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Home , Anasarca, Aortitis, Bartter syndrome, Cerebritis, HEENT examination, Hemorrhoid

Society of General Internal

26th Annual Meeting Vancouver, British Columbia April 30±May 3, 2003

ABSTRACTS

AN UNUSUAL CASE OF . J. Miller1, S. Agrama1, J. Wald1; 1Temple CLINICAL VIGNETTES University, Philadelphia, PA (Tracking ID #76825) LEARNING OBJECTIVES: Recognize that the presenting features of amyloidosis are protean and depend on the organ systems involved. Recognize that cardiac involvement is common in primary amyloidosis and that symptomatic heart involvement carries a poor prognosis. CASE INFORMATION: 66 year old man without PMH presented 8 months of progressive THE INFILTRATING EOSINOPHIL: A CASE OF CHURG STRAUSS SYNDROME. exertional dyspnea and fatigue. Evaluation revealed volume overload with and signs of G. Agarwal1, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73667) biventricular heart failure. LEARNING OBJECTIVES: 1) Recognize the presentation of Churg Strauss Syndrome Laboratory studies revealed renal insufficiency with a creatinine of 1.8 and 2+ proteinuria. (CSS). 2) Diagnose CSS using clinical, laboratory, and histologic parameters. 3) Recognize the serum protein electrophoresis with immunofixation showed a monoclonal IgA kappa treatment of CSS. paraprotein; urine protein electrophoresis was unremarkable. Echocardiogram revealed an CASE INFORMATION: F.T. is a 55-year-old male with adult onset asthma who initially ejection fraction of 20%. Right ventricular function was moderately reduced and right and left presented with progressive asthma exacerbations. A leukotriene inhibitor was added to his ventricular hypertrophy was noted. ECG showed atrial fibrillation with a ventricular response regimen of inhaled beta agonists, and his asthma worsened. He subsequently developed low- of 105 BPM and low voltage. grade , anorexia and a twenty pound weight loss over two months. He also developed Pt. underwent right heart catheterization with endomyocardial biopsy. Tissue stained positive diffuse abdominal and and was admitted to an outside institution. Colonic with crystal violet and Congo red with characteristic green birefringence under polarization thickening was noted on CT scan, and he was diagnosed with . During this microscopy. This result together with the paraprotein established the diagnosis of AL hospitalization, he suffered a myocardial infarction. A cardiac catheterization revealed clean amyloidosis. coronary . Echocardiogram revealed global hypokinesis, depressed ejection fraction, IMPLICATIONS/DISCUSSION: Amyloidosis is a disease characterized by extracellular and a small pericardial effusion. He was transferred for further workup and management. accumulation of insoluble protein fibrils in various organs and tissues. Classification of Physical exam was notable for thin appearance, mild diffuse abdominal tenderness, mild amyloidosis is based on the nature of the precursor proteins that form the fibril deposits. AL abdominal distension, and in his right leg (most notably in the lateral thigh, calf, amyloidosis (primary) is a plasma cell dyscrasia in which clonal plasma cells in the bone marrow and dorsum of his foot). Laboratory work revealed a normochromic normocytic , produce monoclonal immunoglobulin light chains. Clinical manifestations reflect the organ leukocytosis with a marked peripheral eosinophil count, an elevated erythrocyte sedimentation systems involved with kidney and heart involvement being most common. rate (ESR), hypergammaglobulinemia, and an elevated rheumatoid factor level. The Clinically evident cardiac involvement occurs in up to 50% of patients with AL amyloid and antineutrophil cytoplasmic (ANCA) titer was negligible. With a constellation of often leads to significant cardiac dysfunction. Diastolic dysfunction is caused by diffuse adult onset asthma and sinusitis, colitis, possible myocarditis/coronary , mild infiltration of the left ventricular myocardium with resultant stiffening and impaired relaxation neuropathy and the above laboratory findings, the patient was diagnosed with CSS. A and usually precedes systolic dysfunction. Systolic dysfunction results from replacement of revealed diffuse colitis and multiple ulcers. Biopsy revealed areas of active colitis functional myocardial tissue with amyloid protein. The conduction system can be affected by with fibrinoid , fibrin microthrombi in blood vessels and a marked infiltration of amyloid infiltration as well, leading to conduction disturbances, arrhythmias or sudden death. eosinophils. A CT scan of the chest, abdomen, and pelvis revealed pleural effusions, a small ECG findings include low voltage, conduction abnormalities such as AV block, atrial pericardial effusion, and evidence of through much of his small bowel. fibrillation and pseudoinfarct patterns. A mesenteric angiogram revealed areas of caliber change, vessel cutoff, and indistinctness of the This case demonstrates a classic presentation of AL amyloidosis with significant cardiac distal small branches of the SMA and IMA, consistent with a vasculitis. The patient was treated involvement. AL amyloidosis has a median survival of one to two years but patients with with high dose and cyclophosphamide and improved significantly. Repeat CT scans symptomatic heart involvement have a median survival of only six months. revealed resolution of the pneumatosis intestinalis. He was discharged with a taper. On follow up, the patient was noted to be doing well, and an echocardiogram showed improvement in his ejection fraction. AN ETHICAL DILEMMA: THE TREATMENT OF COMPLICATIONS OF INTRAVENOUS IMPLICATIONS/DISCUSSION: CSS is a multisystem disorder characterized by asthma, DRUG USE. S. Agresta1, J. Wiese1; 1Tulane University, New Orleans, LA (Tracking peripheral blood eosinophilia, and a . CSS can affect multiple organ systems, ID #77219) including the pulmonary, cardiovascular, gastrointestinal, and nervous systems. The incidence, epidemiology, and etiology of CSS remain unclear. CSS does not display a gender LEARNING OBJECTIVES: Recognize the importance of counseling patients who have predominance and can occur at any age. A CSS-like syndrome develops as a rare received previous valve replacements that continued intravenous drug use may disqualify them in steroid-dependent asthmatics treated with leukotriene inhibitors. There are three sequential from lifesaving interventions. phases of CSS: 1) a prodromal phase (characterized by atopic disease and asthma), 2) an CASE INFORMATION: A 44 year-old presented with progressive dyspnea, fevers and sub- eosinophilic phase (peripheral eosinophilia and eosinophilic infiltration of organs), and 3) a sternal tightness. He had a endocarditis requiring porcein valve replacement in 1993. He vasculitic phase (a systemic vasculitis of the medium and small vessels). Asthma is the cardinal started using intravenous and heroin weekly one month prior. He had a of 40 C feature, but other features include allergic rhinitis, sinusitis, acute pericarditis, myocarditis, and a holosystolic murmur. Blood cultures grew steptococcus viridans. Transesophageal coronary vasculitis, pulmonary infiltrates, pleural and pericardial effusions, peripheral echocardiography showed aortic valve vegetations on all leaflets and a ring . neuropathies, glomerulonephritis, and eosinophilic . Although there are no Toxicology screen was positive for cocaine. Ampicillin and were initiated. After specific laboratory tests for CSS, peripheral blood eosinophilia is the most characteristic six weeks of therapy, the aortic vegetations and blood cultures persisted. Cardiothoracic finding. Approximately 70% of CSS patients have high ANCA titers. Other nonspecific surgery was consulted, but declined intervention, citing the likely recidivistic drug use and abnormalities include a normochromic, normocytic anemia, an elevated ESR, an elevated IgE futility of care. level, and a positive rheumatoid factor. The diagnosis is suggested clinically and then IMPLICATIONS/DISCUSSION: Surgical intervention in active intravenous drugs users is confirmed by biopsy of affected tissues. Histologic findings include necrotizing vasculitis, an issue of ethical debate. Ninety percent of heroin users will reuse even after successful eosinophilic tissue infiltration, and extravascular granulomas. Most patients respond to rehabilitation. Continued intravenous use represents a hundred-fold increased risk of recurrent corticosteroid therapy. Cyclophosphamide, azathioprine, and high dose intravenous immune endocarditis. The apparent futility of surgical intervention in this setting has prompted surgical globulin have also been used with benefit. Most deaths result from cardiac failure, myocardial services to adopt a ``one strike and youare outpolicy.'' This is almost a certain death sentence infarction, cerebral hemorrhage, renal failure, gastrointestinal bleeding or status asthmaticus. for patients meeting surgical criteria. The ethics committee was involved but could not However, patients that are treated adequately have a survival rate of greater than 70% at establish ethical grounds for challenging surgery's decision. The precedent of withholding five years. organ transplantation from continuing drug users was applied. Physicians should counsel 30 JGIM Volume 18, April (supplement 1) 2003 31

patients who have received previous valve replacements that continued intravenous drug use defective population of erythrocytes, granulocytes and platelets that lack a specific class of cell may disqualify them from lifesaving interventions. Added emphasis on rehabilitation following surface proteins. Intravascular hemolysis occurs because the erythrocytes cannot bind the valve replacement may be the only sure method to avoid this dilemma. CD59 protein that inactivates surface complement. Patients with PNH experience paroxysms of hemolysis during low complement periods such as during protracted infection or modest acidemia due to nocturnal hypoventilation. The presence of the CD59 cell marker is easily UNCOMMON PULMONARY INFECTION IN A HOMELESS MAN. S. Akhtar1, detected using flow cytometry; rendering the Ham's and sucrose tests obsolete. M. Chaudhry1, U. Ahmad1, A. Pervez1; 1UPMC McKeesport Hospital, McKeesport, PA (Tracking ID #76983)

LEARNING OBJECTIVES: 1. To emphasize increase in the incidence of Mycobacterium UNILATERAL BRACHIAL PLEXOPATHY ASSOCIATED WITH WEST NILE 1 1 1 1 kansasi infections. 2. To hilight the similarities of presentation of Mycobacterium tuberculosis MENIGOENCEPHALITIS. K. Almhanna , N. Palanichamy , A. Sil ; Oakwood Healthcare and Mycobacterium kansasi infections. System, Dearborn, MI (Tracking ID #76584) CASE INFORMATION: A 66 y/o white homeless man who is also alcoholic and a heavy LEARNING OBJECTIVES: To recognize that West Nile may cause a unilateral smoker, presented with lethargy, exertional dyspnea, and weight loss of 25 Ibs over 2 months. plexopathy. Examination revealed , clubbing, and findings consistent with right sided pneumothorax. CASE INFORMATION: A 48 year-old Middle Eastern male presented to the ER with sharp CXR confirmed this finding, and also revealed a large cavity in the left upper lobe. Blood work stabbing pain in his back and . He was treated symptomatically and sent home. He showed anemia of chronic disease. A chest tube was placed, and subsequent CT scan confirmed returned three days later with fever, , vomiting, decreased consciousness, slurred speech, the presence of right upper and lower lobe infiltrates and the left upper lobe cavity. PPD test weakness, progressive paresis and ultimately paralysis of the left upper extremity. Physical exam was negative. Sputum and bronchoscopic aspirates were positive for AFB. Patient refused HIV was otherwise unremarkable. A CT scan and MRI examination of the head and spinal cord testing. He was started on INH, Rifampin, Pyrazinamide and Ethambutol for a presumptive were normal. Blood cultures were negative. Spinal fluid showed a red cell count of 10, white diagnosis of pulmonary tuberculosis. Using DNA probing the AFB was later identified as cell count of 470, with a differential of 5 PMNs, 85 lymphocytes and 10 monocytes. Spinal mycobacterium Kansasii. Respiratory isolation was discontinued. Treatment was maintained fluid glucose was 42 mg/dl with a protein of 97 mg/dl. EEG showed diffuse cerebral with INH, Rifampin, and Ethambutol to complete a total of 18 months. dysfunction. An EMG showed diffuse denervation of the left upper extremity consistent with a IMPLICATIONS/DISCUSSION: Diagnosis of infections with nontuberculous mycobacteria left brachial plexopathy. Spinal fluid was positive for West Nile virus IgM antibody. With (NTM) is on the rise. Smoking, pre-existing lung disease, increased alcohol consumption, and supportive therapy the patient's consciousness, speech, and the dexterity of his left hand homelessness are risk factors for developing clinical infection. Unlike other NTM, M. Kansasii improved. Wasting of the left arm as well as the supraspinatus and infraspinatus muscles has has never been isolated from the soil or natural water, however, it is consistently found in tap persisted although there is slight continued improvement. water. Respiratory isolation is not necessary. IMPLICATIONS/DISCUSSION: West Nile virus is a mosquito-borne flavivirus and human, equine and avian neuropathogen. It is indigenous to Africa, Asia, Europe and Australia. Birds are the natural resevoir. It was first detected in the United States in 1999 and has spread 1 STREPTOCOCCAL PERICARDITIS AS AN INITIAL MANIFESTATION OF HIV. E. Al-Hihi , westward. More than 2000 cases of West Nile virus have been reported in the United States in 2 1 H. Abuissa ; Section of General Internal Medicine, University of Missouri-Kansas City, the year 2002. The symptoms of severe or meningitis include headache, high fever, 2 Kansas City, MO; Internal Medicine Residency Program, University of Missouri-Kansas neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, and City, Kansas City, MO (Tracking ID #76106) paralysis. Isolated brachial plexopathy occurs rarely as a consequence of viral infections such as LEARNING OBJECTIVES: 1-To increase awareness of pericardial involvement in HIV varicella and B. The occurrence of brachial plexopathy in association with the patients. 2-To emphasize that HIV should be included in the of flaviviruses, to our knowledge, has not been previously reported. The precise lateralizing unexplained pericarditis or pericardial effusion detected by echocardiography. 3-To outline mechanism of such viral infections is unknown. It is clear however, that unilateral brachial that pericardial involvement in HIV patients is common and entails a poor prognosis plexopathy is now in the repertoire of the West Nile virus. independent of CD4 count. CASE INFORMATION: 47 year old female presented with one week history of fever and central chest pain, dull in nature, exacerbated by lying down, and relieved by leaning forward. AN UNUSUAL CASE OF MUCORMYCOSIS IN A TYPE II DIABETIC. J. Alton1, S. Curry1, Past significant only for and negative HIV test 5 years ago. Social R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76514) history included cocaine use and denial of any IV drug use. No home medications. Physical exam showed tachycardia 125/min, 92/68, afebrile patient, distant , LEARNING OBJECTIVES: (1) To recognize the clinical presentation of mucormycosis in a and clear lungs. White blood cell count was 16,000 with bandemia. EKG showed ST elevation diabetic patient (2) To identify diabetics as patients at risk for mucormycosis. in all leads (fig#1). Chest x-ray showed enlarged heart. Echocardiogram revealed moderate CASE INFORMATION: A 46-year-old female with a history of poorly controlled Type II pericardial effusion with no evidence of tamponade (Fig#2). Pericardiocentesis demonstrated diabetes mellitus, hepatitis C and remote IV drug use presented to the emergency department pus. Pericardial fluid culture was positive for streptococcal pneumonia. Pericardiostomy was with profound lethargy and a two-day history of medication noncompliance. She was admitted done with drainage of pus from pericardial space. Patient was started on high dose Penicillin to the ICU after laboratory tests confirmed the diagnosis of DKA and was begun on an insulin with no response. Cultures from blood, sputum and CSF showed the same organism. Patient drip. The patient's metabolic abnormalities resolved over the next 24 hours and her mental continued to lack any response to appropriate antibiotic and was intubated. She developed Rt status improved. She then was noted to have a small area of mid-forehead induration and sided empyema and required chest tube placement. Given lack of clinical response and erythema with a fixed, dilated left pupil, left eye ptosis, periorbital , proptosis, chemosis persistence of disseminated Streptococcal infection, an HIV test was repeated and was positive and ophthalmoplegia. An MRI of the head showed of the left orbit with with CD4 cout of 42. Patient had trachestomy and became ventilator dependant. nonspecific retro-orbital stranding and an area of T2 prolongation that did not enhance IMPLICATIONS/DISCUSSION: HIV-associated pericardial effusion can easily be under- with gadolinium in the left middle cerebellar peduncle extending into the pons and cerebellar diagnosed and overlooked. The prevalence of pericardial effusion in AIDS patients is 5±10% vermis, consistent with abscess vs. . CT of the sinuses was negative. Blood cultures, with an incidence of 11% per year. These figures suggest that pericardial involvement in HIV lumbar puncture, and magnetic resonance angiography were unrevealing. The diagnosis of patients will become a very important issue in near future. HIV-associated pericardial mucormycosis was entertained but felt to be less likely due to the absence of cutaneous or sinus involvement is an independent predictor of decreased survival independent of CD4 count and involvement. A stereotactic biopsy of the cerebellar lesion was then performed. Grocott Albumin levels. AIDS patients with pericardial involvement survive a median of six months. staining subsequently revealed fungal forms with broad non-septate hyphae consistent with Pericardial involvement in HIV disease is usually a late disease manifestation and our case was zygomycetes. The patient was placed on amphotericin B. Despite this therapy, her mental unusual to have that as the initial manifestation. A high index of clinical suspicion should be status declined. Two subsequent MRIs showed progression of the cerebral lesion in which a maintained in patients who present with unexplained pericarditis with effusion. It would be path from the left orbit into the orbital apex and left cavernous sinus, along the fifth nerve and prudent to perform a routine echocardiograpic evaluation in AIDS patients with disseminated into the pons and cerebellum, could be traced. The maxillary sinuses also exhibited increasing infection, unexplained fever, severe pneumonia or unexplained . opacification. Because of the extensive pontine involvement, surgical resection was not attempted. Exenteration, oculoplastic surgery, further abscess aspiration or liposomal amphotericin B were judged to be unwarranted due to lack of proven benefit. The patient's PAROXYSYSMAL NOCTURNAL HEMOGLOBINURIA AND APLASTIC ANEMIA. condition continued to deteriorate and she expired 25 days after admission. J. Aliota1, J. Wiese1, R. Pearl1; 1Tulane University, New Orleans, LA (Tracking ID #77060) IMPLICATIONS/DISCUSSION: Mucormycosis, while rare in the general population, is common in diabetic patients. With the increasing rate of Type II diabetes in this country, it is LEARNING OBJECTIVES: 1. Provide a method for diagnosing pancytopenia. 2. Provide the likely that internists will face the challenge of diagnosing and treating this life-threatening diagnostic criteria for paroxysmal nocturnal hemoglobinuria. condition. Rhino-orbital-cerebral mucormycosis represents a rare manifestation of the disease CASE INFORMATION: A 61 year-old man presented with three weeks of weakness, fatigue that, before the introduction of amphotericin B in the 1960s, was felt to be uniformly fatal and and shortness of breath. Four months earlier he had been evaluated for similar complaints; a mainly confined to severely immunocompromised hosts. Since that time, there has been an bone marrow biopsy confirmed a hypo-cellular marrow, megakaryocytic and myeloid increasing number of case series reporting treatment successes. Due to the overall paucity of hypoplasia and relative erythroplasia. He had no history of toxic exposures or risk factors cases, however, there is little evidence-based literature on the subject to identify the optimal for infiltrative bone marrow disease. He was diagnosed with idiopathic aplastic anemia and medical or surgical management of this infection. Our case illustrates the many challenges scheduled for a bone marrow transplant. He was transfused and discharged. His physical in the diagnosis and treatment of this disease and an unfortunate outcome for a young examination was normal with the exception of pale conjunctiva. He was again anemic with an diabetic patient. MCV of 82. There were schistocytes on the perpheral smear and in the urinalysis. His renal function was normal. Before initiating a treatment for suspected aplastic anemia, a CD 59 cell marker analysis was performed that was positive. PROGRESSIVE WEAKNESS AND . B. Anderson1, J. Wiese1; 1Tulane University, IMPLICATIONS/DISCUSSION: Although the majority of pancytopenia is due to leukemia New Orleans, LA (Tracking ID #77072) or pre-leukemic diseases, there are a host of diagnoses that must be considered. Because of its protean nature, paroxysmal nocturnal hemoglobinuria should be considered anytime there is a LEARNING OBJECTIVES: 1. Distinguish /polymyositis from other causes confusing case of hemolytic anemia or pancytopenia. Abnormal stem cells gives rise to a of myositis. 2. Provide the typical presentation of dermatomyositis/polymyositis. 32 Abstracts JGIM

CASE INFORMATION: A 53 year-old woman presented with four months of weakness and a area (Harzer's sign). revealed a holosystolic, non-radiating crescendo murmur of rash. The weakness was progressive, symmetric, and proximal. The muscles of both her upper 3/6 in the left parasternal area. Diastole was free and peripheral arteries were normal. and lower extremities were affected. The erythematous rash was located on the inner thighs Laboratory tests were within normal limits, excluding acute conditions such as pulmonary and arms bilaterally. She could not raise her arms and had difficulty holding her head erect; her or cardiac ischaemia. The ECG revealed sinus tachycardia, a vertical frontal axis of leg weakness prohibited standing independently. Sensation and reflexes were not affected. She the QRS complex and complete right bundle branch block. had normal serum electrolytes and complete blood count. Her AST was 200 U/L, ALT 78 U/ A transthoracic echocardiogram revealed a voluminous mass with an echo-dense border and an L, ALKP 52 U/L, CK 7021U/L, and ESR 29 mm/hr. Her TSH, hepatitis panel, ANA, echo-poor centre adjacent to the free wall of the right ventricle, no vascularized (free of internal rheumatoid factor, anti-DS DNA, c-ANCA, and p-ANCA were normal. A muscle biopsy of blood flow), exerting an obvious compression on the right ventricle, the intraventricular left thigh showed vasculitis and perifascicular atrophy and necrosis. Methylprednisolone and pressure being estimated at 80 mmHg based on the high-velocity severe tricuspid methotrexate were initiated with resolution of her symptoms. An age-appropriate screen for regurgitation. Magnetic resonance imaging and computed transverse tomography confirmed cancer was negative. the presence of a hypodense mass, in close contact with the pericardium (Fig. 1 & 2). IMPLICATIONS/DISCUSSION: The diagnosis of dermatomyositis/polymyositis (DM/PM) The severe compression of the right ventricle prompted the surgical removal of this mass. The requires a high degree of clinical suspicion, as it is established based on the combination of mass was adhering to the rib cage and the free wall of the right ventricle. Bacteriological clinical, laboratory, and muscle biopsy findings. This patient demonstrated the proximal investigation revealed the presence of an abscess with coagulase-negative staphylococci. muscle weakness characteristic of DM/PM. Other causes of proximal muscle weakness, Postoperative progress was uneventful, and the medium-term outcome favourable. No including electrolyte abnormalities, hypothyroidism, inclusion body myositis or drug induced abnormal cavity was visualized during transthoracic echocardiography at the 3-month (HMG CoA reductase inhibitors or steroids) were excluded by history and laboratory data. postoperative control. Perifasicular inflammation suggests dermatomyositis; perimysial inflammation is characteristic IMPLICATIONS/DISCUSSION: While infections are known to occur after sternotomy, of drug-induced myositis. Diagnostic criteria for dermatomyositis include symmetric proximal usually involving coagulase-negative staphylococci, the formation of an abscess in the anterior muscle weakness, elevated serum muscle enzymes, perifasicular inflammation on muscle mediastinum several years after the intervention appears to be exceptional. This diagnosis came biopsy, and rash. The classic dermatologic findings of PM/DM include mechanic's hands to mind only after the more common postoperative complications, e.g. or (synthetase AB subset), heliotrope lids, Gottron's sign and shawl sign (Mi-2 subset). Physicians pericardial haematoma, and the wide range of possible diagnoses covering tumours, infections should be aware that most cases of DM/PM present without the classic findings of DM/PM. and malformations of the anterior mediastinum had been considered. Although the signs and Systemic corticosteroids are used for treatment. Immunosuppressive agents are used in cases symptoms were not very specific and potentially psychogenic in a patient living in precarious refractory to corticosteroid treatment. Due to an association with underlying malignancy, conditions, we were inclined to consider a wide range of differential diagnoses, given the an age and gender appropriate cancer screen should be performed in all patients diagnosed patient's history. with dermatomyositis.

