and assess the relative benefits of transcatheter closure versus medical management in patients with PFO. The Data resources searched were English-language journals listed in the MEDLINE data base from January 1996-August 2008. Secondary sources were also used in the search including references. Three non-randomized, observational studies with a sample size of >70 patients comparing medical management versus transcatheter closure were selected. The data from the published studies were manually extracted and summarized. Patients diagnosed with cryptogenic strokes and known to have PFO either had transcatheter closure or were medically managed for an average of 2.87 years. Overall, the rate of recurrent neurologic thromboembolism with transcatheter closure intervention was 0%-7.8% and the incidence of major and minor complication was 7.8% and 6%, respectively. Medical management was associated with a recurrence rate of 8% to 22.2%. In addition, in patients with multiple previous strokes the recurrence rate after transcatheter closure was 0% to 13.8% versus patients medically managed 15%-55.4%. However, limitations resulting from uncontrolled data, non-standardized definitions, and baseline imbalances preclude definitive conclusions about the superiority of a particular approach. In conclusion, the treatment of first stroke should be conservative medical management since that data does not favor transcatheter closure over medical management. However, the data does show transcatheter closure of PFO is superior to medical management for patients with multiple recurrent strokes. However, randomized controlled trials are needed.

 

 

SEPSIS SECONDARY TO VANCOMYCIN-INTERMEDIATE STAPHYLOCOCCUS AUREUS (VISA) OSTEOMYELITIS OF THE LOWER LUMBAR SPINE: A CASE REPORT

Ahmad Kadhim, MD

VISA is specific type of antimicrobial-resistant staph bacteria. VISA has a minimum inhibitory concentration (MIC) of 4-8 µg/ml. VISA cells have thicker cell walls that contain many subunits capable of binding Vancomycin extracellularly and preventing it from reaching the cell membrane. GISA  (glycopeptide-intermediate resistant staphylococcus aureus) acts in a similar fashion against Daptomycin . We report a rare case of 53 y.o man with a medical history significant for heart failure with EF 15% both systolic and diastolic dysfunction s/p AICD removal due to infection with MRSA. The patient also has a lumbar spine injury with tear in the posterolateral annular fibrosis L4/L5 causing compression of L4 nerve root. The patient was admitted initially for chest pain and worsening of his back pain, a couple of days later developed sepsis including fever, and hypotension. TEE did not show any vegetations, CXR showed a right pleural effusion so the patient was started on Vancomycin, Rifampin and Cefepime. The patient responded well to fluids and his blood pressure improved. The blood culture showed VISA and GISA with resistance to Vancomycin, Daptomycin, Rifampin, Oxacillin, and sensitive to Bactrim, Levofloxacin, and Clindamycin. The patient was started on Zyvox and an MRI of the lumbar spine showed ostemyelitis of L4/L5 with discitis and septic arthritis with no visible abcess. At this time neurosurgery was consulted, and recommended medical management and repeating the MRI in 2 weeks, and then reassessing surgical interventions. The patient''s serial blood cultures were negative. The patient was discharged home on 6 weeks of Zyvox, ciprofloxacin, pain control, and was scheduled for a follow up MRI and a follow up appointment with the neurosurgery clinic. This case reports three important findings; first sepsis secondary to VISA bacteremia is rare and requires choosing the right antimicrobial agent in a timely fashion. Second, patients with history of MRSA infections need close monitoring to ensure complete eradication. Third, it is essential that hospitals reconsider the overuse of Vancomycin as cases of VISA and VRSA are becoming more common in literature.

 

 

PAPILLARY FIBROELASTOMA OF AORTIC VALVE: ROLE OF CARDIAC MRI IN PRESURGICAL PLANNING

Suchitra Kamineni MD, Rajika Munasinghe MD

INTRODUCTION: Cardiac fibroelastomas are second most common after myxomas representing 10% of cardiac tumors. With availability of echocardiography more cases are being diagnosed during the lifetime. We report a case of papillary fibroelastoma of aortic valve diagnosed by Tran esophageal echocardiogram (TEE) and Magnetic Resonance Imaging (MRI). This case emphasizes the role of cardiac MRI in presurgical planning. CASE REPORT: A 37 year old female with past medical history of hypertension and hypothyroidism presented with left sided weakness due to transient ischemic attack. Associated symptoms were lightheadedness but no history of chest pain, syncopial attacks or shortness of breath. Labs showed high TSH levels, EKG showed sinus rhythm, carotid and vertebral Doppler studies were normal. TEE showed mobile pedunculated mass arising between right coronary cusp and root of aorta. Cardiac MRI showed hypo dense lesion at same location. To prevent systemic embolisation the patient underwent simple excision of tumor without aortic valve replacement. Histopathology revealed single layer of hyperplastic endocardial cells with a core of hyalanised dense fibrous tissue consistent with a papillary fibroelastoma of endocardium. DISCUSSION: Fibroelastomas commonly arise from aortic valve followed by mitral valve rarely from ventricular wall and chordae tendenae. Fibroelastomas mostly diagnosed incidentally on routine examination and rarely with neurological symptoms, angina, acute myocardial infarction, systemic embolisation or sudden death. Hypothyroidism and hypokalemia are associated with fibroelastomas for unexplained reasons. Literature review reports only one case of fibroelastoma associated with hypothyroidism, our case being second, another with Grave’s disease. Both TEE and MRI define the tumor with its attachment to underlying tissues, exact location and relationship with surrounding structures but MRI excels at making differential diagnosis by its high resolution. Fibroelastomas do not recur. Treatment is simple excision without need for valve replacement. CONCLUSION: In cases of cardiac valvular tumor, MRI plays important role in making a diagnosis and selecting optimal treatment then TEE.

