ACP
Associates Meeting Abstracts 2002
IDIOPATHIC LEFT VENTRICULAR OUTFLOW TRACT TRACHYCARDIA: A RARE ARRHYTHMIA IN A FEMALE PATIENT. Muhammad Akbar, MD, Associate and Ramegowda Rajagopal, MD, FACC, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Idiopathic
ventricular tachycardia (IVT) is an unusual form of ventricular tachycardia
mainly seen in young individuals with no structural heart disease. In 80% of
patients it originates in the right ventricle. An uncommon form of IVT is the
left ventricular outflow tract tachycardia which is associated with RBBB
configuration, left axis deviation, verapamil sensitivity and also rarely with
sudden death; hence the importance of recognizing this entity. This arrhythmia
has been mainly described in males, rarely reported in females.
A 26 years old female presented with multiple daily episodes of palpitations since two years. Her 24 hour Holter revealed 174 runs of rapid ventricular tachycardia (unifocal with RBBB configuration) with a rate of 170-210 lasting up to 7 minutes. Echocardiography and exercise stress test showed no significant abnormalities. Pace mapping identified earliest ventricular activation originating from the left ventricular outflow tract. Radiofrequency ablation was performed at the anterio-superior medial region of the mitral valve. There was immediate cessation of the tachycardia and no induction with isoproterenol infusion upto a heart rate of 130. The patient has remained symptom free for ten months of follow up.
Although
radiofrequency ablation has been shown to be of benefit in idiopathic left ventricular
tachycardia in reported cases, the exact nature of the reentry circuit and the
optimal site of ablation is still a matter of debate. This case demonstrates
success of radiofrequency ablation at a site in the left ventricular outflow
tract determined by pace mapping, with no recurrence on follow up.
Submitted ACP
Associates 2002
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ALEUKEMIC PRESENTATION OF ACUTE PROMYELOCYTIC LEUKEMIA.
Bakhtiar Ali, MD, Associate, Danny Obeid, MD, Associate, Atul Singh, MD, Associate Rajika Munasinghe, MD, Member, and Leopoldo Eisenberg, MD, Member, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Acute Promyelocytic Leukemia (APL-M3) accounts for 10% of all acute myeloid leukemias. The median age of presentation is 37 years. DIC is present in approximately 80% of patients at the time of diagnosis. We describe an atypical case of APL, presenting with aleukemia (absence of blast cells in the peripheral smear) in a 75-year-old female patient.
The patient was admitted for elective surgery for a large 7 cm, abdominal aortic aneurysm. Routine blood counts showed pancytopenia (WBC 700/mm3, Hemoglobin 6.7 g/dL and platelet of 18,000/mm3). No blast cells were detected on peripheral smear. Bone marrow biopsy showed 100% cellularity with 28.6% blasts. The diagnosis of AML-M3 (APL) was confirmed by flow cytometery and cytogenetic studies that revealed the (t 15;17) translocation. The patient was treated with all-trans-retinoic acid (ATRA) therapy. Clinical remission was confirmed after one month of treatment by repeat bone marrow studies that showed a marrow cellularity of 80% with 2.9% blasts. The peripheral smear showed improvement in the pancytopenia (WBC 2900/mm3, Hb 8.4 g/dL and Platelets of 361,000/mm3). Cytogenentic studies revealed a normal karyotype.
ATRA therapy has revolutionized the treatment of APL, which was highly fatal previously. This case report demonstrates that ATRA is effective in elderly patients with atypical presentations of APL. The absence of the (t 15;17) translocation after therapy is associated better long term remission. Aleukemic presentation occurs in only 10% of all myeloid luekemias. We failed to find any previous case reports of APL presenting as aleukemia in the medical literature.
Submitted ACP
Associates 2002
RIGHT ATRIAL MASS PRESENTING AS SYNCOPE
– A CASE REPORT. Siddhartha Annamraju, MD, Associate, Vijayalakshmi
Sankaranarayanan, MD, Associate, Antonio Carrillo, MD, Member and Frank
Baciewicz, MD, Sinai-Grace Hospital, Detroit Medical Center / Wayne State
University, Detroit, Michigan
Right atrial masses, viz. myxomas and thrombi are not entirely uncommon clinical occurrences. Thrombi attached to the tip of indwelling intravascular catheters aren’t infrequent either. However, masses attached to the tips of catheters and extending into the right atrium and ventricle causing syncope, to the best of our knowledge, have not been reported in the literature. We present to you the case of a 45-year old lady who presented to our Emergency Department with syncope and cyanosis. She had a Denver shunt placed earlier for cirrhosis. A trans-thoracic echocardiogram showed a 7 X 3.5 cm cystic mass in the right atrium moving in and out of the right ventricle with each cardiac cycle. An atriotomy was done to remove the mass. This case reveals a unique, hitherto unreported, complication of an indwelling intravascular catheter.
Submitted ACP
Associates 2002
TREATMENT OF CENTRAL PONTINE MYELINOLYSIS WITH IMMUNOGLOBULIN. Atul Singh, MD,
Associate, Nandita Keole, MD, Associate and Mohamed Karim, MD, Member,
Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Central pontine myelinolysis (CPM), a neurological disorder usually associated with rapid correction of hyponatremia. It has also been reported with chronic alcoholism, liver transplantation, adrenal insufficiency and sepsis. The disease has a universally dismal outcome and no effective treatment is established. 75 % of the surviving patients are left with persistent neurological deficit.
We present a case of CPM that survived without any residual neurological deficit. Our patient is a 34-year-old woman, a chronic alcoholic, who initially presented with a sodium of 119 mmol/L. She was discharged after appropriate correction of hyponatremia, using normal saline. She was readmitted 3 weeks later with new onset seizures. Initial neurological examination was normal. On day 4 of hospitalization, the patient was noted to have nystagmus, slurred speech, hyporeflexic tertraplegia, progressive psuedobulbar palsy and finally locked-in-syndrome. MRI of the brain showed changes in the pons consistent with CPM. She was intubated for airway protection and treated with intravenous immunoglobulin (IVIG) 0.4 gm/kg body weight per day for 5 days. On day 13, she began to show signs of neurological recovery with eventual ability to ambulate by day 25. After intensive physical therapy she was functionally independent by day 51.
Finsterer et al. have reported using IVIG for the treatment of CPM in a young male alcoholic patient with good clinical response. Ours is the second such case report that supports IVIG as a promising treatment modality for CPM.
Submitted ACP Associates 2002
BLOOD PRESSURE MEASUREMENT IN PRIMARY CARE RESIDENCY TRAINING PROGRAMS. Himabindu R. Boda, MD, Associate and Rajika L. Munasinghe, MD, Member. Department of Medicine, Sinai-Grace Hospital/Wayne State University, Detroit, Michigan.