MESENTERIC PANNICULITIS Ð AN UNUSUAL CASE OF . P.P. A CASE OF , HYPOXIA, AND TOO MUCH PROTEIN. R.A. Andrews1, Balingit1, T. Hascall2; 1UCLA San Fernando Valley Program, Sylmar, CA; 2University of E.L. Salerno2; 1University of Connecticut, Farmington, CT; 2University of Connecticut, California, Los Angeles, Los Angeles, CA (Tracking ID #76705) Columbia, CT (Tracking ID #76994) LEARNING OBJECTIVES: 1. Describe and recognize mesenteric panniculitis (MP) as an LEARNING OBJECTIVES: 1) Discuss diagnosis, eitiology, and management of pulmonary etiology of abdominal pain. 2. Discuss diagnosis and management of MP. alveolar proteinosis. CASE INFORMATION: A 63 year old Caucasian male with a significant CASE INFORMATION: A.G. is a 29 year old female 15 weeks into her fourth pregnancy who for diabetes mellitus presented to the urgent care clinic with constant, crampy, diffuse presents for diagnosis and treatment of severe hypoxia. Ten weeks prior to admission, she abdominal pain, subjective fever, chills, and five pound weight loss for one month. His primary begins having progressive dyspnea on exertion, non-productive , weakness, fatigue, care physician had prescribed hydrocodone/acetaminophen for his symptoms two weeks prior, nausea, and , but no fevers and occassional chills. Two days prior to admission she is with suboptimal pain control. The patient denied early satiety, nausea, vomiting, , referred to the emergency room for severe hypoxia. Patient denies problems with previous hematochezia, or dysuria. On , the patient was afebrile and normotensive. and is HIV negative. Past medical history and social history are essentially Cardiac and pulmonary exams were unremarkable. No hepatosplenomegaly was present. Mild unremarkable. At presentation, she is afebrile with a blood gas on room air that shows a PaO2 tenderness to was elicited in the hypogastric area. Several small lymph nodes were of 64. Cardiovascular exam is benign, but diffuse course rales are heard on lung exam. The felt in the inguinal region. Genitourinary exam was unremarkable. Rectal exam revealed no patient has perioral and acral and clubbing. Chest xray shows a diffuse patchy alveolar masses or tenderness. Laboratory values included glucose 339 and normal electrolyte, infiltrate. HCT is 49.3 with normal chemistries and negative D-dimer. Patient is placed on a liver transaminase, and lipase levels. Urinalysis revealed the presence of glucosuria with no non-rebreather mask at 100% and started on broad spectrum antibiotics. On day two, she is active sediment or proteinuria. CBC was within normal limits. An ill-defined, cloud-like area of transferred to intensive care with a PaO2 of 54 on 100% oxygen. Video-assisted thorascopic fat stranding within the mesentery surrounding the mesenteric vessels was visualized on biopsy is obtained providing the diagnosis of pulmonary alveolar proteinosis. Patient then abdominal CT. No intra-abdominal mass, lymphadenopathy, or pancreatic inflammation was undergoes whole-lung lavage with improvement in chest xray and PaO2 saturation. evident. The superior mesenteric and , splenic vein, and portal vein were patent. The IMPLICATIONS/DISCUSSION: Pulmonary alveolar proteinosis (PAP) is a non-inflamma- area of mesenteric involvement was felt to be consistent with MP. Prednisone was administered tory disease of the lungs affecting men more than women (2:1) typically between 30 and with subsequent resolution of the patient's presenting symptoms. 50 years of age. The primary defect is either a failure to degrade, or increased production, of IMPLICATIONS/DISCUSSION: MP, also referred to as mesenteric lipodystrophy, surfactant causing an accumulation of amorphous proteinaceous material within the alveoli. sclerosing mesenteritis, and retractile mesenteritis, is an uncommon mesenteric disease with The exact eitiology remains unclear. Patients generally present with dyspnea on exertion, 30% fewer than 300 cases reported. It has a male to female predominance of 1.8:1 with peak are asymptomatic. Common symptoms are dry cough, weight loss, malaise and fatigue. Rales incidence found in the sixth and seventh decades of life. Although the etiology of MP is are present in 50% of cases. Typical xray findings reveal perihilar alveolar infiltrates with unknown, predisposing factors such as malignancy, autoimmune disease, trauma, infection, and typical ``bat wing'' appearance. Diagnosis is made from BAL (bronchioalveolar lavage) or previous abdominal surgery have been suggested. The diagnostic criteria of MP include the lung biopsy. Lavage produces a milky effluent composed of amorphous granular material characteristic radiographic appearance of single, multiple, or diffuse mass-like inflammatory that stains PAS (periodic acid-Schiff) positive. On biopsy, inflammatory cells are rare and there lesions within the mesentery, along with histologic confirmation of fat necrosis and is no fibrosis. Alveoli are congested with proteinaceous material and dysfunctional inflammatory reaction in the mesenteric lesions. Malignant primary mesenteric tumor, macrophages. Standard of care is whole-lung lavage with 30±40% of patients resolving with metastatic neoplasm, lymphoma, and granulomatous diseases may present similarly. The only one lavage while the majority of patients require repeat lavage at 6±12 month intervals. prognosis for MP is generally good and spontaneous remission is the most common outcome. Newer treatments include high doses of GM-CSF (granulocyte macrophage-colony Corticosteroids and immunosuppressive agents have been used successfully in a few aggressive stimulating factor) and possibly bone marrow transplant. Prognosis of PAP has been shown cases. Surgical intervention may be necessary if obstructive symptoms develop. to be a 74% 5-year survival.

PULMONARY EMBOLUS PRESENTING AS NEW-ONSET . S. Ban1, M. Peek1; ATYPICAL CHEST PAIN IN A 25 YEAR OLD ASYLUM-SEEKER. E. Aschwanden1, 1Rush Presbyterian St. Luke's Medical Center, Chicago, IL (Tracking ID #76961) P. Bodenmann1, L. Schlueter2, M. Fivaz-Arbane2, M. Hurni2, A. Jaussi1; 1Medical Outpatient LEARNING OBJECTIVES: 1. Recognize that new-onset seizure can be a presentation of Clinic of Lausanne, Lausanne, Switzerland; 2University Hospital of Lausanne, Lausanne, pulmonary embolus, especially in patients without neurologic or radiographic findings. 2. Switzerland (Tracking ID #74289) Consider alternative diagnoses such as pulmonary embolus in the setting of asthma refractory LEARNING OBJECTIVES: 1. Recognize the long term complications after heart surgery for to standard therapy. 3. Regard the use of low estrogen preparation oral contraceptive pills, felt congenital defect in childhood. 2. Appreciate that patients living in precarious conditions need to be ``low-risk'' in non-smokers, as a risk factor for thromboembolism. careful management that goes beyond an initial impression, although the risk of somatizing CASE INFORMATION: A 28 year old woman with a history of asthma and oral exists. contraceptive use was admitted to the hospital with respiratory arrest and new onset CASE INFORMATION: A 25 year old male asylum-seeker, living in Switzerland for a month, generalized seizure. She had a profound respiratory acidosis and was admitted to the MICU with a history of surgical repair of a pentalogy of Fallot 20 years before with no subsequent with a diagnosis of status asthmaticus. She responded to intravenous steroids and nebulized complications, presented with breathing-related chest pain responsive to paracetamol, albuterol. Her head CT, EEG, and MRI did not reveal a seizure focus, and her seizure was exertional dyspnoea and orthopnoea ± on the same day that five of his compatriots living in attributed to respiratory acidosis. The patient re-presented to the ER three weeks after the same asylum-seeker centre located in a public bomb shelter with the same symptoms! discharge with further complaints of dyspnea that had never resolved after her hospitaliza- He was in good general health, his was 93/66 mmHg, and he had a regular heart tion. She had been treated as an outpatient with azithromycin for fevers and cough without rate of 100 beats/min and a of 25/min. His chest was slightly asymmetrical, improvement in her symptoms. She was treated for a refractory asthma exacerbation. A CT with slight arching of the left hemithorax, the sternotomy scar appeared normal, the apical of the chest demonstrated bilateral segmental and subsegmental pulmonary emboli. A impulse was widened and pulsations were apparent across the whole sternal and left parasternal hypercoaguability workup was negative. With anticoagulation and supportive pulmonary JGIM Volume 18, April (supplement 1) 2003 33

care, her pulmonary status gradually returned to baseline and she was tapered off phenytoin IMPLICATIONS/DISCUSSION: Trimus is defined as spasm of the masticatory muscles, without subsequent seizure activity. with difficulty in mouth opening, and is a characteristic early symptom of tetanus commonly IMPLICATIONS/DISCUSSION: There are very few reports of a pulmonary embolus (PE) referred to as lockjaw. The differential diagnosis of trismus is limited and besides acute tetanus presenting as seizure. Given the acuity of onset of this patient's symptoms and the severity of includes odontogenic infections, peritonsilar abscess, strychnine poisoning, and drug-induced her initial respiratory acidosis, as well as the lack of neurologic findings, we presume that her dystonic reaction. In addition, trismus can be confused with the jaw seen in seizure represents the onset of her pulmonary embolus, though we can not definitively establish temporal as well as the pain of trigeminal neuralgia. Widsom tooth (3rd molar) causal relationship. Clinical suspicion of PE may be compromised by the attribution of infections are the most common odontogenic cause of trismus and notably can present without symptoms to the seizure, such as tachypnea, tachycardia, and hypoxia. The initial evaluation of evidence facial swelling. Acute tetanus is important to recognize because it can progress to seizure patients is primarily neurologic, delaying the diagnosis of a cardiopulmonary syndrome. death as a result of respiratory failure, but the prognosis can be favorable if supportive In this particular case, the patient's medical history played a key role in the delayed diagnosis of treatment is initiated promptly. Predictors of inadequate immunity are older age, birth outside PE, as her pulmonary symptomatology was attributed to asthma, despite the fact that she had the US, low educational status, and poverty. been well controlled on minimal medication prior to admission, and that her clinical signs did not completely resolve with the treatment of her exacerbation. Furthermore, this young, active woman had low risk for thromboembolic disease, especially in the setting of a negative THYROTOXIC PERIODIC PARALYSIS IN A LATINO MALE. E. Batcher1, S. Wali1, evaluation for hypercoaguability. She did use oral contraception, but this particular medication N. Mikhail1; 1UCLA - San Fernando Valley, Los Angeles, CA (Tracking ID #76024) includes only 0.10mg levonorgestrel and 0.2mg ethinyl estradiol and the patient was a non- smoker. Thromboembolism should therefore be considered in any patients with acute dyspnea, LEARNING OBJECTIVES: To recognize the presentation and therapy of thyrotoxic evidence of cerebral hypoperfusion, hypoxia, or unexplained seizure, even in the setting of periodic paralysis. pulmonary pathophysiology. CASE INFORMATION: A 26 yo Latino male was brought to the ER complaining of 12 hours of progressive upper and lower extremity weakness to the point that he could no longer get out of bed. The symptoms began with leg cramps shortly after a family picnic. He had no complaints of abnormal sensation, difficulty breathing or swallowing. He denied recent illness ECLAMPSIA AS AN UNCOMMON CAUSE OF IN PREGNANT WOMEN. or vaccinations, or ingestion of canned food. He also denied past medical problems, C. Barancin1; 1University of Wisconsin-Madison, Madison, WI (Tracking ID #75224) medications, or illicit drug use. His mother and sister had hypothyroidism. The examination showed an alert, well developed male with a mildly enlarged , but no LEARNING OBJECTIVES: 1. To recognize eclampsia as an uncommon cause of a new- tremor or lid lag. Strength in the upper extremities was 3/5, and 2/5 in the lower extremities. onset seizure disorder in women of reproductive age. 2. To recognize the clinical presentation Deep tendon reflexes were 1 plus bilaterally, and the cranial nerve exam was normal. of eclampsia. Labs were remarkable for Na 142, K 1.8, Cl 111, CO2 20. A TSH was drawn. The EKG CASE INFORMATION: J.R. is a 36 year-old healthy female who presented to the emergency showed SR with flattened T waves and prominent U waves. After a total of 120 meq of department after having her first seizure. She was found by her son in bed with jerking of her combined IV and PO KCL, the serum K was 5.1 and the patient's symptoms and EKG left upper extremity. When she regained consciousness she found that she bit her tongue and findings had completely resolved. had urinary incontinence. She was well up until three days before when she developed a The following day, the TSH and FT4 returned at <0.03 and 2.48 respectively, consistent with constant low-grade headache. Her last menstrual cycle was three months before presentation hyperthyroidism. The patient was diagnosed with thyrotoxic periodic paralysis. Propranolol was although she reports some light vaginal bleeding one week prior. Per the patient she had no initiated and a thyroid scan scheduled as an outpatient. Despite compliance with medications, sexual activity for six months. Physical exam on admission was significant for blood pressure of the patient returned to the ER with a recurrence of symptoms after a large Christmas dinner. 145/82 and 1+ ankle edema. The neurological exam was completely normal. The patient did The iodine uptake scan showed a mildly enlarged gland with homogeneously increased uptake: not know she was pregnant on admission but an initial beta-HCG was 12,700. Her urinalysis 20 % (5±17%) at 4h, and 48 % (8±30%) at 24 hours, consistent with Graves disease. showed 3+ proteinuria. An ultrasound confirmed the presence of a 30 week gestation . A Therefore, the patient was treated with radioactive iodine ablation. Four months into followup, head CT showed low attenuation lesions in both subcortical parietal lobes and in the left the patient was doing well, but had become hypothyroid. frontal lobe. The patient was transferred to Labor and Delivery with the presumptive diagnosis IMPLICATIONS/DISCUSSION: Thyrotoxic periodic paralysis is a well described disease in of eclampsia. She received intravenous magnesium sulfate and steroids to enhance fetal lung up to 2 percent of all Asian men afflicted with hyperthyroidism. However, it is being maturity. The next day after some fetal distress she delivered a viable male infant via cesarean increasingly recognized in patients of other racial backgrounds including Native Americans, section. Her vaginal bleeding one week prior to admission was due to placental abruption. Latinos and rarely Caucasians or those of African descent. This disorder is caused by IMPLICATIONS/DISCUSSION: Eclampsia is not commonly encountered in the practice of overactivity of the Na-K-ATPase channel in the presence of increased thyroid hormone, which internal medicine but it should be considered in the evaluation of a new-onset seizure disorder shifts potassium intracellularly. The inital treatment involves modest potassium supplementa- in women of reproductive age. It has an incidence of approximately 5 cases per 100,000 live tion and non-selective beta blockers. The more common familial periodic paralysis is related to births. It is characterized by generalized seizures or coma in the presence of preeclampsia the Na-Ca channel, and presents in a similar fashion, frequently after a carbohydrate rich meal (, edema, proteinuria). It is most common in nulliparous women in the teenage or exercise. It is important for clinicians to understand that thyrotoxicosis of any etiology is an years and early twenties and in women over 35. More than 20% of cases occur before 30 weeks underlying cause of hypokalemic periodic paralysis because treatment of the thyroid disorder gestation, and 75% of cases occur at term or within 48 hours of delivery. It remains the second will also prevent further paralytic episodes. most common cause of maternal death in the United States. Treatment consists of oxygen, intravenous magnesium and antihypertensive medications. medications may be given for recurrent seizures. The fetus should be delivered promptly. Unfortunately this 1 1 woman did not recognize that she was pregnant therefore she did not receive any prenatal care. AN ATYPICAL CASE OF POLYARTERITIS NODOSA. B.N. Batson , J.W. Blackston , 1 1 This case underscores the importance of pregnancy testing in all women of reproductive age C. Subramony ; University of Mississippi Medical Center, Jackson, MS (Tracking ID #75156) with a new-onset seizure disorder to expedite the diagnosis. Eclampsia should be part of the LEARNING OBJECTIVES: Recognize the clinical and lab findings of polyarteritis nodosa. differential diagnosis in the evaluation of a new seizure disorder in all women of reproductive Perform an appropriate workup when polyarteritis nodosa is suspected. age unless she proves not to be pregnant. Early recognition and treatment of this disorder can CASE INFORMATION: A 46 y/o BM was transferred complaining of abdominal pain for 4 prevent some potentially devastating consequences. days that had not improved with conservative treatment. Outside x-rays demonstrated dilated loops of bowel without obstruction. He denied fever, chills, nausea, and vomiting but reported fatigue, anorexia, and a 40-pound weight loss over the past 6 months. He also reported progressive weakness and numbness of both legs which limited ambulation. Physical was WHAT IS THE MEANING OF TRISMUS? H.A. Batal1, R.H. Harris1; 1Denver Health Medical significant for BP of 178/114 and a diffusely tender abdomen without guarding, rebound or Center, Denver, CO (Tracking ID #74878) mass. He had faint bowel sounds and was heme positive on rectal. He had 2/5 strength in LEARNING OBJECTIVES: 1) Identify the differential for trismus. 2) Recognize the acute bilateral hip, knee, and ankle flexors and extensors. Sensation was diminished in both feet up to presentation of tetanus. mid-shin. Reflexes and Babinski's were normal. CXR was negatvie except for blebs, but KUB CASE INFORMATION: A 20 yo previously healthy Mexican native presented with 4 days of showed multiple dilated loops of bowel with air-fluid levels. Lab included WBC 14.1, Hct 27, left cheek spasm associated with pain. He denied any trauma, abrasions or lacerations, thought and plts 417. BUN was 23 and creatinine 1.2. Total protein was 6.7 with albumin 2.3. Hep that he had received his vaccines as a child, and denied any systemic symptoms such as fever or BsAg was positive; p-ANCA was negative. On HD#2, CT abdomen showed a 9x5cm right . He also denied sore or dental pain and did not have a personal or family lower quadrant mass, moderate , and patchy kidney enhancement with wedged-shaped history of neurologic problems, including tics. He had bitten his tongue a number of times due hypodensities. Renal ultrasound showed normal kidney size with inhomogeneous architecture. to his left cheek spasm and was finding it difficult to eat solid food, although his intake of On HD#3, sural nerve biopsy was suspicious for mononeuritis multiplex. Later on HD#3, a liquids was adequate. On examination he had normal and did not appear to be in any mesenteric arteriogram was normal. By HD#4, the patient had decreased abdominal pain with distress. He spoke through slightly clenched lips, but was handling his secretions without stable hematocrit, but creatinine had risen to 2.7. On HD#5 colonoscopy was normal. He then difficulty. He had no apparent spasms or tics involving other muscle groups. His neurologic had an MRI-guided biopsy of the RLQ mass which yielded only red blood cells. On HD#8 exam was normal, although he refused to protrude his tongue, as he was afraid that he would surgical exploration found bloody ascites and an 8x10cm mass of the ileocolonic junction bite it. His exam showed poor dentition but no localizing dental infection and no evidence of requiring hemicolectomy. Ascitic cytology was negative for malignancy. Pathology of the mass pharyngeal abscess. Submandibular and parotid glands were non-tender. He was noted to have showed extensive polyarteritis nodosa involving the small- and medium-sized submucosal and spasm of his left masseter muscle, and broke a tongue blade when an attempt was made to keep mesenteric arteries. his mouth open for examination. He was only able to open his jaw approximately 2 cm. IMPLICATIONS/DISCUSSION: While this patient exhibited many classic symptoms of Laboratory examination showed a normal CBC, calcium, and electrolytes. A dental consultant polyarteritis nodosa, his workup of that suspected diagnosis was confounded by an abdominal was unable to find any underlying odontogenic etiology for the patient's trismus. Dental mass and false-negative mesenteric arteriogram. One must remember that the diagnosis of radiographs and head MRI were unrevealing. Because the diagnosis of acute tetanus was PAN is best made with tissue biopsy of an involved organ system. While a positive p-ANCA is entertained, the patient was admitted for 48 hours of observation during which time his suggestive of PAN, and a mesenteric arteriogram showing pseudo- is sufficient for symptoms did not change. He was discharged with a diagnosis of trismus of unknown etiology diagnosis, both of these tests are positive in less than 50% of patients with known polyarteritis and therapy with tegretol at 200 mg bid was initiated. nodosa. 34 Abstracts JGIM

OUTPATIENT DIAGNOSIS OF . J.L. Beach1, C.C. Smith1; 1Beth or comb her hair. She also noticed a rash on her face, neck, and all extremities. Two months Israel Deaconess Medical Center, Boston, MA (Tracking ID #76010) prior to presentation, she developed difficulty climbing stairs and getting up off chairs. Physical examination was remarkable for symmetric proximal muscle strength of 3+/5 with normal LEARNING OBJECTIVES: Recognize an atypical presentation of pulmonary embolism. distal muscle strength. A maculopapular, erythematous, and scaly rash was noted over her CASE INFORMATION: A 35yo male, with past medical history significant for hypertension, chest, back, all four extremities, knuckles and the extensor surface of her fingers. Laboratory presented to an urgent care visit with a of left sided chest pain. The night prior evaluation revealed negative ANA, normal CBC, electrolytes, TSH, sedimentation rate, to his appointment, he awoke from sleep with sudden onset of anterior left sided chest pain. level, EKG, and chest Xray. CPK was 239 (normal <140), AST 76, ALT 30, LDH 351, The pain was described as sharp, non-radiating and improved with sitting upright. He denied and aldolase 11 (normal <8). Electromyography/nerve conduction study was abnormal and any associated shortness of breath, nausea, vomiting or diaphoresis. Before being seen in the suggestive of an inflammatory myositis. Both a punch biopsy of the skin and the left deltoid clinic the following morning, he had two additional episodes of chest pain. He reported similar muscle confirmed the diagnosis of DM. An extensive search for an underlying malignancy was symptoms in the past which had resolved without intervention. Physical exam was only negative. The patient was treated with glucocorticoids with significant improvement of remarkable for a blood pressure of 160/110. He was diagnosed with gastroesophageal reflux symptoms and normalization of CPK levels. disease and was treated with ranitidine 150mg twice a day; in addition, his atenolol was IMPLICATIONS/DISCUSSION: DM is an idiopathic inflammatory myopathy with an increased to 50mg once a day. Eight days later he presented with persistent symptoms. He incidence of one per 100,000 adults. It presents as insidiously occurring symmetric, proximal reported several acute episodes of left sided chest discomfort which were now associated with muscle weakness. Cutaneous manifestations associated with DM include Grotton's sign, pleuritic pain and shortness of breath. Each episode was brief and resolved spontaneously. heliotrope rash, shawl-like rash over the chest and shoulders, periungual erythema, abnormal Between these episodes, he noted dyspnea on exertion and an overall feeling of malaise which -bed loops, and painful cracking of the skin of the tips of the fingers called seemed to respond to acetaminophen. He had taken the ranitidine as prescribed without relief. mechanic's hand. Fever, weight loss, dysphagia, Raynaud's phenomenon, and cardiopulmonary Otherwise, a remained negative; he specifically denied cough and abnormalities may be present. Differential diagnosis of dermatomyositis includes polymyositis, hemoptysis. Physical exam revealed an obese male in mild distress with a temperature of inclusion body myositis, , motor neuron disease, mysathenia gravis, 98.7, of 62, respiratory rate of 16, a blood pressure of 160/100 and a room air oxygen hypothyroid myopathy, toxic myopathy due to alcohol, cocaine, or drugs, and HIV infection. saturation of 98%. Chest exam was clear bilaterally with decreased effort secondary to splinting Muscle enzymes are elevated in DM but rarely may be normal. Electromyographic abnormalities on deep inspiration. Cardiovascular exam was unremarkable. Musculoskeletal exam revealed support the diagnosis of DM. Muscle biopsy from a clinically weak muscle establishes the tenderness to palpation along the left paravertebral region. An EKG revealed sinus rhythm at diagnosis. DM is treated primarily with corticosteroids; azathioprine, methotrexate, or IVIG are 60 beats per minute with a normal axis and intervals; no ST-T segment changes were noted. reserved for patients who do not respond to steroids. Malignancies may occur in up to 28% of CXR showed parenchymal opacities in the left mid and lower lung zone. Given the suspicion patients with DM. Detection of malignancy, most commonly carcinoma, may precede or follow for pulmonary embolism, a CT-angiogram was performed which revealed a large pulmonary the development of DM. Therefore, a search for malignancy is warranted whenever the diagnosis embolus in the left mainstem pulmonary artery with two associated areas of pulmonary of DM is made. A careful history and physical, along with the recommended age and gender- infarction. specific screening for malignancy, is an appropriate initial step. IMPLICATIONS/DISCUSSION: Pulmonary emboli (PE) occur in over 300,000 patients annually and another 600,000 are thought to go undiagnosed. The mortality rate can be as high as 30% without appropriate diagnosis and timely treatment. Given the success of anti- coagulation in preventing further morbidity and radically decreasing mortality, it is imperative A PAIN IN THE NECK THAT JUST WOULDN'T GO AWAY: A CASE OF ANKYLOSING to have a high level of suspicion for the diagnosis. Common presenting symptoms and signs SPONDYLITIS. J. Behari1, H. Jasti1; 1University of Pittsburgh, Pittsburgh, PA (Tracking include dyspnea, pleuritic pain, cough, hemoptysis, tachypnea, tachycardia, and a prominent ID #74369) pulmonic component of the second heart sound. Often the presentation of PE is nonspecific, and symptoms are indistiguishable from many other common, as well as life-threatening, LEARNING OBJECTIVES: 1) Identify the clinical features of (AS). 2) disorders. As demonstrated in this case, a few relatively inexpensive and noninvasive studies Recognize the extraarticular manifestations of AS. 3) Outline the treatment options for the such an EKG and CXR can help clinch the diagnosis in patients in whom the history management of AS. is atypical. CASE INFORMATION: A 38-year-old male presented with a 12-year history of neck and back pain and stiffness. The patient's symptoms had started insidiously but worsened in the past three years such that the patient was now unable to turn his head or bend at the waist. He also complained of increasing right knee pain, bilateral shoulder stiffness, anorexia, weight loss, 1 1 1 PICA AS PALAEONUTRITION. A. Beck ,E.Warm; University of Cincinnati, and fatigue. He reported three episodes, over the previous two years, of right eye redness and Cincinnati, OH (Tracking ID #76335) photophobia, subsequently diagnosed as acute anterior uveitis. Physical examination LEARNING OBJECTIVES: 1. Recognize pica as a symptom of . 2. Explore demonstrated severely decreased neck motion in all planes and associated spasm of the theories to explain why pica occurs. trapezius and paraspinal muscles. Chest wall expansion was diminished upon inspiration. Waist CASE INFORMATION: Pica has long been associated with iron deficiency, yet the etiology flexion and shoulder abduction were limited to 30 degrees and 90 degrees, respectively. remains unclear. We present two cases. A 48-year-old African American female presented for Laboratory evaluation revealed a hematocrit of 34%, elevated serum C-reactive protein of 72 a routine exam. She admitted that she was ``so addicted to eating baby powder'' that she mg/L (reference range 0±4.9 mg/L), and a positive HLA-B27 antigen test. Radiography craved it and would salivate when commercials for it came on television. On evaluation she revealed bilateral sacroiliitis and fusion of the posterior elements of the cervical spine at several was found to have menorrhagia and a severe iron deficiency anemia. Following iron levels with anterior syndesmophytes. The patient was diagnosed with AS and treatment was supplementation her pica ceased completely and her anemia was resolving. Similarly, a 55- initiated with physical therapy and nonsteroidal anti-inflammatory drugs. year-old African American female taking NSAID's for osteoarthritis presented with IMPLICATIONS/DISCUSSION: AS is an inflammatory disorder that primarily affects the complaints of fatigue and ice eating. She was found to have iron deficiency anemia secondary axial skeleton. The characteristic findings of low back pain and morning stiffness that improves to a bleeding duodenal ulcer. Following blood transfusion and iron supplementation her with activity have an insidious onset before the age of 40. Arthritis of peripheral joints, neck symptoms resolved. pain and stiffness, and constitutional symptoms such as anorexia, weight loss, or fatigue may IMPLICATIONS/DISCUSSION: The term pica was first applied in the 16th century from also be present. Diagnosis is based upon the appearance of radiographic sacroiliitis and either the Latin term for magpie, a bird with odd feeding habits. The Oxford English Dictionary the presence of inflammatory back pain, limitation of motion of the lumbar spine in two planes, describes pica as a pathological craving for substances unfit for food. There are various or decrease in chest expansion. Unilateral acute anterior uveitis, the most common manifestations of pica. Substances that are compulsively ingested include ice (phagophagia), extraarticular manifestation, can antedate the articular symptoms. Aortic insufficiency leading laundry starch or cornstarch (amylophagia), clay and dirt (geophagia), crunchy foods, baby to congestive heart failure, inflammatory bowel disease, and IgA nephropathy may be powder, paper and matches. Patients describe these dietary practices as cravings and associated with AS. While nonsteroidal anti-inflammatory drugs and physical therapy remain insatiable appetites for the substance. It has long been controversial as to whether pica is the as the main modalities of treatment, promising treatments include sulfasalazine, methotrexate, cause of or the symptom of iron deficiency anemia. Existing evidence includes the consistent infliximab, and etanercept. Thus, AS is a chronic disease with an insidious onset that should be cessation of pica following iron therapy but before the patient's anemia is resolved, as seen in diagnosed early and treated aggressively to prevent its potentially disabling consequences in our patient. Why pica manifests at all remains a mystery, although, several theories have been relatively young patients. suggested. The palaeonutrition theory suggests that geophagia is a vestige in the evolution of the human diet. The evidence that certain clays consumed throughout history detoxify ingested poisons and contain minerals supports this. A second theory proposes that pica is attributed to YOU'RE NEVER TOO YOUNG TO BE HYPERTENSIVE: A 21-YEAR-OLD MALE WITH iron depletion in the brain tissues involved with appetite regulation. Regardless of these . J. Behari1, J.M. Frangiskakis1, M.A. McNeil1; 1University of uncertainties, what is eminently important is the fact that pica must be recognized by the Pittsburgh, Pittsburgh, PA (Tracking ID #75463) physician. It not only indicates further work-up of underlying pathology, but also carries risk of complications such as further vitamin and mineral deficiency, gastrointestinal obstruction, LEARNING OBJECTIVES: 1) Know when to suspect renovascular hypertension. 2) parasitic infection, metal poisoning and gestational diabetes. Recognize (FMD) as a cause of in a young adult. 3) Know how to diagnose and treat (RAS). CASE INFORMATION: A 21-year-old male presented with a four-week history of headaches, jitteriness, nausea, and fatigue. His past medical history was unremarkable except THE CASE OF THE SEAMSTRESS WHO COULDN'T LIFT HER ARMS. J. Behari1, for ``slightly elevated'' blood pressure (BP) measured in his physician's office prior to becoming B. Savani2, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA; 2University of symptomatic. The patient was told not to worry, as he was ``too young to have BP problems.'' Massachusetts, Worcester, MA (Tracking ID #73930) His family history was not significant for hypertension. He denied alcohol, tobacco, or drug LEARNING OBJECTIVES: 1) Recognize dermatomyositis (DM) as an etiology of proximal use. His BP was elevated at 150/105±110 in both arms. The rest of his physical examination muscle weakness. 2) Recognize the clinical features and dermatologic manifestations of was unremarkable, including the absence of an abdominal . Workup revealed normal dermatomyositis. 3) Recognize the association between dermatomyositis and malignancy. CBC, electrolytes, BUN, creatinine, ferritin, urinalysis, TSH, serum cortisol, lipid panel, CASE INFORMATION: A 64-year-old seamstress presented with a four-month history of EKG, and chest X-ray. Plasma and were both elevated at 545 microU/ml and bilateral neck pain and weakness and inability to raise her arms over shoulder level, lift objects, 37 microU/ml, respectively. The patient was started on 5 mg of enalapril but his BP did not JGIM Volume 18, April (supplement 1) 2003 35

