Gastric Pacing in Treatment of Obesity

Arwa Laheri,MD

Department of Medicine, SinaiGrace Hospital/ Detroit Medical Center/ Wayne State university,Detroit, MI.

 

Introduction: Obesity has become an escalating epidemic worldwide, associated with a multiple medical conditions like insulin resistance, diabetes, hypertension, CAD, cancers, sleep apnea, GERD, etc. It is the second leading preventable cause of death after smoking. Medical therapies are often ineffective and surgical treatments have significant risk. Implantable Gastric Stimulation (IGS) offers a novel approach to weight loss. Methods: Randomized controlled trials/ multi-center studies were selected. Literature search was from Ovid Medline, Pub med and Cochrane Library. Ovid Medline & Cochrane Library didn’t yield relevant studies. Pub med yielded 5 were relevant & 3 studies met my criteria: 1) US O-01 trial:  a multi-center, randomized, double blinded, placebo controlled trial, N= 103 morbidly obese patients. 2) DIGEST (Dual- lead implantable gastric electrical stimulation trial): a prospective, open label, trial, N=30 morbidly obese patients. Patients were followed not only for complications, post-operative untoward effects, and weight loss but also satiety, appetite & quality of life. The DIGEST trial was unique in 3 ways: a) it used 2 leads & parameters were individualized, b) excluded binge eaters, & c) gave behavioral support & dietary advice to patients at each visit. A preoperative Screening Algorithm (SA)(Age, BMI, and patient’s perception of his/her emotional and physical health) was applied to both these trials retrospectively as they thought some patients responded better to IGS than others. 3) LOSS (Laparoscopic obesity stimulation survey): a multi-center, prospective clinical trial, N= 69 patients in 5 European countries & patients were followed for complications & weight loss.

Results: The mean excess weight loss (EWL) was 20% with US-O 01 trial, 23% after 16 months with DIGEST & 21% at 16 months with LOSS. With the application of SA, almost 40% EWL was achieved for selected patients in both trials. There were no major peri-operative complications seen in all the 3 trials. The SHAPE (Screened Health Assessment and Pacer Evaluation) trial is currently ongoing to prove if combining preoperative screening algorithm and IGS yields significant benefits.

Conclusion: IGS holds promising results for morbidly obese patients, especially for those who are not candidates for or willing for surgery.

 

 

BORDETELLA PERTUSSIS INDUCED ACUTE RESPIRATORY DISTRESS SYNDROME IN AN ADULT MALE.

Platel R, MD, MPH (Associate); Wolf M, MD; Dalal B, MD, (Associate). Sinai-Grace Hospital, Wayne State University, Detroit, Michigan. Detroit, MI

Introduction: We are reporting a case in which Bordetella Pertussis was responsible for Acute Respiratory Distress in an Adult. Case Report: A 55-year-old male health worker, with a recent diagnosis of Autoimmune Hepatitis and on steroid therapy was admitted to the hospital with the complaints of leg pain and weight loss. On day 3 of hospitalization he developed shortness of breath, had a chest x-ray showing interstitial infiltrate suggestive of pulmonary edema or congestion. The patient worsened clinically even with diuretics, repeat chest radiograph showed bilateral air space or alveolar infiltrates. Transferred to the ICU on day 5 and broad-spectrum antibiotics initiated. The relevant lab work up and investigations were sent. On day 13 the patient deteriorated with a PO2 of 50%, and was intubated. The patient was maintaining a PO2>90% only with 90-100% of FiO2. A bronchoscopy and subsequently a lung biopsy were performed. Previously sent results sera came back positive for Chlamydia pneumoniae (IgG) and Pertussis (IgA). Azithromycin was started with an improvement in symptoms and a decrease in FiO2 requirement down to 40% for two days and ready to be extubated. Unfortunately, the patient developed a high-grade fever and ventilator associated pneumonia with Acinetobacter baumannii, treated with Unasyn and was extubated. After 4 weeks of illness the repeat serology for Chlamydia pneumoniae (IgG) remained unchanged while the Pertussis (IgA) titer was negative. In retrospect we concluded that this was a diagnosis of Pertussis induced ARDS. Discussion: There is increasing evidence that pertussis occurs frequently in adults, but information is limited on the clinical course of this disease beyond childhood. It is of note that Pertussis has been added this year to the Adult Immunization Schedule as single dose of Tdap , booster immunization against tetanus, diphtheria, and pertussis every 10 years. We report this case to emphasize the significance of this rare infectious cause of ARDS in adults. To our knowledge, one case report in the pediatric population and no similar presentation in adults have been reported in the literature. We therefore suggest that Pertussis should be thought of as a potential etiologic agent of adult ARDS

 

NON HORMONAL THERAPIES FOR THE TREATMENT OF HOT FLASHES

Raylene Platel, MD, Associate. Sinai-Grace Hospital, Wayne State University, Detroit, Michigan

Clinical Question: 55-year-old Caucasian female is experiencing severe hot-flashes and requesting non-hormonal therapy for her hot-flashes. Her mother used HRT and this patient is aware of the WHI outcome, what can she be prescribed? Data Sources: Medline database from 1985-2005 using PubMed and Ovid. Search Terms: Non-hormonal-therapy for hot-flashes, hot-flashes, non-hormonal therapy. Results: Ovid Medline: 7 Pubmed: 78 Search limited to: RCT, human studies. Studies reviewed: SSRIs-Paroxetine andVenlafaxine. Gabapentin.Clonidine.ICE. Paroxetine: RCT (Stearns et al.) Intervention: 1 wk. Placebo run in phase. Placebo/12.5 mg per day/25 mg per day in a 1:1:1 ratio for 6 wks. N=165 Venlafaxine: RCT (Evans et al.) Intervention: 1 tab daily, 1 week followed by 2 tabs daily, 11 wks. N=80 Gabapentin: RCT (Guttuso et al.) Intervention: 900 mg/day of gabapentin, 12 weeks followed by 5 week open-label-treatment-phase with option to increase dose to 2700 mg/day.2 week screening baseline assessment. N=59 Transdermal-Clonidine: RCT (Manubai et al.) Intervention: Arm Patch changed every week delivers 0.1mg/day of clonidine, 2 weeks. Baseline and 8 weeks treatment. N=30 ICE: Isoflavone-Clover-Extract-Study, RCT (Tice et al.) Intervention: 2 week Placebo run in. Random assignment to Promensil (82 mg), Rimostil (57 mg), placebo with f/u for 12 weeks. N=252 Outcome Measure: Hot-flash score recorded as frequency of hot-flashes by participants in the Clonidine study, severity was also measured. Results: Paroxetine: 62.2%, 64%and 37.8% score reduction for 12.5 mg, 25 mg and placebo groups respectively. Venlafaxine: Average score reduction was 2 points (p=0.25). Gabapentin: 54% and 31% reduction in score with gabapentin and placebo respectively (p=. 01) Clonidine: 80% and 36% score reduction in treatment and placebo groups respectively.73% and 29% decrease in severity in treatment and placebo groups. ICE: Decrease in daily score was 5.1,5.4 and 5.0 respectively for promensil, rimostil and placebo groups respectively. Conclusion: FDA approval of a medication for hot-flashes mandates study periods of at least 12 weeks. ICE, Gabapentin and Venlafaxine were the three studies that qualified of which only Gabapentin showed significant reduction in hot-flash frequency. Paroxetine and transdermal clonidine were found to be effective but inadequate study periods of only 6 weeks/ 8 weeks respectively.

 

Eclamptic Seizures In Pregnancy:

An Unusual Presentation Of Dural Sinus Thrombosis

Vindya Achuthan, MD, Associate, Hassan Makki, MD, Member, Department of Internal  of Medicine, Sinai Grace Hospital, Wayne State University, Detroit, MI.

 

 A 25 year old woman with an intrauterine pregnancy of 27 weeks presented to our emergency room with a witnessed grand mal seizure. She had complained of a headache one day prior to this event with visualization of ‘spots’. She described no prior seizure history and her pregnancy had been uncomplicated thus far. The patient's family history was significant for cerebrovascular accident in mother at age 34 and multiple myocardial infarctions in her father at age 40.  The patient was diagnosed with eclampsia as she  had  systolic blood pressures ranging between 175 to 200. Inspite of urgent management with intravenous magnesium, hydralazine and labetalol, the patient had a recurrent seizure and an emergency ceasarian section delivery was conducted.

Post-operatively, the patient continued to have a headache and visualization of ‘spots’. A CT scan revealed deep white matter ischemic changes in the upper portion of the brain towards the vertex, with edema reflected in the ischemic gyri, suggestive of hypertensive encephalopathy. A magnetic resonant venogram (MRV)was done which demonstrated marked attenuation in the superior sagittal sinus with lack of visualization of the left transverse and sigmoid sinuses. These findings  were highly suspicious for a dural venous sinus thrombosis involving the superior sagittal sinus as well as the left transverse and sigmoid sinuses. Full anticoagulation with intravenous heparin was initiated immediately. Patient had no furthur seizures and is currently 3 months post partum without any complications. Repeat MRV showed persistant decreased attenuation of flow in superior sagittal, transverse and sigmoid sinuses. Hypercoagulable work up done was negative.  

Discussion: Dural sinus thrombosis is a difficult diagnosis, as there are no pathognomonic signs or symptoms. It has been reported to occur during pregnancy and up to two months postpartum. The superior sagittal sinus is not commonly involved. Pregnancy-related hypertension and cesarean delivery are important risk factors. The present case highlights the importance of the differential diagnosis when a pregnant woman develops eclampsia or seizures . Anticoagulant therapy is indicated for three to six months and during future pregnancies.