Background: Hypertension in one of the most common medical conditions diagnosed and managed in the primary care setting. We surveyed primary care residency programs in internal medicine and family medicine to determine how blood pressure is measured in the continuity care clinics where residents receive their ambulatory care training.
Methods: A total of 836 primary care internal medicine and family medicine program directors or their designees were surveyed using a 13 item questionnaire. Program directors were initially contacted by email. If the email addresses was not valid or a response to the email was not received the questionnaire was sent by regular mail.
Results. A total of 203 programs responded out of which 136 responses were received by email. Only 15.6% of programs required the residents to routinely measure blood pressure in all patients while the majority required the resident to measure blood pressure only when deemed necessary by the resident (71.4%). Only 32% of the responding programs required the residents to manually measure and verify abnormal readings. At present, only 50% of responding programs routinely instruct residents on the technique of blood pressure measurement according to JNC VI.
Conclusions: The role of residents in assessment of blood pressure appears to differ substantially among primary care residency programs. More programs should instruct resident on the JNC VI standards for blood pressure measurement.
Submitted ACP
Associates 2002
HEMODIALYSIS RELATED PSEUDOMONAS PAUCIMOBILIS SEPTICEMIA
TREATED WITHOUT GRAFT REMOVAL. Parminder
Chahal, MD, Associate, Viji Nagappan, MD, Associate and Wasif Hafeez, MD,
Memeber, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Widely distributed in soil and water, Pseudomonas paucimobilis is a non-fermenting, strict aerobe, oxidase and catalase positive, gram-negative bacillus. Rarely implicated in community acquired and nosocomial infections of chronically sick humans, including bacteremia associated with hemodialysis, chemotherapy, peritonitis in continuous ambulatory peritoneal dialysis, empyema, visceral organ abscess, meningitis and wound infection. No fatalities reported. At least one case of catheter related septicemia successfully treated without catheter removal is reported.
We present a case of Pseudomonas paucimobilis septicemia in a 54 year old female with end stage renal disease on outpatient hemodialysis via gortex arteriovenous shunt that developed fever immediately after dialysis. She had received a dose of empiric antibiotics after blood cultures were drawn. Blood cultures grew Pseudomonas paucimobilis in 48 hours and the patient was admitted to the hospital only after it was known that she had a bacteremia. At admission her blood cultures had become negative, but because she continued to be febrile she was treated with 14 days of intravenous antibiotics. The patient never had a clinically identifiable source and her AV graft site looked intact so it was decided to only medically manage this infection. An epidemiologic investigation of the outpatient dialysis center showed no other cases and no positive surveillance cultures.
Pseudomonas paucimobilis is rarely found in the hospital water supply, hemodialysis fluids and respirators. In most cases, the source of infection is endogenous as in this case and it represents a case of successful treatment without removal of the graft.
Submitted ACP Associates 2002
A CASE REPORT OF SEVERE GROUP B STREPTOCOCCAL (GBS)
INFECTION AND A REVIEW OF GBS BACTEREMIA. Kashif Chaudhry, MD, Associate and
Wasif Hafeez, MD, Member, Sinai-Grace Hospital, Wayne State University,
Detroit, Michigan.
GBS in
humans can be an asymptomatic colonizer of the genital and lower GI tract or a
pathogen causing an invasive infection with substantial morbidity and
mortality. We present a case of an unusually severe GBS infection, which
prompted a review of all cases of GBS bacteremia at our hospital.
Our
patient is a 48 years old woman, who presented with high fevers, headache, neck
and back pain, right shoulder pain and confusion progressing over a 2 day
period. Diagnostic evaluation resulted in GBS being isolated from blood
culture, CSF culture and right shoulder aspirate. MRI of the spine revealed
L5-S1 vertebral osteomyelitis with discitis with epidural and paraspinal
abscess.
The
patient was treated with ampicillin and underwent surgical drainage of her right
shoulder and L5-S1 laminectomy and debridement. Her response to treatment was
slow but complete. Her primary source of infection remained unclear.
At
Sinai-Grace Hospital we saw 16 cases of GBS Bacteremia in 2001. The M:F ratio
was 7:9; 8 of 16 had diabetes, 6 of 16 presented with shock 6 of 16 had an
identifiable source, 6 were alcoholics and 5 of 16 died.
Off the
16 cases identifiable clinical entities included primary bacteremia in 9,
pneumonia - 2, genital tract -1, pharyngeal abscess -1, penile gangrene -1, and
line sepsis - 1.
Severe
GBS infection in adults usually presents as one of several clinical expressions
of infection such as primary bacteremia, female genital tract infection,
pneumonia, endocarditis, arthritis, osteomyelitis, abscesses or meningitis. Our
patient presented with several of these clinical entities, others at our
hospital have had more focal manifestations of the infection.
Submitted ACP Associates
2002
HOW DOES MUPIROCIN RESISTANCE AMONG STAPHYLOCOCCUS AUREUS ISOLATES EMERGE IN LONG-TERM CARE FACILITIES (LTCF)?
Rasha M.Ghurani, MD1, Associate, Lona Mody, MD2, and Susan F. Bradley, MD2, Sinai-Grace Hospital, Wayne State University1, Detroit and VA Medical Center/University of Michigan2, Ann Arbor, Michigan.
Introduction: Eradication of persistent Staphylococcus aureus (SA) colonization with mupirocin (MUP) may reduce the spread of infection and thus mortality in LTCF. The effect of MUP on persistence of decolonization, reduction in infection and the increased risk for emergence of resistance (MUP-R) has not been prospectively studied in LTCF in a randomized, double-blinded, placebo controlled fashion.
Methods: Residents from a community LTCF and a VA LTCF with persistent colonization in nares or wounds were enrolled. Colonized sites were treated with MUP or placebo for 14 days. Cultures for SA and coagulase negative Staphylococci (CNS) were performed on a regular basis over 6 months. SA and CNS isolates were screened for the presence of MUP-R before and after treatment.
Results: 128 of 150 eligible patients were enrolled and 108 completed 14 days of MUP (n=65) or placebo (n=63) treatment. Of 65 patients randomized to MUP, 87% cleared their SA versus 17% in the placebo group, P<0.0001. All patients who failed MUP treatment at 14 days harbored MUP-R SA either before (n=4) or during (n=3) MUP treatment. All patients with MUP-R SA harbored high level (>500mg/ml) MUP-R CNS. MUP-R SA strains post-treatment had similar genotypes by CHEF typing when compared with pre-treatment susceptible strains.
Conclusion: MUP was effective in clearing SA carriage long-term; however a significant proportion of residents became recolonized. Whether recolonization is due to relapse or new acquisition of SA strains is being assessed. CHEF typing results are highly suggestive that resistance emerged with treatment in the original strains, i.e. relapse of the same strain.