normalize. Magnetic resonance angiography of the abdomen revealed severe stenosis of the distal left renal artery consistent with FMD. The patient underwent contrast-enhanced renal artery angiography that confirmed the diagnosis. Balloon angioplasty of the stenotic left renal artery was performed. The day after angioplasty, the patient's plasma renin decreased to 50 microU/ml and BP to 130/70. IMPLICATIONS/DISCUSSION: Renovascular hypertension should be suspected in patients with age of onset before 20 or after 50 years, severe or refractory hypertension, acute rise in BP over previously controlled hypertension, rise in plasma creatinine concentration especially after starting an angiotensin-converting enzyme (ACE) inhibitor, abdominal bruit, absence of family history of hypertension, a unilateral small kidney, and recurrent acute or unexplained heart failure. RAS may result from FMD or atherosclerotic disease. FMD most commonly affects women between the ages of 15 and 50 and accounts for less than 10% of cases of RAS. is responsible for the other 90% of cases. Gadolinium-enhanced magnetic resonance angiography is the best noninvasive imaging modality to diagnose RAS with 100% sensitivity and 95% specificity. Renal angiography is the gold standard to confirm the diagnosis. Percutaneous angioplasty is the treatment of choice for renovascular hypertension secondary to FMD. Patients with hypertension secondary to atherosclerotic RAS should be treated with , -lowering agents, and smoking cessation. ACE inhibitors and can be used to control hypertension but should be avoided in the presence of bilateral stenosis. Balloon angioplasty is less successful in atherosclerotic RAS but placement of stents improves the success rates. Surgical revascularization should be considered in patients who fail angioplasty.

RECURRENT PAINFUL BLISTERS. M. Bhandari1, S. Vadgama2, O. Melamed1, E.F. Yee3; Epidermolysis Bullosa - Hand & Foot 1UCLA-Olive View Medical Center, Sylmar, CA; 2VA-West LA Health Care, Los Angeles, CA; 3University of California, Los Angeles, Los Angeles, CA (Tracking ID #75879) Epidermolysis Bullosa: Major groupings and distinguishing characteristics LEARNING OBJECTIVES: 1. Identify a likely cause of recurrent painful blistering diseases in young adults Skin Supportive Visceral 2. Identify the classical presentation, manifestations and prognosis of Epidermolysis Bullosa Transmission Onset Blisters Care Involvement Complications Life Span 3. Recognize the main management issues in caring for Epidermolysis Bullosa patients Simplex Autosomal Infancy to Yes, Shortens No Scarring, Mostly CASE INFORMATION: A 19 y/o latina woman presented for evaluation of painful blisters variant dominant early without Blisters Infections Normal over her left hand and both feet after recent initiation of jogging. She reported a history of adulthood scaring Junctional Autosomal Infancy Yes, with No Effect Yes Early Death Very recurrent painful blisters affecting both her hands and feet since childhood. More severe variant receissive scaring Shortened blistering occured in areas where her skin was rubbed. Steroid creams provided no Dystrophic Autosomal Variable Yes, with Variable Mostly Not Scarring, Variable improvement. Lesions in the past healed over about a month, leaving hyper-pigmented scars. variant dominant or scaring Fusion of This current flare involved both her feet and left hand, but no other area. Systems review was recessive Digits negative. Other family members were not affected. She took Tylenol with hydrocodone for pain. On examination the patient had multiple blisters, 2±3 cm in diameter, mostly on the plantar surface of both feet. The soles of her feet were thickened and pigmented in circular A YOUNG WOMAN WITH DIARRHEA. I.A. Binswanger1; 1University of California, San patch-like forms. The blisters were exquisitely tender to touch. Initial differential diagnosis of Francisco, San Francisco, CA (Tracking ID #76396) this patient's condition included bullous pemphigoid, dermatitis herpetiformis, porphyria LEARNING OBJECTIVES: The learning objectives of this case are to recognize and cutanea tarda and bullous SLE. A skin biopsy performed by a dermatologist demonstrated diagnose Celiac Sprue (gluten-sensitive ), learn about the epidemiology of Celiac histologic separation of the basal layer. After immunohistochemistry, a diagnosis of Sprue, and learn about the long-term management of Celiac Sprue. epidermolysis bullosa, simplex form, was made. CASE INFORMATION: A 25 year old woman from Germany presented with one month IMPLICATIONS/DISCUSSION: Epidermolysis Bullosa (EB) is the term given to three history of diarrhea and mid-epigastric abdominal cramps, weight loss, and fatigue. The patient major groups of approximately 16 variants of rare dominant and recessive genetic diseases in was thin and pale but had an otherwise unremarkable physical examination. She was mildly which minor trauma causes non-inflammatory blistering (mechanobullous disease). There are anemic (hemoglobin 11.0), with a low MCV (76), low ferritin (2), and low folate (224). as many as 150,000 Americans afflicted, mostly children, but variants present up to third Endomysial antibody was strongly positive (253). Biopsies from the stomach and small bowel decade of life. Those with medium to more severe kinds of EB can live into their thirties. were consistent with Celiac Sprue. She started a gluten-free diet and her symptoms and Mortality is predominantly related to suprainfections. anemia resolved. Management consists of all efforts to avoid trauma, particularly to the hands and feet via IMPLICATIONS/DISCUSSION: Celiac Sprue is common and under-diagnosed. In North mittens and soft slippers. Adequate long-term pain control is a crucial aspect of taking care of America and Europe, 1/120 to 1/300 people are affected by Celiac Sprue and the prevalence in EB patients, as is prevention and early treatment of supra-infections of the blistering lesions. first degree relatives of cases is 10%. The pathogenesis of Celiac Sprue includes an excessive T- Clasically all EB variants are resistant to all therapy, though literature reports exist of rare cell mediated immune response to gluten, which is a protein found in wheat, rye, and barley. responders to treatment with Phenytoin, a known collagenase inhibitor, as well as IVIg. The symptoms include diarrhea, weight loss, abdominal discomfort, and aphthous ulcers. The Genetic counseling is essential and fetal skin biopsy techniques have been developed for pre- exam may be normal or demonstrate pallor, easy bruising, loss of muscle mass and dermatitis natal diagnosis. herpitiformis. Lab examination often reveals iron deficiency anemia, folate deficiency, , and vitamin D deficiency. Highly sensitive and specific diagnostic tests include IgA endomysial antibody and IgA tissue transglutaminase antibody but the gold standard is duodenal biopsy. IgA antigliadin antibody is useful to monitor response to therapy with a gluten-free diet. There is no role for empiric therapy prior to a diagnosis of Celiac Sprue, because following a gluten-free diet prior to testing can interfere with the sensitivity of diagnostic testing and adhering to a gluten-free diet may require major changes in lifestyle. A life-long gluten-free diet may help prevent conditions associated with Celiac Sprue, such as non-Hodgkin's lymphoma, as well as overall survival.

UNREMITTING ECZEMA HERALDING A PANCREATIC GLUCAGONOMA. M.A. Bishop1, V.T. Martin1, M.E. Bishop1; 1University of Cincinnati, Cincinnati, OH (Tracking ID #73934)

LEARNING OBJECTIVES: Be able to recognize glucagonoma syndrome in any patient with newly diagnosed diabetes or a rash that does not resolve with proper topical treatment and is consistent with necrolytic migratory erytheam. CASE INFORMATION: A 53 year-old woman with a history of hypothyroidism presented with a 2-month history of a pruritic rash and subjective weight loss. Physical exam revealed salmon-colored, scaly patches involving her breasts, abdomen and mid-thigh areas. The rash initially was treated as eczema with topical steroids, Diflucan, and without any improvement. The characteristics of the rash and its non-responsiveness to treatment led to the consideration of a diagnosis of glucagonoma. Biopsy showed acanthosis, parakeratosis, and hyperkeratosis of the epidermal layer and an ill-defined D-E junction. CT scan of the abdomen revealed a 4cm mass in the head of the pancreas without metastasis; glucagon levels were elevated at 757 and 834 pg/ml (normal: 50±200). She had a normal glucose level of 115 mg/dL. Epidermolysis Bullosa - Foot The patient underwent a Whipple procedure to resect the suspected glucagonoma. 36 Abstracts JGIM

The diagnosis of glucagonoma was confirmed by pathologic examination. Upon removal of the CARDIAC TAMPONADE DUE TO SEVERE MYXEDEMA. J. Blonsky1, V. Shivaswamy1, tumor, her rash subsequently cleared without any complications. K. Hoskison1, R. Sekhar1, D. Perry1; 1University of Oklahoma, Tulsa, OK (Tracking IMPLICATIONS/DISCUSSION: Glucagonoma syndrome is a rare syndrome with an ID #75122) estimated incidence of about 1 in 20 million people. It occurs with equal frequency in men and LEARNING OBJECTIVES: Recognize hypothyroidism as cause for cardiac tamponade. women and is usually detected between 40 to 60 years of age. The syndrome is caused by Diagnosis of cardiac tamponade secondary to hypothyroidism. Treatment of cardiac excessive production of glucagon by the alpha-secreting cells of the pancreas. Patients may tamponade caused by severe tamponade. have a characteristic rash, called ``necrolytic migratory erythema'', that involves the perioral CASE INFORMATION: We report a 53-year-old male with an enlarging right testicle, and perigenital regions. There may also be accompanying glossitis, angular chelitis, and progressive dyspnea, severe dependent edema, and cold intolerance. Physical examination blepharitis. The rash usually responds poorly to topical treatment. The only curative treatment revealed faint heart sounds, ascites, ankle jerks with delayed relaxation, and an enlargement of for the syndrome is surgery. Glucagonoma syndrome should be considered in any patient with: the right scrotum consistent with a hydrocele, and a clinical diagnosis of cardiac effusion with 1) newly diagnosed diabetes and 2) a rash that does not resolve with proper topical treatment tamponade was entertained. Further evaluations revealed low voltage complexes on the EKG, and is consistent with necrolytic migratory erythema. and marked cardiomegaly on a Chest Roentgenogram with bilateral pleural effusions. An echocardiogram showed a large pericardial effusion with signs of early tamponade, and a pericardial paracentesis drained 1400ml of . Pericardiocentesis led to significant clinical A DOUBLE WHAMMY: IN YOUNG PERSON IN TWO DISTRIBUTIONS. improvement. To confirm a unifying diagnosis thyroid functions were diagnosed of profound 1 1 P.K. Black ; University of California, San Francisco, San Francisco, CA (Tracking ID #75517) hypothyroidism with a TSH of 52.5 iu/ml. The patient responded well to thyroid hormone LEARNING OBJECTIVES: 1. Recognize the different etiologies and evaluation for stroke in replacement therapy, and demonstrated continued recovery at clinic follow-up visits. The young vs old persons. 2. Diagnose the cause of stroke in two simultaneous distributions. 3. scrotal swelling was confirmed as a hydrocele by ultrasound. Recognize cocaine's role in cerebrovascular disease. Hypothyroid effusions involving the pleural, pericardial, and peritoneal cavities have been CASE INFORMATION: A 44 year old left handed, African- American man with diabetes, described, but uncommon clinically. Pericardial effusions tend to be large, and asymptomatic, hypertension, & increased cholesterol who reported feeling ``funny'' one day prior to as the slow temporal progression permits compensation due to pericardial stretching. The hospitalization. On the morning of admission, he awoke feeling worse, with headache, & right clinical presentation suggests chronic cardiac failure and constrictive pericarditis with pleural arm weakness. PMH: as above. Meds: lovastatin, benazepril, insulin. SH: No tobacco, alcohol effusion, ascites, and anasarca. EKG findings include bradycardia and microvoltage complexes. or drug use. Exam was notable for mild hypertension, no carotid , normal CV exam Treatment with thyroid hormone replacement is nearly always followed by steady regression except for an S4. Neurologically, he had fluctuating ability to concentrate, he was fully of the effusion. Pericardiocentesis is indicated for tamponade, after a confirmatory oriented and had normal speech and naming. Cranial nerve exam showed a right facial droop echocardiogram. which spared his forehead and a right homonymous hemianopsia. He had right sided This presentation illustrates the importance of detecting hypothyroidism as cause for cardiac hyperreflexia and weakness. His labs, EKG & CXR were normal. His Head CT showed a tamponade. Prompt diagnosis is vital to prevent cardiogenic shock, and includes early suspicion left middle cerebral artery & posterior cerebral artery stroke. An extensive evaluation including on the basis of a detailed physical examination, and rapid diagnosis by thyroid functions and hypercoagulable work-up, homocysteine level, rheumatologic tests, hgb electrophoresis, echocardiography. Evacuation of the pericardial fluid, and thyroid replacement therapy leads Carotid US, telemetry & Echo was unrevealing. MRI/A (angiogram) demonstrated the to complete regression and resolution of the condition. without evidence of corresponding . Urine drug screen was positive for IMPLICATIONS/DISCUSSION: Hypothyroidism may lead to cardiac tamponade. Prompt cocaine. diagnosis is vital to prevent cardiogenic shock. Complete resolution of pericardial fluid IMPLICATIONS/DISCUSSION: Stroke in young people (age <45 years) accounts for 5± following evacuation and thyroid replacement therapy. 10% of all strokes. There is a much broader differencial of disorders that cause infarction in younger people. Full evaluation is required to determine an underlying cause to treat patients accordingly and prevent recurrence. As opposed to stroke in the elderly which are often due to A HISPANIC MAN WITH LYMPHADENOPATHY AND EOSINOPHILIA. D. Bolger1; 1Johns atherosclerosis and embolism, only 40% of strokes in the young are accounted for by these two Hopkins University, Baltimore, MD (Tracking ID #76421) etiologies. Other important causes include , vasculitis, blood disorders, pregnancy, mitral valve , , and patent foramen ovale. Given this patient had simulanteous LEARNING OBJECTIVES: 1. Recognize the clinical features of Kimura's disease. anterior and posterior strokes, some of these etiologies are more likely, including: proximal 2. Recognize that a constellation of nonspecific clinical signs can represent a specific entity emboli or a disseminated process such as vasculitis, blood disorder or drug use. This young when pursued. person's stroke was a result of cocaine use. Proposed mechanisms by which cocaine causes 3. Develop a differential diagnosis for lymphadenopathy and differentiate accordingly. stroke is that it induces , vasospasm, hypertension and/or vasculitis. Case CASE INFORMATION: A 63 year old man born in the Dominican Republic but residing in reports have documented stroke secondary to cocaine use in patients who had infarction in New York City for 30 years presented to a medical clinic with 2 years of right neck swelling. multiple distributions. Several of these cases were confirmed to have cocaine-induced vasculitis The gentleman initially noticed a small, painless bump in his neck. The bump enlarged to an on autopsy despite having had negative MRA. eventual size of 8cm by 14cm. Similar bumps also arose in the right neck, left neck, and right axilla. Eventually the predominant lesion became painful and itchy. The patient felt healthy otherwise, denying fevers, fatigue, and weight loss. The patient had a history of hypertension, PPD positivity with negative CXRs, and remote microscopic hematuria. He was taking AN UNUSUAL CASE OF DELAYED METHAMPHETAMINE TOXICITY. J.W. Blackston1, hydrochlorothiazide and prazosin for his hypertension. He was married with 2 children. A He D. Howell1, M. Horn1; 1University of Mississippi Medical Center, Jackson, MS (Tracking traveled to the Dominican Republic every year for holiday. No other travel was noted. His ID #76379) physical exam was remarkable for a mobile nodular mass 8cm  14cm in the right anterior LEARNING OBJECTIVES: To distinguish the toxicity of ``crystal meth'' (methampheta- cervical neck. There were discrete subcutaneous nodules on both sides of the neck. There was mine) from other syndromes in a patient presenting with psychomotor agitation and lymphadenopathy in the left neck and right axilla. The nodules and lymph nodes were mobile tachycardia. and firm but without fluctuance. There was no hepatosplenomegaly or other lymphadenopathy CASE INFORMATION: A 22 year-old male with unremarkable PMH presented to the ED via present. Pertinent labs included a wbc count of 8100/mm3 with 38% eosinophils (absolute eos ambulance with the acute onset of diaphoresis, tachycardia, and restlessness. He had been in count 3078) IgE levels were high at >1800kIU/L. HIV test was negative. Excisional biopsy of police custody for approximately 48 hours, and charged with public intoxication. After his revealed follicular hyperplasia with distinct lymphoid follicles with surrounding symptoms developed, he admitted to ingesting a ``2 gram rock of crystal meth'' to avoid charges fibrosis, abundant eosinophils, post-capillary venules, no granulomas or necrosis, and of illegal drug possession. Physical exam revealed an anxious but alert WM, BP 119/72 mm Hg, preserved architecture. Cultures and smears were negative for AFB, fungi, , and HR regular at 179 bpm, unlabored RR 16 per min., rectal temp T 99.3 degrees F, and O2 sat. Reed-Sternberg cells. Flow cytometry was negative for lymphoma. In addition, skin snips from 97% on RA. Auscultation of his chest was clear and his neurologic exam was nonfocal; but he was the patient were negative for microfilariae. tremulous, pale, and his skin cold and clammy. He required substantial doses to The patient was started on prednisone with rapid resolution of lymphadenopathy, however this achieve sedation: diazepam 5mg IV en route to the ED, and a total of 8mg IV lorazepam and recurred when prednisone was tapered. The patient was restarted on full dose prednisone and 14mg IV midazolam in the ED. The patient was electively intubated for ``airway protection.'' scheduled for curative radiotherapy. His hospital course was uneventful; he was extubated within the first day of admission and IMPLICATIONS/DISCUSSION: Kimura's disease is a rare disease usually seen in Asian men. transferred back to incarceration in 2 days. CPK levels were normal in the ED, but subsequently They present with lymphadenopathy of the head and neck and eosilophilia. Pathology reveals increased to ten times the ULN. A serum toxicology screen was positive for amphetamines and preserved lymph node architecture with necrosis, predominant eosinophils, endothelial venules, cannabinoids, and negative for salicylates, acetaminophen, methanol, ethanol, and ethylene and capsular fibrosis. Often lymphadenopathy is attributed to an infectious agent or malignancy. glycol. Confirmatory testing revealed a serum methamphetamine level of 80,000 ng/dL. As this case illustrates, there are other causes to consider. A thorough evaluation and exclusion IMPLICATIONS/DISCUSSION: Delayed methamphetamine toxicity, defined as symptom of important entities such as Hodgkin's disesase, extra-pulmonary TB, and Cat Scratch Disease onset 48 hours after ingestion, has not been previously reported in the medical literature. The is critical. Histological evaluation often provides a definitive diagnosis, but not always. The crystalline form of methamphetamine, also known colloquially as ``crank,'' is a stimulant drug pathology along with the clinical signs (features) were required for the diagnosis in this case. of abuse that is usually nasally inhaled, snorted, or smoked. It is rapidly absorbed from any mucous membrane and produces almost immediate metabolic and psychotropic effects. This patient reported orally ingesting the drug in a plastic container, thus with gastrointestinal 74-YEAR-OLD MAN WITH A THREE MONTH HISTORY OF BACK PAIN. L. Borodyansky1, transit time and even partial digestion of the container, the drug may have been easily absorbed D. Joffe1, J.G. Carr1; 1Boston City Hospital, Boston, MA (Tracking ID #75021) later in the distal GI tract. Alcohol withdrawal with incipient delirium tremens may also explain his presenting symptoms, but his markedly elevated CPK, a usual laboratory finding with acute LEARNING OBJECTIVES: Diagnose Pott's disease. Distinguish Pott's disease from other methamphetamine overdose, and strongly positive serum methamphetamine level at the time causes of back pain. Manage advanced spinal necrosis when definitive cause is unknown. of maximal symptomology, suggest methamphetamine toxicity as the etiology of his distress. CASE INFORMATION: A 74-year-old PPD positive Filipino man presented with two This case stresses the need for medical personnel to obtain complete drug exposure histories months of progressive low back pain. He denied any history of systemic symptoms. Chest from agitated patients, including explicit questioning with regard to drug ingestion stemming radiography (CXR) revealed clear lungs and disc space narrowing at T12/L1 with sclerosis and from attempts to conceal illegal activities. irregularity of the opposing endplates. Computed tomography (CT) demonstrated discitis, JGIM Volume 18, April (supplement 1) 2003 37