 

 

FLORID NECROTIZING GRANULOMA SIMULATING LUNG CARCINOMA

Liana Maxa, PGY1, Sokunbi MD, Akintayo

INTRODUCTION: Clinical appearance and imaging of florid necrotizing granuloma in this case mimics the presentation of lung carcinoma.   CASE REPORT: A 52 years old African American male presents with right side pleuritic chest pain, cough, hemoptysis , fatigue, weight loss and history of undiagnosed lung mass. Patient has significant history of smoking, exposure to TB and family history of lung cancer in father and grandmother. Physical examination revealed decreased breath sounds on the right lung base and positive right dullness to percussion over the right lung base. A right lower infiltrating lung mass was noticed on CT scan that originally was described as 22x14mm infiltrative type mass suspicious of malignancy. A diagnosis was not made at the time of the finding because of insurance issues. Over 8 months period an interval increase in size and new lymphadenopathy was noted. At the time of the examination, the mass measured 70mm in diameter and appeared spiculated raising again the suspicion for primary lung malignancy. Patient underwent right lower lobe lobectomy for lung mass. Pathology report described a florid necrotizing granuloma with abscess formation, focal organization and bronchiectasis and three reactive lymph nodes with anthracosis. No evidence of malignancy was found. Patient was followed up with CT scan 2 months later that revealed no new processes.  DISCUSSION: In the case presented here, we had a very high index of suspicion for primary lung cancer because of the clinical presentation as well as the risk factors associated. Smoking accounts for approximately 90% of lung cancers and genetics is known to be a factor in developing lung cancer. There is no useful screening test for lung cancer since no test has been shown to reduce mortality. The diagnosis of lung cancer is based mainly on the evaluation of the individual with symptoms. Although in our case the diagnosis was of necrotizing granuloma, lung cancer is the most common cause of mortality in both men and women worldwide, so the primary differential diagnosis was considered to be of lung malignancy until the pathology report was received.

 

 

A case of bilateral interstitial pneumonitis and serositis due to systemic lupus erythematosus (SLE).

Prasad, Navin, MD.  Karunwi, Adedji, MD

Introduction: Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease. Its presentation is highly variable, ranging from indolent to fulminant.  Case report: A 57-year-old African American female with a history of coronary artery disease status post stent, diabetes mellitus, hypertension and resolved pulmonary tuberculosis presented with chief complaints of productive cough, shortness of breath and chest tightness for 3 weeks. She was febrile and had bilateral diffuse rhonchi. CT-thorax revealed bilateral mixed air space and interstitial diffuse pulmonary opacities more prominent in middle and lower lobe of right lung suggestive of interstitial pneumonia. She had persistent fever, worsening of lung opacities despite being on antibiotics. Bronchoscopy showed a black-purplish-colored lesion of the right upper lobe, its culture grew Candida albicans. Biopsy of right lower lobe showed focal chronic active interstitial inflammation. A presumptive diagnosis of fungal interstitial pneumonitis was made and a two weeks course of oral Diflucan was initiated.   5 weeks later, she presented with complaints of nonproductive cough, left sided pleuritic chest pain and shortness of breath of 3 days duration. CT thorax showed interval development of bilateral small pleural effusion, large pericardial effusion, and bilateral scattered ground glass opacities. Pericardial window and open lung biopsy were performed that showed chronic interstitial inflammatory infiltrates composed primarily of lymphocytes without any granuloma, suggestive of systemic collagen vascular disease. Autoimmune screen showed ; ANA titer 1:40960, positive anti ds DNA antibody (1:640 ), rheumatoid factor (246.4 IU/ml), elevated other autoantibodies (Anti Smith , Anti RNP , Anti SSA , Anti SSB , Anti SCL-70 , Anti JO-1 , histone antibody) and absence of CCP antibody. She had nonhemolytic normocytic anemia and chronic thrombocytopenia. A diagnosis of SLE was made and she was started on oral prednisone 40 mg once a day and her symptoms improved.   Discussion: Pleurisy with or without pleural effusions is the most common feature of pulmonary involvement in SLE. Interstitial pneumonitis is relatively an uncommon presentation. Treatment of active lupus pneumonitis generally begins with oral prednisone and immunosuppressive agents are needed if the response is inadequate.  Serositis like pleuritis/pericarditis with or without effusion when mild may respond to NSAID, if severe may need glucocorticoid therapy.  Our case highlights the importance of considering collagen vascular disease like SLE in differential diagnosis of interstitial pneumonitis.

 

 

PULMONARY AND RENAL INVOLVEMENT IN MICROSCOPIC POLYANGIITIS

Sinan H. Sarsam, MD

Microscopic polyangiitis is a necrotizing small vessel vasculitis characterized by pulmonary capillary alveolitis and glomerulonephritis. It presents with cough and/or hemoptysis, hematuria and constitutional symptoms like fever, weight loss, fatigue, and sometimes with neurological symptoms. Diagnosis is by biopsy showing necrotizing, pauci-immune inflammation of arterioles, capillaries and venules with no granulomas or easinophilic infiltrates. P-ANCA is positive in 70%. Treatment is usually with steroids and cyclophosphamide.  We report a case of an 87-year-old African American female who presented with a 4-day history of non productive cough, shortness of breath, fatigue and fever. Her past medical history was significant for Ulcerative Colitis and Breast Cancer, treated with lumpectomy and radiation in 1995. The patient was admitted and started on levofloxacin for suspected pneumonia, but the symptoms persisted. Chest X Ray showed bilateral pulmonary infiltrates. Urinalysis showed 5-10 RBCs and 1+ Blood. Two days later, the patient deteriorated and went into respiratory failure and was intubated. Chest X Ray showed increased infiltrates. CT thorax showed diffuse bilateral infiltrates suggestive of hemorrhage which was confirmed by bronchoscopy.  Biopsy showed chronic active inflammation with no granuloma. The patient developed worsening hematuria and renal function. ANCA was ordered and showed P-ANCA in high titer. The patient was started on high dose corticosteroids. She responded gradually over 10 days and was extubated. Her symptoms resolved. Renal biopsy was done 10 days later when the patient was stable, and showed severe tubular injury with erythrocyte stasis, RBC casts, and thrombotic microangiopathy. The use of cyclophosphamide was discussed, and considering the patient’s age she was discharged home on corticosteroids only. She remained symptom free and a follow up chest X ray was done six weeks later and was clear.    This case reports that microscopic polyangiitis or other forms of vasculitis should be suspected in patients with persistent pulmonary symptoms not responding to antibiotics for suspected pneumonia. Finding of renal involvement in this scenario should raise the suspicion of vasculitis.