Submitted ACP
Associates 2002
SYMPTOMATIC LACTIC ACIDOSIS SECONDARY TO NUCLEOSIDE ANALOGUE REVERSE
TRANSCRIPTORS INHIBITORS (NRTI). Haleh Haerian, MD, Associate, Manesh
Kottapuram, MD, Associate and Geetha
Krishnamoorthy, MD, Member, Department of Medicine, Sinai-Grace
Hospital, Wayne State University, Detroit, Michigan.
Introduction: Type “B” lactic acidosis is a rare but potentially life-threatening complication of NRTI therapy and is often accompanied by other serious clinical manifestations of mitochondrial toxicity, such as hepatic steatosis, pancreatitis, myopathy, and peripheral neuropathy.
Objective: To describe the development of symptomatic lactic acidosis in four patients treated with NRTIs and to emphasize on the importance of early recognition since a fatal course will follow shortly.
Cases: Our four patients were 30 to 61 years of age and diagnosed with HIV infection. Their CD4+ counts were in the range of 7 to 920 and the viral loads ranged from undetectable to 400,000 copies/ml. They presented with symptoms of exertional dyspnea, sever fatigue, leg pain, nausea, and pedal edema. Arterial lactate ranged from 4.3 to 14.9 mmol/L. The NRTIs that these patients were on were AZT, Stavudine, and Lamivudine. All the four patients responded to discontinuation of NRTI, administration of CoQ, Riboflavin, Thiamine, Levocarnitine and supportive therapy.
Discussion: An often-fatal syndrome of lactic acidosis and hepatic steatosis is a recognized but rare complication of NRTI therapy for HIV infection. Nucleoside analogues can inhibit Gamma-DNA polymerase, the enzyme responsible for mitochondrial DNA synthesis, which is the underlying mechanism of lactic acidosis. The first case was reported in 1991 and was linked to monotherapy with Zidovudine. Since then, other NRTI drugs have been linked to the condition, particularly Stavudine, Didanosine and Lamivudine.
Submitted
ACP Associates 2002
EPIDEMIOLOGY OF
HEPATOCELLULAR CARCINOMA IN HEPATITS C VIRUS INFECTED PATIENTS. Atul Singh, MD,
Associate and Firdous Siddiqui, MD, Member, Sinai-Grace Hospital and Division
of Gastroenterology, Wayne State University, Detroit, Michigan
Recent studies have shown an increase in incidence of Hepatocellular carcinoma (HCC) in the United States, from 1.4 to 2.4 per 100,000 patients. We analyzed the epidemiology of patients with hepatitis C virus associated HCC treated at an inner city hospital.
Epidemiological and histological parameters for 94 patients were collected retrospectively using diagnostic code for primary liver cancer (ICD-9-CM 155.0) and presence of HCV antibodies. All patients (except for one patient, who had MRI Abdomen documented HCC) had histologically proven HCC.
There was male predominance in our patients as a group (male: female ratio of 67:33 %) and also when divided into sub groups by age and race. 60% of patients were African American, 26% Caucasians and the remainder were Hispanic, and Arab Americans. 21 % of patients had concomitant exposure to HBV. 82% of the patients were more than 50 years old (mean age 61 years). AFP was elevated in 90 % of the patients, with very high levesl (>1000μg/l) in one third of the patients. Histologically, most of the tumors were moderately differentiated (47 %). It is noteworthy that 51 % of our patients did not have any known risk factors for HCV infection.
The age specific trends for HCC have been towards younger people; we found that our patients had lower mean age than national averages. Predominance of HCC in males and African American was seen, but with higher female percentages. Study further supports the use of AFP levels in screening for HCC in patients with HCV infection.
Introduction: Thyroglossal Duct Cysts are the most common mid line neck swellings and carcinoma is found in approximately 1 percent of the lesions. In the literature, less than 200 cases are reported. The cysts are usually asymptomatic and distinction from carcinoma is seldom possible clinically. Papillary carcinoma comprises 80 percent of the thyroglossal cyst carcinomas.
Case Report: A 35-year-old male presented with a lump in his neck that was increasing in size. On physical exam, a 3cm mobile, cystic, nontender, midline neck mass was present at the level of the hyoid bone. The mass moved up with protrusion of the tongue. Ultrasound was consistent with the diagnosis of a thyroglossal cyst. Sistrunk procedure was done and the histopathology revealed papillary carcinoma. The lymph nodes were negative for neoplasm. Thyroid scan and thyroid function tests were normal and thyroxin was started.
Discussion: Controversy exists over the origin of thyroglossal duct carcinoma, whether it is a primary tumor or a metastasis from the thyroid gland. The question arises as to what to do with the thyroid gland, and whether prophylactic thyroidectomy is advised. Given the excellent prognosis and low risk of recurrence, the optimal surgical procedure for the thyroglossal duct carcinoma is the same as for a benign cyst. Thyroid suppression is recommended for all patients with papillary carcinoma of the thyroglossal duct.
Submitted ACP Associates 2002
ADNAB-9 LABELING IN MIXED POLYPS. K. Qureshi, MD, Associate, N. Ullah, MD, P. Sochaki, MD, J. Hatfield, PhD., V. Iordanova, J. Bowman, M. Lawson, PhD., M. Tobi, M.B.,ch.B. Departments of Medicine and Pathology, Sinai-Grace Hospital, J. D. Dingle VAMC, Detroit, Michgan; and Kaiser Permanente, Sacramento, CA.
Submitted ACP
Associates 2002
Isolated Familial Hyperparathyroidism - A case report, Tawhida Khatoon, MD, Associate, Savitha Balaraman, MD, Associate and Geetha Krishnamoorthy, MD, Member, Sinai-Grace Hospital, Wayne State University.
A twenty nine year old African American lady presented to the hospital with severe abdominal pain, nausea, constipation and bone pain. Her past medical history included right ankle fracture following minor trauma and major depression. Her family history was significant for hyperparathyroidism in her maternal grandmother, father, two maternal aunts and her twin sister requiring surgery. Laboratory studies revealed a serum calcium of 13.7 mg/dL, parathormone level of 605 pg/ml and a creatinine of 0.8 mg/dL. Urine analysis showed 5-10, white cells, 5-10 red cells and calcium oxalate stones. Abdominal X-ray revealed bilateral renal calcifications. A diagnosis of primary hyperparathyroidism was entertained. No other endocrinopathies were reported in her family members. A neck exploration revealed a 2x3 cm adenoma in her right inferior parathyroid gland which was excised. Postoperative course was complicated by hungry bones syndrome that was managed medically.