osteomyelitis and an epidural phlegmon. Magnetic resonance imaging (MRI) showed cord IMPLICATIONS/DISCUSSION: Although there are case reports of AML occurring with compression. Needle biopsy of the abscess was performed, yielding prurulent material. In other hepatic porphyrias, there is only one known prior case report of AIP and AML occurring consultation with Infectious Disease and Pulmonary services, empiric treatment for TB was in tandem. This represents the second known incidence of these two disorders occurring held as it could mask a pyogenic process. By the eleventh hospital day, needle biopsy failed to simultaneously. grow organisms. Polymerase chain reaction (PCR) results of the biopsy aspirate was positive for mycobacterium tuberculosis (M.Tb) and the patient began therapy with isoniazid, rifampin, pyrazinamide and ethambutol. He subsequently underwent surgery for spinal stabilization and SARCOIDOSIS PRESENTING AS CERVICAL CORD SYNDROME. D. Bradley1, E. Lower1, was discharged on an 18 month course of antibiotics. R. Baughman1, L. Coberly1; 1University of Cincinnati, Cincinnati, OH (Tracking ID #73947) IMPLICATIONS/DISCUSSION: Low back pain is the fifth leading reason for medical visits in the United States. A careful history identifies ``danger'' signals of infection or malignancy, LEARNING OBJECTIVES: To recognize that sarcoidosis is a rare but treatable cause of such as constitutional symptoms, immunosuppression, age and unremitting nocturnal pain spinal cord lesions that can mimic malignant tumors of the spine clinically and radiologically. unrelieved by recumbency. In Pott's disease, systemic symptoms are often absent, and patients CASE INFORMATION: A 53 year-old African American male presented with a six month do not undergo testing until the process is advanced. CXR is not useful in diagnosis since more history of worsening neck pain, progressive upper and lower extremity weakness, and than 50% of patients do not have lung disease. The primary focus starts in the anteroinferior difficulties with bowel and bladder function. He also noted severe fatigue and a 30 pound aspect of the vertebral body of the thoraco-lumbar spine. Local destruction leads to collapse, weight loss over the last eight months. Physical examination was remarkable for flaccid disc herniation and cord compression. Likewise, a tuberculous abscess, seen in more than 50%, paralysis of his right upper extremity, 3/5 strength of his left upper extremity, and 3/5 can impinge and compress the spinal cord. CT, myelography, and MRI are useful in diagnosis. strength of his lower extremities. He had decreased rectal tone. Significant laboratory findings While biopsy and culture are sensitive and specific, serology and PCR are useful for timely included a normal CBC, chemistry panel, and liver function studies. Calcium was elevated at diagnostic confirmation. Literature reports culture sensitivity for mycobacterial detection is 11.5 mg/dL (nl 8.4±10.2), an ACE level was normal. Cerebral spinal fluid studies were improved by culture media supplemented with oleic acid, albumin, dextrose, and catalase, unremarkable. MRI of the spine showed extensive abnormal signal involving the entire however detection is not specific to M. Tb. PCR of fixed, paraffin-embedded tissue samples, cervical cord extending through T3 with diffuse, patchy nodular enhancement and edema was shown to have sensitivity and specificity of 94% and 83% respectively. In summary, TB from C3±C7 suspicious for malignancy. CT of the chest revealed mediastinal adenopathy. remains a major problem. Before the disease can be treated it must be recognized. Biopsy of subcarinal lymph nodes showed noncaseating granulomas consistent with TB should be considered in cases of spinal osteomyelitis. Early institution of therapy reduces sarcoidosis. The patient was treated with high dose corticosteroids and IV cyclophosphamide morbidity and mortality. (off label use as a steroid sparing agent) with marked improvement. Repeat MRI six months later was normal. IMPLICATIONS/DISCUSSION: The spinal cord is involved in less than 1% of patients with ASTHMA OR ARE WE MISSING SOMETHING. C. Borrego1, E. Flenaugh1, D. Norman1, sarcoidosis. It is rarely the first manifestation of disease. Sarcoidosis of the spinal cord can be J. Henao1; 1Morehouse School of Medicine, Buford, GA (Tracking ID #74416) can be clinically and radiologically indistinguishable from a malignant tumor of the spine. Definitive diagnosis requires pathologic examination of the spinal cord lesions or, as in our LEARNING OBJECTIVES: Diagnosis and Treatment of Pulmonary Blastoma. patient, other associated lesions such as hilar adenopathy. Prompt treatment with high dose CASE INFORMATION: This patient is a twenty-seven year old black male who has a past corticosteroids is essential to a favorable outcome. Steroids may need to be continued medical history of asthma since eight years old. He is a non-smoker. He states that eight indefinately. There has been some success using steroid-sparing agents such as cyclopho- months ago he started to work at a police impound. Where he states he was exposed to a lot of sphamide to decrease the dose and duration of steroid therapy. Sarcoidosis is a treatable dust. Six months later he started having shortness of breath, cough with whitish to yellowish condition that should be included in the differential diagnosis of spinal cord lesions. sputum, and wheezing with associated left lateral chest pain. He then went to the hospital were he was treated for an asthma exacerbation with improvement and subsequently discharged. He then returned with chest pain, left sided rated 8/10 and admitted. On physical exam blood 1 1 pressure was 90/43, pulse 97, respirations 20, and temperature 97.3 degrees Fahrenheit. Room ZOSTER SINE HERPETE: A CASE OF MASKED DIAGNOSIS. J. Bratcher , S. Patel , 1 1 1 air pulse oximetry was 97%. He has decreased breath sounds on the left hemithorax. Otherwise K. Cynamon , J. Andrieni ; Lenox Hill Hospital, New York, NY (Tracking ID #75529) physical exam was normal. Chest x-ray showed left lung to be completely opacified by tumor LEARNING OBJECTIVES: 1) Expand the differential for abdominal pain; 2) Diagnose an mass or , with some cystic components. CT scan off chest showed a large soft atypical presentation of herpes zoster in the absence of skin lesions; 3) Recognize that zoster tissue mass completely replacing the left lung of mixed density most likely representing a sine herpete is a clinical diagnosis. neoplastic process such as sarcoma, invading and obstructing the left main bronchus. The CASE INFORMATION: A 58 year-old male with history of nephrolithiasis presented with bronchoscopy showed the right lung to be patent and 3 cm below the carina going to the left abdominal pain, fever, and chills. Physical exam was significant for low-grade fever and left main stem bronchus, the airway was completely occluded by a tumor mass in the lumen. Endo upper quadrant tenderness. Radiographic studies revealed a 5.3 Â 4.6 cm dissecting aortic bronchial biopsy was performed at that time, which revealed pulmonary blastoma, at the level of the diaphragm, and a separate dissection of the right common iliac monomorphic epithelial type (well differentiated fetal adenocarcinoma). artery. The patient was admitted with a diagnosis of an infected and evaluated IMPLICATIONS/DISCUSSION: Pulmonary blastoma is hard to be diagnosed before by vascular surgery. The patient continued to complain of left upper quadrant pain, described operation. The main symptoms can be cough, expectoration. This tumor is extremely rare and in a definite dermatomal distribution along the left lower costal margin with radiation to the manifest's a mixture of epithelial and mesenchymal neoplastic cells. This is a low grade tumor left flank. Despite absence of any physical evidence of rash, the description was suggestive of that consists of immature embryonic epithelial elements forming tubules and glands and herpes zoster. Varicella titers were then ordered and positive IgM titers were revealed. Zoster primitive lung structures, surrounded by a malignant-appearing mesenchymal stroma. Other sine herpete was diagnosed, and the pain spontaneously resolved without medical intervention. tumors with better differentiated background mesenchymal elements or neuroendocrine cells On follow-up, the patient remains asymptomatic, never having developed a rash, and repeat in the stroma have also been reported and may represent part of this tumors spectrum. These CT scans reveal stable aneurysms. tumors presents in children and adults and most commonly appear as parenchymal masses. IMPLICATIONS/DISCUSSION: Herpes Zoster (Shingles) is a reactivation of varicella- Pulmonary blastoma is more common in women, and is usually diagnosed by surgical zoster virus, which lies dormant in the dorsal or cranial nerve ganglia. Upon recurrence, resection. This is usually curative, although if late relapses and metastasis occur they are usually patients typically have a prodrome of fever, along with pain or tingling in the affected not curable. For palliative treatment radiation therapy may be used, and a role for dermatome (50% thoracic, 20% cervical, and 10% lumbosacral). In most cases, the virus chemotherapy is not defined. creates vesicles along the dermatome after three days, which then crust and resolve within two to three weeks. A small percentage of patients, however, develop acute segmental neuralgia, with a concomitant rise in varicalla IgM in the absence of skin lesions. This is zoster ACUTE MYELOMONOCYTIC LEUKEMIA IN THE SETTING OF ACUTE INTERMITTENT sine herpete, and as our case illustrates, patients can be initially misdiagnosed with a host of PORPHYRIA, A RARE OCCURRENCE. C.W. Bowkley1, M.W. Martinez2; 1UMDNJ-Robert other illnesses, including myocardial infarction, , , or . Wood Johnson Medical School, Piscataway, NJ; 2Mayo Clinic, Rochester, MN (Tracking Very little has been published concerning zoster sine herpete since many cases spontaneously ID #77049) resolve without ever having reached the diagnosis. In this particular case, a CT of the abdomen revealed a dissecting aortic aneurysm, which was unrelated to the patient's chief complaint. By LEARNING OBJECTIVES: Acute Myeloid Leukemia (AML) is an exceedingly rare diagnosis relying more on physical exam, the patient's description of the pain, and prior radiographic to find in association with Acute Intermittent Porphyria (AIP). Only one case report studies, the diagnosis might have been made more efficiently. This case stresses the importance documents such an occurrence. of history and physical exam in the clinical diagnosis of zoster sine herpete. Otherwise, the CASE INFORMATION: We present the case of a 61-year-old man with a long-standing diagnosis can be masked by confounding information. history of known Acute Intermittent Porphyria, (AIP) diagnosed in 1996, who was admitted to the internal medicine service for treatment of pharyngitis and severe . He had never undergone any chemotherapy and his AIP was fairly well controlled, with only four THE NEEDLE'S EYE: RISKS OF . F.C. Brokaw1; 1Dartmouth-Hitchcock exacerbations noted including the sentinel episode. At presentation for his current admission Medical Center, Lebanon, NH (Tracking ID #76118) the patient described fatigue and increasing retropharyngeal pain associated with deglutition, which had steadily progressed during the preceding three days. His CBC was significant for LEARNING OBJECTIVES: 1. Describe a case of tension pneumothorax attributable to hemoglobin of 10.6 g/dl, WBC of 170.4/mm3, and a platelet count of 102,000/mm3. The acupuncture. 2. Delineate known risks of acupuncture, and how these may be minimized. differential was 24% segmented , 0% bands, 3% lymphocytes, 57% monocytes, and CASE INFORMATION: An 81 year old man with moderate chronic obstructive pulmonary 7% blasts. The patient had hepatosplenomegaly and a global petechial skin rash. Bone marrow disease (COPD) and Stage I chronic lymphocytic leukemia, who suffered from post-herpetic studies were done to characterize the underlying etiology. Cellularity to fat ratio was 100:0 with neuralgia located in left T6 distribution, presented to the emergency department (ED) with normal bony spicules. Myelofibrosis was completely absent, and granulopoiesis was increased approximately 1.5 hours of acute left sided chest pain and dyspnea. Sharp pain began shortly with an abnormal appearance. The blast estimate was greater than 20%. Over the subsequent after receiving acupuncture treatment for his neuropathic pain. By the time he arrived home he week the patient experienced a rapid clinical decline with worsening coagulopathy. In accord was dyspneic and was transported to the ED. Examination on arrival disclosed tachypnea (rate with decisions made by the patient, his family, and consulting hematologists, chemotherapy was 36) and tachycardia (120 and irregular.) Lung sounds were absent on the left, with normal not instituted. AIP is the most common and most severe of the porphyrias. breath sounds on the right. EKG (to be included) showed atrial fibrillation with rapid 38 Abstracts JGIM

ventricular response. CXR (photo to be included) disclosed severe tension pneumothorax with concentration that was adequate to cause rhabdomyolysis. Therefore, we would recommend complete collapse of the left lung and slight mediastinal shift to right. Emergent placement of a avoidance of CYP3A4 inhibitors such as nefazodone in those receiving simvastatin therapy. chest tube resulted in re-expansion of the lung, and stabilization. The patient did well and was discharged from the hospital 2 days later. IMPLICATIONS/DISCUSSION: Use of complementary/, often in 5-FLUOROURACIL INDUCED SMALL BOWEL IN A PATIENT WITH STAGE III concert with ``mainstream'' medical treatment, is common and widely practiced in the COLON CANCER, WITH ANGIOGRAPHIC EVIDENCE OF VASCULITIS. I.D. Bucaloiu1, United States. Acupuncture is effective as sole or adjunctive therapy for management of S. Dubagunta1, K.K. Pachipala1, N.R. Kamal1, F. Fata1; 1Geisinger Medical Center, many types of pain, and is generally regarded as safe. The current vignette describes a case of Danville, PA (Tracking ID #76029) tension pneumothorax directly attributable to acupuncture treatment. Traumatic injury from acupuncture is rare, but review of the medical literature discloses numerous reports of LEARNING OBJECTIVES: 5-Fluorouracil (5-FU) is one of the most commonly used adverse events resulting from acupuncture treatments. Pneumothorax is the most commonly chemotherapeutic agents in clinical oncology practice, alone or in different combinations. In reported traumatic injury, especially among patients predisposed by presence of COPD; stage III , 5-FU based therapy has been shown to be associated with a survival other risks include cardiac tamponade, peripheral nerve injury, and injury to blood vessels benefit. We report a case of ischemic small bowel injury in a patient who received adjuvant including pseudoaneurysm formation. Non-traumatic adverse effects of acupuncture include chemotherapy with Oxaliplatin, 5-FU and LV and was found to have angiographic evidence of infections (hepatitis and other blood-borne diseases, as well as reports of septicemia and vasculitis in the superior mesenteric artery (SMA) territory. endocarditis.) The overall safety profile of acupuncture is positive, but patients and CASE INFORMATION: A 73 year-old male underwent a left hemicolectomy for Stage III physicians should be aware of potential risks of treatment. State laws vary widely regarding colon cancer. He was enrolled in an adjuvant chemotherapy research protocol consisting of 5- requirement for certification; referral to licensed or certified medical acupuncturists is FU 500-mg/m2 intravenous (IV) weekly boluses each over 1 hour, LV 500-mg/m2 IV weekly recommended. infusions each over 2 hours and Oxaliplatin (OP) 85 mg/m2 IV infusions every 2 weeks for 6 weeks followed by two weeks of rest. After the third weekly dose of cycle one of 5 FU/LV he presented with weakness, diarrhea, crampy abdominal pain and poor appetite. His abdomen was distended and he had heme positive stools. Stool cultures and clostridium difficile toxin FEVER, RASH, AND POLYARTHRALGIAS. F.C. Brokaw1; 1Dartmouth-Hitchcock Medical antigen were negative. He was not neutropenic. Colonoscopy revealed dusky edematous Center, Lebanon, NH (Tracking ID #76815) changes in the ascending colon and focal ulceration with patchy submucosal hemorrhages in LEARNING OBJECTIVES: 1. Recognize the clinical presentation of Adult-onset Still's the distal ileum. Biopsies of the colon mucosa showed densely neutrophilic infiltrates of the disease (AOSD) in a patient presenting with . 2. Describe diagnostic lining and associated mild focal cryptitis. A SMA angiogram was performed and it criteria, clinical course, prognosis, and treatment strategies for AOSD. revealed beading in ileal branches, consistent with the ischemic territory. Vasculitis serologies CASE INFORMATION: A healthy 40 year-old woman presented with one month of fevers, were negative. The patient was treated conservatively with hydration and IV antibiotics and evanescent rash, myalgias and arthralgias, severe fatigue, and anorexia with 20 pound weight later he was rechallenged with a 20% reduction of 5-FU dose with no recurrence of his loss. Examination disclosed T 39.48C, tender posterior cervical lymphadenopathy, no obvious symptoms in 12-month follow-up. synovitis, and a salmon-colored macular exanthem on the lower extremities. CBC showed IMPLICATIONS/DISCUSSION: Our patient had superficial erosions and ulcerations in the normocytic anemia (Hgb 9.8,) slight leukocytosis (WBC 11.1 with 82.3% granulocytes,) ileum as well as an ischemic appearance of the colon. The characteristic findings of ``beading'' normal LFTs except for slight elevation of AST, normal BUN/Cr, UA, and CXR. Further tests on the angiogram suggest an underlying ischemic mechanism related to 5 FU based therapy. revealed ESR 90, negative ANA and RhF, and ferritin >2000. Further diagnostic workup This case will add to the series of patients reported with 5-FU induced vascular injury to the included negative PPD, negative blood cultures, normal echocardiogram, normal CT scan small bowel. except borderline mediastinal lymphadenopathy and mild hepatosplenomegaly, and negative titers for HIV, EBV, CMV, and Lyme disease. Lymph node biopsy disclosed reactive node with no evidence of a clonal population of cells. The patient was diagnosed with AOSD and THROMBOTIC THROMBOCYTOPENIC PURPURA AND EXTENSIVE BONE MARROW had minimal response to aspirin. She was treated with steroids and is presently minimally NECROSIS SECONDARY TO METASTATIC SIGNET RING CELL ADENOCARCINOMA. symptomatic on and NSAID. I.D. Bucaloiu1, J. Brady1, S. Walker1, K.K. Pachipala1; 1Geisinger Medical Center, IMPLICATIONS/DISCUSSION: AOSD is a rare disease (incidence 1.6 cases/million Danville, PA (Tracking ID #76352) persons/yr) that highlights the importance of clinical history and physical examination, since there is no definitive test to make the diagnosis. Diagnostic criteria have been proposed (will be LEARNING OBJECTIVES: Although rare, the association between Thrombotic Thromb- delineated.) ASOD usually follows one of three patterns: self-limited (monophasic) disease with cytopenic Purpura and extensive Bone Marrow Necrosis can be the presenting picture of complete resolution of symptoms within one year, intermittent (polyphasic) course with metastatic adenocarcinoma. complete remission between flares, or persistent active disease, with chronic destructive arthritis. CASE INFORMATION: A previously healthy 49 years old male was transferred from another First line treatment is aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs;) patients hospital with a two-week history of severe, intractable back pain, short-term memory loss with more severe disease may respond to steroids. There are no controlled trials of immune fatigue and shortness of breath. On exam he was afebrile, icteric and had multiple ecchymoses modulating drugs in ASOD. Reports exist of success using methotrexate to control systemic on the trunk. Complete blood count revealed severe anemia and trombocytopenia, with serum symptoms; other agents used (all off-label) include gold salts, azathioprine, cyclophosphamide, hemoglobin of 4.6 g/dl, a platelet count of 16 Â 109/L and white blood bell count of 3.22 x cyclosporine, sulfasalazine, and intravenous immune globulin. Recent reports suggest etanercept 109/L. There was evidence of severe hemolysis with serum lactate dehydrogenase of 2659 U/L and infliximab may have benefit in patients not responding to other therapies. and Serum Haptoglobin of 7 mg/dL. Direct Coombs test was negative. The absolute reticulocyte count was 42.6 K/uL. The peripheral smear revealed schystocytes and thrombocytopenia. A CT scan of chest, abdomen and pelvis showed splenomegaly, and was RHABDOMYOLYSIS ASSOCIATED WITH CONCURRENT USE OF SIMVASTATIN AND otherwise unremarkable. The initial bone marrow aspirate and biopsy revealed extensive NEFAZODONE PRESENTING AS PROXIMAL MUSCLE WEAKNESS AND SHORTNESS necrosis of bone marrow with marked reduction of normal hematopoietic elements. Flow OF BREATH. J.E. Bruce1, V.T. Martin1; 1University of Cincinnati, Cincinnati, OH (Tracking cytometry was negative for a clonal lymphoid proliferation. The repeat contralateral iliac crest ID #73944) biopsy revealed among the extensive necrosis, small aggregates of highly atypical cells with pleomorphic hyperchromatic nuclei. Some cells had signet ring morphology and they stained LEARNING OBJECTIVES: 1. To report a case of rhabdomyolysis associated with the positive with mucicarmin and cytokeratin stains, which indicate a carcinomatous origin. The concurrent use of Simvastatin and Nefazodone. 2. To discuss the role of the CYP 450 3A4 patient received multiple blood transfusions, high dose steroids and plasmapheresis, but none pathway in the onset of statin-mediated rhabdomyolysis. of these interventions had a significant impact on the clinical course. His delirium worsened, CASE INFORMATION: A 74 year old white female presented with a 3 day history of developed respiratory failure and expired on the 7th day of hospitalization. ``difficulty getting out of a chair'', dyspnea on exertion and ``tea colored'' urine. Her past IMPLICATIONS/DISCUSSION: Massive bone marrow necrosis is known to occur in the medical history was significant for depression and hypercholesterolemia. Her past medications context of malignancy, usually hematopoietic, lymphomas, leukemias, but also solid tumors. At included simvastatin (40 mgs po qd) and nefazodone (150 mgs po bid). She had been started on the same time TTP has been reported to occur in the setting of , especially the nefazodone 3 months ago for treatment of depression and shortly thereafter developed a adenocarcinomas, usually gastric, pancreatic and breast. The association of TTP and massive fever, nausea/vomiting and muscle spasms. Physical examination revealed significant weakness bone marrow necrosis, although rarely reported in the literature may represent as illustrated in of the proximal musculature: 3/5 strength in the shoulder abductors and 2/5 strength in the hip our case report the heralding picture of metastatic cancer. It is important for physicians to be flexors. Her laboratory data revealed: CK 37,050, AST 1,744, ALT 1,029, BUN 17, Creatinine aware of this association as it forces one to search for an unapparent neoplasm. 0.8 , Urinalysis: SpGr 1.020, pH 6.0, protein 100, large blood, granular casts. The nefazodone and simvastatin were discontinued and a forced bicarbonate diuresis was initiated. Polymyositis was suspected and steroids were started empirically pending the outcome of testing. An EMG CUSHING SYNDROME SECONDARY TO AN ADRENAL CELL CARCINOMA showed no evidence of an underlying myopathy). ANA and an anti-Jo-1 antibody tests were PRESENTING AS A NOCARDIA INFECTION. D. Buch1, V.T. Martin1; 1University of negative. A muscle biopsy showed age-appropriate atrophy but no necrosis of myocytes and no Cincinnati, Cincinnati, OH (Tracking ID #73949) evidence of lymphocytic infiltrate, thus ruling out the diagnosis of polymyositis. Her renal function remained normal throughout the hospitalization. Her CPK was 1,776 eight days after LEARNING OBJECTIVES: 1. Recognize the clinical features of Nocardia infection. 2. admission and she gradually regained strength in her proximal muscle groups. She was thought Diagnose patients with Nocardia infection. 3. Treat Nocardia infection. to have developed rhabdomyalyis secondary to a drug interaction between simvastatin and CASE INFORMATION: A 44 year-old man with no significant past medical history nefazodone. presented with complaints of a cough with productive sputum, shortness of breath and fatigue. IMPLICATIONS/DISCUSSION: To our knowledge, this is the second case report of an Physical examination revealed oral thrush, anterior cervical lymphadenopathy, diffuse rhonchi adverse event associated with the concomitant use of simvastatin and nefazodone. Simvastatin and wheezes throughout both lung fields, a distended, mildly tender abdomen with purple is metabolized via the CYP3A4 system and nefazodone is a direct inhibitor of CYP3A4 stria, and multiple hyperpigmented and ulcerated lesions on his arms and legs. Significant enzymes. While myositis and rhabdomyolysis are adverse events associated with simvastatin laboratory findings included serum glucose greater than 350 mg/dL and a white blood cell monotherapy, we speculate that the introduction of nefazodone into this patient's regimen count of 12,000 with 30% bands. Chest radiography revealed right and left upper lobe sufficiently inhibited the CYP3A4 system to cause an increase in serum simvastatin infiltrates with cavitary lesions on the left. Computerized tomography of the chest, abdomen JGIM Volume 18, April (supplement 1) 2003 39