 

 

IS IT WORTH SCREENING FOR INTRACRANIAL ANEURYSM IN FIRST DEGREE         RELATIVES OF PATIENTS WITH SPORODIC CEREBRAL ANEURYSM

Seema Srivastava, MD, Sinai Grace Hospital, Detroit Medical Center, Detroit, MI

Background – The outcome of subarachnoid hemorrhage from ruptured aneurysm is poor, with case fatality rate of 50%-70% and functional dependence of 20%. The risk of subarachnoid hemorrhage (SAH) among first degree relatives of affected patients is 3-7 times that in the general population. SAH is classified as familial when more than one first degree relative is affected and sporadic when the family history is negative. While screening asymptomatic family members in the setting of familial SAH is recommended, the yield from screening in the setting of sporadic SAH is not yet well established. Methods – A literature search of OVID-MEDLINE, Pubmed , and Up To Date was undertaken to identify studies done for screening for intracranial aneurysm in first-degree relatives of patients with sporadic SAH.  The MARS study published in 1998 and conducted at the University of Utrecht and the Academic Medical Centre of the University of Amsterdam is the only prospective study to evaluate the value of screening in sporadic SAH. Magnetic resonance angiography was used for screening and the diagnosis of aneurysmal SAH was confirmed by cerebral angiography.  Patients with nonaneurysmal SAH were excluded and elective surgery was offered to confirmed cases.  Six month after the surgery, outcome was assessed by Rankin scale of neurological function. Results – A total of 626 first-degree relatives of 160 patients with sporadic SAH were screened and 25 aneurysms identified (4%; 95% confidence interval, 2.6 to 5.8%).  Out of the 25, 18 underwent surgery, which resulted in decrease in function in 11(disabling in 1).  On average, surgery increased estimated life expectancy by 2.5 years for these 18 subjects (or by 0.9 months per person screened), at the expense of 19 years of decreased function per person. Conclusions- The implementation of screening program for the first-degree relatives of patients with sporadic SAH did not offset the risk of postoperative sequelae.  The benefits of screening may have changed since the MARS study as safer treatments, such as endovascular therapy have become widely available as alternatives to surgery.

 

 

A Link Between Periodontal Disease and Cardiovascular Disease (CVD)

Thien H. Van, MD, Department of Internal Medicine Sinai Grace Hospital, Wayne State Univ. /Detroit Medical Center

Introduction:  Periodontal gum disease has been shown to be linked to several systemic diseases such as CVD, stroke and diabetes.  Coronary heart disease (CHD) is one of the most prevalent amongst these.  By age 40, 49% of males and 32% of females have CHD.  50 million people (15% of total US population) have gum disease.  In the past 15 years, there have been a number of studies supporting the correlation between periodontal disease (PD) and CVD/CHD.  Extensive literature search suggests that there is a positive correlation between PD and CVD/CHD. Methods:  A comprehensive literature search of various studies including prospective cohort studies, cross-sectional and observational studies have been thoroughly reviewed for pertinent evidence on this topic.  The inclusion criteria were random controlled trials (RCT), meta-analyses, reviews on human studies in English.  The exclusion criteria were congenital, valvular and infectious heart disease.  Out of the initial 111 articles found, 11 studies were selected for their pertinence correlating the relationship between PD and CVD/CHD.   Results:  Of the prospective cohort studies, the First National Health and Examination Survey Epidemiologic Follow-up Study (NHANES I) evaluated the risks of CHD amongst those with gum disease, PD and neither from a total population of 8032 (ages 25-74 without CVD history).  It showed a correlation (p>0.05) between PD and CVD.  Among the nine longitudinal studies, 6 out of 9 showed a positive association between oral hygiene and CVD.  The majority of the case control and cross-sectional studies demonstrated evidence correlating poor dental index with increased CVD risks.  Out of 1,526 meta-analysis studies, 31 supported a modest association between PD and atherosclerosis, a risk factor for CVD.  An additional 11 studies also showed a modest association between PD and CVD.  A total of 9 perspective studies looked at a total of 94,869 people with 4,105 CHD events suggested that chronic periodontitis increased CHD by 15% (95% confidence interval; CI 1.08-1.22).  Meta-analyses also showed that PD increased the risk of CVD by 19% (relative risk of 1.19; CI 1.08-1.32). Conclusion:  There is a modest association between PD and CHD/CVD although the relationship is not causal.  This modest association needs to be further evaluated and substantiated with more observational studies and may one day justify dental hygiene as a screening tool for heart disease.

 

 

DOES BILE HAVE A ROLE IN THE DEVELOPMENT OF BARRETT’S ESOPHAGUS AND CONSEQUENTLY THE INCREASING INCIDENCE OF ESOPHAGEAL ADENOCARCINOMA?