 

 

Hereditary Hemorrhagic Telangiectasia (HHT) – A Case Report

Anupam Gupta, MD, Associate, Asadullah Mohammed, MD, Member, Department of Internal Medicine, Sinai-Grace Hospital/DMC, Wayne State University, Detroit, MI.

Background: Hereditary hemorrhagic telangiectasia (HHT) or Osler-Weber-Rendu syndrome is a autosomal dominant disorder characterized by epistaxis, cutaneous telangiectasia and visceral arteriovenous malformations. It is estimated that half a million population worldwide have HHT.

Case Report: We describe a 37 year old female with a long standing history of migraine, multiple transient ischemic attack (TIA) in the past, irritable bowel syndrome with GI bleed, recurrent pulmonary symptoms and epistaxis during pregnancy. The onset of her symptoms was at an early age of 8-9 years when she started having repeated attacks of headache, weakness and numbness of the right side of the body, decreased vision. During that time, CT of the head was negative and she was diagnosed with migraine headache and TIA. At age 17, she started to develop pulmonary symptoms like dyspnea and tiredness after exertion, severe chest pain. X-Ray and CT scan results were negative.  Ten years later, she was admitted for pneumonia and at that time X-Ray/CT scan results showed minor left PAVM. No treatment was suggested until she became pregnant two years later and the chest pain / dyspnea symptoms got worse. CT scan and MRA showed enlargement of PAVM with a risk of bleeding and she was treated with embolization and coils. She was eventually appropriately diagnosed to have HHT at 31 years of age.  Her mother had a history of migraine headache and facial telangiectasia and her brother died of a stroke at an early age of 12. After her HHT diagnosis, her five children were screened and all of them meet 2-3 HHT criteria out of 4.  

Discussion: HHT has long been viewed as rare condition. However, this disorder is now considered to be more common than previously thought. The overall incidence of HHT in North America is estimated to be about 1:10,000; however, it is likely that this represents an underestimation because of underdiagnosis of the condition.    

Conclusion: This report serves to remind clinicians about the early detection of HHT to prevent any major complications. This case also illustrates the importance of hereditary counseling for patient and to suggest HHT screening in patient’s relatives.

 

Purple urine bag syndrome (PUBS) **  A Case Report and literature review

Irfan Hameed MD, Gulnaz Khan MD, Wasif Hafeez MD,Wayne State University/Detroit Medical Center (Sinai-Grace Hospital) Porgram, Detroit, MI.

Purple urine bag syndrome (PUBS) is an interesting phenomenon of irresolute etiology first reported in 1978, associated with chronic urinary catheterization.  This syndrome is more frequently observed in chronically catheterized constipated elderly women in geriatric wards or patients lived in nursing homes.

           

We are describing a case report of PUBS in 80 year old male from home with a history of quadriplegia secondary to spinal abscess resulting in bed bound state and chronic indwelling catheter since last 10 years.  Patient presented with abdominal distension, vomiting and chronic constipation.  On presentation he was found to be hypotensive, lethargic and confused with distended abdomen.  He also had supra pubic catheter for years secondary to repeated urinary tract infection.  The catheter bag was filled with purple color urine which showed pH of >9.0, 3+ bacteria and leukocytes.  Abdominal imaging was consistent with fecal impaction through out the colon.  He was treated with intravenous fluid, cefepime and disimpaction.  Urine culture grew multiple organisms.

PUBS is characterized by the purple discoloration of the urine, collecting bag, and tubing. A number of factors are involved, but not always present, in its development including female sex, gram negative lower urinary tract infection, constipation, laxative suppository use, indicanuria, institutionalization, the use of a plastic (PVC) urinary catheter and alkaline urine.  The etiology is still controversial but in the literature researched most authors believe that indigo, which is blue, and indirubin, which is red, are responsible for the colors obtained.  Chronic constipation is commonly associated with bacterial overgrowth in the bowel in which tryptophan has been converted to idol and yields the high levels of indigo (blue) and indirubin (red) in urinary bags of patients with bacterial infection of the urine, because indigo-producing bacteria have indoxyl phosphatase or sulfatase that can produce indigo and indirubin.  Despite multiple theories that involve the complex tryptophan metabolism to the tubing dye, the cause remains elusive.

The common pathogens isolated from the urine samples are Escherichia coli, Providencia var. spp., Proteus mirabilis, Klebsiella pneumoniae and Pseudomonas Aeruginosa.  The syndrome resolves usually after treatment of urinary tract infection or changing of the collecting bag.

 

 

Actinomyces meyeri  Bacteremia:  Presenting as Pneumomediastinum and Myocarditis,   A Case Report

Irfan Hameed MD, Gulnaz Khan MD, Asadulla Mohammad MD, Mark Wolf MD, Sinai Grace Hospital / Wayne State University, Detroit, MI.

Introduction: Actinomycosis is a relatively rare infection, caused by Actinomyces species, a commensal in humans.  A. Israeli (85%) is the most common pathogen.  Dentogingival disease and alcoholism are risk factors for acquiring A. meyeri, which is more commonly reported in pulmonary infections.

Case Report: We are describing a case report of a patient who is a 21-year-old male with no significant past medical history presented with pleuritic chest pain, shortness of breath and palpitations for one week, anorexia, nausea, fatigue and profound weight loss since five months.  Physical examination revealed a cachectic man with hypotension and subcutaneous emphysema.  Workup showed pre-renal azotemia and pneumomediastinum but CT scan of the chest and esophagogram did not show any perforation at the time of presentation. Later patient developed fever and worsening chest pain with elevated troponin. An EGD was performed and a large ulcer at the gastroesophageal junction was found with suspected perforation. He underwent surgical exploration of chest and abdomen which showed large gastric ulcer but no evidence of perforation. Echocardiogram of the heart showed global hypokinesia with ejection fraction of 15%. Alpha-1 antitrypsin level was normal. Blood culture grew Actinomyces Meyeri for which he was treated with Unasyn. Repeated echocardiogram showed ejection fraction of 55%. Patient had an extensive workup in the search for the site of local infection which was negative.

Discussion: Actinomycosis is a chronic disease, most commonly involving the cervicofacial, thoracic, abdominopelvic and CNS regions. A break in the mucosa of the GI tract is often the portal of entry. In tissues it is associated with a chronic inflammation with granulation tissue, fibrosis and sinus tract formation. Diagnosis is best made by growing it in culture. Penicillin is the drug of choice and treatment duration is usually prolonged. Our case appears to be the result of a gastroesophageal tear. Whether cardiac involvement occurred as a result of hematogenous spread from gastroesophageal tear or from aspiration with subsequent spontaneous resolution of the pulmonary site is unknown. This patient demonstrated a globally decreased EF which improved after antibiotic course. This supports previous reports of cardiac involvement by actinomyces.

 

 

Fatal Spontaneous Massive Hemorrhage In SLE

Shireen Jindani, MD, Associate, G. Cipullo, MD, Associate, T. Piskorowski, MD, Member, Department of Internal Medicine, T.Matthys,M.D, Director of Special Procedures Sinai-Grace Hospital/Detroit Medical Center, Wayne State University, Detroit, Michigan.

 

Introduction

SLE is an autoimmune disease mediated by autoantibodies and immune complexes. 90% of patients are women of childbearing age. The highest prevalence of SLE in United States is among African Americans.We report a rare case of fatal spontaneous hemorrhage of the breast in a patient with SLE.

Case report

55-year-old African American woman with past medical history significant for Diabetes, Hypertension, ESRD on Hemodialysis and SLE was admitted for neuroglycopenic symptoms of hypoglycemia. Patient was treated for her symptoms and on day number 5 of hospital stay developed sudden chest pain with hypotension that required cardiopulmonary resuscitation. ACLS protocol was followed leading to intubation and transfer to ICU. During resuscitative efforts a hematoma was found in left chest wall. Patient was found to have coagulopathy,  (PTT, PT, INR 200, 35.9, 3.55 respectively) acute on chronic anemia (hemoglobin from 10 gm/dl to 2.5 gm/dl) and thrombocytopenia (platelet count dropped from 114,000/cmm to 75,000/cmm). Peripheral blood smear did not reveal any schistocytes and was negative for any evidence of microangiopathy . Work up for acute coronary syndrome was negative. Complement levels CH50 was found to be very low and anticardiolipin antibody was negative. Patient was aggressively treated with Packed Red Blood Cells, Frozen Plasma, and Cryoprecipitate and given vitamin K. Uncontrolled bleeding of left breast required embolization of feeding branches of subclavian artery. Although hemostasis was achieved, patient died on hospital day 9 due to VDRF (Ventilator Dependent Respiratory Failure) and Multiple Organ Failure. Post mortem revealed left breast   hematoma (30cm x20 cm x15 cm). Microscopy shows fibrinoid necrosis of vessels consistent with SLE

Conclusion

This acute and fatal presentation of massive hemorrhage is unique. An extensive review of literature reveals that bleeding complications are rare with SLE and typically present with pulmonary hemorrhage some cases of GI, Intra cranial bleed or hematoma associated with oral anticoagulation or with APLA .Our case is first reported case of subclavian artery hemorrhage as bleeding complication of SLE.

 

 

Carcinoid tumourlet presenting as ectopic Cushing's syndrome.

P Misra MD, Z Shahid MD, R Thirumala MD, B Dalal MD, O Alzohaili MD, Department of Internal Medicine, Sinai-Grace hospital/ Wayne State University, Detroit, MI.