Primary Hyperparathyroidism is a relatively common condition with an annual incidence of 1 in 1000 men and 2-3 in 1000 women beyond the age of 50. A small subset of primary hyperparathyroidsm may occur as a part of Multiple Endocrine Neoplasia I or II A or as Isolated Familial Hyperparathyroidism. Isolated Familial Hyperparathyroidism has been reported only in 70 families in the literature. Its inheritance is autosomal dominant, presenting at the mean age of 22 with hypercalcemia, early nephrolithiasis and aggressive bone disease. The pathology usually reveals parathyroid hyperplasia though chief cell adenomas have been reported rarely. The significant features of this case report including a literature review of this rare clinical entity is presented.
Submitted ACP Associates 2002
PROTECTION OF CARDIOMYOCYTES AGAINST METABOLIC STRESS BY 17b-ESTROGEN IN CULTURE. Manesh T. Kottapuram, MD, Associate, Department of Internal Medicine, Sinai-Grace Hospital, Wayne State University School of Medicine, Detroit, Michigan.
Objective: To
understand the mechanism in which estrogen protects cardiomyocytes in culture
against metabolic stress injury.
Background: The
beneficial effects of estrogen on the cardiovascular system have been
traditionally ascribed to decrease in peripheral vascular resistance and
antiatherogenic action. However, the
molecular mechanism for this protection is still poorly understood.
Hypothesis:
Estrogen protects cardiomyocytes by upregulating the Akt kinase signal
transduction pathway and by accomplishing Ca2+ homeostasis at
cellular level.
Methods:
Ventricular cardiomyocytes isolated from female Sprague- Dawley rats were
incubated in serum free culture medium with and without 17 b- estradiol.
Then cells were either lysed to isolate proteins for detection of Akt
signal transduction pathway activation or treated with various agents (2-3 DNP,
Thapsigargin, and Ionomycin) to induce chemical hypoxia and Ca2+
loading in cardiomyocytes. Activation of
Akt kinase was determined by western blot assay using specific anti-phospho-Akt
antibody. Ca2+ loading and
its subsequent homeostasis assessed by Fura-2 dye and dual excitation
fluorometer.
Results: Estrogen may upregulate Akt signal
transduction pathway in cardiomyocytes.
Pre-treatment with estrogen significantly affects Ca2+ loading
in cardiomyocytes either by decreased rate of loading or by facilitating efflux
of cytoplasmic Ca2+.
Conclusion: The
preliminary reports may support the hypothesis that the protective effect of
estrogen on cardiovascular system can be attributed either to the upregulation
of Akt kinase signal, which is a well-known ‘antiapoptotic’ cell survival
signal or to the efficient cytoplasmic Ca2+ homeostasis in
cardiomyocytes”.
Submitted ACP
Associates 2002
AORTIC DISSECTION PRESENTING AS UNSTABLE ANGINA COMPLICATED BY FEVER AND ATELECTASIS. Mohamed Rouf, MD, Associate, Farah Ubaid, MD, Associate and Rajika Munasinghe, MD, Member, Department of Internal Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
We describe a
42-year-old African-American male with hypertension, smoking and cocaine use
who presented with severe sharp substernal pain strongly suggestive of angina.
Physical examination was unremarkable except for an elevated blood pressure of
160/90 mmHg. Peripheral pulses and blood pressure in the upper extremities were
equal. The ECG showed left ventricular hypertrophy. The chest radiograph
revealed cardiomegaly and serial troponin levels were normal. Echocardiogram
revealed a dilated left ventricle with severe hypokinesis. Patient was admitted
and treated for unstable angina. The next day he developed a temperature of 100
F, with leukocytosis. Repeat chest radiograph showed the development of
plate-like atelectasis of both lung bases. He was started on antibiotics for
pneumonia but chest pain, fever and leucocytosis persisted. A chest CT done to
ascertain the cause of atelectasis revealed Stanford type B aortic dissection.
The patient was managed conservatively and discharged shortly afterwards.
The diagnosis of
Thoracic aortic dissection may be missed when patients present with atypical
symptoms instead of the characteristic severe tearing chest pain associated
with hypertension. Previous case reports have described fever in patients with
aortic dissection thought to result from injury to the vessel wall, hematoma
formation and tissue ischemia. Atelectasis in our patient was most likely due
to diminished respiratory effort from chest pain, which also could have
contributed, to his fever. Clinicians should be aware that fever, chest pain
and atelectasis are clinical findings that can be associated with aortic
dissection and pursue this diagnosis when clinically indicated.
Submitted ACP Associates 2002
A RARE CASE OF ADULT MEDULLOBLASTOMA.
Mohammad Khan, MD, Associate, Atul Singh, MD, Associate and Mohammad Karim, MD,
Member, Sinai-Grace Hospital, Wayne State University.
Medulloblastoma is the most common type of
primary solid malignant brain tumor in children, accounting for 30% of
childhood brain tumors. In contrast, medulloblastoma represents only 0.2% of
all brain tumors found in adults older than forty years of age.
We describe a case of a 48 year-old
African-American male who presented to our clinic with a two-month history of
headache and clumsiness when walking. The patient’s medical history was
significant for injection drug use, Hepatitis B, and Hepatitis C infection. On
physical examination the patient had difficulty with tandem walking. MRI showed
a mass involving the vermis of the cerebellum. A stereotactic resection of the
brain tumor was performed. The pathology revealed the mass to be a primitive
neuroectodermal tumor with glial differentiation. Chromosomal analysis was
performed on 20 cells with 4/20 cells showing a deletion in chromosome 22. This
is an uncharacteristic finding in medulloblastoma. Postoperatively, he was
scheduled to have radiation and chemotherapy.
In this case report, we describe a patient
with a midline adult medulloblastoma. We will discuss the clinical
characteristics of this case and compare it to other cases of adult
medulloblastoma that have been reported in the literature.
Submitted ACP
Associates 2002
MEDICAL IMPROTANCE OF APERT'S SYNDROME. Apurva Motivala, MD, Associate, Atul Singh, MD, Associate, Mamatha Reddy, MD, Associate, and Geetha Krishnamoorthy, MD, Member, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
We describe a 51 year old Caucasian male brought to our hospital after he was found unresponsive in his driveway. The patient was cyanotic at presentation. We noted exophthalmos, large ears, hypertelorism, syndactyly, evidence of skin infection and ecchymosis secondary to leg trauma. In the emergency department, the patient had improvement after supplemental oxygen and was fully awake with reversal of cyanosis. He admitted to alcohol intake prior to this episode. Based on his clinical features, we diagnosed the patient with Apert's syndrome.