Mukhtar Al-Saadi, MD; Rajika Munasinghe, MD

Introduction: The incidence of esophageal adenocarcinoma (EAC) is increasing considerably. In the United States, the rate of increase in EAC in the last 30 year is greater than that of any other major malignancy.     Objectives: Our aim is to identify evidence evaluating an association between exposure of the esophageal mucosa to bile and development of EAC.     Methods: A Medline search was performed to identify all pertinent English language reports of GERD, duodenogastroesophageal reflux (DGER), Barrett’s esophagus (BE), and EAC until December of 2008.    Results: The rising incidence of EAC represents a real increase of disease burden. BE is considered the only confirmed risk factor of EAC and caused by chronic GERD. GERD symptoms can be relieved in about 80-90% of cases with acid suppression therapy (AST); however, no decrease in the incidence of EAC has been documented. There is a concern that partial gastric acid suppression into PH ranges of 2-6 by AST encourages the formation of non polarized, soluble bile acids, which can penetrate and injure esophageal mucosa. AST does not suppress DGER and direct measurement of esophageal bilirubin exposure as a marker for DGER has shown that about half of patients with GERD have increased esophageal exposure to duodenal secretions. Animal studies have shown that bile reflux into the esophagus increases the prevalence of BE and EAC. Experimental studies showed that combined bile and gastric acid can induce genes involved in differentiation, signal transduction and carcinogenesis of the esophageal epithelium and upregulate oncogenes implicated in BE and EAC. Acid and DGER was the predominant reflux pattern in 95% of patients with BE.   Conclusion: Combined bile and gastric acid reflux could result in more severe esophageal mucosal injury manifested as BE and EAC. Incomplete acid suppression with AST may predispose to the development of BE and consequently EAC. This theory may explain the increasing incidence of EAC that has been observed concomitantly with the increasing use of AST.

 

 

A CASE OF OSTEOMYELITIS OF THE MANUBRIUM

Osteomyelitis of the manubrium is an uncommon cause of chest pain, which delays its early diagnosis.   A 29-year-old African American female presented with swelling on the front of her chest with pain for 2 days. About a month before, she presented to the emergency department with chest pain which was treated with naproxen for 10 days. The pain was at the center of the chest with radiation to the back, 10/10 in intensity, sharp; the pain worsens with movement and deep breath. It was associated with palpitations, chills, and poor appetite. No report of shortness of breath, lower limb swelling, cough, fever, night sweats, or weight loss. Reviews of symptoms were significant for dizziness, and heart murmur. No history of past surgeries was reported except for ectopic pregnancy. Family history turns out to be significant for heart murmur, seizure disorder, and lung cancer. The patient is an occasional drinker of alcohol and denied any substance abuse, smoking, or risk factor for HIV infection. On examination, generally she looked ill. Her temperature was 36.8 but reached 38.2, and was tachycardic. There was tenderness on her sternum, and had systolic murmur. The rest of the examinations were unremarkable. On admission her white cell count was 7.8 k/cumm, chest computed tomography scan (CT) showed radiolucent lesion on the right side of the manubrium sternum with significant swelling of the soft tissue around in the retrosternal region suggesting possible osteomyelitis or neoplastic bone tumor. A CT guided needle biopsy was performed and samples were sent for pathology and culture. In the meanwhile she was treated with nafcillin for sepsis secondary to osteomyelitis. HIV test was negative. The pathology report was consistent with abscess with no evidence of malignancy. The gram stain was negative, anaerobic culture grew rare Propionibacterium species, and the fluorescent stain was negative for acid fast bacilli. The tissue culture showed no growth after 4 days. The plan was to discharge her on intravenous Vancomycin (She developed thrombophelitis to nafcillin) but the patient refused and was discharge on bactrim for 6 weeks, instead. The mycobacterium culture was negative after 2 weeks. This is a report of an uncommon presentation of osteomyelitis in a healthy patient with no apparent risk factors; however suspicion lead to early diagnosis.

 

 

Carotid Endarectomy and CABG: What is the best plan of care?

Camille Henson, D.O.

Background and Objectives: It is well established that the presence of carotid artery stenosis is a significant predicator of poor outcomes in patients undergoing coronary bypass graft surgery (CABG). Operating on the carotid lesion first might increase the risk of myocardial infarction. While operating on the coronary lesion or lesions first might increase the risk of preoperative stroke. The objective was to investigate the most recent studies involved in addressing management of these patients. Methods:  A computerized literature search of Pubmed, OVID, National Institute of Health and Annals of Vascular Surgery was reviewed to identify studies that examined the interventional protocols for patients presenting with coronary artery disease requiring surgery in the presence of carotid artery disease.  Results: Four studies were identified. The first a meta-analysis of 56 studies reviewed three operative strategies, simultaneous carotid surgery and CABG, carotid surgery followed by CABG and CABG followed by carotid surgery. It concluded that perioperative stroke rates were 10% if CABG preceded carotid surgery, and somewhat lower if carotid and coronary surgery were combined (6%) and if carotid surgery preceded CABG (5%). While the second meta-analysis of 16 studies with a total of 844 combined patients and 920 staged patients concluded combined coronary artery bypass grafting and carotid endarterectomy may be associated with a higher risk of stroke or death than staged procedures. A systematic review of 97 published studies following 8972 staged or synchronous operations concluded overall, there was no significant difference in outcomes for staged and synchronous procedures. In the final study, four strategies were analyzed: CABG in the presence of carotid stenosis, combined CEA and CABG, reverse (CABG + CEA <3months) and prior staged (CEA + CABG <3 months).  Comparative analysis indicated a significant reduction in stroke for prior versus combined procedures.  Discussion: It is difficult to determine optimal management strategies for persons that present with symptoms of coronary artery disease and have carotid stenosis secondary to the inconsistent results of the many retrospective studies and lack of adequate randomized trials.