Introduction: Bronchial carcinoid tumours are rare, low-grade malignant neuroendocrine tumors accounting for 2.5% of all lung tumors & 12-15% of carcinoid tumors. We report a case of carcinoid tumourlet presenting as ectopic Cushing’s syndrome.

Case report: An 80-year old African American female with a history of CHF was found to have persistent severe hypokalemia. Basic lab work revealed a normal serum aldosterone with extremely high renin and serum cortisol. On further investigation of her hypercortisolism, a low dose dexamethasone suppression test was done that failed to suppress the cortisol. Subsequently, a high dose dexamethasone suppression test also failed to suppress the cortisol. Further, the serum ACTH was found to be very high. A search for the source of her high ACTH with a CT abdomen revealed bilateral adrenal hyperplasia. An MRI brain did not reveal any pituitary adenoma. This entire constellation of findings favored an ectopic source of high ACTH. To differentiate between a pituitary micro adenoma and an ectopic source of high ACTH, a petrosal venous sampling with CRH stimulation was performed. It did not reveal a gradient between the central and peripheral serum ACTH levels, which confirmed an ectopic source of ACTH. Therefore, a CT chest was done which showed bilateral small ground glass appearance more on the right. Bronchoscopy and BAL were negative for malignant cells. Subsequently, a right open lung biopsy revealed carcinoid tumorlet that was weakly positive with ACTH immunostaining. The patient’s serum FSH, LH and TSH were also inappropriately suppressed while serum prolactin and IGF-1 were normal. But the patient’s respiratory condition deteriorated and the patient died a couple of months after initial presentation.

Discussion: Our case report highlights the following facts: 1) Only 2% of carcinoid tumours present as Cushing’s syndrome. 2) Unusual clinical presentation of bronchial carcinoid tumor at this age group. 3) High serum cortisol can cause feedback suppression on FSH and LH. 4) The approach to determine the etiology of Cushing’s syndrome. The drawback in our case is our inability to rule out tumor/metastasis at other sites by tissue biopsy, which might have explained the rapid deterioration in this case.

 

 

Predicting cardiovascular outcomes -postprandial blood glucose or HbA1C?

P Misra MD, Department of Internal medicine, Sinai Grace hospital/Wayne state university. Detroit MI.

Background: Currently we use HbA1C as an index of glycemic control and a predictor of micro vascular complications of diabetes. There is a controversy as to the role of PP2BS in predicting cardiovascular outcomes. There is a direct relation between PP2BS and increased vascular tone, endothelial damage and postprandial hyperglycemia promotes production of adhesion molecules, inflammatory markers which along with hyperlipidemia promote atherosclerosis. The aim of this study was to analyze the efficacy of PP2BS as an effective predictor of cardiovascular events.

Methods: Extensive literature search was carried out using pubmed and Ovid as the search engines. Selection criteria were cohort, retrospective or prospective studies of adequate sample size assessing the relationship between PP2BS and cardiovascular events. Statistical significance was evaluated using hazards ratio, odds ratio, relative risk or a p value <0.05.

Results: 8 studies showed direct evidence linking PP2BS with cardiovascular events while 5 studies were found to have indirect evidence for the above.

Conclusion: Epidemiological data suggest that HbA1C alone is not a good predictor for cardiovascular events. When supplemented with postprandial blood sugars, it gives a better prediction for cardiovascular events. The limitation of the above analysis was that there is no study comparing head to head HbA1C and PP2BS in the context of cardiovascular events in diabetics. Also most of the data is observational.

Discussion: If PP2BS were a more reliable predictor of cardiovascular risks this would have implications both in the treatment (using alpha glucosidase inhibitors, meglitinides, analog insulin) and the timing of monitoring of glycemic events. We look forward for answers to the HEART2D study determining the effect of PP2BS control on cardiovascular outcomes in type 2 diabetics keeping a target of HbA1C of <7% in both of the 2 randomized groups.

 

 

The Influence of Renal Angioplasty and Stent Placement on Attainment and Persistence of JNC-7 Goal Blood Pressure.

 

Kavitha Potluri, MD, R.Galla, MD, Zongshan Lai, MPH, Peter Dews, Delair Gardi, MD, John M Flack, MD MPH, 

Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, Michigan.

 

Background:  Atherosclerotic renal artery stenosis is the most common form of secondary hypertension; percutaneous transluminal angioplasty (PTA) with stenting being the most common therapeutic intervention.

Objectives:   To characterize  blood pressure (BP) and kidney function response to renal angioplasty and stent placement, and to examine attainment and persistence of JNC 7 BP goals before and after revascularization.

Population:  Fourteen patients who underwent PTA with stenting for critical renal artery stenosis, were identified from MedTrace© electronic health records. All were African American, mean age was 70 years (range: 57-85), and all had difficult to control hypertension.

Methods:  Data considered included patient demographics, diabetes status and measures of kidney function, BP recordings, medication use, and results of duplex / MRA / angiography procedures. Mean pre- and post-intervention BP and kidney function values were calculated and BP responses determined. SBP and DBP responses to revascularization were examined in random coefficient mixed models adjusted for patient age, sex, weight, estimated glomerular filtration rate (EGFR), diabetes status, and treatment with antihypertensive and statin drugs.

Results:  Mean BP averaged 168/87 mm Hg pre-intervention and 147/75 mm Hg at the first visit post-revascularization (P<0.005, both SBP and DBP). In the adjusted mixed models, mean BP declined by 19/7 mm Hg following revascularization (P< 0.003, both SBP and DBP). Prior to revascularization, BP was below JNC-7 BP goal levels at only 6% of visits compared to 30% of visits post-revascularization (P=0.01). Mean pre- and post-revascularization EGFR was nearly identical (57.8 vs. 57.7 ml/min/1.73m2, P=0.39); mean post-revascularization serum creatinine increased from pre-revascularization values (1.3 vs.1.6 mg/dL, P=0.35); and median spot urine albumin:creatinine ratio values declined following revascularization (37.9 vs. 32.3, P=0.25).

Conclusion:  Renal artery revascularization with stenting lowered BP and significantly improved attainment of and persistence below JNC-7 BP goals in an older African American cohort with critical renal artery stenosis.

 

 

COUGH, TESTICULAR MASS, LOSS OF CONSCIOUNESS AND BLURRY VISION: COULD THAT BE A PRESENTATION OF SARCOIDOSIS?

S. Rajaguru, M.D (Associate), J. Gowda, M.D (Associate), V. Nayak, M.D (Associate), Lackey Lawrence S Jr. MD (Member), Department of Medicine, Sinai Grace Hospital/Wayne State University, Detroit, Michigan.

Introduction: Sarcoidosis is a multisystem disease of undetermined etiology, which is characterized by noncaseating granulomas. The most common sites of involvement of the disease are lungs and thoracic lymph nodes. However any organ system can be involved.

Case report: A 32 year old African American male with no significant past medical history presented to Sinai Grace emergency department with a history of loss of consciousness and fall. He also complained of early morning headache, blurry vision, productive cough and night sweat for past 2- 3 weeks duration. Also he noted 60 pounds of weight loss over 2-3 months. Other than a 0.5 cm non-tender firm left testicular nodule revealed in testicular examination the rest of the physical examination was unremarkable. CAT scan of thorax revealed extensive thoracic and upper abdominal adenopathy, patchy air space disease of upper lobe of left lung, pleural based mass and multiple small parenchymal nodules. MRI of head showed a large mass involving middle cranial fossa that extends to the right orbit. USS of testis revealed a 6mm solid nodule in left testis. Histopathology of brain mass and lung tissue showed noncaseating granuloma.

Discussion: Sarcoidosis presents with broad range of physical symptoms. However the manifestation of central nervous and urogenital system as initial presentation of the disease is rare. Since sarcoidosis is a multisystem disease and can be indolent, rarely it could present initially as combination of symptoms. Therefore along with the other possible diagnoses like metastatic testicular cancer, lymphoma and tuberculosis sarcoidosis also should be considered in high-risk patients with the above-mentioned presentation.

Conclusion: Here we would like to announce a rare presentation of multisystem involvement in sarcoidosis.

 

 

Hypothyroidism Refractory to Oral Thyroid Hormone Supplementation.

K. Ramesh, MD, A. Reddy, MD, O.Alzohaili, MD.

Department Of Internal Medicine, Sinai Grace Hospital, Detroit Medical Center, Wayne State University.

Hypothyroidism is well controlled in compliant patients with adequate doses of oral thyroid hormone replacement. In a minority of patients, an adequate response to this is not observed. Here we present one such unusual case of hypothyroidism where oral levothyroxine therapy failed.

A 34-year-old African American female with a history of hypothyroidism on very high doses of oral Synthroid (300micrograms per day), was seen for persistent symptoms of hypothyroidism. She had thyroidectomy for goiter in the past. Physical exam revealed central obesity and acanthosis nigricans. Labs showed a high TSH of 58.8 and a low Free T4 of <0.2 (after >4weeks of therapy). Trials were done in the office with different formulations - Synthroid, Levoxyl and also single high dose Levothyroid 1000mcg orally on different occasions. Free T4 level was measured at one, two, three and four hours. Free T4 remained undetectable. Since levothyroxine failed, trials with oral T3, cytomel, thyrolar, armour thyroid were done. These also failed to suppress TSH and raise serum thyroid hormone levels. A workup for malabsorption syndromes done in the Primary care physician’s office was also negative. The probable explanation for this was the patient’s inability to absorb oral thyroid hormones. Irrespective of the formulary chosen, the problem with absorption persisted.