Apert's Syndrome was first described in a newborn in 1906. It's inheritance is autosomal dominant. However, more commonly it is caused by a sporadic mutation of Fibroblast Growth-factor receptor-2 located on chromosome 10. It is a form of acrocephalosyndactyly which involves developmental defects of the skull and digital fusion. Associated congenital defects include hydrocephalus, sleep apnea, tracheo-esophageal fistula, anomalous tracheal cartilage, pulmonary aplasia, pyloric stenosis, biliary atresia, ventricular septal defect, polycystic kidneys, hydronephrosis, severe acne, ear infections, absent right middle lobe of the lungs and mental retardation.
These patients, due to improved modalities of corrective surgery in childhood, now have a better median survival. Recognition of this syndrome is important to the internist as the presenting medical conditions may have an underlying congenital pathology that should be recognized and treated appropriately. Our patient is one of the oldest surviving patients diagnosed with Apert's syndrome reported.
Submitted ACP
Associates 2002
A CASE OF CHRONIC MYELOID LEUKEMIA
FOLLOWING NON-SMALL CELL CARCINOMA OF THE LUNG AND SQUAMOUS CELL CARCINOMA OF
THE LARYNX. Nagaprasad
Nagajothi, MD, Associate, Rajika L. Munasinghe, MD, Member and Leopoldo
Eisenberg, MD, Member, Department of Medicine, Sinai-Grace Hosptial/Wayne State
University, Detroit, Michigan.
The association between squamous cell carcinoma of the larynx and aerodigestive tract cancers including non-small cell lung cancer is well established. However, the association between chronic myeloid leukemia (CML) and non-small cell lung cancer or carcinoma of the larynx is unclear, either as a second primary cancer or as a complication of treatment with radiotherapy and/or chemotherapy.
We report a case of a 73 year old male patient with a 50 pack year history of smoking who was diagnosed with non-small cell cancer in 1993, carcinoma of the larynx in 1995, and CML in 2000. He was treated with lobectomy and external beam radiotherapy with a total dose of 5,193 cGy/30Fx/45Days for his lung cancer and vocal cord stripping followed by radiotherapy to the larynx with a total dose of 6,600cGy/33Fx/46Days for the laryngeal cancer. The CML with positive cytogenetics for Philadelphia chromosome was detected in 2000 subsequent to a work up for leukocytosis when he had a relapse of his lung cancer.
The development of CML in this patient could be independent or dependent of the prior treatment with radiotherapy. Though the cytogenetics for CML is well studied not much is known about what triggers these mutations. As opposed to acute leukemias there is no definitive evidence from large population based case-control studies that the risk of developing CML is higher in individuals submitted to chemotherapy and /or radiotherapy than in the general population. This does not include atomic bomb survivors. A large epidemiological study specifically designed to assess the risk of developing a second primary CML after chemotherapy and /or radiotherapy would be helpful.
Submitted ACP
Associates 2002
COMPLEMENT DEPENDANT CYTOTOXICITY (CDC) IS A MAJOR MECHANISM OF ACTION OF
RITUXIMAB, Nagaprasad Nagajothi, MD1, Associate, William
Matsui, MD2; Galina Mukina, MD2; Robert A. Brodsky, MD2.,
1Department of Medicine, Wayne State University/ Sinai-Grace
Hospital, Detroit and 2 The Johns Hopkins Oncology Center,
Baltimore.
Rituximab is an anti-CD20 monoclonal antibody used to treat B cell lymphoproliferative disorders. Rituximab is believed to kill cells through (CDC), antibody-dependent cellular toxicity and apoptosis. Recent data demonstrate that a major cause of resistance to rituximab is upregulation of the complement regulatory proteins, CD59 and CD55. Paroxysmal nocturnal hemoglobinuria (PNH) is a hematopoietic disorder which results in loss of all glycosylphospatidylinositol (GPI)-anchored proteins from the cell surface including, CD55 and CD59. PNH is caused by somatic mutations in the PIGA gene, the product of which is required for the biosynthesis of GPI-anchors. The purpose of this study was to examine the impact of disrupting cell surface GPI-anchor proteins in order to augment rituximab-mediated CDC. Here, we used the PNH cell line LD- which is a CD20+ve B cell line that is devoid of GPI-anchor proteins; the isogenic cell line LD-PIGA+ was established by stably transfecting an expression vector containing the full-length PIGA gene to restore GPI-anchor protein expression. Both cell lines were cultured in media containing rituximab (10mg/ml), complement (25% human serum), or rituximab and complement. Viability at one hour was measured using propidium iodide and annexin V staining. The combination of rituximab and complement resulted in greater than 65% killing of the LD- line and less than 20 killing in the LD-PIGA+ line. Complement alone or rituxan alone resulted in less than 10 killing of both cell lines. To confirm that disruption of GPI-anchor proteins augments rituximab mediated CDC we treated the LD-PIGA+ line with PIPLC, a phospholipase that selectively cleaves GPI-anchored proteins. Following PIPLC treatment, the LD-PIGA+ line became as sensitive to the combination of rituximab and complement as the LD- cells. Thus, CDC is a major mechanism for action of rituximab. Disrupting cell surface GPI-anchor proteins may improve the efficacy of ritiximab for treating lymphoproliferative disorders and B cell-mediated autoimmune disorders.
Submitted ACP
Associates 2002
RITUXAN IN THE TREATMENT OF
REFRACTORY IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP): SPLENECTOMY MAY IMPROVE
RESPONSE. Nagaprasad Nagajothi, MD, Associate, Rajika L. Munasinghe, MD, Member
and Leopoldo Eisenberg, MD, Member, Department of Medicine, Sinai-Grace
Hosptial/Wayne State University, Detroit, Michigan.
Idiopathic (Immune) thrombocytopenic purpura (ITP) is caused by premature platelet destruction by autoantibodies against platelet antigens. There have been a few case reports on treatment of refractory ITP with Rituxan (Rituximab) but well controlled trials in this area are lacking. Rituxan is a chimeric monoclonal anti CD20 antibody that depletes CD20+B cells thereby interfering with the production of platelet autoantibodies. We report our experience with Rituxan in the treatment of refractory ITP in five patients.
We conducted a retrospective study of five patients using a standardized questionnaire. All patients had failed at least two treatments for ITP. Three patients had splenectomy. Platelet count at the start of treatment varied from 14,000/ul to 64,000/ul. All patients received Rituxan 375mg/m2 every week for 4 weeks. There was a complete response in the three patients who had splenectomy with platelet counts greater than 100,000/ul and this response was maintained (without additional ITP treatment) even in the sixth month post treatment in two patients. One patient had relapse of ITP five months post treatment after a flu like illness. He had a complete response when retreated with Rituxan. There was a partial temporary response in one patient who did not have splenectomy and the platelet count rose to 114,000/ul one month after treatment and stayed at 90,000/ul for three months but subsequently declined to the point requiring treatment with steroids. There was no response in the other patient who did not have splenectomy and who also had systemic lupus erythematosus.