and pelvis with subsequent abdominal MRI confirmed cavitary lesions in the left upper lobe UNEXPLAINED INTRACEREBRAL LESIONS IN AN HIV PATIENT PRESENTING WITH and revealed a 12 Â 10 Â 7.5 cm adrenal mass. A serum ACTH was low at 3 pg/mL (normal 9± FOCAL NEUROLOGICAL DEFICITS. S. Burugu1, W.A. Harb1, R. Kiel1; 1Oakwood 52 pg/mL) and a serum free morning cortisol of greater than 50 mcg/dL (normal 6±20 pg/mL) Healthcare System, Dearborn, MI (Tracking ID #76589) confiming a diagnosis of Cushing syndrome. Urine catacholamines were normal. The adrenal LEARNING OBJECTIVES: To recognize the dilemma posed by an inconclusive MRI in mass was later surgically removed with pathology confirming a diagnosis of adrenocortical cases of intracerebral mucormycosis and to emphasize the need for brain biopsy. carcinoma. Sputum cultures obtained by bronchoscopy grew significant colonies of Nocardia CASE INFORMATION: A 42 year-old male with HIV presented with a five-day history of Farcinica and Nocardia Nova. The patient was started on intravenous trimethoprim- headache, fever, left sided weakness and multiple falls. Physical exam showed a left sided, sulfamethoxazole for six weeks followed by oral therapy. central, facial nerve palsy, weakness and left sided hyperreflexia. The patient's CD4 count was IMPLICATIONS/DISCUSSION: Nocardiosis is a rare finding in immunocompromised 56. Cryptococcus, toxopolasmosis, tuberculous meningitis, atypical infectious agents and patients with an estimate of 500±1000 new cases per year. Most cases involve the lung with lymphoma were considered in the working differential diagnosis. CT scanning and CSF inhalation as the mode of entry. Although an immunocompromised state predisposes patients analysis were negative. MRI revealed a mass in the right basal ganglia with associated edema to Nocardia infection, steroid use is considered to be an independent risk factor. Our patient, and a midline shift. An MRI guided brain biopsy showed mucormycosis. In spite of while not taking exogenous steroids, did have very high levels of endogenous cortisol. amphotericin B therapy he expired ten days later. Definitive diagnosis is typically made by routine culture of an isolated specimen. The most IMPLICATIONS/DISCUSSION: Mucormycosis in an immunocompromised host with HIV effective treatment for Nocardiosis remains speculative and is based mostly on small has rarely been described in the literature. Notably, in such cases neither CT nor MRI retrospective studies and case reports. Trimethoprim-sulfamethoxazole demonstrates synergy scanning is sufficient to make the diagnosis. In these instances, surgical exploration is against Nocardia and general consensus supports high doses of this drug initially followed by mandatory and can provide crucial diagnostic information. long-term treatment with lower doses for up to one year due to the high degree of recurrence of disease. As demonstrated in this case, one should consider Cushing syndrome as a risk factor for the development of Nocardia infections. DOWN BUT NOT OUT. S. Agresta1, J. Canterbury1, J. Wiese1; 1Tulane University, New Orleans, LA (Tracking ID #77016) 1 1 1 A RARE BUT DEADLY CAUSE OF MENINGITIS. C. Burgdorf , J. Wiese ; Tulane LEARNING OBJECTIVES: 1. Recognize an under-diagnosed cause of rhabdomyolysis. University, New Orleans, LA (Tracking ID #77086) CASE INFORMATION: A 55 year-old obese man presented with severe shortness of breath LEARNING OBJECTIVES: 1. Recognize the presentation of deep tissue infections due to after being found at his nursing home. His morbid (550 pounds) confined him to a Staphyloccocus aureus. 2. Integrate the increasing incidence of MRSA in designing empiric wheelchair. On the evening prior to admission, he fell from his wheelchair without a loss of treatment regimens for IVDU patients. consciousness or traumatic injury. A nursing aid found him twelve hours later. At presentation, CASE INFORMATION: A 49 year-old man presented with one day of abdominal and back he complained of diffuse pain; he noted associated shortness of breath but no chest pain or pain. He was a daily heroin user and his last injection was two hours prior to presentation. palpitations. His heart and breath sounds were normal; pitting edema extended to the knees. During his evaluation, he became uncooperative and combative, subsequently leaving against His vital signs were normal. His urine was scant (less than 10 cc/hr) and dark brown in color. medical advice. Two hours later he was found disoriented on the street. His temperature was His CPK was 35,000 U/L, BUN 75 mg/dL and creatinine 2.1 mg/dL. 39 C; he had nuchal rigidity and tenderness to palpation over the lumbar spine. There were no IMPLICATIONS/DISCUSSION: Although rhabdomyolysis is usually seen with crush murmurs, purpura, or petechiae. He rapidly developed respiratory failure and was intubated. or toxic myopathies, prolonged stasis and extended isometric contraction as occurs Blood, urine, and CSF cultures grew methicillin-resistant Staphylococcus aureus. He received with seizures should also prompt immediate evaluation for the syndrome. A timely diagnosis is seven days of , and rifampin, After stopping a seven day course of antibiotics, his essential, as the degree of renal tubular necrosis is proportional to the time and duration of fever returned. A repeat lumbar puncture revealed persistently positive MRSA. Vancomycin tubular exposure to the myoglobin pigment. Aggressive diuresis decreases this exposure time; and rifampin were restarted , and his fever resolved. An MRI of the lumbar spine demonstrated this is the main focus of treatment. The color of the urine (brown as opposed to yellow or clear) pyomyosits of the paraspinal muscles. He received 42 days of vancomycin and rifampin with predicts the pigment concentration in the tubules, and is a better measure of severity and clinical improvement. treatment efficacy than the CPK level. Early diuresis, with or without alkalinization, should be IMPLICATIONS/DISCUSSION: Back pain in the intravenous drug user, especially when maintained until the urine is consistently clear. Acute renal failure is often attributed to the associated with fever, must prompt high suspicion for meningitis, discitis, oteomyelitis of primary disease (, MI) in patients found down. Rhabdomyolysis should be excluded as an pyomyositis. Although meningitis from Staphyloccocus aureus is usually secondary to independent cause of renal failure in all patients found down for an undetermined or prolonged neurosurgical procedures, intravenous drug users are susceptible to staph CNS infections period of time. due to their frequent innoculation and impaired immunity. With the increased availability of antibiotics on the street, methicillin-resistant Staphyloccocus aureus is increasingly becoming a community acquired pathogen. As this case illustrates, serious CNS infections in an LISTEN TO ME, NOT MY THYROID. E. Chan1, J. Wiese1; 1Tulane University, New Orleans, intravenous drug user may warrant empiric vancomycin until definitive cultures return. LA (Tracking ID #77077) Staphyloccocus aureus bacteremia requires at least two weeks of intravenous antibiotics; longer courses are required for deep-seated infections. A secondary focus should always be sought, as LEARNING OBJECTIVES: 1. Listen to the patient's previous history to establish Staph is a rare primary infection. This case illustrates the importance of maintaining a high appropriate management decisions. 2. Use the history of the patient's symptoms to distinguish degree of suspicion for Methicillin-resistant Staphyloccocus aureus in intravenous drug users Graves disease from propylthiouracil . presenting with back pain and fever. CASE INFORMATION: A 23 year-old woman presented with recurrent palpitations, muscle weakness and dyspnea. She had a past history of Graves disease but had refused propylthiouracil therapy. She had a heart rate of 130, and a temperature of 104 F. There was right eye exophthalmos, a diffusely enlarged thyroid. A venous hum was heard over the MITOCHONDRIAL TOXICITY AND HIV THERAPY. S. Burridge1, L. Coberly1; 1University of thyroid; she had proximal muscle weakness and hyperreflexia. The thyrotropin levelwas 0.06U/ Cincinnati, Cincinnati, OH (Tracking ID #75159) ml and the FT4 was 17.01 g/dl. She was treated with with potassium iodide, propylthiouracil LEARNING OBJECTIVES: Recognize the clinical presentation of mitochondrial toxicity and propranolol with resoluton of her symptoms. Three days later, she developed severe secondary to nucleoside reverse transcriptase inhibitors. generalized arthralgias and myalgias with progressively deteriorating muscle strength and CASE INFORMATION: A 43-year-old white male with AIDS presented with altered mental swelling of her fingers. Her anti-nuclear antibody, anti-histone antibody, and acetylcholine status, nausea, vomiting, right upper quadrant pain and myalgias. Medications included receptor antibody were negative. The anti-striated muscle antibody, rheumatoid factor and didanosine, efavirenz, lopinavir/ritonavir and stavudine. His temperature was 101.28F, HR p-ANCA were also negative. The propylthiouracil was discontinued based upon the hypothesis 120, BP 135/85 and RR of 26. Physical examination was significant for bitemporal wasting, oral that the new symptoms were due to an allergic response, Her symptoms resolved the following thrush, dry oral mucosa, ketotic breath, pain to palpation in the right upper quadrant and a day. Upon further questioning, she noted a similar reaction to a previous treatement with of 20cm. There were no identified sources of infection. Laboratory examination was propythiouracil as the cause of her non-compliance with this therap. A subtotal thyroidectomy, significant for sodium 126mmol/L, potassium 5.1mmol/L, chloride 88mmol/L, and resulted in complete resolution of her symptoms. bicarbonate 13mmol/L. Lactate was markedly elevated at 9.9mmol/L. Transaminases were IMPLICATIONS/DISCUSSION: The appropriate management decision is often obtained 111 IU/L and 128 IU/L, alkaline phosphatase was 209 IU/L and total bilirubin was 4.10 mg/ by listening to the patient. In the thrill of treating Graves's disease, the reason for the patient's dL. Triglycerides were greater than 1,000 mg/dL. Abdominal CT revealed hepatomegaly with previous non-compliance with propylthiouracil was ignored. Although an allergic reaction to fatty infiltrate. Medication toxicity was suspected and HAART therapy was discontinued. propylthiouracil is rare, it is characterized by arthralgias, myalgias, anxiety and tachycardia Riboflavin supplementation was initiated. when it occurs. Distinguishing this reaction from continued symptoms of Graves's disease IMPLICATIONS/DISCUSSION: Mitochondrial toxicity is a rare syndrome that has been requires a meticulous history. Thyroidectomy is the treatment of choice in patients who are reported in patients treated with nucleoside reverse transcriptase inhibitors, particularly unable to tolerate propylthiouracil therapy. Carefully listening to why patients have declined zalcitabine, didanosine, and stavudine. The diagnosis is clinical. Patients present with nausea/ previous therapy is important in preventing recurrence of previous adverse effects. vomiting, abdominal pain, weight loss, malaise, fatigue, dyspnea and sometimes fever. Laboratory evaluation reveals lactic acidosis, hypertriglyceridemia and elevated liver enzymes. Imaging studies demonstrate hepatomegaly with fatty infiltration. The mechanism of WHEN EXERCISE BECOMES DEADLY: A RENAL ABSCESS STORY. J. Chanez1, mitochondrial injury is postulated to be inhibition of the mitochondrial gamma polymerase, L. Hunter1; 1Methodist Hospitals of Dallas, Dallas, TX (Tracking ID #74210) the enzyme that directs the replication of mitochondrial DNA. The mitochondria are unable to replicate, the citric acid cycle is blocked and lactate production increases. Fatty acid oxidation LEARNING OBJECTIVES: To better distinguish common and uncommon organisms in is inhibited leading to accumulation of lipid droplets. Treatment involves the administration of perinephric and renal . To recognize that clinical findings are more important than mitochondrial supportive therapy such as riboflavin, thiamine, ubiquinone and acetyl-carnitine radiological findings in evaluation of a patient. To review the possible factors associated with in addition to the cessation of antiretroviral therapy. Unrecognized, this syndrome carries a pneumococcal bacteremia. 60% mortality attributed to worsening acidosis with resulting cardiovascular collapse or CASE INFORMATION: A previously healthy 39-year-old African-American male physician progressive hepatic failure. with no significant medical history performed a new, strenuous morning workout, which 40 Abstracts JGIM

included rolling and lifting weights on an exercise ball. After returning home he became massive effusions. Pleural symptoms may precede other manifestations of SLE by months or nauseated, diaphoretic, weak, and experienced excruciating left flank pain followed by an years, particularly in men. To diagnose pleural effusions caused by pleuritis, one must episode of watery diarrhea. His symptoms worsened and he presented to the emergency room rule out other causes including pulmonary embolism, congestive heart failure, infections (i.e. the following morning. Physical examination at that time revealed a well-nourished man in parapneumonic or tuberculous), and malignancy. Effusion ANA titer detection is a very marked distress secondary to intractable pain. There was significant tenderness to minimal sensitive but nonspecific test while anti-DNA antibodies or LE cells in the pleural fluid are palpation and in his lower left quadrant and over his left costovertebral angle diagnostic but not very sensitive. Treatment includes NSAIDs for mild cases and systemic region. An initial computerized tomography (CT) of the abdomen showed an insignificant left corticosteroids for more severe cases. Early diagnosis and prompt treatment can greatly renal cyst. Laboratory evaluation was significant for leukocytosis with a left shift, mild decrease morbidity from this disease. normocytic anemia, slightly elevated creatinine and CPK, and urine which showed pyuria but was sterile. Overnight he experienced fever and worsening pain with apparent peritoneal signs. The next morning a chest x-ray was done which showed no evidence of pneumonia. CT of the VITAMIN C DEFICIENCY IN A 60 YEAR OLD MAN. S. Chaudry1, R. Liddicoat1, N. Torres- abdomen was repeated. In view of the patient's declining condition, this subsequent CT was Finnerty1; 1Boston City Hospital, Boston, MA (Tracking ID #75715) read as a possible abscess. Aspiration of the renal abscess grew Streptococcus pneumoniae, as did all blood cultures. Predisposing factors for pneumococcal bacteremia were excluded. He LEARNING OBJECTIVES: 1. Recognize clinical features of vitamin c deficiency 2. recovered fully after a two-week course of ceftriaxone and four weeks of levofloxacin. Treatment of scurvy. IMPLICATIONS/DISCUSSION: Streptococcus pneumoniae is a very uncommon pathogen CASE INFORMATION: 60 year old man presents with complaints of progressive leg in renal abscesses. Extrapulmonary pneumococcal infection is most often metastatic from the swelling, erythema, 30 lb weight loss, and severe bilateral hip pain over 3 months. He initially lung. No respiratory disease was noted in our patient. Only two published cases of noted several fluid filled blisters and pedal edema that spontaneously resolved. Over the next Streptococcus pneumoniae renal abscesses have been reported. These will be discussed, one in several weeks he described progressive bilateral hip pain requiring the use of crutches for full detail. The etiology of our patient's Streptococcus pneumoniae continues to be a mystery. ambulation. The month prior to admission the patient was bed bound secondary to pain. He Two hypotheses will be presented. denied other constitutional symptoms. Of note, he had eliminated fruits and vegetables from his diet 3 years ago. The patient had emigrated from Ethiopia 35 years ago. Physical exam revealed poor dentition, a perifollicular petechial rash of his lower extremities, hyperpigmenta- tion of his upper thighs and bilateral lower extremitity edema. MRI was significant for lower SKIN HARDENING IN RENAL FAILURE. J.E. Chang1; 1University of Wisconsin-Madison, extremity soft tissue edema and osteoporotic femoral heads with abnormal marrow signal. Middleton, WI (Tracking ID #75422) Laboratory values were notable for a normocytic anemia, normal coagulation panel, and electrolyte panel and a Vitamin C level of <0.12 mg/dL. Punch biopsy of the petechial lesions LEARNING OBJECTIVES: Often uncommon diseases present initially in the primary care demonstrated perifollicular hemorrhage and corkscrew hair follicles. Vitamin C supplemena- setting, and appropriate referral and diagnosis are essential. The following case illustrates an tion 1000mg per day was initiated with resolution of symptoms over several weeks. Repeat unusual seen in a primary care setting in order to expand the generalist MRI of his LE noted resolution of soft tissue edema and improving osteoporosis. physician's differential diagnosis of dermatologic conditions associated with renal failure. IMPLICATIONS/DISCUSSION: Symptoms of scurvy have been described as early as 1500 CASE INFORMATION: The patient is a 36-year-old woman with a history of type I diabetes BC by the ancient Egyptians. In contemporary history, epidemics have been described in the complicated by renal failure for which she underwent a kidney-pancreas transplant ten years Renaissance era, when sailors were frequently affected, and during the 19th century, by those ago. Her transplanted kidney remained functional until three months prior to presentation, at who experienced the Great Potato Famine, American Civil War armies, and the California which time hemodialysis (HD) was initiated. Within one month of starting HD, she developed Gold Rush communities. A cofactor and strong reducing agent, vitamin C is crucial to thickening and hardening of the skin on her left hand, which rapidly expanded to involve the numerous biochemical pathways including collagen synthesis, norepinephrine synthesis, entire left arm, and the right hand and arm. Within two months, the feet, lower legs, buttocks, synthesis, and antioxidant function. Collagen synthesis disruption in particular and areas of the back had areas of skin hardening. The face, abdomen, and chest were spared. leads to the clinical syndrome of scurvy including ecchymoses, bleeding gums, petechiae, and These areas of skin hardening were associated with minimal overlying skin changes, but she arthralgias. Other include muscle pain, microcytic anemia, decreased developed burning during this time for which she was treated with oxcarbazepine. wound healing, mood disturbances, and anorexia. While scurvy occurs rarely in the US, A skin biopsy confirmed the diagnosis of nephrogenic sclerosing dermopathy (NSD), with the typically it is seen in elderly or alcoholic patients and those with diets devoid of fruits and findings of increased numbers of dermal spindle cells and thick collagen bundles in the vegetables. Sudden cardiac death has been reported in these patients however, morbidity and reticular dermis. mortality largely occurs as a result of hemorrhage which can occur in any organ. Skin biopsy IMPLICATIONS/DISCUSSION: NSD was first described in September 2000 in a case series findings of perifollicular hemorrhage and follicle corkscrewing are pathopneumonic for the of 14 patients with a fibrotic skin condition resembling scleromyxedema. Each patient had a disorder. Symptoms typically improve over days to weeks with the addition of Vitamin C to the history of renal failure and 12 of the patients were receiving HD at the time of diagnosis. diet. Prognosis is excellent with timely diagnosis and treatment. Patients displayed skin thickening and hardening with overlying brawny skin discoloration, which was localized to the torso and limbs with sparing of the face. Several patients complained of painful paresthesias beginning with the onset of skin hardening. In each case, the skin condition has been progressive with no known effective therapy. The etiology of NSD is NOT JUST ANOTHER DIARRHEA: A CASE OF SECONDARY AMYLOIDOSIS 1 1 1 unclear, but infectious agents or toxic agents (toxins in the dialysate, endogenous toxins not ASSOCIATED WITH LYMPHOMA. J. Chowdhury , A. Gomez ; UCLA San Fernando cleared by dialysis) have been proposed. Resolution of the skin lesions occurred in one case Valley, Sylmar, CA (Tracking ID #76168) when HD was stopped following resolution of . Through accurate LEARNING OBJECTIVES: 1) Recognize lymphoma as a chronic inflammatory state that can referral and diagnosis of patients, more can be learned about the etiology, prevention, and be associated with secondary amyloidosis 2) Distinguish between primary and secondary treatment of NSD. Early recognition of NSD may allow early referral for transplantation to amyloidosis. prevent progression of disease on HD, although there is not definitive evidence to date that CASE INFORMATION: A 44 year old Hispanic male with non-Hodgkin's lymphoma, NSD regresses following transplantation. diagnosed and treated in Mexico with chemotherapy and radiation five years ago presents with five months of large volume, watery diarrhea. He had four to six episodes of blood-tinged diarrhea per day, with abdominal cramps, nausea and vomiting. The patient had anorexia with a twenty pound weight loss, and bilateral lower extremity edema. His blood A SINGULAR PLEURAL PRESENTATION. M. Chang1, M.C. Nguyen1; 1UCLA-San pressure was 60/palp, pulse 88, and he was afebrile. He had dullness to percussion and Fernando Valley Program, Sylmar, CA (Tracking ID #74456) decreased breath sounds over the left lower lobe as well as 1+ pitting edema in BUE and 2+ LEARNING OBJECTIVES: 1. Identify the clinical presentation of lupus pleuritis. 2. pitting edema in the BLE. A CBC was normal, BUN 38, creatinine 1.3, PT 29.6, INR 2.47, Recognize lupus pleuritis as a presenting symptom of systemic lupus erythematosus (SLE), PTT 47, albumin 1.4, AST 10, ALT 13, alkaline phosphatase 153, total bili <0.1, LDH 762. especially in older patients. Urinalysis showed small blood, 3+ proteinuria, 2 rbc's and 3 wbc's. CXR showed a left-sided CASE INFORMATION: A 58 year old Mexican man presented with progressive shortness of pleural effusion. The patient was admitted to the ICU and started on IV steroids and pressors. breath and a dry cough for over 1 month. Review of systems was positive for dyspnea on Thoracentesis revealed a with many lymphocytes, but no malignant cells. CT scans exertion, three pillow orthopnea, and an eight pound weight loss. His past history is non- revealed a mass in the left upper lobe of the lung and left hemithorax volume loss, colon contributory, and he uses no medication, tobacco or alcohol. On physical exam breath sounds dilation to 6 cm and small bowel dilation to 3 cm. Biopsy of the lung mass revealed Hodgkin's were decreased with bilateral rales 1/2 way up. He was tachycardic with a loud P2, a jugular lymphoma. Bone marrow biopsy was positive for both crystal violet and Congo Red, venous pressure of 10cm and 2+ edema to the shins. Chest x-ray showed bilateral pleural suggesting amyloidosis. Rectal biopsy showed friable mucosa and revealed apple green effusions; right greater than left. Echocardiogram revealed an ejection fraction of 70% with birefringency when viewed with Congo Red stain, confirming the diagnosis of gastrointestinal . Laboratories were significant for a normocytic anemia with low iron, amyloidosis. Unfortunately he succumbed to the disease a week later while on steroids and TIBC and reticulocyte count; ESR 116; urinalysis with trace protein and 20 red cells; and chemotherapy. negative serologies for hepatitis B/C, HIV, and coccidiodes. CT chest was negative for IMPLICATIONS/DISCUSSION: Both primary and secondary amyloidosis present in a pulmonary embolism and infiltrate. Diagnostic thoracentesis removed 200cc of hazy fluid with variety of ways, including heavy proteinuria, edema, hepatosplenomegaly, hematochezia, pH 7.48, 1250 white cells (81% lymphocytes) and cultures negative for bacteria, fungi and acid congestive heart failure, and carpal tunnel syndrome. Secondary, or AA, amyloidosis occurs in fast bacilli (AFB). Cytology was negative for malignant cells. Rapid reaccumulation later chronic inflammatory states, such as , inflammatory bowel disease, or prompted removal of another 1L of fluid. A tuberculin skin test was 8 mm but sputum AFBs osteomyelitis. However, reports of an association with lymphoma are rare. Obtaining a good were negative. Further work-up revealed a positive ANA (1:2560 titer) and strongly positive past history for chronic inflammation is nevertheless important when diagnosing AA anti-Smith antibody with negative anti-dsDNA and ANCA. He was diagnosed with SLE and amyloidosis. The only disease linked to primary, or AL, amyloidosis is multiple myeloma. started on prednisone 40 mg daily with resolution of the effusion and improvement in Once the diagnosis of amyloidosis is made from tissue biopsy, the distinction between primary pulmonary hypertension. and secondary amyloidosis is made based on the presence of a chronic inflammatory state in IMPLICATIONS/DISCUSSION: Pleural effusion is the initial manifestation in 1%, and secondary amyloidosis or the presence of certain paraproteins, found in about 90% of primary pleurisy in 3%, of SLE patients, more often in those with late-onset (after age 50). Lupus amyloidosis. We diagnosed this patient as secondary amyloidosis based on his history of pleuritis usually presents as pleuritic chest pain with fever, cough and dyspnea but rarely with lymphoma. JGIM Volume 18, April (supplement 1) 2003 41

``MY TOOTH IS KILLING ME!'': OVER THE COUNTER ANALGESIC RISKS AND alpha-fetoprotein level was within normal limits. During the ensuing four days, the patient HEPATITIS C. E. Coffey1, E. Schneider1; 1Hennepin County Medical Center, Minneapolis, rapidly deteriorated with additional liver enlargement of 4cm, falling platelet count and MN (Tracking ID #76561) metabolic acidosis. On day five of admission, a transjugular liver biopsy demonstrated alpha- beta-hepatosplenic T-cell lymphoma. LEARNING OBJECTIVES: 1. Recognize increased risks of acetaminophen and nonsteroidal IMPLICATIONS/DISCUSSION: Rapidly progressive hepatosplenomegaly is not widely antiinflammatory drugs (NSAIDs) for patients with Hepatitis C. 2. Recognize importance of discussed in the literature. However, reviewing MEDLINE and EMBASE databases, one can adequate medical and medication history, even for common complaints. conclude that it is most common in hematologic malignancies and infection. The above typical CASE INFORMATION: 50 year old male presented to a walk-in clinic seeking medication for presentation of an uncommon peripheral T-cell lymphoma illustrates that lymphoma can a two week old toothache. Nonprescription pills at home didn't help. He also reported 2 days present without lymphadenopathy or bone marrow involvement. Hepatosplenic T-cell of nausea, vomiting, loose bowel movements, diffuse myalgias, generalized weakness. He lymphoma is an aggressive cancer with a poor prognosis. Despite aggressive treatment, our denied alcohol, infectious contacts. PMH included hepatitis C, alcohol and cocaine use. patient died on the 28th hospital day. Physical exam remarkable only for an ill appearing male with an abscessed tooth and mild abdominal tenderness. Labs included K 3.8, BUN 32, creatinine 2.9, ALT 3460, AST 2575, bilirubin 5.1, alk p'tase 135, lipase 111, INR 1.4. Acetaminophen level 52. Salicylate level was 1 1 not elevated. He later admitted to taking up to 20 tablets of naproxen and acetaminophen a day A PAIR OF PAINFUL HANDS. A. Cooper ; University of Pennsylvania, Philadelphia, PA over the last few days. He was admitted to the medicine service, and improved with (Tracking ID #73721) acetylcysteine and supportive care. He was counselled about acetaminophen use. A dentist LEARNING OBJECTIVES: 1. To review the American College of Rheumatology diagnostic extracted the abscessed tooth before discharge. criteria for rheumatoid arthritis (RA). 2. To discuss initial treatment of newly diagnosed RA. IMPLICATIONS/DISCUSSION: Acetaminophen and NSAIDs are associated with increased CASE INFORMATION: A 39 y/o homeless woman with a past medical history significant for transaminases in patients with hepatitis C. Renal failure has been associated with NSAIDs and hypertension, diabetes, hepatitis C, and asthma on no medications was admitted to the with paracetamol poisoning.This case illustrates that the presenting problem isn't always the inpatient psychiatric unit for depression with suicidal intent. The medicine service was most serious. The non-pain symptoms, past history and specific information on his self consulted for evaluation of hand pain. The patient had been having 2 months of progressively medication were keys to diagnosis. Given potential toxicities of analgesics, patients with worse pain in both her hands, as well as 1 month of swelling and morning stiffness lasting 90 hepatitis C are well advised to seek advice for pain issues rather than self medicating. minutes before improvement. The symptoms made it difficult for her to make a fist or hold her cigarette. Over the last 1 week, all of her symptoms markedly increased. Additionally, she recently noted a sensation of numbness and tingling in her first three fingertips of the right DIAGNOSIS AND TREATMENT OF POST PRANDIAL NAUSEA, ALLERGY AND hand that wakes her from sleep. The patient denied any fevers, chills, night sweats or other 1 1 1 1 1 EOSINOPHILIA. D. Coleman , J.S. Scolapio , J.R. Cangemi , J.C. Guarderas ; Mayo joint involvement. She denied dry eyes or mouth, as well as urethritis/vaginitis. Review of Clinic Jacksonville, Jacksonville, FL (Tracking ID #76262) systems in detail was otherwise negative. Social history was significant for a 20 pack year LEARNING OBJECTIVES: Eosinophilic gastroenteritis, is a disorder characterized by smoking history. Family history was noncontributory. Physical exam was significant for infiltration of eosinophils into the mucosa of the gastrointestinal tract. As a clinical entity with bilateral symmetric swelling, mild erythema and boggy tenderness of 8 proximal inter- recognizable symptoms it is a rare disorder. Here we discuss the extensive treatment course of a phalangeal joints. There was no involvement of the distal interphalangeal joints or thumbs and refractory case of eosinophilic gastroenteritis. minimal tenderness of the MCP joints. There was no wrist tenderness. Remainder of the joint CASE INFORMATION: A 16-year-old male patient who presented with post-prandial exam was unremarkable. Remainder of the physical exam was significant for a blood pressure of fullness and nausea. He had a history of seasonal , asthma, and peripheral eosinophilia. 130/90, mild expiratory wheezes bilaterally at the lung bases, and a positive Phalen's sign. Endoscopy of the stomach with mucosal biopsies revealed predominate eosinophils. A Pertinant negatives included a temperature of 97.9, moist mucous membranes, no cardiac diagnosis of eosinophilic gastroenteritis was made. He was treated with a proton pump murmurs, no or nodules and a negative Tinel's sign. Laboratory results were significant inhibitor (Prilosec) an oral cromolyn (for gastrointestinal symptoms), initially. After no for normal electrolytes, renal function, TSH, WBC and hemoglobin levels. The ESR was response, he began on high dose prednisone with a gradual taper, with clinical response, to normal at 9. Anti-Scl 70, dsDNA, and complement levels were normal. The ANA was weakly every other day prednisone indefinitely. Several years later, he again experienced symptoms of positive at 1:160. The patient had a positive RF of 104 IU/mL (normal 0±29 IU/mL). dysphagia, early satiety, nausea and occasional vomiting. He had been compliant with his Parvovirus IgM was negative, as were Hep B serologies and HIV. medications. The oral steroids (20 mg every other day) had not been tapered because of IMPLICATIONS/DISCUSSION: Discussion: This patient was diagnosed with early recurrent symptoms upon dose reduction. As a result of his prolonged predisone use, bone moderately severe RA. The American College of Rheumatology criteria for diagnosis of RA mineral analysis was performed and showed signs of early osteoporosis. He was treated with were initially developed to help classify patients for clinical studies. However, they have proved Fosamax 5 mg a day, vitmain D 50,000 IU twice a week, and Calcium 1000 mg a day. A trial of useful in diagnosis as well. The guidelines are as follows: A patient has RA if at least 4 of these an elemental nutrition formula was attempted in hopes of reducing his gastrointestinal criteria are met (the 1st 4 of which must have been present at least 6 weeks): 1) Morning eosinophilia. Although his peripheral eosinophil count significantly decreased on this stiffness, usually lasting at least 1 hour before maximal improvement. 2) Arthritis of at least 3 or elemental diet (Vivonex) he was unable to continue with it because of its poor . Given more joint areas. 3) Arthritis of hand joints. 4) Symmetric arthritis. 5) Rheumatoid nodules. 6) his refractory symptoms and continued risk of complications from chronic steroid use he was Serum rheumatoid factor. 7) Radiographic changes±erosions, unequivocal bony decalcification treated with Interferon Alpha, starting at a low dose and gradually increased to a dose of 1 adjacent to affected joints. Radiographic changes are present in 15% of patients in the 1st year million units per day. His peripheral blood eosinophils initially dropped from 5410 to 1020 but of disease, in >90% of patients after the 1st 2 years. The initial diagnosis of RA may be difficult then slowly began to increase. In early 2002 his gastrointestinal symptoms recurred and his because early RA may satisfy few of the diagnostic criteria. Additionally, systemic lupus peripheral blood eosinophils began to rise. He had been compliant with medications. Because erythematosis, Sjogren's syndrome, and mixed disease may also commonly the majority of his symptoms were gastroesophageal, we elected to try oral flonase. Since this present with a positive rheumatoid factor, and may be difficult to differentiate from RA early in newest therapy was begun, he has experienced a marked drop in peripheral blood eosinophils the course of illness. Finally, seronegative RA, or RA presenting in a single large joint such as (the lowest to date) and his gastrointestinal symptoms have markedly improved. the knee, poses it's own obvious diagnostic dilemma. The diagnosis of RA is supported by IMPLICATIONS/DISCUSSION: This case is unique because it illustrates an unusual findings of carpal tunnel syndrome, as seen in this patient, as well as weight loss, fever, anemia, approach to a refractory case of eosinophilic gastroenteritis. Most known and reported serositis, pulmonary nodules and peripheral neuropathy. Therapy for RA is usually initiated therapies had failed in our patient with the exception of high dose steroids and, more recently, with non-steroidal antiinflammatory drugs (NSAIDs). Prednisone is added for rapid oral Flonase. Unfortunately his dependence upon corticosteroids resulted in the serious improvement when severe joint symptoms are present, and is usually tapered after sequelae of osteoporosis. Although a systemic illness with marked peripheral eosinophils, the inflammation is controlled. Disease modifying anti-rheumatic agents (DMARDs) are added symptomatology of this patient was predominantly gastrointestinal. if symptoms are not controlled with NSAIDs, if symptoms are moderate or severe in nature, or if radiographic changes are present. DMARDS are medications that have been proven to reduce the rate of bony destruction in RA. The most common DMARD used for initial RAPIDLY PROGRESSIVE HEPATOSPLENOMEGALY. K. Cooke1, S. Rusch1; 1University treatment is methotrexate, started at a dose of 7.5 mg/week. The maximum dose of of Illinois, Peoria, IL (Tracking ID #76040) methotrexate is 25 mg subcutaneously/week. It is important to monitor patients for methotrexate toxiticy including liver function tests (), pulmonary symptoms LEARNING OBJECTIVES: Discuss the differential diagnosis of rapidly progressive (interstitial lung disease), and bone marrow toxicity. hepatosplenomegaly while highlighting a typical presentation of an uncommon lymphoma. CASE INFORMATION: A previously healthy 32-year-old woman initially presented to her primary care physician with pleuritic left shoulder pain and a normal physical exam. SCREENING FOR IN CHRONIC HEPATITIS B Laboratory results then included platelets of 104,000/L; alkaline phosphatase of 125 U/L; INFECTION: THE JURY IS STILL OUT. K.M. Cordasc1; 1University of California, San alanine aminotransferase of 58 U/L; and aspartate aminotransferase of 65 U/L. Two weeks Francisco, San Francisco, CA (Tracking ID #76914) later, the patient returned with acute onset of fevers, fatigue and nausea. Physical examination was benign except for marked hepatosplenomegaly. The liver was LEARNING OBJECTIVES: 1) Apply epidemiologic factors to decisions of whether to screen palpable 11cm below the right costal margin and the spleen 5cm below the left costal margin. for hepatocellular carcinoma (HCC) in chronically Hepatitis B-infected individuals. Laboratory results included platelets of 42,000/L; alkaline phosphatase of 1,045 U/L; alanine 2) Recognize the limitations of current screening modalities for HCC. aminotransferase of 285 U/L; and aspartate aminotransferase of 610 U/L. Admission CASE INFORMATION: An asymptomatic 23 year-old male student presents to clinic after computed tomography showed diffuse homogenous enlargement of the liver, spleen and being told by a former sexual partner that he had ``given her an infection.'' He has no kidney with a few mildly enlarged retroperitoneal lymph nodes. significant past medical or surgical history. His review of systems is negative. He was born in Serologic evaluation was negative for hepatitis A, B and C , cytomegalovirus, Epstein China and immigrated to the United States at two years of age. He uses a half-pack-per-day of Barr virus, herpes simplex virus, toxoplasmosis and human immunodeficiency virus. Bone tobacco, alcohol to intoxication 1±2 times per week, no recreational drug use. His physical marrow biopsy on day two of admission was negative for malignancy, infection and amyloid. examination is normal. His laboratory values are significant for being hepatitis B (HBV) surface Screening for antinuclear antibody and extractable nuclear antigen antibodies was negative. antigen positive, surface antibody negative, core antibody positive, e antigen negative, and The patient's history did not reveal risk factors for unusual infections or toxins. Noninvasive HBV viral load undetectable. Hepatitis C and Human Immunodeficiency Virus (HIV) are doppler ultrasound was not consistent with Budd Chiari. Blood cultures were negative and negative. His liver function tests are all within normal limits. 42 Abstracts JGIM