 

Clinically overt ‘Celiac Disease’ (CD) has been suggested as a possible cause for many of the cases of replacement failures. Apart from ‘CD’, ‘Pseudo-Malabsorption’ (Factitious and Munchausen’s) and drug interference with intestinal absorption, particularly with calcium salts have been reported. Our patient was compliant and took the thyroid replacement on an empty stomach with no interference from other drugs. She had no absorption problems for any of her medications for hypertension and hypercholesterolemia (showed appropriate response). She appeared to have a selective intestinal malabsorption for thyroid hormone preparations.

There are very few reported cases of selective thyroid hormone malabsorption in the absence of CD, Factitious Disorder and drug interference. A good response to parenteral thyroid replacement was documented in these cases. Our clinical scenario also calls for parenteral forms of thyroid replacement. Arrangements are currently made to initiate this therapeutic process.

 

 

Multiple Daily Injections or Continuous Subcutaneous Insulin Infusion for better Glycemic control in Type 1 Diabetes.

 

K Ramesh MD,S Marur MD.

Department of Internal Medicine, Sinai Grace Hospital, Detroit Medical Center, Wayne State University,Detroit, Michigan.

Introduction: 1 out of 800 people in the United States have Type 1 Diabetes. The Diabetes Complications and Control Trial (DCCT) was a Randomized Controlled Clinical Trial that studied the relation between Glycemic control and vascular complications in Type 1 Diabetes. DCCT concluded that intensive therapy of Diabetes decreased the complications significantly. Intensive therapy is possible with either Multiple Daily Injections (MDI) of Insulin or Continuous Subcutaneous Insulin Infusion (CSII). This literature review analyzes the various studies comparing CSII and MDI for glycemic control.

Methods: Articles were searched in Ovid, PubMed and Cochrane. The search criteria used were CSII and MDI. The search yielded 31, 61 and 5 articles in Ovid, PubMed and Cochrane respectively. Articles in English with comparison between CSII and MDI, in adults with Type 1 diabetes were considered relevant. Articles dealing with non comparison on glycemic control between CSII and MDI, those dealing with children, pregnancy or Type 2 Diabetes were considered as not relevant. This filtering yielded 7, 11 and 0 relevant articles in Ovid, PubMed and Cochrane.

Results: Many articles were common in the search results .The study by Hissa MN et al had a P value of <0.05 for HbA1c compared to baseline. The study by Hanaire-Broutin H et al using lispro had P value for HbA1c as < 0.001.The metanalysis by Retnakaran etal showed P=0.002 for interaction between baseline HbA1c and treatment modality. The Randamized Controlled Trial by Hoogma RP et al had P<0.001. The study by Tsuii et al had a P >0.1.Other 6 studies reviewed showed better glycemic control with CSII.

Conclusion: All of the above, except one concluded that CSII was better than MDI for lowering the HbA1c. The exception showed no difference between CSII and MDI. However, not all these studies considered the other aspects like hypoglycemia, incidence of DKA, dose and weight changes with either of them. Best results with CSII, needs patient education on how to maintain the pump and importance of blood sugar monitoring. Hence, though CSII appears to offer better glycemic control, this treatment modality needs to be individualized to each patient.

 

 

Calcium in colon cancer: Mitogen Activated Protein(MAP) kinase pathway.

M Reddy, N Bhagavathula, EA Kelly, KC Nerusu, C Leonard, K Fay,

S Chakrabarty, J Varani

Department of Medicine, Wayne State University(Sinai-Grace) Program, Department of Pathology, University of Michigan; Southern Illinois University Cancer Institute.

Introduction:

Calcium has been shown to inhibit growth and promote differentiation of various types of cancer cells. There is evidence to show that intake of calcium can reduce the incidence of colorectal cancer. There is however no evidence for the exact mechanism of action. Our study showed that the Calcium Sensing Receptor(CaSR) in the colon cancer cell line called CBS, acts through Extracellular signal-Regulated Kinase(ERK), which is part of the Mitogen Activated Protein(MAP) Kinase pathway. When an inhibitor of the MAP kinase pathway UO126 was added, the growth inhibition and differentiation induction by calcium was inhibited.

Materials and Methods:

The colon cancer cell line- CBS were grown in Spinner Modified Essential Medium (SMEM). CBS cells were grown in SMEM without calcium, and with different concentrations of calcium. This was repeated using UO126 inhibitor. Cell counts were performed using the coulter counter. Cells grown in six well plates were then harvested for further analysis of ERK, E-cadherin, and &#946;-tubulin, using the Western Blot technique. Statistical analyses were performed using ANOVA paired-t test, and Student’s t-test.

Results:

In the presence of high calcium the CBS cell lines showed a significant (p<0.05) reduction in the total number of cells. The level of phosphorylated-ERK (p-ERK) was also increased at higher calcium level, as compared to low calcium (p<0.05). This effect was inhibited by UO126, which reversed these changes more so in low calcium, than in the high calcium medium. However CaSR expression was not affected by the use of UO126 inhibitor.

Discussion:

This experiment threw more light about the mechanism of action of calcium in CBS cells. The significance could mean that not only calcium at higher concentrations, but promoters of different intermediates of the MAP kinase pathway, could be used as pharmacological agents to inhibit colon cancer. There is however need for more studies to be done, especially in-vivo, including animal models to obtain more data on the role of calcium.

 

 

MEDIASTINAL CASTLEMAN DISEASE ASSOCIATED WITH LUNG CANCER

Mohammad Rezvani, MD (Associate), Arvind Reddy, MD, MPH (Associate), Geetha Krishnamoorthy,MD (Member),Surendra Marur,MD(member) Sinai-Grace Hospital, Wayne State University, Detroit

 

Introduction:Castleman Disease (CD) is a rare non malignant lymphoprolipherative disease, with unknown etiology and 95% of cases presenting as a localized mediastinal lymph node enlargment. Histopathologically,It has two major variants: hyaline vascular and plasma cell types, which former comprises 90% and latter 10% of cases.We are presenting the Plasma cell type of CD that was associated with Squamous cell cancer of Lung. As per our literature review, this is the second reported case of concurrent mediastinal CD and squamous cell lung Cancer.

Case:A 54 year old African American male, heavy smoker,was admitted with chest and neck pain with hoarseness of voice lasting over 2 months. He also reported a 30 lb wt loss and weakness. On Physical Exam, he had a diffuse swelling of the right side of neck and supra clavicular region. The remaining physical exam was unremarkable. Chest X-ray revealed a moderate-sized mass in the upper part of right mediastinum which was described by CT-thorax as a large, irregular, heterogeneous mass measuring 9x 6x 7 cm with necrotic areas,compressing the trachea and superior vena cava (SVC). A satellite nodule measuring 13 mm was located in the superior segment of right lower lobe of lung. With high index

 of suspicion for a metastatic lung cancer, a Mediastinoscopic biopsy of this mass was performed that showed a plasma cell variant of Castleman disease.He was HIV negative. Resection of the lung nodule was then performed that showed a 1 cm poorly differentiated squamous cell carcinoma,staged as T4N2Mx. Radiation therapy was started and was continued after discharge. Patient reported significant improvement in his symptoms after radiation.

Discussion:CD associated with lung cancer is rare and must be considered in patients who present with a disproportionately large mediastinal lymphadenopathy. This can possibly avoid overstaging of cancer. it is,also, important to exclude other possible concomitant pathologies (Squamous cell lung CA) for an atypical finding in CD (lung nodule).

 

 

Comparison of Selective and non-selective NSAIDs and the risk of Coronary Heart Disease

Sabeeh A.Siddiqui, MD(Associate)

Sinai-Grace Hospital/Wayne State University,Detroit,MI

 

Background: In the recent past the risk of Cardiovascular Events with COX-2 Inhibitors has been established with trials like APPROVe and VIGOR. It remains uncertain if the non-selective NSAIDs also carry an increased cardiovascular risk and whether this risk is any similar to that reported by COX2 inhibitors.

 

Methods: We performed a literature review to answer the above question using Medline and Pubmed. Several studies were analysed from above mentioned resources. Four trials were selected for this study, namely CLASS, TARGET, ADAPT and APC. Each one of these studies was a large, multicentric, randomized controlled trial comparing COX-2 vs Nonselective NSAIDS and cardiovascular events as secondary end-point.

Discussion :CLASS showed slightly increased incidence of Cardiovascular events in Celecoxib (1.6%) vs Diclofenac(1.2%) but with no significant p-value. The same is true in TARGET with Lumiracoxib vs Naproxen(1.77%) or ibuprofen(0.66%) ,but again with no significant p-value. The study which caught everyone’s attention, ADAPT, showed increased cardiovascular events with Naproxen compared to Celecoxib and at the same time was statistically significant. These preliminary studies, although being equivocal, have caught the attention of FDA to issue black box warnings to all prescription NSAIDs.

Conclusion: Multiple lines of evidence indicate that COX-2 inhibitors are associated with an increased risk of cardiovascular outcomes, which is mostly evident in patients with established atherogenic disease; however same cannot be said about Nonselective NSAIDs. Still, we lack adequate information to make confident statements about the exact levels of risk for each drug, the time course of risk during therapy, and the population of patients in whom benefit exceeds the risk.

 

 

CHALLENGING MANAGEMENT OF BREAST CANCER ‘is it inflammatory or not'

A CASE REPORT

 

SINAI GRACE HOSPITAL DETROIT MEDICAL CENTER

WAYNE STATE UNIVERSITY SCHOOL Of MEDICINE

Sabeeh Siddiqui M.D( ACP Associate),.Padmaja Naidu M.D(ACP Associate)

Leopoldo Eisenberg M.D (FACP)

 

CASE REPORT:A 72-year old African American Female presented with c/o pain on L-breast which was diagnosed as Invasive Ductal Carcinoma by needle biopsy. Past medical history included perforated diverticulosis requiring colostomy, and antibiotic therapy for MRSA bacteremia. In preparation for neoadjuvant chemotherapy, a  chemoport was placed and 24 hours later, infection developed at site.Treatment included levofloxacin for fourteen days.