Our results suggest that Rituxan may be efficacious in the treatment of refractory ITP, but large-scale studies are needed to evaluate this and to determine if splenectomy improves the response to Rituxan.
Submitted ACP
Associates 2002
AUREOBASIDIUM PULLULANS INFECTION OF THE KNEE JOINT IN A PATIENT WITH HISTORY
OF SPOROTRICHOSIS OF THE SAME JOINT. Danny Obeid, MD, Associate, Bakhtiar Ali,
MD, Associate, Viji Nagapan, MD, Associate, and Wasif Hafeez, MD, Member,
Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Aureobasidium Pullulans is a fungus that is widely found as a saprophyte. It is rarely associated with human infections; usually it causes fungal keratitis and peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD).
Here we report a case of Aureobasidium Pullulans infection of the right knee in a 47 year old male with a history of alcohol abuse and a history of sporotrichosis of the same knee diagnosed 2.5 years ago and treated with Itraconazole for 1.5 years. He used to be a gardener and his job makes him deal with dead decaying wood. Six months after he finished the antifungal course, he presented with swelling, pain, and limitation of movement of his right knee. The joint was tapped and synovial fluid grew Aureobasidium Pullulans. The patient was treated with Itraconazole and he reported improvement of his symptoms in a few weeks although not completely resolved.
The importance of this case comes from the fact that
Aureobasidium Pullulans knee infection has not been reported before. We don’t
know yet whether the history of sporotrichosis predisposed him for this
infection or it is a completely independent one.
Submitted ACP
Associates 2002
ASSOCIATION BETWEEN
HEIGHT, WEIGHT, BODY MASS INDEX AND DISCORDANT REGIONAL BONE MINERAL DENSITY.
Violeta Botea, MD, Associate, Gary W. Edelson, MD, Fellow and Rajika L.
Munasinghe, MD, Member, Department of Medicine, Sinai-Grace Hospital, Wayne
State University, Detroit, Michigan.
Introduction:
Patients with generalized osteoporosis have a body mass index (BMI) that is
significantly lower than patients with normal bone mineral density (BMD).
Discordant regional BMD is defined when the BMD is in the osteoporotic range at
one site while being normal at the other sites. This study was conducted to
study anthropometric characteristics of patients with discordant regional BMD.
.
Methods:
Data from 7095 bone densiometry scans from a suburban osteoporosis testing
center in Detroit were analyzed. A patient was classified as having generalized
osteoporosis if the t score was less than -2.5 at 3 sites (spine, femur and
forearm) and non-osteoporotic if the t score > -1 at 3 sites. Patients were
determined to have discordant regional osteoporosis when the t score was <
-2.5 at one site with a t score > -1 at the other two sites.
Results.
Forearm was the site where isolated regional osteoporosis was most prevalent
(64 patients, 0.9%). Patients with generalized osteoporosis were older (mean
age 72), shorter ( height 158 cm) and had lower BMI (23.6) compared to
non-osteoporotic patients (mean age 54, height 161 cm and BMI 28.6). Patients
with discordant low forearm BMD were similar in age (mean age 70 yrs), but were
taller (height 158cm) and had BMI values that were significantly higher (BMI
28.9, p < .001) than patients with generalized osteoporosis .
Conclusion: Patients with discordant BMI at the forearm have anthropometric characteristics that are significantly different from patients with generalized osteoporosis. These differences may represent differences in etiology of osteoporosis in cortical bone compared to trabecular bone.
Submitted ACP
Associates 2002
A COMPUTER A COMPUTER SIMULATION TO STUDY THE ASSOCIATION BETWEEN PATIENT
CENSUS, TYPE OF CALL SCHEDULE AND AVERAGE LENGTH OF STAY IN ACADEMIC RESIDENCY
PROGRAMS. Dhaval Shah, MD, Associate, Mohamed Siddique, MD, Fellow, Marc
Feldman, MD, Fellow and Rajika Munasinghe, MD, Member, Sinai-Grace Hospital,
Wayne State University, Detroit Michigan.
Background: Optimal clinical training in internal medicine residency programs is dependent on the opportunity to learn without being overwhelmed by having to care for a large number of patients. Current RRC guidelines specify service caps on the number of patients admitted and the maximum number of patient that should be covered by a trainee. The type of call schedule (periodic 1:4 or 1:5 call vs. night float), number of admissions and the average length of stay (LOS) are important factors that determine the patient census of a trainee.
Methods: A computer program was developed to predict the number of patients on a team using the above variables. This model was used to study resident work load for several call schedules incorporating different frequencies of long call and short call (day call) as well as a night float system
Results: The number of admissions and the average LOS are the two most important determinants of patient census. The patient census on a team is relatively independent of the type of call schedule. When the LOS decreases the number of admissions over a specified period has to be increased in order to maintain a certain minimum patient census.
Discussion: The average patient census is traditionally used as a measure of resident workload and as an indicator of adequate clinical training. This may not be a representative estimate of resident effort when the LOS is low as workload related to patient turnover could be high. The computer simulation of daily patient census allows us to study these associations with greater accuracy and predict the impact of changes made to optimize resident training.
Submitted
ACP Associates 2002
NON-OBSTRUCTIVE TRIPLE VESSEL CORONARY ARTERY
ANEURYSMS CAUSING ST ELEVATION
MYOCARDIAL INFARCTION: A CASE REPORT.
Fadi A.
Saab, MD, Associate, Surendra Marur, MD, Associate and Antonio Carrillo, MD,
FACC. Sinai-Grace Hospital, Wayne State
University, Detroit, Michigan.
Multiple Coronary Artery Aneurysms are rarely seen in adults. In association with Myocardial Infarction, there are less than ten cases reported since 1967.
A 55 year-old African- American male presented to the emergency department with classical features of myocardial infaction. Risk factors for coronary artery disease included cigarette smoking and strong family history. EKG displayed ST-elevations in the inferolateral leads. He was treated with Reteplase, intravenous heparin, intravenous nitroglycerin, beta-blocker, and aspirin. He continued to have angina and underwent emergency cardiac catheterization which revealed diffuse aneurysmal dilatation of the Right Coronary, Left Anterior Descending and Left Circumflex Arteries with slow flow. Dilatations ranged from 6 to 8 millimeters. No occlusions were seen. Our patient was discharged two days later with standard medical management and Cardiac Rehabilitation Phase II.
In adults, in addition to congenital aneurysms the etiology of Multiple Coronary Aneurysms includes Systemic Lupus Erythematosis, Neurofibromatosis, Atherosclerosis and Chest Trauma. Treatment options include lifelong anticoagulation, stenting, and surgery although not all authors agree that any treatment is required. Our patient had no evidence of any of the above etiologies for Coronary Aneurysm outside of possibly a Congenital cause.