IMPLICATIONS/DISCUSSION: The incidence of hepatocellular carcinoma (HCC) in nature that progressively worsened, associated with remarkable forehead swelling, and individuals with chronic Hepatitis B (HBV) infection increases with the duration of infection. . One week prior to admission she received a two-week course of cefuroxime for Observational studies show that among perinatally-infected individuals, incidence of HCC frontal sinusitis. Her past medical history was significant for fibrodysplasia of the ethmoidal begins rising in young adulthood (20±30 years of age). Among those who are infected later in sinus during childhood requiring five surgical interventions. Admission physical exam was life the incidence of HCC begins rising at 40 to 50 years of age. Other major risk factors for remarkable for forehead swelling with tenderness over the frontal bone and absence of fever. HCC include presence of cirrhosis, e-antigenemia, exposure to other hepatotoxins including Computerized axial tomography scan of the head revealed opacification of the frontal sinus. alcohol and tobacco, and co-infection with hepatitis C virus. HCC screening is usually done at The frontal sinus was drained and a purulent discharge was obtained. Gram stain and culture 6±12 month intervals. Common modalities used include serum alpha fetal protein (AFP), showed no organisms or growth. Frontal headache and swelling improved after drainage. She ultrasound (US), and computed tomography (CT). The usefulness of AFP is limited by was placed on ampicillin/sulbactam for a total of two months. She was scheduled for frontal sensitivity (approximately 60%) and specificity (approximately 85%). Thus, US or CT must be sinus obliteration after completing the antibiotics. used in conjunction with AFP. Ultrasound, the most widely-used modality, has a variable IMPLICATIONS/DISCUSSION: Pott±Puffy tumor represents a rare complication of frontal sensitivity determined by operator experience, reported to be 35% to 84%. CT, with less sinusitis. Only 21 cases have been reported after the antibiotic era, of wish 7 have presented in operator-dependent variability and sensitivity greater than 90%, is the most expensive of adults. The importance of making this diagnosis is to prevent expansion of the infection to the screening modalities. Given the limitations of existing screening methods and overall small brain. We would like to highlight the importance of making an accurate diagnosis, especially in survival-benefits of current widely-available treatments, the cost-effectiveness of HCC patients treated for frontal sinusitis. Five cases in which no organisms have been identified are screening has been questioned. There are no randomized studies assessing cost-effectiveness reported in the literature. This entity can be successfully treated with antibiotics and drainage. of HCC screening. Non-randomized studies have shown conflicting results. Thus, although a recent survey of U.S. hepatologists showed that 84% of respondents screen for HCC in individuals with cirrhosis, no official guidelines have yet been provided by the National Cancer 1 1 Institute (NCI). REFRACTORY HYPERTENSION: ``A GIANT PROBLEM''. M. Crissler , D. Stuart , R. Granger1; 1Hennepin County Medical Center, Minneapolis, MN (Tracking ID #76139)

LEARNING OBJECTIVES: Recognize the importance of secondary causes for hypertension. ALONG CAME A SPIDER ... CAUSING UNUSUAL ULCERS. N. Correia1, R. Abou CASE INFORMATION: A 51 year old diabetic gentleman with obstructive sleep apnea Jawde1, S. Baghdasarian1, S. Schmitt1; 1Cleveland Clinic Foundation, Cleveland, OH treated with CPAP and a long-standing history of hypertension came to our clinic for a routine (Tracking ID #76813) visit. Despite five anti-hypertensive medications, blood pressures remained near 180/100. This prompted a search for secondary hypertension. Studies were negative for renal vascular disease LEARNING OBJECTIVES: To emphasize the extensive differential diagnosis of lower and as well as primary . Despite preserved renal extremity (LE) ulcers, the incidence of pyoderma gangrenosum (PG) following trauma and the function, consultation was obtained with the resulting suggestion that this may be importance of accurate diagnosis, we present a case in which lesions that appeared following a a case of occult noncompliance. However, the patient regularly attended appointments and spider bite were intially treated as infection. filled all of his antihypertensives in a timely manner. This convinced us to look further into CASE INFORMATION: A 59 year old man presented with non-healing painful left LE additional possible rare causes for secondary hypertension. ulcers. He was bitten by a spider after which he noted a small red tender spot over his shin that On one subsequent follow-up visit, the patient did complain of jaw changes and a thick tongue. progressed to an ulcer with purulent drainage. He was treated with oral and intravenous He has coarse facial features, a large fleshy nose and large tongue along with multiple skin tags antibiotics, local wound care and surgical debridement without improvement. During and large hands. The constellation of hypertension, sleep apnea, diabetes, and a documented treatment he developed a new ulcer on the same leg and an inflamed nodule over the history of carpal tunnel syndrome, along with his complaints and findings raised the possibility of contralateral malleolus. acromegaly as a reason for refractory hypertension. For the initial workup, a screening insulin- IMPLICATIONS/DISCUSSION: PG, a deforming ulcerative skin disease, usually presents like growth factor 1 level was then ordered, which returned at 2.5 times the normal range. A with erythematous nodules or vesiculopustules on the legs. The lesions undergo a rapidly subsequent confirmatory glucose tolerance test with measurement of growth hormone levels destructive necrotizing process to form large ulcers with surrounding erythema. Although then failed to show GH suppression with a glucose load, supporting the diagnosis of acromegaly. frequently associated with inflammatory bowel disease or immunosuppression, in adults PG IMPLICATIONS/DISCUSSION: Acromegaly is a somatic growth and proportion disorder can occur spontaneously, following trauma (including spider bites), or in association systemic with elevated levels of GH and ILGF-1 found as hallmarks of this syndrome. It is most often diseases. Biopsy confirmed the presence of PG in our patient and he improved dramatically on caused by GH-secreting pituitary tumors. Some of its features include skeletal overgrowth, prednisone. arthropathy, skin changes, and respiratory dysfunction. Hypertension is one important complication of acromegaly, with the prevalence of hypertension in acromegalic patients estimated to be about 35%, although there is no consensus in the SARCOIDOSIS PRESENTING AS TESTICULAR MASS: CASE REPORT AND REVIEW medical literature regarding the exact mechanisms involved in its pathogenesis. While OF THE LITERATURE. L. Corsino-Nunez1, M. Kam1, C. Kaye1; 1Wayne State University, hypertension is a common condition treated by internists, fewer than 5% of cases are found to Detroit, MI (Tracking ID #75657) have secondary causes. This case highlights the need to consider rare causes of hypertension in patients resistant to treatment, and demonstrates why acromegaly should be considered in LEARNING OBJECTIVES: To recognize sarcoid presenting as a testicular mass. the differential. CASE INFORMATION: Sarcoidosis a chronic multisystem disease of unknown etiology characterized by noncaseating granulomas. The most commonly involved organs are the lungs, lymph nodes, skin, uvea, liver and bone. Sarcoidosis of the male urogenital tract is uncommon. Physicians need to be aware of this occurrence especially in males with a known history of THE TUMOR THAT MELTED AWAY. J. Cunningham1,M.Panda1; 1University of sarcoidosis. Case: A 31 y/o African American male presented to the Emergency Department Tennessee±Chattanooga Unit, Chattanooga, TN (Tracking ID #76984) complaining of dyspnea, fever and night sweats. Past medical history was significant for LEARNING OBJECTIVES: 1. To recognize the similarity in the radiographical and clinical asthma. Admission physical exam was remarkable for bilateral, nontender, mobile, cervical presentation of pulmonary blastomycosis and neoplasms. 2. Stress the importance of a high lymph nodes and a right testicular mass. Chest- x- ray revealed mediastinal and bilateral hilar index of suspicion to avoid misdiagnosis and unnecessary invasive diagnostic procedures. lymphadenopathy. Computarized Axial Tomography scan of the chest, abdomen, and pelvis CASE INFORMATION: 57 year old white female with a 40 pack/year history of tobacco was consistent for bilateral lymph nodes in the axillary and inguinal region. Ultrasonography of abuse presented with persistent cough, mucoid and occasionally bloody sputum for 2 the right testicule was done and showed marked enlargement of the right epididymus and small months. She denied fever, chills, night sweats, dyspnea, or recent travel. Her vital signs and hydrocele. Biopsy of one of the submandibular lymph node revealed non-caseating room air oxygenation were normal. Physical exam revealed diffusely diminished breath granulomas. A right orchiectomy was performed. The pathology report was consistent with sounds with no accessory muscle use or clubbing. Labs were normal except for a normocytic non-caseating granuloma involving the epidiymis and focal testicular parenchyma. The anemia, and thrombocytosis. CXR showed a right upper lobe infiltrate. CT revealed a large spermatic cord was free of granulomatous inflammation. right hilar structure surrounding the distal main stem bronchus with impingement, IMPLICATIONS/DISCUSSION: Discussion: Sarcoidosis with testicular involvement is infiltrative changes surrounding the mass, and an enlarged precarinal lymph node. An rare. Only 0.2% of patients with sarcoidosis have urogenital involvement. Forty-three cases endobronchial biopsy and aspiration of the mass revealed no neoplastic cells. Gram stain was have been described in the English language medical literature. We want to enhance negative, and cultures revealed no fungal growth after 28 days. Aspiration smears from the physicians' awareness of urogenital sarcoidosis and include in the differential diagnosis of a precarinal area were nondiagnostic, but smears from the postcarinal area revealed palpable testicular mass. The treatment for urogenital sarcoid is corticosteroids, identical to Blastomyces dermatitidis. She was treated with Itraconazole with complete resolution on systemic sarcoid. Review of the literature shows that a great unnecessary percentage of repeat CT scan after 6 months. patients with testicular sarcoid have undergone orchiectomy. Thus awareness of this condition IMPLICATIONS/DISCUSSION: Blastomycosis is a pyogranulomatous infection that can may result in prevention of this radical approach in males who present with sarcoidosis and a involve many organ systems, but primarily affects the lungs. Infection results from inhalation of testicular mass. the Blastomyces conidia, which may be asymptomatic or present in ways indistinguishable from TB, bacterial pneumonia, ARDS, histoplasmosis, and most ominously bronchogenic carcinoma. Most cases occur in areas surrounding main waterways in North America. POTTS-PUFFY TUMOR: CASE REPORT OF A FORGOTTEN COMPLICATION OF Demographics indicate no specific sex, age, race, occupation or seasonal predilection, but FRONTAL SINUSITIS AND REVIEW OF THE LITERATURE. L. Corsino-Nunez1, exposure to soil is a common factor linking infections. Blastomycosis radiographically mimics D. Piontkwosky1, J. Garcia1, A. Weinmann1; 1Wayne State University, Detroit, MI many lung diseases with carcinoma being the most common primary diagnosis. Definitive (Tracking ID #75945) diagnosis is made by isolation in sputum smears or growth in sputum culture which may take LEARNING OBJECTIVES: To recognize Pott±Puffy Tumor as a complication of sinusitis. up to 30 days. Bronchoscopy requires special considerations in order to obtain a higher yield of CASE INFORMATION: Pott±Puffy Tumor is defined as subperiostial abscess and fungus. Treatment with inhibits growth & limiting concentration to 1g/dL has been osteomyelitis of the frontal bone seen as a complication of frontal sinusitis. With the advent recommended. B. dermatitidis can be missed on H&E specimens, so silver or PAS stains of antibiotics, Pott±Puffy Tumor is a rarely recognized entity. A 31 y/o white female, should be used. If no diagnosis results invasive thoracoscopy or thorocotomy are often done previously healthy until one day prior to admission, presented with frontal headaches, dull in hastily before the fungus has had time to grow in culture because of the common presentation JGIM Volume 18, April (supplement 1) 2003 43

of Blastomycosis and carcinoma. Blastomycosis infection has been known as ``the great DESQUAMATIVE INTERSTITIAL PNEUMONITIS: AN UNUSUAL ETIOLOGY OF masquerader'', therefore, it is very important for physicians to be familiar with the DIFFUSE PULMONARY INFILTRATES. S. Daud1, R. Granieri1; 1University of Pittsburgh, epidemiology in order to develop an index of suspicion for the fungus in endemic areas. Pittsburgh, PA (Tracking ID #73698) Thus, patients can be spared from the distress of undergoing unnecessary testing and invasive LEARNING OBJECTIVES: 1) Recognize the common causes and workup of diffuse surgical procedures. pulmonary infiltrates. 2) Recognize the usual presentation of desquamative interstitial pneumonitis. CASE INFORMATION: A 45 year-old male with a history of COPD and multiple A PAIN IN THE NECK. T. Dang1, P.P. Balingit1; 1UCLA San Fernando Valley Program, pneumonias within the past year was admitted to the hospital for complaints of cough Sylmar, CA (Tracking ID #74673) productive of yellow sputum, fevers, chills, and worsening shortness of breath. He was found to be febrile and hypoxemic, and have a leukocytosis with a predominance of neutrophils. A chest LEARNING OBJECTIVES: 1. Recognize carotidynia as an etiology of neck pain. 2. Review x-ray showed the presence of diffuse interstitial infiltrates. He was admitted to the hospital and features of carotidynia and discuss diagnosis and treatment. treated for pneumonia with antibiotics and bronchodilators for 11 days without significant CASE INFORMATION: A 30 year old Latino male presented to the emergency room improvement. Sputum and blood cultures were negative for bacterial pathogens. Computed with a five day history of severe sharp, pulsatile left sided neck pain, worsened with tomography (CT) of the thorax showed ground-glass opacities in all lung fields, worse on the exertion and head movement with flexion and lateral rotation. This neck pain waxed and right. Pulmonary function testing revealed mild restrictive disease with decreased lung volumes waned in intensity throughout the five days prior to admission. The patient reported and decreased DLCO. He did not improve clinically and was scheduled for open lung biopsy. weakness and numbness of the left arm, which he had used while driving to the emergency Pathology revealed the diagnosis of desquamative interstitial pneumonitis. He was started on room. This weakness resolved with lowering of the left arm. He denied having associated Prednisone 60mg daily, had significant clinical improvement and was discharged from the headaches or visual disturbances. The patient was afebrile with a blood pressure of 127/76. hospital. CT of the thorax performed one month later showed near-complete resolution of the Physical examination revealed marked tenderness upon palpation over the left carotid ground-glass infiltrates. artery. Carotid artery bruits were not present on auscultation. No thyroid tenderness, IMPLICATIONS/DISCUSSION: The differential diagnosis of a patient with diffuse enlargement, or nodularity was evident. Funduscopic examination, evaluation of cranial pulmonary infiltrates is broad. Acute diffuse lung diseases (less than 4±6 weeks in duration) nerve function, and assessment of motor and sensory function in the upper and lower include infection, pulmonary edema, pulmonary hemorrhage, hypersensitivity pneumonitis, extremities were within normal limits. The patient was admitted for treatment of possible and acute eosinophilic pneumonia. Chronic diffuse lung diseases include idiopathic pulmonary left carotid artery dissection and anticoagulation therapy with unfractionated was fibrosis, sarcoidosis, pneumoconioses, and interstitial lung disease associated with connective initiated. An MRI/MRA of the neck was subsequently performed to evaluate for carotid tissue diseases. Desquamative interstitial pneumonitis (DIP) is one of the distinct clinical and artery dissection. No abnormal flow voids or evidence of dissection were noted. A histopathological entities belonging to the family of idiopathic interstitial pneumonias. The sonogram of the neck failed to reveal evidence of dissection. ESR was 5, CBC was within average age of onset is about 45 years of age, and a male preponderance has been noted. normal limits. The diagnosis of carotidynia was made, and the patient's symptoms resolved Cigarette smoking has been linked consistently to this diagnosis. The typical presentation is an with prednisone and NSAIDS. insidious onset of dyspnea and cough. Chest roentgeography often shows a diffuse pattern of IMPLICATIONS/DISCUSSION: Carotidynia is an idiopathic neck pain syndrome arising reticulonodular opacities, with CT showing a ground-glass appearance. Pulmonary function from the cervical carotid artery resulting in unilateral neck pain that frequently radiates to the testing shows a restrictive pattern. Diagnosis is best made with lung biopsy demonstrating the ipsilateral face and and sometimes to the head. Facial pain is a common primary symptom characteristic appearance of alveolar filling by mononuclear cells and thickening of the alveolar and carotid artery tenderness and overlying soft tissue swelling are the major physical findings. septa. Pateints are generally treated with corticosteroids until symptoms are improved at which Two forms of this disorder have been described, an acute form that results in a monophasic point they are tapered slowly. Data are lacking regarding the optimal duration of treatment and illness usually lasting less than two weeks and tending not to recur, and a chronic recurring prognosis of DIP. form which manifests as a vascular headache variant, responsive to antimigraine therapy. Both forms are responsive to the administration of corticosteroids. An evaluation for structural disease of the carotid arteries should be considered in patients with ipsilateral neck pain. MRI/ MRA of the neck has proven highly sensitive. Other imaging modalities to consider include ATYPICAL PRESENTATION OF THROMBOTIC THROMBOCYTOPENIA PURPURA AND ultrasound and angiography. The diagnosis of carotidynia should be considered only after MYOCARDIAL INFARCTION. J.A. Davis1,C.V.Mueller1; 1University of Cincinnati, careful evaluation for other etiologies of neck pain. Considerations for ipsilateral neck pain in Cincinnati, OH (Tracking ID #77197) the region of the carotid artery near its bifurcation include carotid dissection, migraine headache, thyroiditis, aneurysm of the carotid system, neck neoplasms, or rarely, temporal LEARNING OBJECTIVES: Recognize atypical presentations of TTP, including coronary arteritis. arteries. CASE INFORMATION: A 44 year old African American woman presented with the acute onset of shortness of breath and substernal chest pain with radiation of the pain to the neck and left arm. She was diagnosed with acute myocardial infarction with positive CK and isoennymes AN UNUSUAL CAUSE OF CHEST PAIN: SPONTANEOUS PNEUMOTHORAX. S. Daud1, and troponin-T. Initial ECG did not indicate an acute injury pattern, however ST-T wave R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73682) change in V5 and V6 suggested lateral . Platelet count on initial presentation was 36,000. Her initial Hgb was 9.2. No previous laboratory data were available to review. She was LEARNING OBJECTIVES: 1) Recognize spontaneous pneumothorax as an etiology of chest initially treated with aspirin, low molecular weight heparin, and GIIB/IIIA inhibitors. pain. 2) Describe the typical presentation of spontaneous pneumothorax 3) Recognize the Subsequent to this her blood count was repeated and platelet count had dropped to 11,000. At treatment options and prognosis of spontaneous pneumothorax. this time her peripheral smear was reviewed and 20±25 schistocytes were identified per high CASE INFORMATION: A previously healthy seventeen year-old male was seen in the power field. The case was discussed with the Hematology division and plasmapheresis was emergency department for complaints of chest pain. His pain was described as a sharp pain initiated within 12 hours. After two double volume exchange transfusions, her platelet count above his nipples, bilaterally, which initially had occurred at rest. The pain was neither had rebounded to 50,000 and her LDH was falling as well. Her platelet count slowly continued exacerbated nor relieved by movement or deep inspiration. There were no associated to improve over the course of her hospitalization. At discharge on hospital day #8, her platelet palpitations nor diaphoresis or vomiting. He was taking no medications, but smoked count was 236,000. At no point did the patient have renal dysfunction, neurologic symptoms, marijuana weekly for the past few months. He occasionally smoked cigarettes, but never or fever. consumed alcoholic beverages. There was no family history of coronary artery disease, IMPLICATIONS/DISCUSSION: TTP is characterized by arteriolar lesions in various hypercoagulable states, or vasculitis. Examination revealed a 501100 young man in mild distress. organs that contain platelets and fibrin. This results in MHA, and thrombocytopenia. The His weight was 60 kg, his respiratory rate was 16, and his heart rate was 84. He had no oral tissue hypoxia that ensues is responsible for the symptoms. Myocardial vessel involvement may lesions and had normal dentition. The cardiac exam revealed normal heart sounds and no be a cause of sudden death in some patients. However the isolated involvement of myocardial murmurs. The lungs were clear to auscultation and had a normal percussion note. The vessels is rare, especially when there is no of involvement of renal and cerebral vessels. TTP is abdomen was scaphoid and non-tender. There was no . Electrocardiogram treated with plasmapheresis initially. The disease is now 90% survivable if therapy is initiated and pulse oximetry were normal. A chest roentgenogram revealed bilateral apical promptly. Before this therapy was available, TTP had a 90% mortality. Plasmapheresis is pneumothoraces. They were estimated to be 10% each. Bilateral apical drainage catheters conducted until platelet count, LDH, and MHA resolves. At that time, pheresis is gradually were placed and the patient's symptoms resolved. The patient was admitted to the hospital weaned. Those patients who relapse can be treated with corticosteroids, cyclophosphamide, or for observation. vincristine. Splenectomy is also an option. IMPLICATIONS/DISCUSSION: Primary spontaneous pneumothorax is defined as a pneumothorax without a precipitating factor such as trauma, in a patient without clinically evident lung disease. It typically occurs in tall, thin males between 10 and 30 years of age. The AN H. PYLORI CASCADE. N. Dawson1, B. Eidelman1; 1Mayo Clinic, Jacksonville, FL use of smoking tobacco has been reported to increase the risk in men by as much as a factor of (Tracking ID #76839) 20 in a dose dependent manner. Subpleural bullae are found in virtually all patients; their mechanism of formation is not completely understood, but is thought to be related to LEARNING OBJECTIVES: 1. Diagnose B12 deficiency on clinical grounds 2. Recognize the degradation of elastic fibers in the lung. This process is thought to be accelerated by smoking. relationship between H. pylori infection and B12 deficiency 3. Assess potential complications The primary spontaneous pneumonthorax results in a decrease in vital capacity, and an increase of B12 deficiency. in the alveolar-arterial oxygen gradient, leading to hypoxemia. Because underlying lung CASE INFORMATION: A 65 year old male was admitted to our hospital with a two month function is normal, hypercapnia is not usually seen. Most patients present with ipsilateral history of progressive gait instability, weakness and bilateral lower extremity numbness. He was pleuritic chest pain occurring at rest. Tachycardia is frequently the only abnormal physical unable to walk without assistance, was totally dependant for activities of daily living, had finding. The diagnosis is confirmed by the identification of a thin, visceral pleural line recently become incontinent of urine and had developed severe . He also displaced from the chest wall on chest roentgenography. Treatment with observation, needle complained of mild numbness, tingling and weakness in his upper limbs, and had difficulties aspiration, or drainage through a chest tube all have been advocated. The average rate of with hand motor control. He denied fevers, myalgias, pain, involuntary limb movements, recurrence is about 30%, with pulmonary fibrosis, asthenic habitus, and history of smoking all headaches, or trauma, however he did have a forty pound weight loss over the previous three thought to be risk factors for recurrence. months. He had no significant past medical history and was on no medications. Physical exam 44 Abstracts JGIM