 

 

Spontaneous Diabetic Myonecrosis Disguised as Possible Lower Extremity DVT

Thien H. Van, MD, Department of Internal Medicine Sinai Grace Hospital, Wayne State Univ. /Detroit Medical Center

INTRODUCTION:  Diabetic muscle infarction, also referred to as diabetic myonecrosis, is one of the many micro- and macrovascular complications of long term diabetes.  It is usually associated with longstanding and poorly controlled diabetes mellitus (IDDM > NIDDM).  The infrequency of this disease makes it a formidable diagnostic challenge.   CASE REPORT:  A 62 year old African American female with a past medical history of systolic congestive heart failure dysfunction (EF:15%) s/p AICD placement, hypertension, diabetes mellitus (>40 years) and nephrotic syndrome, presented to the emergency department with upper abdominal and bilateral thigh swelling for approximately one week.  Prior to this, the patient has been admitted multiple times for the same symptoms.  She was treated with dobutamine drips, lasix and zaroxyln with some symptomatic relief but still recurring swelling.  Throughout the course of the hospital stay, the patient complained of intractable left thigh pain despite being ruled out for any deep vein thrombosis of bilateral lower extremities.  In addition to medical management of her anasarca secondary to her CHF, the patient had left thigh pain with an unknown etiology.  A right lower extremity CT with contrast was done instead of MRI (contraindicated due to AICD) showed no significant findings except swelling of soft tissue.  Her highest CPK and ALP were 329 and 260, respectively.  The patient received a biopsy to rule out infection before starting on steroids.  Despite all types of pain medications the pain persisted.  After approximately one week, the pathology report returned showing ongoing myofiber necrosis with diffuse endomysial reactive process, indicating a myonecrosis rather than an inflammatory process.  The patient was treated with prednisone and instructed to follow up with rheumatology.   DISCUSSION:  This case illustrates that not all extremity swellings may be due to PE or DVT but can also represent debilitating diseases such as pyomyositis, polymyositis and diabetic myonecrosis.  However, it differs from other diseases in that there is no leukocytosis, fever nor fluid collection.  Treatment of diabetic myonecrosis is one of spontaneous healing within a couple of weeks to a month.  Hence it is imperative to not only look to rule out common diagnoses such as DVT and infections but also to look for rare diseases such as diabetic myonecrosis with all patients coming in with initial complaint of lower extremity pains.

 

 

ROLE OF LOCAL STEROID INJECTIONS IN TREATMENT OF RADICULAR CHRONIC BACK PAIN; AN EVIDENCE BASED REVIEW

Dr. Zuhair Aejaz, M.D.

ROLE OF LOCAL STEROID INJECTIONS IN TREATMENT OF RADICULAR CHRONIC BACK PAIN; AN EVIDENCE BASED REVIEW  Dr. Zuhair Aejaz, M.D., Internal Medicine, DMC/ Sinai-Grace Hospital, Detroit, MI  Introduction: Back pain is the second most common reason for visiting a physician in the U.S.  Approximately 1000/100,000 people in the U.S. are chronically disabled because of back pain which costs  $20-50 billion annually.  Intervertebral disc herniation (IDH) is a very common cause of nerve compression and radicular back pain.  In this study, we performed an evidence based review to assess the effectiveness of local steroid injections for long-term syndrome relief of chronic persistent back pain with a radicular component.    Methods: An Ovid and Pubmed search of the literature was conducted using the keywords chronic back pain, low back pain, mechanical, radicular, corticosteroid and epidural steroid injection. Two hundred and sixteen studies met the search criteria.   All double-blind randomized controlled trials published in English were reviewed and two relevant studies published in 1997 and 2005 were identified.  Results: In one study with 158 patients up to 3 epidural injections of methylprednisolone acetate and isotonic saline were given in the active and placebo group, respectively.  Patients were evaluated at 3, 6, and 12 weeks.  It was found that at 3 weeks after first injection, the groups did not differ significantly with respect to primary outcome measure.  Results at 6 weeks were similar to those at 3 weeks [P=0.30] and at 3 months the two groups did not differ statistically in any of the outcome measures.  In another study with 228 patients, randomized in two groups to either receive 3 epidural steroid injections (ESIs) of triamcinolone acetonide or saline injections at 3 week intervals.    It was found that at 0 and 3 weeks ESI group demonstrated a transient benefit over the placebo group [P=0.016].  By six weeks the benefit of ESI was lost and at all subsequent visits there were no statistically significant differences between the groups on any outcome measure.    Conclusion: The review indicates that there is no benefit of ESIs in medium or long term treatment of radicular chronic back pain in terms of pain relief, surgery, or return to work and there is no benefit of repeated ESIs over a single injection.

 

 

Tight Glycemic Control in Pneumonia Patients.

Muhammad Umair Alam D.O.

Introduction:  Overall rate of Community Acquired Pneumonia (CAP) ranges from 8 to 15 per 1000 person per year; highest rate at the extremes of age.  Most hyperglycemic patients are diabetics.   Hyperglycemia can also present in non diabetic patients secondary to various etiologies.  There are limited number of studies relating to hyperglycemia and outcome of pneumonia, especially in USA.   Resources:  Literature search resources include Medline, UptoDate, International research Database.  Research was specifically limited to association between pneumonia, hyperglycemia, and other co morbidities associated with pneumonia.  There are no specific US studies about hyperglycemia and pneumonia outcome.   Results:  Nine articles were reviewed on this topic. Several proposed mechanisms are associated with hyperglycemia and poor pneumonia outcome.  Hyperglycemia associated microangiopathy increases the risk of pleural effusions and other complications.  Hyperglycemia is also associated with impaired Neutrophil function.  Neutrophil functional responses were inversely correlated with fasting plasma glucose (r = -0.89; P = 0.042). Hyperglycemia in CAP is also associated with increased mortality.  Patients with glucose > 200 mg/dL had an increased risk of death (9%, P = 0.03). Studies also show significant high mortality rate in hyperglycemic patients vs patients with tight glycemic control.   Conclusion:   Lungs are also a target organ for diabetic microangiopathy.  Better glycemic control pre-admission and during hospitalization reduces mortality. Studies also show that tight glycemic control improves survival in CAP.