Coronary Aneurysms are rare in adults and even more rarely lead to ST-Elevation Myocardial Infarction. A consensus on any treatment in addition to the standard Myocardial Infarction medical management has yet to be reached.
Submitted ACP Associates 2002
Fadi Saab, MD
5049 Heather Drive
Dearborn, MI 48126
(313) 336-4604
ACP #01209023
CARDIAC AMYLOIDOSIS: A RARE PRESENTATION OF WALDENSTROM’S MACROGLOBULINEMIA. Saima Saad, MD, Associate and Mohamed Siddique, MD, Fellow, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Waldenstrom’s Macroglobulinemia (WM) is a rare lymphoplasmacytoid cell disorder with an overall annual incidence of 2.5/million/year. Of these, less than 5% develop amyloidosis. From 1978 to 1998, only five cases of WM. were reported in African-American women.
We describe a case of 54-year old African-American female with Waldenstrom’s Macroglobulinemia presenting with worsening shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea of 3 weeks duration. Physical examination revealed an elevated JVD, a displaced point of maximal impulse and a S4 gallop. The EKG and 2-D Echocardiogram suggested an old inferior wall infarction and dilated cardiomyopathy respectively. Cardiac catheterization revealed normal coronary arteries. Endomyocardial biopsy was done to search for the cause of cardiomyopathy, which stained positive with Congo red indicating amyloid deposits within the cardiac tissue.
From 1969 to 1990 only 11 cases of systemic amyloidosis with WM. have been reported, thus emphasizing the rarity of the disorder. The clinical course of amyloidosis associated with monoclonal IgM appears to be different from that of other patients with primary amyloidosis. The most striking difference being a higher incidence (44% versus 27%) of cardiac involvement with IgM than with IgG amyloidosis.
In conclusion, when patients with WM. develop symptoms of heart failure, amyloidosis should be suspected and confirmed as amyloidosis complicating WM. is associated with a much shorter survival than in patients with WM. alone.
Submitted ACP Associates 2002
BRONCHOCUTANEOUS FISTUAL: A RARE COMPLICATION OF TUBE THORACOSTOMY. Sanoj K.
John MD, Associate and Thomas Piskorowski, DO, FACP, Sinai-Grace Hospital, Wayne State University, Detroit,
Michigan.
Bronchocutaneous
fistula is a very rare complication of chest-tube placement. It can also happen
as complication of positive pressure ventilation and pneumonectomy. Although
benign most of the time, bronchocutaneous fistula can be annoying to the
patient. Krumpe et.al described a
unique physical sign in patients with bronchocutaneous fistula - a high-pitched
squeak over the affected chest area during sustained valsalva maneuver. CXR may
show air in the subcutaneous space and CT-Scan may reveal the fistula.
Treatment options include endoscopic repair, parietal pleurectomy or chemical
pleurodesis.
Our
patient is a 53-year-old female with history of carcinoma of the soft palate,
who presented with rll pneumonia and effusion. Thoracocentesis drained fluid
with ph 7.1, glucose <20 mg/dl,
and LDH of 2500 mg/dl, but no organisms. Thoracic surgery was consulted
for a complicated parapneumonic effusion. After a difficult chest-tube
placement, CXR and CT-Scan revealed persistent loculated hydropneumothorax.
The
original chest-tube was removed, and a second tube was placed in a lower
intercostal space. On expiration, a loud gurgling gush of air could be heard
over the original chest-tube site. CT-Scan revealed a fistulous tract from the
bronchus to the skin at the site of the original chest-tube and CXR revealed a
subcutaneous fistulous air tract in the lateral chest. Thoracotomy was required
with fibrin-glue placement to close the fistula.
Our case is the only case of bronchocutaneous fistula reported after chest-tube placement. In addition, the unique ct findings presented in this case helped to confirm the diagnosis of bronchocutaneous fistula in the setting of subtle CXR findings, which may be easily overlooked.
Submitted ACP Associates 2002
ARDS WITH BRONCHO-PLEURAL FISTULA TREATED WITH
ULTRA-HIGH FREQUENCY JET VENTILATION (UHFJV). Sanoj K. John, MD, Associate and Thomas Piskorowski, DO, FACP, Sinai-Grace Hospital, Wayne State University, Detorit, Michigan.
We report a case of ARDS complicated with Broncho-Pleural fistula successfully treated with UHFJV.
A 24-year-old male presented with multiple rib fractures, pulmonary contusions and hemothorax after a Pedestrian-Motor Vehicle accident. He was intubated, had bilateral chest-tubes placed and was mechanically ventilated. With worsening of his respiratory status and increasing levels of PEEP, he developed worsening bilateral pneumothoraces. Despite nine chest-tubes, he had bilateral pneumothoraces with inability to oxygenate or ventilate. At that point he was placed on UHFJV. Over the next two weeks, his condition improved to where conventional ventilation could be re-initiated with minimal levels of PEEP. While on UHFJV, there were several episodes of sudden O2-desaturation requiring urgent fiber-optic bronchoscopy to clear large mucus-plugs obstructing the airway. One week later he was extubated and all chest-tubes were removed.
Conventional ventilation may cause additional lung injury in ARDS from overdistention during inspiration, repeated opening and closing of small bronchioles and alveoli, or from excessive stress at margins between aerated and atelectatic regions. Smaller tidal volumes and higher end-expiratory lung volumes may be protective. UHFJV is a extreme mode of low tidal volume ventilation. High respiratory rates allow near-normal PaCO2 levels. High inspiratory airway pressures with conventional ventilation can generate and/or increase leak through Broncho-Pleural fistulas. UHFJV can decrease the airway pressures during ventilation.
Our case represents a dramatic example of benefit from UHFJV in a unique patient population, but also demonstrates the hazards described with UHFJV, with several life-threatening episodes of airway-obstruction by jet-induced tracheal mucous-plugs.
Submitted ACP
Associates 2002
VALPROIC ACID (VA) OVERDOSE - SUCCESSFULLY TREATED WITH HIGH-FLUX HEMODIALYSIS
WITHOUT CHARCOAL HEMOPERFUSION.
Shanthi Marur, MD, Associate, Hani Wadei, MD, Associate, B. Bushek RPh, Irfan Omar MD, MRCP and M. Ahsan, MD, FRCS, FACP, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan.
Objective: To report a case of valproic acid overdose successfully treated with high-flux hemodialysis without charcoal hemoperfusion.