showed no cranial nerve defects, mild proximal weakness and proprioceptive loss, with severe, (the above plus positive tourniquet sign, thrombocytopenia, and increase vascular permeability) diminished lower extremity strength, , vibration and sensation. Lower extremity to Dengue shock syndrome (the above plus hypotension and narrow pulse pressure). Diagnosis tendon reflexes were brisk with positive Babinskis. Bilateral crackles at mid lung fields were of Dengue is usually by isolation of the virus or serologic testing such as ELISA for IgM. evident on chest exam. Laboratory values on admission were significant for hemoglobin of 10.8 Dengue fever is typically self-limited with symptoms lasting appoximately 7 days. Warning g/dl, mean corpuscular volume of 106.8 fL, and B12 of 75 ng/L (190±900). Arterial blood gas signs for Dengue shock syndrome include sustained abdominal pain, persistent vomiting, on 2L of oxygen showed pH of 7.456, PCO2 of 40.4, and PO2 of 69.0. With the laboratory change of level of consciousness, and a sudden decrease in platelet count. Dengue has 4 diagnosis of B12 deficiency, a homocysteine level was obtained and was significantly elevated at serotypes and repeat infection with another serotype is more likely to casue severe disease. In 188 mmol/L (0±13). Chest X-ray showed extensive bilateral reticular infiltrates and small addition to improved mosquito control, a vaccine is currently being developed. bilateral effusions. Due to these findings, a computed tomography of the chest was done which revealed left apical bullae, extensive ground glass opacities, and multiple filling defects in the interlobar and branch arteries consistent with pulmonary emboli. Lower extremity Doppler BLOOD IS THICKER THAN WATER: THE MANAGEMENT OF HYPERVISCOSITY IN ultrasound confirmed deep vein (DVT). An esophagogastroduodenoscopy was ADULTS WITH CYANOTIC HEART DISEASE. A. DeFilippis1, S. Aaberg1; 1Emory ordered to help determine the cause of the B12 deficiency. This showed mild chronic University, Decatur, GA (Tracking ID #76037) and H. pylori organisms. Serum studies for intrinsic factor and parietal cell antibodies were negative. He was treated with intravenous B12, triple therapy for H. pylori, anti-coagulation LEARNING OBJECTIVES: 1. Recognize the clinical presentation of hyperviscosity and oxygen support, however his respiratory status declined over the next three to four weeks syndrome in patient with chronic hypoxia. 2. To recognise the complications of phlebotomy and he died approximately one month after admission. Autopsy confirmed sub acute combined in the treatment of erythrocytosis of cyanotic heart disease. 3. To recognise the appropriate use degeneration in the spinal cord and organizing thromboemboli with diffuse alveolar damage of of hydroxyurea in the treatment of erythrocytosis of cyanotic heart disease. the lungs. CASE INFORMATION: A 19-year-old male with uncorrected tetralogy of Fallot presented IMPLICATIONS/DISCUSSION: This case demonstrates a cascade of events that most likely to the emergency room after a ground level fall after climbing two steps. The fall was preceded began with the relatively common finding of H. pylori gastritis. Our patient then developed by two episodes of lightheadedness. He denied , bowel or bladder incontinence, chest B12 deficiency, which has a known association with this infection. This in turn contributed to pain, dyspnea, or palpitations. At presentation, he was afebrile with a pulse of 90 beats per elevated homocysteine by interfering with its conversion to methionine. This contributed to a minute, blood pressure of 117/63, 30 respirations per minute and an oxygen saturation of 79%. hypercoagulable state and in combination with immobility from the B12 deficiency induced Physical examination was remarkable for a well developed, alert and oriented male in no sub acute combined degeneration, led to the DVT and pulmonary emboli. This directly distress, clubbing in all digits, normal S1 and S2 heart tones with a II/VI early systolic ejection contributed to the patient's respiratory decline. This case demonstrates that when H. pylori murmur heard throughout the chest; a cardiac heave over the left side of the chest, no jugular gastritis is confirmed, the association between this infection, B12 deficiency and hyperhomo- venous distention, no peripheral edema or crackles. Chest radiograph revealed a large boot- cysteinemia should be considered, as this can have profound consequences. shaped heart and right-sided aortic arch. EKG was notable for a normal sinus rhythm with left axis deviation and right atrial enlargement. Remarkable laboratory values were hemoglobin of 24g/dL and a hematocrit of 76 %. The patient was phlebotomized 500ml of blood and discharged from the hospital after remaining in normal sinus rhythm and asymptomatic for NARCOTICS CAUSING ABDOMINAL PAIN. P. De Silva1, H. Shu1, G. Applebaum1; 24 hours. 1UCLA±San Fernando Valley Program, Sylmar, CA (Tracking ID #76060) IMPLICATIONS/DISCUSSION: Complications of chronic hypoxia including erythrocyto- LEARNING OBJECTIVES: 1) Review symptoms of opiate withdrawal. sis, hyperviscosity, abnormalities of hemostasis, cerebral abscesses or stroke and endocarditis 2) Recognize opiate dependence from prescription narcotics. are among the most common consequences of cyanotic heart disease in adults. The 3) Discriminate between opiate dependence and addiction. compensatory erythrocytosis of cyanotic heart disease can become pathologic by causing an CASE INFORMATION: A 29-year-old male with a history of hemophilia and hepatitis C increase in blood viscosity, which decreases perfusion, resulting in a decrease in total oxygen presented with recurrent episodes of crampy abdominal pain over the past seven months. He delivery and an increased risk of veno-occlusive/hyperviscosity syndrome. Treatment of denied fevers, chills, nausea, vomiting. There was no change in bowel habits or alteration of the hyperviscosity secondary to erythrocytosis in cyanotic heart disease is controversial. Data pain with food or . He denied previous surgeries or intravenous drug use. Physical suggest that phlebotomy has the potential to increase exercise capacity, reduce the symptoms of exam showed no fever, heart rate 106, dilated pupils, diaphoresis, and a soft abdomen with hyperviscosity syndrome and reduce the potential increased risk of vasoocclusive disease in voluntary guarding. The patient had undergone an extensive prior workup for these symptoms selected patients with polycythemia secondary to cyanotic heart disease. Unfortunately, including CT scanning, colonoscopy, and upper endoscopy- all of which were normal. On our repeated phlebotomy can quickly lead to iron deficiency. Microcytic erythrocytes produce further review we learned that the patient had been taking two narcotic medications prescribed higher viscosity than normocytic erythrocytes at comparable hematocrits putting patients at from different doctors. He described occasionally taking these medications for pain control, high risk for vasoocclusive events. There is limited data on the use of hydroxyurea to suppress but was unaware both were narcotics. His symptoms completely resolved after starting a low erythrocytosis in this patient population. Thus we concluded that until newer approaches to dose methadone taper, and the patient was grateful for ending a seven-month cycle of pain. decreasing the hematocrit, without causing iron deficiency anemia, are shown to be safe and IMPLICATIONS/DISCUSSION: The symptoms of opiate withdrawal can include sweating, efficacious, phlebotomy should only be used for the acute resolution of hyperviscosity headache, nausea/vomiting, abdominal cramping, diarrhea, dilated pupils, piloerection, symptoms; and the use of hydroxyurea should be limited to recurrently symptomatic patients. insomnia, agitation, and anxiety. Opiate withdrawal can occur from chronic prescription narcotic use, but may go unrecognized by patients and physicians. In our patient with hemophilia, prescription narcotics rather than NSAIDS were given for minor . His CARDIAC SARCOID AND RISK OF SUDDEN DEATH. A. DeFilippis1, A. Palacio1, abdominal pain along with dilated pupils and diaphoresis suggested withdrawal leading to a D.W. Brady1; 1Emory University, Decatur, GA (Tracking ID #76794) more extensive review of his medication use. Despite using his medications as prescribed, his chronic use led to physical dependence. Addiction is defined as the compulsive use of a LEARNING OBJECTIVES: 1. Recognize the clinical presentation of cardiac sarcoid. 2. Treat substance despite negative consequences. Dependence, however, does not usually have the cardiac sarcoid and its inherent risk for sudden cardiac death. psychological associations that are seen in addiction, making it harder to recognize. CASE INFORMATION: A 58-year-old female with cutaneous sarcoid presents to the Nonetheless, patients with physical dependence can experience severe distress, as did our emergency room with a 3 month history of progressive dyspnea on exertion. She also reports a patient. Opiate withdrawal causing abdominal pain remains a diagnosis of exclusion and other 2-week history of proximal nocturnal dyspnea, cough, 2-pillow orthopnea and lower extremity serious causes should always be ruled out. edema. She denies chest pain, fever, chills, or palpitations. Her past medical history includes hypertension, diabetes, hypercholesterolemia and obstructive sleep apnea. On presentation, she was afebrile, pulse 106, blood pressure 120/60, respiratory rate of 28 and oxygen saturation of 88% on room air. Physical exam was significant for S3 gallop, normal pulmonary exam, lower MOSQUITOS CAN BREAK BONES?A CASE OF DENGUE FEVER IN A TRAVELER extremity edema and several silver dollar size hyperpigmented lesions on her legs. Routine RETURNING FROM BRAZIL. M. Decker1, G. Mathisen1; 1UCLA/San Fernando Valley laboratory testing was unremarkable, chest radiograph revealed mild cardiomegaly as Program, Sylmar, CA (Tracking ID #75544) compared to a normal radiography 1 month earlier. EKG revealed a new right conduction LEARNING OBJECTIVES: 1. Discuss approach to fever in travelers 2. Recognize Dengue system block as compared to a normal EKG 2 years earlier. High resolution CT scan was fever presentation 3. Realize importance of controlling mosquito vectors. negative for pulmonary embolus and deep but revealed multiple enlarged CASE INFORMATION: 23 year old male with no prior history presents with 3 days of fever, mediastinal lymph nodes. Echocardiogram was notable for hypokinetic lateral and inferior wall malaise, headache and body aches. He returned to the US 6 days prior after a month-long motion, new from a normal dobutamine stress echocardiogram 2 years earlier. Cardiac backpacking trip in Brazil. His fever has no pattern and is relieved with . His catheterization revealed normal coronary angiography, an ejection fraction of 20% and headache is bitemporal with some associated photophobia and neck pain. His body aches are regional wall motion abnormalities, which lead to a cardiac biopsy that revealed non-caseating generalized but most severe in the lower back. He denied HIV risk factors and review of granulomas consistent with active cardiac sarcoid. The patient improved with diuresis and systems is negative. He did not receive any vaccines or prophylactic medications. His bp is systemic afterload reduction. She was started on a 6-month course of prednisone and equipped normal, pulse 70, and temperature 38.6 degrees Centigrade with malaise and a maculopapular with an automated internal cardiac defibrillator with rescue pacing, prior to discharge from rash over the trunk. Otherwise exam was negative. At this point the differential included flu, the hospital. , typhoid fever, leptospirosis, acute HIV, and Dengue fever. Laboratory investigation IMPLICATIONS/DISCUSSION: Dyspnea and cough are amongst the most common revealed a mild leukopenia with normal platelet count. CSF, HIV p24 Ag, thick and thin smear, clinical presentations of sarcoid but are attributed to pulmonary rather than cardiac pathology. RPR were all negative. Dengue titer came back positive for serum ELISA IgM. He was treated Although less than 10% of sarcoid patients demonstrate symptoms secondary to cardiac symptomatically with resolution of symptoms within a week's time. sarcoid, cardiac involvement is found in up 76% of sarcoid patients at autopsy and accounts for IMPLICATIONS/DISCUSSION: Dengue fever is caused by a single stranded RNA virus in 50% of the mortality in this patient population. The most common presentation of cardiac the family Flaviviridae (found throughout the tropics) and transmitted to humans by the Aedes sarcoid, found in approximately 50% of patients, is arrhythmias or cardiac conduction aegyptia mosquito. With urbanization and subsequent inadequate waste and water manage- abnormalities as a result of granuloma formation in the conduction system. Sarcoid granulomas ment, Dengue incidence is increasing in South America and the Caribbean. There is a disease in the ventricular myocardium may lead to ventricular arrhythmias in as many as 22% of spectrum with Dengue ranging from a relatively non-specific illness, to Dengue fever (acute patients with sarcoid. Granulomas in myocardium can result in diastolic or systolic dysfunction illness with leukopenia, headache, malaise, myalgias/arthralgias) to Dengue hemorrhagic fever and has accounted for 25±75% of the deaths in some studies of cardiac sarcoid patients. JGIM Volume 18, April (supplement 1) 2003 45

Endomyocardial biopsy is highly specific but due to the non-homogeneous pattern of hospital the patient presented to our institution reporting that the facial swelling had not infiltration will only lead to a diagnosis of cardiac sarcoid in approximately 20% of cases. With improved with prior therapies. Additionally, he complained of bilateral blurry vision with arrhythmias or cardiac conduction abnormalities accounting for 30±65% of the deaths in- increased sensitivity to light. On physical examination the patient was afebrile. HEENT patients with cardiac sarcoid, automated internal cardiac defibrillators (AICD) with rescue examination was significant for left-sided facial swelling with infraorbital involvement, a pacing are standard of care in survivors of deadly arrhythmias. Although no trials have assessed greenish-yellow discharge from the left medial canthus and left nares, photophobia and a the efficacy of AICDs in the absence of ventricular tachyarrhythmias, many advocate their use necrotic plaque of the hard palate. The patient was unable to medially deviate his left eye. in all cases of known cardiac sarcoid; others reserve the use to patients with EKG abnormalities Laboratory work revealed a normal white cell count and differential, and a normal chemistry by standard of Holter monitor testing. Treatment of the underlying pathological process with panel with the exception of an elevated serum glucose of 256. The differential diagnosis at this immunosuppression is controversial and void of any large randomised trials to access efficacy. point included among other conditions fungal sinusitis, bacterial sinusitis, lymphoma and A small uncontrolled study demonstrated improvement and/or reversal of EKG abnormalities Wegener's granulomatosis. MRI of brain revealed extensive paranasal sinus opacification with in greater than 50% of patients treated with corticosteroids. In one retrospective study of abnormal dural enhancement extending from the left sphenoid sinus to involve the left patients with cardiac sarcoid, 5-year survival was increased from 10% to 75% with the use of cavernous sinus, left middle cranial fossa and left fifth cranial nerve with no intracranial, corticosteroids. Opponents to the use of corticosteroids raise concern that corticosteroids parenchymal or orbital involvement. The patient underwent a nasal biopsy that revealed convert granulomas to scar tissue increasing the risk of aneurysms. Cardiac transplant has been multiple hyphal elements consistent with Mucormycosis. The patient was started on successful with recurrent disease possible but rare. Amphotericin B at 1.5/mg/kg/day and underwent extensive surgical debridement. Although no orbital involvement was confirmed on MRI, the patient's cranial nerve palsy and opthalmoplegia were understood to be a manifestation of rhino-orbital mucormycosis. The A WOMAN FROM CAMEROON WITH FEVER, ABDOMINAL PAIN AND EOSINOPHILIA. hospital course was complicated by acute renal failure, septic shock, diabetic ketoacidosis and K. Dendrinos1; 1Boston University, Boston, MA (Tracking ID #75960) cardiac arrest. While serial MRIs showed no regression of disease, the patient was medically stabilized, and showed clinical improvement over an eight week hospital course. However, the LEARNING OBJECTIVES: Review the Differential Diagnosis of Eosinophilia, Evaluate patient's vision loss and opthalmoplegia did not improve with treatment. Fever of Unknown Origin. IMPLICATIONS/DISCUSSION: Rhizopus oryzae accounts for 90% of rhinocerebral CASE INFORMATION: A 70 year old woman, recently emigrated to the U.S., presents to mucormycosis. Patients in DKA are highly susceptible because the acidic, glucose rich this hospital complaining of fever and chills for the past 3 months. She also complained of right environment provides a perfect medium for growth. The clinical presentation includes classic and left upper quadrant pain. These complaints originally began in her home country of sinusitis symptoms and signs along with nasal necrosis (38%) and palatal or gingival necrosis Cameroon, she came to the U.S. one week prior to her initial admission. During her first (14%) as in the case of our patient. The diagnosis of mucormycosis is histologic, and it is the admission, she was febrile daily to 101 degrees Fahrenheit. Her exam was notable for right only fungus that can be seen with H & E stain. The mainstays of treatment are surgical upper quadrant abdominal tenderness. Her laboratory examinations were significant for a CBC debridement and reversal of predisposing factors. While lipid containing formulations allow with an eosinophilia of 43%, that would peak later that month at 60%. Suspicion was high for a for higher doses to be given due to reduced toxicity there may be problems with delivering the parasitic infection. Serologies would later be positive for multiple parasites endemic to complex to infarcted tissue and obtaining effective concentrations. Administration of Cameroon. She was treated with a wide array of antibiotics, including anti-tuberculosis intravenous Amphotericin B along with alternative routes such as aerosolized and CSF medications, anti-fungals, and anti-helminthics. Her clinical course deteriorated and she died perfusion pathways is an aggressive treatment modality. Hyperbaric oxygen is an accepted, but in the intensive care unit. On autopsy, she was found to have widely disseminated lymphoma not commonly utilized adjuvant to treatment. Even with early detection and treatment the involving nearly every organ system. overall mortality rate in patients with rhinocerebral mucormycois remains high. IMPLICATIONS/DISCUSSION: This case initially appeared to be a classic presentation of a parasitic infection: a patient with fever and eosinophilia from an endemic area with positive serologies. It presents a chance to review the differential diagnosis of eosinophilia, and to again LOSS AS A PRESENTATION OF NEUROSYPHILIS. L. Dinh1, R.R. Cader2; rethink the work-up of a fever of unknown origin. This case again demonstrates that ``common 1UCLA±San Fernando Valley Program, Northridge, CA; 2University of California, Los things occur commonly'' (even when the patient comes from an unfamiliar part of the world). It Angeles, West Los Angeles, CA (Tracking ID #75449) also demonstrates the importance of keeping the differential diagnosis open, especially when the therapy instituted according to the initial dianosis fails. LEARNING OBJECTIVES: 1. Recognize as a presentation of neurosyphillis. CASE INFORMATION: A 59 year old homosexual Caucasian male presented with complaints of b/l hearing loss, tinnitus and vertigo for several months prior to presentation. Patient had an performed which showed moderate to severe symetrical sensorineural hearing loss. ``LOCKING'' IN THE CASE FOR PREVENTIVE IMMUNIZATIONS. J. Derby1, C. Manhart1, Patient did not have a history of recent aminoglycoside use and was not a diabetic. He was C. Murphy1; 1Creighton University, Omaha, NE (Tracking ID #74723) worked up with thyroid stimulating hormone, sedimentation rate, coagulation tests, rheumatoid LEARNING OBJECTIVES: Recognize that there are many patients at risk who have not factor and anti-nuclear antibody titers which were all within normal limits. PPR was positive at received a primary series in tetanus. Distinguish a differential diagnosis of tetany. Manage a 1:16 and MHA-TP was positive at 4+. He refused an HIV test. Patient subsequently received a tetanus infection. lumbar puncture which was positive for VDRL . He was thus diagnosed with neurosyphilis and CASE INFORMATION: A 71 year old female with no significant past medicial history and on admitted to the inpatient medicine wards where he received a 14 day course of IV Penicillin. no medications presented to the ER complaining of waking up in the middle of the night and Hearing loss improved with treatment of the neurosyphilis. being unable to move for the last 24 hours due to muscle stiffness. On initial exam she had IMPLICATIONS/DISCUSSION: Neurological manifestations of can occur during marked neck stiffness with muscle spasms triggered by light touch and deliberate speech. A CT any phase of this disease as the central nervous system is seeded during spirochetemia. Up to scan was unremarkable. A trial of IV diphenhydramine was administered to rule out a dystonic forty percent of patients infected with Treponema pallidum will have cns involvement. reaction. Stychnine levels and tetanus antibodies were drawn ( both later reported as negative). Although neurosyphilis can be aymptomatic, symptomatic neurosyphilis can present earlier as Over the next few hours obvious trismus developed. Her muscle spasms spread inferiorly to syphilitic meningitis or later in the infection, can have a meningovascular or parenchymatous involve her abdominal wall, and her upper and lower extremities demonstrated lead pipe pesentation. Cranial nerve involvement, especially of cranial nerves II±VIII, can be seen. rigidity. The patient was intubated prophylactically and IV diazepam was begun. The patient Syphilitic is a form of neurosyphilis that can present as , vertigo and/or tinnitus was given tetanus immunoglobulin as well as a Td vaccination (since the illness is not and should considered in patients who present sensorineural hearing loss. If treated early, protective). Metronidazole was administered IV. syphilitic otitis may be curable, but can lead to irreversible damage if untreated. IMPLICATIONS/DISCUSSION: The majority of reported cases of tetanus in the US are in patients over the age of 60 years old. Currently, nearly 50% of elderly patients in the United States have non-protective titers. This is attributed to waning immunity in patients who have PASTEURELLA MULTOCIDA PNEUMONIA IN AN IMMUNOCOMPRISED PATIENT not received booster shots. Additionally, many elderly never received the primary series as SUFFERING FROM DELIRIUM TREMENS. X. Dong1; 1Yale University School of children (which was not available until the 1950's). This patient had received one booster Medicine, New Haven, CT (Tracking ID #76928) without a primary series which did not protect her,but may have prevented her mortality. Many immigrants as well, may have never received the primary tetanus series. Physicians must be LEARNING OBJECTIVES: Recognize human Pasteurella Multocida infection associated diligent in immunizing at-risk groups and ensure that all patients whos tetanus immunization with animal exposure. status is unknown receive a primary series. Recognize immunocompromised patient's risks for pulmonary Pasteurella Multocida infection. Recognize treatment choices for Pasteurella Multocida. CASE INFORMATION: 78 years old man with coronary artery disease, emphysema and alcoholism presents with short of breath and palpitations. He had clear chest film, but was A CASE OF RHINOCEREBRAL MUCORMYCOSIS IN A PATIENT WITH TYPE I found to be in rapid atrial fibrillation and controlled with diltiazem. On day 3 of hospital stay, DIABETES MELLITUS. R. Dickens1,V.Akopov1; 1Emory University, Atlanta, GA his mental status deteriorated and rapidly went into delirium tremens. He subsequently had (Tracking ID #76466) temperature spike to 103.0(F) with associated leukocytosis. His oxygen saturation became very LEARNING OBJECTIVES: To analyze an interesting presentation of rhinocerebral unstable and eventually requiring mechanical ventilation. He repeat chest X-ray showed right mucormycosis and review current diagnostic and treatment modalities. lower lobe consolidation. His sputum gram stain showed 4+ small gram negative rods which CASE INFORMATION: The patient is a 26 yo African American male with a past medical was identified to be Pasteurella Multocida. He had been a long time avid deer hunter and has history significant for Type I Diabetes Mellitus who presented with a chief complaint of left- three dogs which he is in close contact with. He was treated with a third generation sided facial swelling for nine days. He stated that the onset of facial swelling occurred over few cephalosporin and his condition slowly improved. His subsequent CT of chest revealed left hours and that the progression was rapid. Pt reported subjective fevers and chills. He denied lung nodule. The biopsy of the nodule was consistent with squamous cell carcinoma of upper respiratory or sinus-related symptoms. He initially presented to an outside hospital after the lung. two days of facial swelling. There he underwent a sinus CT that revealed mucosal thickening IMPLICATIONS/DISCUSSION: Pasteurella Multocida is common organism in many involving the left ethmoid, maxillary and ethmoid sinuses. He was treated with a seven day domestic and wild animals. Human Pasteurella is a major pathogen in wound infections due to course of Rocephin and Cleocin. The patient was in DKA at the time of presentation and was animal bites. Greater than 70% of the reported cases of Pasteurella Multocida pneumonia treated for two days per hospital DKA protocol. On the day of discharge from this outside occurred in patients with non-traumatic exposure to colonized animals. 46 Abstracts JGIM