Patient was seen by oncologist 3 weeks after initial evaluation, redness, swelling and pain of the involved breast was noted along with fever. Extensive erythema of chest wall and breast was noted . Patient looked septic and was thus admitted. Cultures were obtained and antibiotic stated.

U/S and CT of breast revealed doubling of massin size,no abscess and central necrosis.

Inspite of  antibiotics patient remained febrile with cultures being negative and therefore chemotherapy was administered as Infectious Disease questioned tumor fever.

CT of Breast showed probable central necrosis but no evidence of Abscess. Surgery was consulted for biopsy or mastectomy about nine days into chemotherapy and felt breast was improving as consulting surgeon had seen patient just prior to admission. By day nine patient became afebrile ,local symptoms improved substantially and patient was discharged home.

DISCUSSION: Inflammatory Breast Cancer is usually diagnosed when patient presents with peau-d-orange, redness and pain. In this case, none of these were present initially. We question whether delay in treatment because of patient being staged could generate picture of ‘inflammatory cancer’.

CONCLUSION: Inflammatory breast cancer has not been noted to cause fever, even when locally advanced therefore, are we dealing with a late manifestation of inflammatory cancer or a superimposed infection ? Our conclusion is that in cases like this all suspected entities should be treated

 

 

MANAGEMENT OF PATIENTS WITH ASYMPTOMATIC PATENT FORAMEN OVALE

AKINTAYO SOKUNBI M.D.ASSOCIATE, SINAI GRACE/WAYNE STATE UNIVERSITY, DETROIT, MICHIGAN

 

Background: Patent foramen ovale is seen in about 25 % of the normal population. It is usually asymptomatic. However, several medical conditions which include cryptogenic stroke, paradoxical thromboembolism, migraine with aura and the platypnea-orthodeoxia syndrome has been linked to a patent foramen ovale. Method: Electronic search of the MEDLINE database with PubMed, Ovid, and Cochrane library for relevant articles was done. This was supplemented with manual search of secondary sources including selected references from the primary articles. Search terms included: patent foramen ovale, combined with various words including, treatment, asymptomatic, stroke, migraine, risk and prevention. Results: In the absence of controlled trials, identified articles were systematically screened for the following inclusion criteria: a study cohort with primary prevention of complications attributable to a patent foramen ovale, minimum of 10 patients per cohort and mean duration of follow up of at least 5yrs. There were no studies found in the literature to support any form of primary prevention of complications in asymptomatic patient with patent foramen ovale. However there are many on going studies for the management of complications secondary to this common congenital defect. Conclusion: Patent foramen ovale is common enough in the general population to be considered a variant of normal and until there are appropriate studies to measure the impact of any form of intervention, asymptomatic patent foramen ovale will continue to be observed as a variant of normal.

 

VITAMIN D3, Seocalcitol AND QUININE : APOPTOSIS AND DIFFERENTIATION IN BREAST CANCER CELL LINES

Melhem Solh MD, Catherine Lobocki MS, Linda Dubay MD,FACS, Vijay Mittal MD,FACS

Wayne State University/Detroit Medical center Sinai Grace Hospital

Providence Hospital and clinics

Objectives: Vitamin D3 and quinine have been considered modulators of cell differentiation and proliferation, as well as inducers of apoptosis.  In vivo studies investigating Vitamin D3 for breast cancer treatment have been faced with the side effect of hypercalcemia. The purpose of this study was to examine the growth inhibitory and cellular differentiation effects of 1,25-dihydroxyvitamin D3 and seocalcitol(a Vitamin D3 analog) alone and in combination with quinine on four breast cancer cell lines (MCF7, T-47D, SKBR3 and BT474).

Methods:  Cells were seeded in triplicate into 96 well plates. After 24 hours cells were exposed to Vitamin D3, seocalcitol alone or in combination with quinine.reagents were added every 2 days. Growth inhibition was determined using the colorimetric MTT assay after 4 and 7 days of drug treatment.  Lipid visualization using the Oil Red O stain was used to assess cellular differentiation.Cells containing 10 or more lipid droplets were considered differentiated, and were counted in a blinded-fashion. Data from MTT assays are the average of 3 separate experiments.

Results:  Both time and dose dependent effects were demonstrated. The IC50’s for MCF7, T-47D and SKBR3 were:  3 – 5 x 10-8 M and 14 – 29&#61549;M for 1,25-D3 and quinine, respectively.  Seocalcitol was significantly more potent with an IC50 of 2 – 3 x 10-9 M.  The BT474 cell line was relatively resistant to all drugs tested.  The combination of drugs showed a significant decrease in growth (p < 0.02), as well as a dramatic increase in lipid staining after 4 or 7 days of treatment compared to single agents.

Conclusion: 1,25-D3 and Seocalcitol can cause cell death and induce differentiation in breast cancer, and when combined with quinine, a better growth inhibitory response is achieved.  The combination may allow for a dose reduction of Vitamin D3 or its analogue, and potentially reduce the risk of hypercalcemia in patients.

 

 

PROGNOSTIC FACTORS IN PRIMARY ADENOCARCINOMA OF THE SMALL INTESTINE

Melhem Solh MD, Kongrit Chaiyasate MD, Gelen Del Roserio MD,PHD, vijay Mittal MD FACS

Introduction

Although the small bowel constitutes 90% of the intestinal mucosa,s surface area,  malignant neoplasms of the small intestine account for only 2% of the gastrointestinal cancers. Small bowel tumors constitute a diagnostic challenge due to the nonspecific presentation. The aim of this study is to evaluate the diagnostic difficulties and review the prognostic indicators of small bowel adenocarcinoma.

Methods

This study is a retrospective review of patients presenting with small bowel adenocarcinoma between 1990 and 2004 at a single academic institution. Data on demographics, presenting symptoms, diagnostic methods, diagnostic modalities, treatment and lifetime survival were collected. TNM categories were classified according to UICC 1997 criteria.

Results

27 patients were included with a mean age at diagnosis of 62 years. 36% were males and 64% were females. Nausea and vomiting (74%) was the most common symptom followed by abdominal pain,melena,anemia and jaundice. 48% had a definitive preoperative diagnosis whereas 38% had a suspicious diagnosis and 14% had no preoperative diagnosis. Diagnostic modalities included ultrasonography(93%), laparatomy(52%), EGD(48%),contrast radiography, angiography and tagged RBC scan.

Location varied between duodenum (48%), jejunum (22%) and ileum (30%).

The mean survival was 34 months with an overall 5 year survival of 30%. The survival was independent of age and gender, however; it was dependent on degree of differentiation(62 months for well differentiated versus16 months for poorly differentiated p<0.01), nodal metastasis(72 month for node negative versus 29 month for node positive) distant metastasis, postoperative residual tumor, stage and location of the tumor. Chemotherapy did not affect the outcome of stage3 and stage 4 tumors.

Discussion

In concordance with the literature, our data shows an average age between 50-70 years, accurate preoperative diagnosis between 30%-72%, prognostic indicators of nodal staus, differentiation, stage, and vascular invasion. However, unlike the reported series, ileal tumors were more common than jejunal and age and chemotherapy were not survival predictors. Surgical procedure was an independent predictor.

Conclusion

Small bowel adenocarcinomas is a rare entity. The diagnostic challenges are more common with jejunal and ileal tumors. Treatment modalities are based mainly on surgical resection which requires significant expertise. More research should be targeting potential therapies for small bowel adenocarcinoma as was the case with the GI stromal tumors. The new modality of capsule endoscopy might have a significant impact on earlier diagnosis as well a better overall outcome of small bowel adenocarcinomas.

 

 

Interplay of Nuclear Factor kappa B & RhoC GTPase in Inflammatory Breast Cancer

Saad Z. Usmani, MD1(Associate), Sofia D. Merajver MD, PhD2

1 Department of Internal Medicine, Sinai-Grace Hospital/Detroit Medical Center, Wayne State University, Detroit, Michigan

2 University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan

 

BACKGROUND:

NFkB is a sequence-specific transcription factor that activates multitude of immunologic and angiogenic molecules. It has been found to have increased activity in several cancers including breast cancer. RhoC, a member of the Rho family GTPases, is implicated in the pathogenesis of inflammatory breast cancer. It has been shown that Rho family GTPases can activate and be activated by NFkB. We hypothesize that NFkB is involved with activation of RhoC GTPase.

MATERIALS & METHODS:

LifeSeq databases were searched to identify RhoC cDNAs (complementary DNA) with the longest 5'-end extensions. The cDNA was subsequently mapped to the human genome. A 10 kb genomic region upstream of the cDNA start site was analyzed with the Transplorer 1.4 software.  A genomic fragment upstream of the ATG translation initiation site of RhoC GTPase containing the putative promoter and transcriptional start site will be amplified. Primer 3 software will be used in constructing 20-21 b primers for gene amplification. Truncated clones containing those sites will be used in cell-based assays of luciferase to observe expression of RhoC mediated by TNF or IL-1 activation of NFkB.

RESULTS:

A putative RhoC GTPase promoter was identified starting at -3647 with a transcriptional start site at -2478 using the Transplorer software. It was observed that this promoter region has multiple transcription factor binding sites, including c/EBP, SP1 and NFkB. Gene amplification of a 5 kb was attempted using cDNA but yielded a very low DNA concentration. Bacterial Artificial Chromosome (BAC) clones were then employed in an attempt to isolate 1 kb segments and subsequently anneal the 5kbp fragment. We have isolated the first 1 kb segment.