Case Summary: A 24-year-old male was brought to the emergency room several hours after ingesting an unknown amount of valproic acid (VA). The patient was found to be comatose, hemodynamically unstable, with an anion gap metabolic acidosis, and a valproic acid level of 789 mcg/ml (therapeutic range of VA is 50-100 mcg/ml and half-life is 15 to 30 hours in cases of toxicity). High-flux hemodialysis was performed for four hours with an F80A dialyzer. Pre- and post-procedure total drug levels were 596mcg/ml and 260 mcg/ml respectively. The calculated half-life of VA pre-, during and post-procedure was 20 hours, 3.3 hours and 23.9 hours respectively. This suggests high-flux hemodialysis effectively reduce the half-life of VA. The patient’s anion gap metabolic acidosis resolved, and the hemodynamic status and mental condition improved with the acute reduction in the VA levels.
Discussion: In the setting of VA overdose, respiratory depression, coma and even death has been reported. 80 to 95 % of VA is protein bound at therapeutic concentrations and is considered undialyzable. At levels greater than 150 mcg/ml, the fraction of unbound VA increases. There is limited information about the use of high-flux hemodialysis without charcoal hemoperfusion for VA overdose. On performing an extensive medline search, only one case report was found. We report the second case.
Conclusion: High-flux hemodialysis without charcoal hemoperfusion is an effective therapeutic modality for rapidly reducing toxic concentration and serious adverse effects of VA along with other standard measures of treatment.
Submitted ACP
Associates 2002
ECHO-GUIDED VS. ECG-GUIDED AV INTERVAL: CLINICAL IMPLICATIONS IN CARDIAC
RESYNCHRONIZATION THERAPY. Srikar Reddy MD, Associate,
Marc Meissner, MD, FCCP, Lalitha Rudraiah, MD, John E. Burnes, Michael R.S. Hill and Randy Lieberman, MD, FCCP, Sinai-Grace Hospital and Harper University Hospital, Wayne State University, Detroit, Michigan.
Introduction:Clinical trials have demonstrated that Biventricular Pacing/ Cardiac Resynchronization Therapy (CRT) can improve CHF parameters. Programmed AV interval (AVI) affect acute hemodynamics during CRT. CRT trials have programmed the AVI by echo-guidance (trans-mitral flow) or a surface ECG derived formula based on LV pressure measurements (0.5 x (PR-30)). We previously reported lack of a correlation between the AVI determined by Echo (EAVI) and PR (PRAVI) methods. A PRAVI is desirable because it is clinically simpler and less costly than EAVI.
Hypothesis: In CRT patients, there is no difference in a variety of acute clinical parameters, whether the programmed AVI is EAVI or PRAVI.
Methods: Informed consent was obtained. CRT devices were programmed to DDD mode, rate adaptive AV OFF, lower rate 40 bpm. Pts were randomized to EAVI and PRAVI. Systolic and diastolic blood pressure (SBP/DBP), heart rate (HR), respiratory rate (RR), 6 minute hall walk distance (6MHW), and symptom questionnaire were assessed at baseline and pre-and post-AVI programming. A minimum of 30 minutes rest was provided between 6MHW tests.
Results: 10 patients (8 NYHA II, 8 CAD, 8 LBBB, LVEF=16±4% , PR=269+38ms, QRS=163±8ms) were enrolled (*p<0.05). No significant differences in evaluated clinical parameters were noted between the two methods used to program the AVI.
Conclusions: Although EAVI and PRAVI are statistically different, acute 6 min hall walk distance, rest and exertion symptoms, and vital signs were not differentially affected by method used to program AVI (EAVI or PRAVI). These data suggest that additional studies are necessary to demonstrate whether or not EAVI is needed to program CRT devices.
Submitted ACP Associates 2002
METASTATIC MALIGNANT LYMPHOMA PRESENTING AS SUPRAVENTRICULAR TACHYCARDIA.
Bhamini Sudhir, MD, Associate, Savitha Balaraman, MD, Associate, and Rose
Andriacchi, MD, Member, Sinai-Grace Hospital, Wayne State University, Detroit,
Michigan.
A 38 year old man presented to the hospital with Intermittent palpitations and was found to have Supraventricular tachycardia that spontaneously resolved. On physical examination, the patient was noted to have an enlarged, hard right testis measuring about 8x5 cms. Ultrasound of the testis revealed a heterogenous, diffuse enlargement of the right testis with increased vascularity. Beta-HCG and alphafetoprotein were within normal limits. Echocardiography performed to evaluate for structural heart disease revealed a 4cm mass effluxing in and out of the Tricuspid valve with significant infiltration into the interatrial septum, peri-tricuspid and peri-aortic area with septal thickening. Further staging with CT scan revealed bilateral hilar and retroperitoneal adenopathy with pleural and pericardial effusions and ascites. High inguinal orchiectomy of the right testis revealed a high grade, aggressive, Non-Hodgkin's lymphoma with significant vascular and spermatic cord invasion. HIV serology turned out to be positive. The patient was discharged home uneventfully, but unfortunately died of unknown cause after the first cycle of chemotherapy.
Malignant lymphoma in HIV-positive individuals is an AIDS-defining illness that carries a poor prognosis. Cardiac metastases in the form of endocardial, myocardial and pericardial invasion occur in about 8% of patients with lymphoma and carry a very high mortality. A literature review revealed that it is commoner in Non Hodgkins than in Hodgkin's lymphoma and can frequently be the cause of death in this population. We would therefore like to review the incidence, clinical presentation, course, and prognosis of lymphoma with significant cardiac invasion in HIV-positive individuals.
The patient is a 68-year-old African-American male who presented with hemoptysis of one weeks duration. He denied other symptoms. He had never smoked during his lifetime. He did have colon cancer in 1997 for which he underwent surgery and chemotherapy. He had apparent lung metastases by chest X-ray in June 2000. Chest films during this admission revealed multiple nodules, which had increased in number and size, compared to prior films. Bronchoscopy revealed a mass arising from the right upper lobe. Pathology revealed poorly differentiated adenocarcinoma. Immunostaining confirmed metastatic colon cancer with strong positivity for CK20. Immunostains were negative for CK7 and TTF.
Endobronchial metastases from nonpulmonary tumors are uncommon, with estimated incidence of 2%. Breast, colon, and renal carcinomas have been found to predominate. Bronchoscopy is usually diagnostic; the yield is optimized with both biopsy and bronchial brushings. Treatment is usually palliative. Endobronchial metastases occur by direct spread to the bronchus, invasion by a parenchymal lesion or mediastinal or hilar lymph nodes, or peripheral lesions extending along proximal bronchi. In our patient, we believe metastases developed via extension of peripheral lesions. This is supported by bronchoscopic findings and the location of the pulmonary nodules with interval increase in size. This is one of the few documented cases in the literature of endobronchial spread from a nonpulmonary tumor.
Submitted ACP Associates 2002