 

 

NON-TRAUMATIC ATANTOAXIAL SUBLUXATION PRESENTED AS ACUTE ACQUIRED NON-TRAUMATIC CERVICAL DYSTONIA IN A HOSPITALIZED PATIENT.

Mukhtar Al-Saadi, MD (Associate), Adriss Faraj, MD (Associate), Sonali Sud, MD (Associate), Sarmad Al-Mansur, MD (Member)

Introduction: Cervical dystonia is a clinical sign of an underlining disease process that manifests as involuntary contractions of the neck muscles leading to abnormal postures and movements of the head.  Dystonia in general can be classified based on age of onset, distribution, and/or etiology.   Case Presentation: We present a 76 year old woman with a history of hypertension, diabetes, atrial fibrillation and unknown arthritis of the hands who was admitted to the hospital with complicated urinary tract infection.  Clinical examination on admission revealed normal vital signs, irregular pulse, and boutonniere deformities of the 2-5 digits bilaterally. The day after hospitalization the patient developed sudden onset neck stiffness with pain. Her head was extended and tilted to the left side with spasm of the neck muscles spasm on the right side. Limited range of motion of the neck and left lower extremity weakness was also noted.  CT scan of the cervical spine showed 45-degree leftward rotatory subluxation of the atlas over the axis with mild cord compression at the level of C2-3 disc space due to a spur at level of the C1- C2 joint.   Discussion: Cervical dystonia also known as torticollis is one of the major types of focal dystonias. It typically present in the fourth to sixth decades and affects women more than men.  Acquired torticollis is a common but non-specific clinical finding.  Differential diagnosis includes a wide range of etiologies including neurological, orthopedic, infectious, traumatic, rheumatic disorders as well as tumors, medications and other conditions like myopathy, Down syndrome and Marfan syndrome. In 1977 Feilding and Hawkins mentioned that persistent clinical deformity and painful restricted neck movements are features of undiagnosed atlanto-axial rotatoy fixation that leads to compromised atlanto-axial stability in which even minor injury to the neck can cause serious neurological problems.  Most cases of acute acquired not-traumatic torticollis are of benign etiology but some patients have more serious underlying disorders requiring thorough investigation.

 

 

Role of Steroids in Drug induced Acute Interstitial Nephritis (AIN)

Kanwal Razzaq MD, Sinai Grace Hospital, DMC, Detroit, MI

Background: Drug induced acute interstitial nephritis is a known cause of renal failure in 1% of all patients who present with new onset acute renal failure. Although steroids have been used traditionally in acute interstitial nephritis refractory to offending drug withdrawal, but this practice is controversial.  Data Sources: Pubmed and Ovid 1956 to 2008. Keywords used were AIN, Acute renal failure, steroids. Total number of studies found was 586. Those included here, were the largest studies done on this subject so far.  Study Selection: Study 1: Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis. Kidney Int 2008; 73: 940-946. Study 2: Acute Interstitial Nephritis: clinical features and response to corticosteroid therapy. Nephrol Dial Transplant 2004; 19:2778.  Outcome Measures: Study 1: Outcome was defined in terms of final serum creatinine and need to stay on chronic dialysis. Study 2: Outcome was set as final serum creatinine.  Results:  Study 1: 52 patients were treated with steroids 23 ± 17 (range 2-68) days after the withdrawal of offending drugs (Group 1). Final outcome of Group 1 was significantly better than Group 2 (no steroid treatment). No side effects of steroid treatment were observed. Study 2: Out of 42 patients, 60% received steroid therapy while remainder received only supportive care. No difference in out come was observed in terms of final serum creatinine. P value was not significant.  Conclusion: There is some evidence in support of steroid use in AIN, but data is insufficient. We need to do randomized controlled trials with larger number of subjects to define the exact role of steroids in AIN.

 

 

A CASE OF RECCURENT ACUTE DECOMPENSATED HEART FAILURE SECONDARY TO BIVENTRICULAR PACEMAKER BATTERY FAILURE

Seema Srivastava, MD, Faraj Adriss, MD Sinai Grace Hospital, Detroit Medical Center, Detroit, MI

INTRODUCTION: Heart failure (HF) is a common clinical syndrome representing the end-stage of a number of different cardiac diseases. It can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. CASE REPORT:  A 64-year-old Caucasian male with past medical history of hypertension, diabetes, COPD, coronary artery disease, aortic valve replacement, chronic systolic heart failure with left ventricular dysfunction (ejection fraction of 15%) and left ventricular dysynchrony status post biventricular automatic implantable cardioverter defibrillator (AICD) placement was getting admitted multiple times within the last 5 months to hospital with diagnosis of acute decompensated heart failure with no obvious precipitating cause.  During his workup it was found that his AICD with biventricular was depleted of battery since the first time of his hospital admission for heart failure. His batteries were replaced and since then he remained stable. DISCUSSION: AICD with biventricular pacemaker and medical management been recommended in patients with advanced HF (usually NYHA class III or IV), severe systolic dysfunction (eg, left ventricular ejection fraction &#8804;35 percent) and intraventricular conduction delay (eg, QRS >120 msec).  It may improve pump performance and reverse the deleterious process of ventricular remodeling.  It reduces regional and global molecular remodeling via resynchrization. The increased contractility is associated with no change or a modest reduction in myocardial energy demands and myocardial oxygen consumption.  SUMMARY:  With the increasing application of cardiac resynchronization therapy, clinician should evaluate device function in addition to other causes when patients present with acute decompensated heart failure.