CONCLUSION:

Inflammatory breast cancer (IBC) is the most aggressive form of breast cancer. RhoC plays a pivotal role in IBC by promoting angiogenesis. It is known that NFkB and Rho family have multiple interlinked pathways in tumor angiogenesis. We have thus far identified multiple NFkB binding sites in the RhoC promoter region. Gene amplification using cDNA did not give an adequate DNA concentration for further experiments but employing BAC clones has provided an alternative way of amplifying the require genomic segment. The final data from our experiments may help in creating biological agents for targeted cancer therapy.

 

 

A RARE PRESENTATION OF NON SECRETORY MULTIPLE MYELOMA FOLLOWING A SOLITARY PLASMACYTOMA

Saad Z. Usmani MD (Associate), Ashraf Ahmed MD (Associate), Leopoldo Eisenberg MD FACP.

Department of Internal Medicine, Sinai-Grace Hospital/Detroit Medical Center, Wayne State University, Detroit, Michigan

 

INTRODUCTION:

Multiple myeloma (MM) accounts for 1% of all malignant diseases and 10% of all hematological malignancies. Only 1% of patients present without serum or urine monoclonal proteins. We present such a case of a patient with history of solitary bone plasmacytoma (SBP) who progressed to a non-secretory multiple myeloma.

CASE REPORT:

57 years old female presented with 20-pound weight loss over 3 months, fatigue, anorexia, back and neck pain refractory to analgesics for four weeks. The past medical history was significant for frontal sinus plasmacytoma treated with surgery and radiation therapy in 2004. Physical examination showed hyperreflexia and sensorimotor deficits in all extremities. She had MRI Thorax and pelvis, which showed lytic lesions in the T 7, 8, 9, 10 and L1 as well as the right 8th rib. MRI of the cervical region showed a lytic lesion in C3 compressing the cord. Bone survey confirmed multiple lytic lesions. The serum calcium level was normal (10.3 mg/dl), normal serum albumin (3.9 gm/dl), normal serum creatinine (0.6 mg/dl), and normal blood counts. The urine and serum immunoelectrophoresis were normal. Bone marrow biopsy showed only 4% plasma cells. She was started on IV steroids and had radiation therapy with improvement in symptoms. She received outpatient chemotherapy with thalidomide and dexamethasone. She was then evaluated for and underwent autologous stem cell transplant showing very good response to therapy.

DISCUSSION:

This case represents an uncommon presentation of non-secretory MM following a SBP. Monoclonal protein spikes in urine or serum accompany most solitary plasmacytomas. SBP can progress to florid multiple myeloma in 30-50% of cases. Our patient had multiple osteolytic lesions without evidence of systemic manifestations.  The purpose of this case report is to alert internists that patients with SBPs can progress to non-secretory disease and thus need close follow-up after being treated for the SBPs.

 

 

Asystole during Dipyridamole Administration.

Vikas Veeranna MD, Kavitha Potluri MD, Syed Mahmood MD FACC, Lawrence MacDonald, MD, FACP.

Department Of Internal Medicine, Sinai Grace Hospital, Detroit Medical Center, Wayne State University, Detroit, Michigan.

 

Introduction

Dipyridamole is an indirect coronary vasodilator which works by increasing intravascular adenosine levels, causing functional ischemia in susceptible individuals. This is basis for its use in pharmacologic stress testing. Only rarely have serious side effects been reported during use of intravenous dipyridamole. We report a case of asystole which occurred after the administration of dipyridamole.

Case report

A 67-year-old African American female underwent elective dypiridamole stress testing as an outpatient. She had presented after experiencing dyspnea and chest discomfort on exertion. She took a beta blocker (metoprolol 50 mg twice daily) for hypertension. During the infusion of dypiridamole she experienced nausea, dizziness and loss of consciousness. Electrocardiographic monitoring during the procedure demonstrated asystole for 20 seconds coincident with these symptoms. No other dysrhythmias were noted. This spontaneously resolved, with return of consciousness and hemodynamic stability. Theophylline was administered, and was associated with a brief period of atrial fibrillation. After transfer to our institution she underwent further workup for coronary artery disease. There was no EKG or enzymatic evidence of myocardial infarction. No significant epicardial coronary artery disease was noted on angiogram. Echocardiography showed normal cardiac function.

Discussion

Dipyridamole acts through adenosine. A review of literature suggests an indirect inhibitory action of dipyridamole through adenosine on the conducting system potentiated by beta blockade. With the absence of EKG changes and normal coronary angiography, dipyridamole induced ischemia is an unlikely cause.

Conclusions

We feel that dipyridamole is the probable cause of asystole in this individual. Beta blocking agents have an inhibitory effect on cardiac conduction and impulse generation and may have contributed.

Recommendations

In patients with underlying conduction abnormalities, bradycardia or concomitant beta blocker administration caution should be exercised before administration of dipyridamole.

 

 

ARE WE THERE YET? – USE OF 16 SLICE CT SCANNERS IN DIAGNOSIS OF CORONARY ARTERY DISEASE.

 

Vikas Veeranna MD, Surendra Marur MD.

Department Of Internal Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.

 

Introduction Coronary artery disease [CAD] is the single leading cause of death with a prevalence of 13 million in the United States. About 1.5 million undergo diagnostic cardiac catheterization with coronary angiography each year. Computed tomography is a new diagnostic tool in the diagnosis of coronary stenoses [block >50%], especially multi slice CT scanners [MSCT]. This study reviews the literature published on the use of 16 Slice CT for diagnosis of CAD. Methods A literature review was done on the effectiveness of MSCT angiography in comparison with interventional coronary angiography in diagnosis of CAD in native vessels. The search included all articles published between July 1998 and July 2005 with a focus on 16 slice scanners. Pubmed, Ovid Medline and Cochrane were searched, yielding 137 results. 121 of these were exclude as they did not meet inclusion criteria [humans, Comparison with Coronary Angiography, native coronary vessels] or MSCT for screening or used calcium score for diagnosis. This yielded 13 studies. Cost was not a factor. Results Most 16 slice CT scanners had small groups with definite inclusion criteria. All the study group individuals had undergone or underwent invasive coronary angiography, which was the measure of comparison. In most studies patients were placed on Beta blockers to reduce the heart rate and ECG gating used to improve image quality. The sensitivity of the tests ranged from 63% to 95%, indicating a high level of false negatives. Specificity range was 80% to 98%. Positive likelihood ratio of >10 was found in 10 studies, while negative likelihood was < 0.1 in only 5 studies, suggesting that MSCT angiography may be useful to detect the disease and increase post test probability but not rule out the disease. Conclusion Based on the literature review it can be concluded that 16 slice CT angiography do not have a better ability to diagnose CAD compared to invasive coronary angiography. A substantial number of patients would be missed [false negatives] hence not receiving adequate or early treatment. Invasive coronary angiography is still recommended.

 

 

Allergic bronchopulonary asperigillois: An unusual cause of resistant

bronchial asthma

 

M.Venkatram, MD Associate, A.Mohammed,MD Member. Department of Medicine,  Wayne state univ/Sinai Grace hospital, Detroit, MI.

Introduction: Allergic Bronchopulmonary Aspergillosis (ABPA) is an

underdiagnosed pulmonary disorder in 2-28% of asthmatic patients. We present a case of ABPA presenting as resistant asthma.

Case report: A 58 year old male presented with recurrent exacerbations of asthma which was difficult to control. CT Scan chest revealed infiltrates & central bronchiectasis. His serology showed elevated total IgE levels & IgE antibodies to Aspergillus fumigatus & ABPA was diagnosed. His syptoms responded fully to prednisone & Itraconozole.

Discussion: ABPA is an allergic response to antigens expressed by fungi,

mostly Aspergillus fumigatus. It is characterized by chest infiltrates associated with cough, wheeze and sputum production that usually respond to oral steroids. The diagnostic immunological and radiological findings

include elevated total serum IgE levels, presence of IgE antibodies to Aspergillus and central bronchiectasis. The natual history may be

complicated by progression to bronchiectasis and pulmonary fibrosis. If ABPA is diagnosed and treated early,these complications may be prevented. Long term treatment with steroids is often required for effective management. The adverse effects of chronic steroid use have led to attempts at treatment with antifungal agents such as itracanazole.

Summary: ABPA should be considered in patients with resistant asthma

with radiographic infiltrates, central bronchiectasis. It responds well to long term steroids. Itraconozole may be effective as a steroid-sparing agent & in some cases as a sole therapy.

 

The role of Multi detector CT scans versus Pulmonary angiography for the evaluation of acute pulmonary embolism

M.Venkatram, MD Associate, Department of Medicine,  Wayne state univ/Sinai Grace hospital, Detroit MI, V.Krishnamurthy MD,Dept of Radiology,Univ of Michigan,Ann Arbor MI.

Clinical question

Are the Multi detector CT scans (MDCT) better than Pulmonary angiography (PA) for the evaluation of acute pulmonary embolism(PE)?

Methods:

Data source : Cochrane, Embase & MEDLINE database

Study selection: Prospective or retrospective or Randomized controlled trials were searched using the keywords  CT , Pulmonary embolism ,PE, MDCT, Pulmonary angiography individually and by combination. Pertinent articles on PE were chosen if MDCT scans were used for the evaluation & selective pulmonary angiography was the gold standard.

Clinical Outcome of Interest : Evidence of acute PE in MDCT and PA

Search results : Only 2 prospectve trials satisfied all the above criteria which are as follows:

1.Winer Muram et al (Radiology 2004;233:806-815) - Ninthy three patients underwent MDCT (4 Channel) & PA within 48 hours apart and 3 Radiologists who were blinded to the diagnosis evaluated the films. On PA, 18 patients were positive & 75 were negative for PE. While MDCT in the same patients was positive for PE in  26 & negative in 67 patients. Considering PA as gold standard,  MDCT had a Sensitivity of 100% & Specificity of 89% in detecting acute PE. Three false positive cases on MDCT had clinical evidence of PE. If this was considered as true positive, the sensitivity, specificity & accuracy of MDCT increased to 100%, 93%, 95% while that of PA would be 86%,100% and 97% respectively.

 

2. Qanadli SD et al (Radiology 2000;217:447-455) - In this study on 157 patients, MDCT (dual section) & PA were performed within 12 hours apart & 2 radiologists who were blind to the diagnosis, evaluated the films. On PA, 62 patients were positive & 95 were negative for PE. MDCT was positive for PE in  59 & negative in 92 patients. Considering PA as the gold standard, MDCT had a Sensitivity of 90-95% & specificity of 94-97% (range due to inconclusive CT studies) in detecting acute PE.

Conclusion : MDCT is a very sensitive & specific diagnostic test in acute PE and it can replace PA for the direct demonstration of PE. However, the role of MDCT in the adequacy of detecting sub segmental PE is still not certain.

 

ANTIEMETIC EFFICACY OF CANNABINOIDS IN TREATMENT OF CHEMOTHERAPY INDUCED NAUSEA AND VOMITING - A SYSTEMATIC REVIEW

Prakash Vishnu, MD (Associate), Joel Appel, DO, FACP (Fellow)

Department of Medicine, Sinai Grace Hospital, Detroit Medical Center/Wayne State University, Detroit, Michigan

 

INTRODUCTION

Marijuana (Cannabis sativus) also known as ‘Indian hemp’, is one of the oldest psychoactive plants known to humans. Historically, based on its putative analgesic, anti-inflammatory, anti-spasmodic, anti-asthmatic and anti-convulsant properties, it was used for a variety of conditions. In the current era of medical therapeutics, marijuana in its natural form is not approved by the Food and Drug Administration (FDA), though the synthetic derivative of one of its psychoactive ingredients - delta-9-tetrahydrocannabinol (THC) has been approved for treatment of breakthrough chemotherapy induced nausea and vomiting (CINV) and AIDS-related wasting syndrome.

OBJECTIVE: 

Systematic review of antiemetic efficacy and side-effects of cannabinoids used for CINV.

DATA SOURCES:

References were identified by searching MEDLINE and Cochrane Central Register of Control Trials published during the years 1970 - 2005.

RESULTS

24 randomized trials could be retrieved. The studies compared the efficacy of cannabinoids vs. placebo, prochlorperazine, chlorpromazine, thiethylperazine, haloperidol, alizapride, metoclopramide +/- dexamethasone. &#61508;9-THC (oral +/vs. inhaled), Nabilone (oral) and Levonantradol (intramuscular) were studied. Cannabis or naturally occurring cannabinoids were not used in any of the studies. There were no studies comparing the efficacy of cannabinoids vs. the contemporary antiemetics including 5HT3 receptor antagonist and substance P/NK-1 receptor antagonists.

DISCUSSION/CONCLUSION

Studies are heterogeneous in terms of primary and secondary end points due to lack of standardized scales to assess efficacy and side effects. They also vary in terms of the age of sample population (5-78 years), tumor types and chemotherapeutic regimens. Of note is the differential efficacy of cannabinoids in different chemotherapeutic regimens. While cannabinoids were more effective against the moderately emetogenic drugs, they were not so effective against low and high risk emetogenic agents. The incidence of severe degree of side effects and modest therapeutic efficacy compared to the conventional antiemetics would limit its wide spread use as an antiemetic in the treatment of CINV. Larger homogenous/multi-center trials comparing cannabinoids with newer generation antiemetics are needed. Alternate routes of cannabinoid administration and synergistic use of other active cannabinoids in Cannabis along with THC also needs to be evaluated.

 

 

SPORADIC VON HIPPEL-LINDAU DISEASE PRESENTING WITH BILATERAL RENAL CELL CARCINOMA - A RARE ENTITY

Prakash Vishnu, MD (Associate), Saad Usmani, MD (Associate), Department of Medicine, Sinai Grace Hospital/Wayne State University, Detroit, Michigan

Ulka Vaishampayan, MD, FACP (Fellow), Karmanos Cancer Institute, Wayne State University, Detroit, Michigan

 

INTRODUCTION

von Hippel-Lindau disease (VHL disease) is a rare hereditary syndrome with an autosomal dominant inheritance pattern. Patients usually present with cerebellar hemangiomas, pancreatic cysts and/or renal cell carcinoma between 20-40 years of age. We report a rare case of late onset VHL disease presenting as bilateral clear cell renal carcinoma with multiple pancreatic cysts and left cerebellar hemangioblastoma.

CASE REPORT

A 51-year-old Caucasian female was referred for management of bilateral renal masses, which were found when she underwent a CT scan of the abdomen as a part of workup for refractory anemia of six months’ duration. CT scan revealed complex cystic and predominantly solid renal masses in both kidneys. Multiple cystic lesions in the pancreas were also noted. CT guided core biopsy of each renal mass suggested a histopathological diagnosis of clear cell renal cell carcinoma. Patient underwent a two-stage nephron sparing surgery - right partial nephrectomy followed by left radical nephrectomy. One month following the surgery, patient developed complaints of persistent nausea, vomiting and recurrent headaches. CT scan of the brain revealed a mass lesion in left cerebellar hemisphere. Gadolinium enhanced MRI defined the lesion as nodulo-cystic, the nodular component measuring 60 mm in diameter and the cyst, 40 mm. She underwent a craniotomy and excision of the nodulocystic lesion. Histopathology showed the lesion to be hemagioblastoma, thereby establishing the diagnosis of VHL disease. Pedigree analysis was negative for VHL lesions or disease in the family and the patient has no children. 

DISCUSSION AND CONCLUSION

Sporadic VHL is rare and occurrence of bilateral renal cell carcinoma is even rarer. The late age of onset in this case is unusual considering that most patients present between 20-40 years of age. With a clinical presentation of bilateral renal cancer of clear cell histology, the possibility of VHL should be considered despite the older age of the patient. Because of increased survival with VHL related tumors, patients need a long-term clinical follow-up and surveillance for onset of new tumors in other organ systems particularly retina. Genetic evaluation is indicated to identify and start early screening for family members at high risk.

 

 

CANDIDA GLABRATA PAROTITIS: UNUSUAL INFECTION IN AN UNUSUAL SITE - IS THIS A HARBINGER OF IMMUNOCOMPROMISED STATE ?

Prakash Vishnu, MD (Associate), Geetha Krishnamoorthy, MD (Member), Wasim Hafeez, MD (Fellow)

Department of Medicine, Sinai Grace Hospital, Detroit Medical Center/Wayne State University, Detroit, Michigan

 

Introduction:

Candida glabrata, a yeast that forms part of normal microbial flora of digestive tract, skin and vagina, is known to cause superficial infection in immunocompetent hosts of all ages with a benign course and full recovery. However, in immunocompromised hosts, it can result in systemic illnesses, which is associated with high morbidity and mortality. We report a case of fungal parotitis caused by Candida glabrata.

Case report:

66-year-old female with a past medical history of hypertension and well controlled diabetes mellitus, presented to the primary care clinic with complaints of progressive painful swelling over right parotid area of 2 months duration. CAT scan of neck revealed an irregular contrast-enhancing lesion suggestive of neoplastic process vs. infection. FNAB/FNAC revealed chronic granulomatous inflammation in a purulent background. Fluid cultures grew Candida glabrata while concurrent blood cultures were sterile. Fluid culture for AFB was negative. CAT scan of thorax revealed no abnormality. Patient had no previous history of surgical intervention to right parotid gland. HIV testing was non-reactive. Patient was treated with IV caspofungin and was closely followed up in the outpatient clinic every two months. Patients clinical course was uneventful for next eighteen months, after which she presented with symptoms of dysphagia and altered voice. Chest x-rays revealed a mediastinal mass. CAT scan of the thorax revealed a large left mediastinal mass with multiple lung nodules. Biopsy of mediastinal mass revealed small cell carcinoma of the lung. Further workup revealed metastatic lesions in the liver. Patient underwent 5 cycles of VP-16 based chemotherapy with interval resolution in the size of mediastinal mass.

Discussion:

Systemic infection caused by Candida glabrata in an immunocompetent host is unusual. Theoretically, although any organ in the body can be affected, to date there has been no case report of parotitis caused by Candida glabrata. When an unusual organism is isolated from an unusual site causing infection, does it become pertinent to rigorously workup for co-morbid conditions that herald an underlying immunocompromised state? Will frequent clinical follow-up help in early detection of such conditions, thereby giving us a chance for early intervention? These questions still remain unanswered. 

 

 

PERTUSSIS – IS IT MAKING A COME BACK ?

Prakash Vishnu, MD (Associate), Krithi Ramesh, MD (Associate), Frank Attanasio, MD (Member), Dennis Treece, MD, Wasim Hafeez, MD (Fellow)

Department of Medicine, Sinai Grace Hospital, Detroit Medical Center/Wayne State University, Detroit, Michigan

 

INTRODUCTION:

Pertussis also called whooping cough or “100 day cough” is a bacterial disease caused by Bordetella pertussis or parapertussis. The annual incidence in adults in US for 2001-03 was 1.1/100,000. Over the last two decades incidence of pertussis has increased in adolescents and adults. We report 2 cases of persistent cough in adults which were diagnosed as pertussis.