 

 

Acute Hearing Loss and Heroin overdose.

Muhammad Umair Alam D.O.

Heroin overdose can cause increased production of free radical oxygen species.  Studies have also shown evidence of ototoxicity via free radical.  Thus Heroin overdose can cause acute rise in free radical which can lead to acute ototoxicity.   48 year old male with no available past medical history is brought to hospital via EMS due to altered mental status.  Patient was found to be unresponsive by his daughter.  On EMS arrival, patient had GCS of 7, his blood pressure was 97/71 and pulse was 90.  Pulse ox was 98% on room air.  Blood sugar was 59.  Per daughter patient did not complain of any symptoms the night before.  She also admits that she has a high suspicion that patient was using IV heroin again.  Upon arrival to hospital, patient was found to be awake but confused.  Patient was also complaining of bilateral hearing loss.  Patient was able to communicate through writing. Triage lab work showed mild hyperkalemia, CPK level of 11144, troponin of 11.48, and Urine drug screen positive for opiates.  CT of the head showed no acute process.  Patient was taken for cardiac catheterization.  No evidence of coronary artery occlusion was found.   A detail neurological exam showed no focal deficit.  Further evaluation via MRI revealed no evidence of acute ischemic event.  Patient was started on IV dexamethasone in hospital.  Patient was eventually discharged from hospital with tapering dose of prednisone.   This patient''s isolated hearing loss, without any other neurological deficit, is likely due to the acute free radical production secondary to acute heroin overdose. Furthermore, repeated brain imaging did not show any sign of ischemic brain injury.

 

 

CRYPTOGENIC ORGANIZING PNEUMONIA PRESENTING AS BILATERAL DIFFUSE PULMONARY NODULES MIMICKING METASTATIC CANCER

Mukhtar Al-Saadi, MD; Hassan Makki, MD

Introduction:  Cryptogenic Organizing Pneumonia (COP), also known as idiopathic Bronchiolitis Obliterans Organizing Pneumonia (BOOP), is a well-known pathologic and clinical entity.  The classic presentation (typical BOOP) is that of non productive cough, low grade fever, dyspnea, and malaise. Although the majority of cases are idiopathic, BOOP may occur in association with a variety of diseases including bacterial infections, rheumatologic or connective tissue disorders, HIV, organ transplantation, radiation and drug toxicity, and environmental exposures. The most usual CT scan appearance is bilateral areas of patchy air space consolidation which may be migratory. Case: We report a relatively rare entity of a 44-year-old African American woman, smoker, who presents with worsening non-productive cough of three months duration, and dyspnea.  Chest x-ray revealed a mass in the right lower lobe. CT scan of the chest revealed multiple nodules bilaterally, the largest measures 1.6x2.3 cm.  CT guided FNA of a left lower nodule was non diagnostic. A fiberoptic bronchoscopy with biopsy revealed features suggestive of BOOP.  Due to the concern for metastatic cancer, the patient underwent video-assisted thoracoscopic surgery (VATS) with wedge resection of the left lower lobe nodule which revealed features of BOOP.  Treatment with prednisone 40 mg a day commenced and a follow up CT scan in 4 weeks revealed complete resolution of bilateral pulmonary nodules. Discussion: COP is a heterogeneous disorder with insidious onset, non specific physical findings, and variable radiographic patterns but with typical histopathologic findings that are sine que non for diagnosis.  The caveat is that COP is a diagnosis of exclusion.  There is no sex predilection.  COP occurs most commonly in the sixth decade.  When COP presents as solitary or multiple nodules or masses, it may be termed as localized organizing pneumonia which is a relatively rare entity as in our patient.  The precise biologic nature, natural history, and response to treatment are therefore still to be defined. Conclusion: Localized organizing pneumonia is clinically and radiologically different from typical “BOOP”.  It is difficult to distinguish BOOP from primary or metastatic tumor.  Surgical biopsy via VATS with wedge resection is the favored diagnostic method. The prognosis of treatment with steroids is good for typical BOOP, but unclear for localized organizing pneumonia. Our patient experienced a dramatic symptomatic and radiologic improvement with steroid therapy.

 

 

Tricuspid Valve Fibroelastoma Mandates Open Heart Surgery

Cibar Benitez, MD.  Adriss Faraj, MD

Cardiac Papillary Fibroelastoma is a rather rare benign tumor of the heart that is seen for the most part, in autopsies, as incidental findings. Its location as well as the symptoms associated with it, dictate the therapeutic approaches.  A 66-year-old-man with a medical history of coronary artery disease presented to an outpatient cardiology office for a regular follow up. A routine transthoracic 2-D echocardiography revealed the presence of a 5.2 x 5 mass attached to the tricuspid valve. Physical examination of the cardiovascular system was unremarkable, a 12-lead EKG was normal. A trans esophageal echocardiography revealed a lobulated mass with its stalk attached to the posterior portion of the septal leaflet of the tricuspid valve. The echocardiographic findings were consistent with a myxoma. The patient was then referred for cardiac surgery for tumor resection. The excised mass histopathological examination revealed acellular collagenous papillary projections with elastin fibrils within. These features are consistent with the diagnosis of Papillary Fibroelastoma. The patient was discharged home a few days after the procedure.  Fibroelastomas are usually asymptomatic, benign, and accidentally-found tumors of the heart. They usually occur on the left side of the heart more than on the right. This case illustrates how fibroelastomas, should be surgically excised, disregarding of their benign nature, because of the risk of complications such as massive pulmonary embolism in this patient.

 

 

HYPOTHYROIDISM INDUCED HEART FAILURE _COMPLETE REVERSAL OF CARDIOMYOPATHY  WITH  LEVOTHYROXINE

Mona Khalid M.D, Associate, Department Of Medicine, Sinai Grace Hospital, Detroit MI

The systemic hypo metabolism associated with hypothyroidism results in decrease in cardiac  output that is mediated by reduction in heart rate and contractility. Thyroid hormone regulate  genes encoding for specific myocardial enzymes involved in contractility and relaxation. Signs and symptoms of heart failure are usually absent in patients who have no other cardiac disease. Advanced  heart failure in hypothyroid patients have been described only in severe symptomatic cases mostly during myxedema coma . We present a case of a young, hypothyroid patient who presented with congestive heart failure and cardiomyopathy with complete reversal of condition with levothyroxine. A 38 year old African American female presented to ER with gradually worsening exertional dyspnea and lower extremity edema .On exam patient had bilateral chest crackles elevated BNP.TSH was high with very low T4. EKG showed normal sinus rhythm. Troponin enzyme was negative.  Echocardiogram showed dilated ventricles with severely depressed systolic function, ejection fraction of 20-25%,along with moderate pericardial effusion. Patient got pericardial window and levothyroxine was started along with a beta blocker and ACE inhibitor. Patient was discharged when became euthyroid and was followed up as an outpatient. Four months later echocardiogram was repeated which showed that the size of ventricles was back to normal and ejection fraction was 55%.The patient was also completely asymptomatic with normal TSH. This case emphasizes the fact that cardiovascular dysfunction associated with hypothyroidism subsides when euthyreosis is restored. This case also suggests heart dysfunction in hypothyroidism is similar to that observed in heart failure .Hypothyroidism may also result in accelerated atherosclerosis and CAD, however our patient had no sings and symptoms of ischemic

 

 

TUBERCULOUS LYMPHADENITIS- REMAINS AN IMPORTANT CAUSE OF LYMPHADENOPATHY

Wasif Hafeez,fellow,department of infectious disease,Sinai Grace hospital,detroit MI

Tuberculous Lymphadenitis- Scrofula remains a common cause of extra pulmonary tuberculosis (T.B). In endemic areas it accounts for 43% of all cases of peripheral adenopathy. In USA 5.4% cases of T.B are extra pulmonary and 31%of these cases involve the lymphatic system. We present the case of T.B lymphadenitis presenting as asymptomatic enlarging cervical lymphadenopathy. A 26-year old, immigrant from South East Asia, presented to doctor with the complaint of progressively enlarging lymph node in front of neck over three months. The patient denied any symptoms of cough, fever, nightsweats or weight loss. On exam an enlarged, firm, mobile, nontender lymph node was palpated in anterior cervical chain.CT neck with contrast showed a few more enlarged lymph nodes in right parotid region.CT chest showed multiple small, subcentimeter non calcified nodules in bilateral lower lung lobes .No hilar,mediastinal or axillary lymphadenopathy was seen. At this point the differential included lymphoma, sarcoidosis and T.B. FNA was  done on cervical lymph node that showed numerous normal lymphocytes and few histiocytes suggesting ill-defined granulomas. Flow cytometry was normal. Later on Excision biopsy of the lymph node was carried out. The results of pathology showed multiple granulomas, a few with central necrosis. Special stains for fungi and fluorescent staining for AFB were however negative. Five weeks later the culture result came positive for Mycobacterium Tuberculosis. It is interesting to note here that repeat fluorescent staining was still negative for AFB. In the non HIV population T.B lymphadenitis presents as isolated non tender lymph node enlargement without systemic signs.FNA has sensitivity of 77% in non HIV patients. Lymph node biopsy cultures are a more reliable method of diagnosis. Inclusion of PCR assay leads to earlier diagnosis when special stains for AFB are negative.Also PCR is more sensitive to detect bacteria as compared to culture when there are only few bacilli..

 

 

BENIGN RECURRENT INTRAHEPATIC CHOLESTASIS

Khokhar, S. PGY3; Thien, V. PGY1,  Department of Internal Medicine Sinai Grace Hospital, Wayne State Univ. /Detroit Medical Center

INTRODUCTION: Benign recurrent intrahepatic cholestasis is a rare hereditary disorder seen in young adults characterized by recurrent episodes of cholestatic jaundice seen more commonly in females. It is subdivided into 2 subgroups. Our case is unique because it represents this condition in a young male with overlapping clinical manifestations between the 2 subgroups & lack of resolution of symptoms as seen with almost all reported cases. CASE REPORT: 33 year old African American male with PMH of GSW s/p surgical repair & recurrent jaundice since 4 years presented to the hospital with c/o abdominal pain, diarrhea, wt. loss & discoloration of eyes. No h/o active alcohol &/or drug use or family h/o liver or biliary tract disease. Physical exam findings positive for diffuse abdominal pain & scleral icterus.US abdomen showed a contracted gallbladder, no biliary dilatation, normal liver & spleen size. CT results unremarkable with normal ERCP, EGD & Colonoscopy. Liver biopsy results were consistent with benign recurrent intrahepatic cholestasis. DISCUSSION/CONCLUSION: First described in 1959, benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive disease classified into two subgroups based on genetic classification, pathogenesis & clinical manifestations. BRIC-2 is due to a mutation in bile salt export pump, more common in females presenting with symptoms of hepatobiliary disease & cholestasis. Disease course includes abdominal pain, recurrent bouts of jaundice & pruritis lasting weeks to months with spontaneous resolution & without progression to liver damage in most cases. Our case is different because of its rare occurrence in a male, late onset & overlapping clinical manifestations. Our patient is undergoing genetic testing to identify the gene mutation; his symptoms however have been persistent since months with no response to any medications.