CASE DISCRIPTION

Case 1: 26 year old Mexican woman with a benign past medical history seen in clinic for persistent cough and vomiting for 2 months.

Case 2: 45 year old African American female with persistent dry cough and vomiting for over 3 weeks and no other past medical history.

Both patients had persistent cough of more than 2 weeks with ‘post-tussive emesis’. Immunization status was unknown in either of the patients. Serology for Bordetella pertussis was requested. Both patients had positive titers for IgM, IgG and IgA antibodies. They were treated with azithromycin for 5 days. 

DISCUSSION

Pertussis is an airborne highly communicable, yet vaccine-preventable disease. Following introduction of vaccination among infants and children in 1940s, incidence of pertussis declined over the next few decades. Resurgence among adults and adolescents since 1980s is attributed primarily to more effective diagnosis and reporting of the disease, waning of vaccine-induced immunity and loss of vaccine efficacy due to emergence of new strains. While clinical presentation is typical in children characterized by catarrhal, paroxysmal and convalescence stages, it is usually nonspecific in adults presenting as persistent cough needing a high index of clinical suspicion for diagnosis. Hence, in adults it may go unrecognized making the infected adult a reservoir and significant source of infection to non-immunized household contacts. Complications include hypoxia, apnea, pneumonia, seizures, encephalopathy and malnutrition. Diagnosis is based on PCR or culture of nasopharyngeal swabs or serology.

CONCLUSION

Waning of vaccine induced immunity over time leaves most adolescents and adults susceptible to infection. Physicians must be aware that pertussis can occur at any age regardless of immunization status. High index of clinical suspicion is needed to diagnose pertussis in any adolescent or adult who has had cough for 2 weeks or longer.

 

 

CAN ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) BE USED IN PATIENTS WITH HISTORY OF ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR INDUCED ANGIOEDEMA ?

Prakash Vishnu, MD (Associate), Surendra Marur, MD (Member), Department of Medicine, Sinai Grace Hospital, Detroit Medical Center /Wayne State University, Detroit, Michigan

Introduction:

Angiotensin converting enzyme (ACE) inhibitors and Angiotensin II receptor blockers (ARBs) are widely used in the treatment of hypertension, chronic renal disease and congestive heart failure, and prevention of diabetic nephropathy. ACE inhibitors are associated with major side effects such as acute renal failure, hyperkalemia, cough and angioedema. Characterized by localized edema of the skin and/or subcutaneous tissue, angioedema is a potentially life-threatening side effect of ACE inhibitors. Incidence of angioedema with ACE inhibitors, which is considered a class related side effect, is estimated to be around 0.1 to 1.2%. Few cases of angioedema have also been reported with the use of ARBs.

Clinical Question:

Is it safe to use ARBs in patients who have experienced ACE inhibitor induced angioedema ?

Search Strategy:

Data sources: MEDLINE and Cochrane Library (Jan 1991 - April 2006)

Key words: Angioneurotic edema, angioedema, angiotensin converting enzyme inhibitors, ACE inhibitors, AT-II receptor blockers, angiotensin receptor antagonists, and ARBs.

Results:

Results of retrospective analyses and placebo-controlled trials of ARBs demonstrate that a ‘small' proportion of patients with ACE inhibitor related angioedema continue with this symptom when switched to an ARB.  

1. Cicardi et.al reported a retrospective analysis of 54 patients with ACE inhibitor induced angioedema who were switched to different treatment. 26 patients had switched to an ARB, and of these, angioedema persisted or recurred in 2 patients after switching to an ARB and disappeared upon its withdrawal.

2. CHARM-alternative trial, a large multi-center double-blinded randomized control trial described the effects of candesartan in congestive heart failure patients intolerant to ACE inhibitors. 3 out of 39 patients in candesartan group with a history of ACE inhibitors had recurrence of angioedema.  

Conclusions/Recommendations:

Only a small proportion (7-8%) of patients with ACE inhibitor related angioedema develop or persist to have this symptom when switched to an ARB. The cardiovascular benefits and potential reduction in mortality from use of these drug classes are important and significant. Hence, a risk-benefit assessment should be considered when substituting ARBs in patients who develop angioedema from ACE inhibitors.

 

 

ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACE INHIBITORS), ANGIOTENSIN RECEPTOR BLOCKERS (ARBS) OR COMBINATION IN HEART FAILURE PATIENTS, AN EVIDENCE BASED MEDICINE REVIEW.

Ziad S. Zaky, MD (Associate)

Department of Internal Medicine, Sinai Grace Hospital, Detroit, Michigan.

 

Introduction: ACE inhibitors improve morbidity and mortality in chronic heart failure (CHF) and after myocardial infarction (MI).This occurs through the inhibition of angiotensin II production. This inhibition is incomplete with ACE inhibitors. Therefore, a selective angiotensin II antagonist could provide better protection than ACE inhibitors. Our clinical question is: in elderly males, with history of hypertension, MI and presenting with CHF (NYHA class&#8805;II, ejection fraction &#8804; 30%), is the substitution of ACE inhibitors by ARBs or the addition of ARBs to ACE inhibitors of any clinical benefit?

Methods: Our literature search included database from Pubmed, Ovid, ACP Journal club and ACP Pier. Keywords were males, ACE inhibitors, ARBs, CHF, randomized controlled clinical trial, meta-analysis. Studies selected were comparing ARBs vs. placebo, ARBs vs. ACE inhibitors and ARBs+ACE inhibitors vs. ACE inhibitors. The outcome was all-cause mortality and CHF hospitalization with follow-up duration > 4 weeks. The ARBs studied were losartan, candesartan, valsartan, eprosartan, irbesartan and telmisartan.

Results: Our search resulted in 24 studies. Meta-analysis of 9 studies comparing ARBs vs. placebo included 4623 patients. CHARM-Alternative study contributed most of data. This revealed a significant reduction in all-cause mortality (odds ratio (OR) 0.83 [95% confidence interval (CI), 0.69 to 1.00] P= 0.048) and reduction in CHF hospitalizations (OR 0.64 [CI, 0.53 to 0.78]). Meta-analysis of 8 studies comparing ARBs vs. ACE inhibitors, including 5201 patients, revealed no difference in all-cause mortality (OR 1.06 [CI, 0.9 to 1.26]) and no difference in CHF hospitalizations (OR 0.95[CI, 0.8 to 1.13]). ELITE II study contributed most of data. Meta-analysis of 7 studies comparing ARBs+ACE inhibitors vs. ACE inhibitors ,including 8260 patients, revealed no difference in all-cause mortality (OR 0.97 [CI, 0.69 to 0.87]). Combination therapy was associated with adverse effects, e.g. hypotension and renal impairment.Val-HeFT and CHARM-Added were the most contributing studies.

Conclusion: Use ACE inhibitors in all patients with CHF regardless of functional class except in patients with a history of angioedema. Consider using ARBs in patients who cannot tolerate ACE inhibitors. The combination of ARBs and ACE inhibitors does not have any additional benefit and may have more deleterious effects.

 

 

TRICUSPID VALVE ENDOCARDITIS CAUSED BY STREPTOCOCCUS AGALACTIAE POST

VOLUNTARY TERMINATION OF PREGNANCY

 

Ziad S. Zaky, MD (Associate); Padmaja Naidu, MD (Associate), Oronde

White, MD (Member), Surendra Marur, MD (Member), Mark Wolf, MD

Department of Internal Medicine, Sinai Grace Hospital / Wayne State

University, Detroit, Michigan.

 

Group B streptococcus (GBS; streptococcus agalactiae) is a common cause

of sepsis and meningitis in the neonates. Adult GBS infections are less

known with reported annual incidence 4 to 6 per 100.000. The typical

host is elderly with underlying disease. Diabetes, malignancy, HIV

infection, alcoholism, cardiovascular diseases, and advanced hepatic and

renal disease are risk factors for invasive GBS infection. Approximately;

two to nine percent of GBS bacteremia develops endocarditis. GBS

endocarditis involves left sided valves more commonly than right sided. The

incidence of infective endocarditis after obstetric and gynecologic

procedures is low, ranging between 0.03 to 0.14 per 1000 deliveries. The

incidence is especially lower after abortions, about one per million

abortions.

We report a case of a 28 year old African American female who presented

with fever and chills four weeks after an elective abortion. Workup

revealed a positive blood culture for GBS, right lower lobe pneumonia and

bilateral pleural and pericardial effusions.  Transvaginal ultrasound

and CT abdomen was negative for any retained products of conception or

abscess.  Despite resolution of pneumonia both clinically and

radiologically, daily fever spikes persisted.  A transesophageal echo (TEE) was performed and revealed tricuspid valve endocarditis with a vegetation measuring 1.2 x 1.7cm involving the septal leaflet. The patient was started on vancomycin 1.5gm Q8h for 6 weeks and gentamycin 140mg Q12h for 2 weeks. Fever resolved and the patient underwent tricuspid valve

replacement with bioprosthetic valve. One month later, at the time of follow up, the patient was doing well. All repeat blood cultures were negative.

Our patient presents a rare case of subacute GBS endocarditis involving

native tricuspid valve following an elective abortion. The patient was

young, with no underlying disease and no history of drug abuse. The

overall mortality rate of GBS endocarditis is lower with combined medical

and surgical strategy than with medical therapy alone (range of 20% vs.

40% - 50%). Fevers post voluntary termination of pregnancy should

prompt a full work up including a TEE if no other focus is found.