Respiratory infection caused by Pasteurella Multocida can range from asymptomatic exam is significant for mildly decreased breath sounds in left upper lobe and guaiac positive stool colonization to , sinusitis, epiglottitis, pneumonia, empyema and lung abscess. but no palpable rectal mass. Lab results show hemoglobin 10.9, MCV 78.0, and WBC 6.4. HIV The degree of pulmonary infection depends on the immunity state of the host and can carry a test is negative. Colonoscopy with biopsy shows squamous cell cancer. Staging studies including very high mortality. chest x ray and a CT scan of the thorax display a 3.5 cm mass in the left upper lobe and CT pelvis Treatment of choice for Pasteurella Multocida infection is either penicillin, second or third confirms anorectal mass. Biopsy of the lung mass is consistent with a metastatic lesion. He is generation cephalosporins, or doxycline. Prolonged antibiotic treatment is warranted in treated with chemotherapy and undergoes resection of the solitary lung mass. immnocompromised host. IMPLICATIONS/DISCUSSION: carcinoma can be overlooked in young otherwise healthy patients as rectal bleeding is often attributed to . Squamous cell cancer of the anal canal has a high association with human papilloma virus (HPV) NEW ONSET VENTRICULAR TACHYCARDIA SECONDARY TO MACROPHAGIC particularly HPV-16. HPV DNA is isolated in 88% of anal cell cancers. Other risk factors MYOFASCIITIS. L. Donohue1,V.Martin1; 1University of Cincinnati, Cincinnati, OH include chronic immunosuppressive therapy, HIV, and smoking. Past treatment for anal canal (Tracking ID #74088) carcinoma involved abdominoperineal resection with permanent colostomy. Cure rates with surgical resection ranged between 40±70%. However, in recent studies, chemotherapy with LEARNING OBJECTIVES: 1) To understand systemic causes of ventricular tachycardia. 5-FU and mitomycin combined with radiotherapy offer a 66±70% cure rate and lower rate of 2) To consider macrophagic myofasciitis in patients presenting with proximal muscle weakness complications. Prognosis is dependent on the size of tumor, distant metastases, and nodal and myalgias. involvement. In conclusion, recurrent rectal bleeding in young patients with associated risk CASE INFORMATION: Macrophagic myofasciitis is a syndrome of proximal muscle factors warrants a more thorough investigation. weakness, pain and fatigue. Clinical presentation is very similar to polymyositis, with proximal muscle pain, weakness, fatigue, fever and ternderness. Macrophagic myofasciitis is distinguished from polymyositis microscopically, with infiltration of the fascia with CEREBELLAR ATAXIA IN A MAN WITH ACQUIRED IMMUNE DEFICIENCY macrophages in MM. Cardiac involvement is found in over 70% of patients with polymyositis. SYNDROME. R. Dua1,G.Applebaum1; 1UCLA±San Fernando Valley Program, We report a case of macrophagic myofasciitis presenting with proximal muscle weakness and Sylmar, CA (Tracking ID #74427) ventricular tachycardia. A 49 year-old African American female with several months of progressive muscle weakness presents with palpitations and dizziness. Physical examination LEARNING OBJECTIVES: 1) review the clinical presentation of Progressive Multifocal demonstrated significant proximal muscle weakness with no evidence of a skin rash. Laboratory Leukoencephalopathy(PML) 2) compare PML to other demyelinating diseases 3) review data revealed a creatinine kinase of 1301 u/liter (normal <2oo), a CK-MB of 41.7 (normal 0± diagnostic tests and treatment for PML. 60) and an aldolase of 40.2 (normal 1.5±8.1). An EKG showed a wide complex tachycardia with CASE INFORMATION: A 48 year old male presented with ten days of progressive difficulty a rate of 220. A coronary angiogram was normal and electrophysiologic studies failed to induce walking, stating he had weakness in the lower extremities and in his right hand. He also ventricular tachycardia. Electromyopathy was consistent with a myopathy and her muscle reported slurred speech. Pt had no known medical problems and denied the use of medications, biopsy revealed macrophagic infiltration of fascia, consistent with a diagnosis of macrophagic illicit drugs, tobacco or alcohol. Physical examination was significant for 3/5 right lower myofasciitis. Her ventricular tachycardia was postulated to have arisen from a myofasciitis. extremity strength with absent reflexes of the right leg. Sensory exam was grossly intact. The After initiation of high dose steroids, her muscle enzymes normalized and no further episodes patient had poor performance of finger to nose testing and difficulty with rapid alternating of tachyarrhythmia occurred. movements. There was severe gait instability. Babinski's sign was bilaterally equivocal. CBC, IMPLICATIONS/DISCUSSION: MM is a relatively new muscle disease, with a first case chemistry panel, ESR, TSH, RPR, EKG were normal. After an unremarkable head CT, an report in 1993 in France. In several ways, it is similar to polymyositis, with bilateral muscle MRI of the head showed a demyelinating pattern involving the middle cerebellar peduncles. weakness and pain. Both are associated with an altered immune system. Cardiac arrhythmia in The CSF protein, gram stain, culture, cell count, and glucose were within normal limits. On polymyositis is fairly common, occurring in over 70% of patients. These arrhythmias are due hospital day 4, HIV serology was positive and thus confirmed the clinical diagnosis of PML. to an increase in spontaneous and disorganized myopathic contraction. There are no previous CSF testing for JC virus later returned positive. reports of cardiac disrhythmias in macrophagic myofasciitis. Most patients respond well to IMPLICATIONS/DISCUSSION: PML is a demyelinating disease associated with infection of treatment with steroids and/or antibiotics in a few weeks. the JC virus. An AIDS defining condition, PML may present with rapid or progressive focal neurological deficits, including aphasia, ataxia, hemiparesis, hyporeflexia, and impaired cognition. In AIDS, PML implies a very poor prognosis with a survival expectancy of about six months. The diagnosis of PML is made through a clinical constellation which includes HIV SEVERE HYPOTHYROIDISM PRESENTING AS PSEUDO±PREGNANCY AND ANEMIA positivity, characteristic MRI findings, and positivity for JC virus in the CSF. MRI findings of IN AN 18 YEAR OLD FEMALE. E. Doyle1, C.V. Mueller1; 1University of Cincinnati, PML are similar to those seen in Acute Disseminated Encephalomyelitis (ADEM), a demy- Cincinnati, OH (Tracking ID #77193) elinating process associated with infections or vaccinations in children, but they differ from those LEARNING OBJECTIVES: To recognize rare presentations of severe hypothyroidism. seen in (MS). The MRI with MS typically shows plaques in the periventricular CASE INFORMATION: 18 year old African American female presented to the teen region, corpus callosum, centrum semiovale, and less commonly in the deep white matter pregnancy center secondary to increased abdominal girth and amenorrhea. She also reported structures. There is no specific therapy for PML, and improvement of symptoms relies on fatigue, hair loss, dyspnea on exertion, and sadness. Physical exam was significant for alopecia, a increasing CD4 count via antiretroviral therapy. There has also been suggestion of improved large goiter, markedly distended abdomen with fluid wave, tense edema of the hands, and clinical response with the addition of Cidofovir, a drug typically used to treat CMV retinitis. delayed deep tendon reflexes. Labs were remarkable for a TSH of 240 with undetectable T4 and T3, marked microcytic anemia and an erythrocyte sedimentation rate of 140. CXR revealed a globular pericardial silhouette and ultrasound of the abdomen showed a large ABDOMINAL PAIN: A CASE OF NARROWLY±FOCUSED DIFFERENTIAL. A.K. Duncan1, amount of ascites. Echocardiogram was unremarkable except for a moderate pericardial W.E. Wysokinski1, A.K. Ghosh1; 1Mayo Clinic, Rochester, MN (Tracking ID #74267) effusion. Pelvic ultrasound showed enlarged cystic ovaries, consistent with Van Wky Grumbach syndrome. Peritoneal fluid studies were consistent with myxedematous ascites. LEARNING OBJECTIVES: 1) Recognize the need to expedite the work-up of poorly Upon further questioning, the patient stated that she had been treated for hypothyroidism as a responding abdominal pain; 2) Recognize that vasculitis could present with diarrhea. young teen and had been lost to follow-up for two years. She also had a history of prior suicide CASE INFORMATION: A 72-year-old women was transferred to our hospital for attempts and depression. management of her diarrhea and weight loss. Three months prior to admission, she had an IMPLICATIONS/DISCUSSION: The manifestations of thyroid disorders are many, episode of upper respiratory tract infection and was treated with a 10 days course of antibiotics. myxedematous ascites are a well-known but not often seen presentation. Serositis from One month prior to entry, she developed profuse diarrhea and malaise. EGD reveled mild hypothyroidism may be caused by several things: a resulting from the gastritis, small bowel follow through and colonoscopy was normal and she was empirically dearth of thyroid hormones, an SIADH-like picture causing body cavity fluid accumulation, or treated with metronidazole for pseudomembranous colitis. She complained of increasing high hyaluronate concentrations in the body fluid acting as an osmotic attractant. The anemia abdominal pain and was found to have air on an upright abdominal film. Exploratory of hypothyroidism is thought to be caused by either direct bone marrow toxicity, lack of laparotomy revealed necrosis, inflammation and perforation in the small bowel and nodular stimulation of erythropoiesis, decreased RBC survival time, and increased 2,3-DPG lesions in the liver. She underwent extensive small bowel resection, cholecystectomy, and liver concentration. Van Wky Grumbach syndrome is a rare condition in which the TSH at high biopsy. Liver histology was reported to reveal stellate granulomata consistent with Yersinia. levels acts as an FSH analogue to cause ovarian hyperstimulation/cyst formation. This should However, cultures and serology for Yersinia were negative. She was empirically treated with be considered when a patient with no known thyroid disease presents with cystic ovaries. ciprofloxacin and transferred to our hospital. Examination revealed an elderly woman, with mild dyspnea, and atrial fibrillation with HR of 110/mt. She was mildly icteric, with skin breakdown in the sacral and inter-scapular region. Chest examination revealed bilateral basilar crackles. Abdomen was mildly tender and CARCINOMA OF THE ANAL CANAL IN A YOUNG MAN. N. Dryden1,L.Lu2; 1Baylor distended. revealed generalized but asymmetric neuropathy. College of Medicine, Houston, TX; 2Veterans Affairs Medical Center, Houston, TX (Tracking Re-evaluation of the small bowel biopsy revealed transmural fibrinoid necrosis with ID #76842) granulomatous inflammation typical of polyarteritis nodosa (PAN). EMG was consistent with LEARNING OBJECTIVES: 1. Review clinical presentation and symptoms of anal canal mononeuritis multiplex. ANCA was negative. Visceral angiogram revealed micro-aneurysms in carcinoma. 2. Recognize the risk factors associated with anal canal carcinoma. 3. Understand the spleen, kidney, jejunal and ileal branches. She was initiated on prednisone and pulse the treatment options. cyclophosphamide therapy with rapid improvement in symptoms. On follow-up at 3 months CASE INFORMATION: A 38 year old Hispanic male with no significant past medical history she continues to gain weight and has no new symptoms. presents to our clinic with a one year history of intermittent bright red blood per and two IMPLICATIONS/DISCUSSION: PAN affects the gastrointestinal tract in over 40% of cases. week history of mild dyspnea on exertion. He has previously been evaluated for the rectal bleed PAN cases presenting with acute abdomen has been associated with a high mortality (60%). GI at various clinics and treated with topical hemorrhoidal ointments without relief. Patient denies bleeding, perforation, , renal insufficiency, proteinuria, cardiomyopathy and CNS chest pain, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain, bowel changes, fever, vasculitis are poor prognostic factors. A high index of suspicion and re-examination of a broad chills, and weight loss. He is a sexually active homosexual. Family history is negative for colon differential diagnosis in cases of acute abdomen, could lead to earlier detection of PAN and cancer and polyps. Vital signs show temperature 100.3, BP 138/76, HR 75, RR 14. Physical successful therapy of this potentially fatal condition. JGIM Volume 18, April (supplement 1) 2003 47

HYPOGLYCEMIA AND HYPONATREMIA: A HIGHER CAUSE. E.J. Dzielak1, N.C. Post-operatively, the pt was emergently intubated for acute respiratory failure. Physical exam Chiappetta2; 1Dunmore, PA; 2Moses Taylor Hospital, Scranton, PA (Tracking ID #77122) revealed Temp 39.2, HR 146 (reg), BP 107/38, slight RUQ tenderness, liver span 13 cm, no fluid wave or shifting dullness, and 2 vesicular lesions on the Rt upper inner thigh. LEARNING OBJECTIVES: DDX of hypoglycemia W/U of and DDX of primary, secondary DDx at this point included HELLP syndrome, acute fatty liver of pregnancy, acute viral and tertiary causes of . hepatitis, pyelophlebitis, , and acute hepatic failure secondary to sepsis. CASE INFORMATION: A 74 year-old man with past medical history of hypothyroidism, Antimicrobials were changed to ceftazidime, vancomycin, and acyclovir. On hospital day 11, prostate carcinoma, iron deficiency anemia, paroxysmal atrial fibrillation, and hyponatremia, PCR for HSV type 1 and 2 returned positive. In addition, cultures of the vesicular lesions on presented nausea and vomitting. Physical exam was normal. Abnormal laboratory data included the patient's right thigh grew herpes simplex. Further questioning of the patient's partner a sodium of 125, glucose of 40, and mild normocytic anemia. His hypoglycemia did not correct revealed a hx of genital herpes. With the initiation of acyclovir, the pt defervesced and her with exogenous glucose administration. An A.M. cortisol level returned as 1.3. ACTH level was transaminases decreased. However, she suffered multiple ICU complications, as well as herpes then drawn and returned as 20 pg/ml. Further evaluation to distinguish between secondary and encephalitis. The newborn infant was in the NICU with herpes meningitis. tertiary adrenal insufficiency was preformed with a corticotropin stimulation test. The results IMPLICATIONS/DISCUSSION: Hepatitis due to herpes simplex virus (HSV) is an of this test confirmed the diagnosis of secondary adrenal insufficiency. uncommon, but potentially fatal cause of hepatitis that is often not considered in the DDx IMPLICATIONS/DISCUSSION: Secondary adrenal insufficiency is a deficiency of ACTH of acute hepatitis during pregnancy. HSV can affect the liver during primary or recurrent from the anterior pituitary gland resulting in a decreased production of cortisol . In the adrenal infection, although hepatitis during recurrent infection has not been documented in gland, ACTH stimulates the zona fasiculata, while having minimal affect on the zona immunocompetent hosts. Review of the literature suggests that HSV hepatitis can present glomerulosa. Therefore, manifestations of aldosterone deficiency (hyperkalemia and hypoten- with wide clinical spectrum from mild symptoms to fulminant hepatic failure. However, the sion) are not present, as this case demonstrated. To confirm adrenal insufficiency, an AM initial symptoms are often nonspecific. Therefore, a high index of suspicion and early cortisol level of <1.3 is needed. If the cortisol level is greater than 1.3, the diagnosis of adrenal diagnostic tools, such as HSV DNA detection are essential. Unfortunately, serological tests insufficiency could be confirmed by a cosyntropin stimulation test. To distinguish between have limited value for establishing an early diagnosis, though they may be used retrospectively primary and secondary adrenal insufficiency, an ACTH level should be drawn which should be to support the diagnosis. Definitive diagnosis is made with a liver biopsy, but this is frequently >100 pg/ml in primary adrenal insufficiency. The Metyrapone and Insulin Induced not possible because of severe coagulopathy. Hypoglycemia tests confirm secondary adrenal insufficiency. To distinguish between tertiary and secondary adrenal insufficiency, the corticotropin stimulation test is indicated. An absent response from baseline with ACTH and cortisol confirms secondary adrenal insufficiency, while ``JUST A MED REFILL''. S. Elad1, G. Applebaum1; 1University of California, Los Angeles, an prolonged and exaggerated ACTH repsonse is consistent with tertiary adrenal insufficiency. Sylmar, CA (Tracking ID #74705)

LEARNING OBJECTIVES: 1. To recognize the impact the closing of community clinics has A GASTROINTESTINAL LINK TO OSTEOPOROTIC FRACTURES. L. Eck1, C. Jachna1; had on uninsured and indigent patients. 1Kansas University Medical Center, Kansas City, KS (Tracking ID #74458) 2. To raise the possibility that short term economic gains resulting from the closure of primary care clinics may result in preventable hospitalizations. LEARNING OBJECTIVES: To recognize that celiac disease is commonly associated with CASE INFORMATION: `Maria' is a 56 -year old woman with a past medical history of low peak bone mass and adult osteoporosis leading to disabling fractures. diabetes, hypertension and hyperlipidemia that came to the hospital urgent care for a `med CASE INFORMATION: A 49 year old white male with a history of multiple atraumatic refill'. She ran out medications 2 months ago after her community clinic was closed secondary fractures including a hip fracture at age 22, wrist fracture at age 16, multiple rib fractures and a to `budget cuts'. Today Maria reports she has noticed increased urination and thirst for the past recent wrist fracture presented for evaluation of osteoporosis. Bone mineral density studies two weeks and a frontal headache with blurry vision for the past three days. She denies chest revealed a T-score of À3.1 at the spine, consistent with osteoporosis. On clinical history, the pain or shortness of breath. She has not been febrile. Maria had been on two medications for patient reported a long-standing history of approximately eight loose bowel movements per her blood pressure and diabetes, and a pill for high cholesterol. Presently she is completely out day associated with abdominal cramping. He also reported low body weight through young of her medications. adulthood and . Lab studies were notable for an elevated IgG antigliadin When questioned why she waited two months to get her medications refilled Maria stated the antibody of 132 Units, with a reference range of >30 Units being strongly postive for a two hour bus ride and 6 hour wait in the emergency room required her to take time off work diagnosis of celiac sprue. Follow up small bowel biopsy revealed villous atrophy consistent with she could not afford. the diagnosis of celiac sprue. On exam, Maria's blood pressure was 190/108 with a pulse of 83. The rest of her cardiac, IMPLICATIONS/DISCUSSION: Celiac disease is caused by a genetically based inability to pulmondary and nuerologic exam was unremarkable except for bilateral decreased visual acuity. digest gluten, a major protein commonly found in grains. Due to the availability of new highly Her blood was 275 with sugar and protien in her urine but no ketones. Her anion gap sensitive and specific serologic diagnostic tests, it is increasingly recognized in the United was normal as was her blood count. States as a cause of . Celiac disease is often asymptomatic but symptoms Maria was given a dose of lisinopril and her headache resolved once her blood pressure suggesting the diagnosis include bloating, flatulence, chronic diarrhea and lactose malabsorp- decreased to 160/90. She was restarted on her oral diabetes medication. Her medications were tion. Other than gastrointestional symptoms, celiac disease also has a wide spectrum of refilled and she was instructed to return to urgent care in one week to have her blood pressure extraintestinal manifestations including iron deficiency anemia, low bone mineral density, and and blood sugar rechecked. dermatitis herpetiformis. In a study of North American adults with celiac disease, 70% of IMPLICATIONS/DISCUSSION: The national health care crisis has been the topic of many subjects had low bone mineral density, predisposing them to fractures. Other studies have news programs and newspaper articles for the past year. According to the Kaiser Family suggested that in subjects with celiac disease, bone manifestations may be more severe in men Foundation approximately 19% of Californians are uninsured. In California, which faces a than in women possibly due to estrogen's protective effects on the bone. multi-billion dollar deficit, politicians have been discussing ways to trim costs which have Historically, initial screening for celiac disease involved detection of antigliadin antibody. included proposals to close hosptials and clincs. The recent closure of several primary care However, more specific serologic tests, including antiendomysial and antitissue transglutami- clinics in Los Angeles County has left many patients like Maria without access to health care. nase antibodies, are now available. Histologic identification of gluten sensitive enteropathy, By the time Maria was able to visit the hospitals' urgent care clinic she had run out of with characteristic small bowel mucosal abnormalities including villous atrophy, crypt medications and both her diabetes and hypertension were poorly controlled. Had Maria heperplasia, and an increased density of inflammatory cells, still remains diagnostic. required hospitalization at the time of her visit the cost would have been much higher. Maria's The pathogenesis of low bone mass and osteoporosis in celiac disease is multifactorial. The primary care visit to the emergency room was entirely avoidable had her clinic not been closed. reduction in surface area of the intestinal mucosa may contribute to calcium malabsorption and Much of the short term economic gains obtained by closing county subsidized clinics may later subsequent secondary hyperparathyroidism leading to increased bone resorption. Vitamin D be lost by patients utlizing our emergency rooms for primary care visits. Even in the context of deficiency is also believed to be common. Those who are undiagnosed during childhood and our current financial situation steps need to be taken to ensure that uninsured patients have young adulthood may never achieve peak bone mass. In addition, some researchers suspect that reasnable access to primary care services outside the hospital setting. systemic effects of inflammatory cytokines involved in the intestinal mucosa inflammation may also contribute to the development of bone disease. Not only should patients with celiac disease be screened for osteoporosis, but patients with low bone mineral density and no evident osteoporosis risk factors should be evaluated for celiac sprue. A CASE OF CANDIDA ALBICANS VERTEBRAL OSTEOMYELITIS COMPLICATED BY STAPHYLOCOCCUS AUREUS INFECTION/ E.H. Elbadawy1, M.S. Marcu2, K.V. Gopal1; 1Fairview Hospital, Cleveland, OH; 2University of Cincinnati, Cincinnati, OH (Tracking HERPES SIMPLEX LEADING TO HEPATIC FAILURE IN PREGNANCY. A. El-Sharkawi1, ID #74207) S. Kripalani1; 1Emory University, Atlanta, GA (Tracking ID #75179) LEARNING OBJECTIVES: 1- To recognize fungal vertebral osteomyelitis as an etiology for LEARNING OBJECTIVES: Hepatitis due to herpes simplex virus (HSV) is an uncommon, worsening back pain in patients with history of multiple back surgeries. 2- To consider but potentially fatal cause of hepatitis that is often not considered in the differential diagnosis secondary bacterial infection in patients who fail to respond to appropriate antifugal therapy. of acute hepatitis during pregnancy. Serological tests have limited value in establishing an early CASE INFORMATION: A 48-year-old male presented in January 2001 with worsening back diagnosis and a high index of suspicion and early diagnostic tools, such as HSV DNA detection pain, bilateral leg weakness and urinary incontinence. Condition started in 1993 after back are essential. Early treatment with acyclovir decreases mortaility from herpes simplex hepatitis. injury during demolition job that required multiple back surgeries. Examination was CASE INFORMATION: A 19 y/o woman, G2 P1, with no significant PMHx, presented with remarkable for bilateral leg weakness and local tenderness over lumbar spine. MRI examination premature labor at 32 weeks gestation. The initial symptoms were controlled, but over the next revealed disc space infection at the L3-4 level with adjacent vertebral osteomyelitis. CT guided several days, the pt developed a cough, dyspnea, RUQ abd pain, and fever of 39C. Evaluation aspiration of L3-4 space was performed and cultures grew Candida albicans. Treatment was of blood, urine, and amniotic fluid cultures was unremarkable. CXR revealed bibasilar instituted with IV Amphotericin B via Mediport. Therapy was switched to oral fluconazole 400 atelectasis versus infiltrate, and she received azithromycin and ceftriaxone for presumptive mg daily. In March 2001, he developed Mediport related Staphylococcus aureus sepsis and was pneumonia. The pt remained febrile with increasing RUQ pain. Labs revealed declining Hb treated with cefazolin for two weeks. Patient was re-admitted in April with worsening back (7.1), WBC (5.6 with 56% bands), and Plt counts (62,000), with rising liver transaminases pain. MRI examination revealed worsening inflammatory changes within L3 and L4 vertebral (AST 2490, ALT 796), INR 2.5, T. Bili 2.2. RUQ U/S showed hepatomegaly and fatty liver. bodies and small epidural abscess. CT guided aspiration was performed and cultures grew Considering her worsening condition, obstetrics performed a C-section on hospital day 5. methicillin sensitive Staphylococcus aureus. We started treatment with Nafcillin 2 gm IV every 48 Abstracts JGIM

4 hours in addition to fluconazole. Surgical debridement followed by physical therapy and long CASE INFORMATION: A 28 year old white male with no significant past history was term IV antibiotics controlled our patient's symptoms. referred for preoperative clearance for left foot amputation. Patient had non-healing ulcers on IMPLICATIONS/DISCUSSION: Candidal vertebral osteomyelitis is a rare disease with 65 his left heel and ankle for 1 month with no response to antibiotics. One year prior, he had a flu- cases identified in literature. Risk factors have been associated with hyperalimentation, surgical like illness, hematuria and painful left testicle which resolved spontaneously except for a procedures, abdominal surgeries, immunosuppressive therapy and IV drug abuse. The usual persistent dry cough. CXR revealed a spot on the left lung. His TB skin test was negative. The mode of spread is hematogenous during episodes of fungemia. The most frequent mode of patient denied hematospermia, weight loss, night sweats, trauma, neurologic or GI symptoms. presentation is severe back pain and diagnosis can reliably be made only when the organism is On exam he was a healthy appearing male with previously unnoticed 2 crusted, raised lesions isolated from the lesion. Both medical and surgical treatment resulted in more favorable measuring 2.5 Â 2.5 cm on the left arm. These lesions had not been documented during his outcome for most patients. This case demonstrates the importance of recognizing fungal earlier visit notes though patient admitted to having these lesions for many months. He also vertebral osteomyelitis as a cause of worsening back pain in patients with history of back had 3 left foot lesions, 1 on the heel and 2 draining lesions on the left malleolus. A plain film of trauma and multiple back surgeries even in the absence of risk factors. left ankle revealed a lytic area in the distal tibial metaphysis. Bone scan was consistent with acute osteomyelitis. Biopsy of left bony lesion revealed chronic inflammation & giant cells but negative AFB stains and routine cultures. On H & E stain, a multinucleated, thick double A CASE OF STERNOCLAVICULAR JOINT SEPTIC ARTHRITIS. E.H. Elbadawy1, contoured wall of yeast with single, broad-based buds was visualized consistent with BD. The K. Gopal1; 1Fairview Hospital, Cleveland, OH (Tracking ID #76754) patient had complete resolution of all skin lesions and CXR after 6 months of itraconazole treatment. LEARNING OBJECTIVES: 1- To recognize the clinical picture of sternoclavicular septic IMPLICATIONS/DISCUSSION: BD is a fungus found in the soil and causes multisystemic arthritis. 2- To emphasize the importance of early diagnosis and treatment in preventing pyogranulomatous disease. Blastomyces in endemic in areas bordering Mississippi and Ohio devastating complications. river basins and the Great Lakes. Initial infection is usually via the lungs, can be asymptomatic CASE INFORMATION: A 43-year old white male admitted with 2 days history of worsening in 50% of patients or be mistaken for the flu or pneumonia. Pulmonary manifestations include dull aching pain, swelling and erythema at the right sternoclavicular joint (SCJ) area. Condition involvement of upper lobes with cavitation, mass lesion with productive cough, hemoptysis, started 2 days after he sustained a fall as he was wrestling with his 8-year old son. Patient denied dyspnea, pleuritic chest pain, low grade fever, night sweats, and weight loss. Skin lesions are fever, chills or dyspnea. Past medical history was significant for hypothyroidism and depression. usually painless, nonpruritic, hyperkeratotic, ulcerative plaques on the face or extremities and Patient denied IV drug abuse, alcohol intake or smoking. On examination he was febrile at 103 F may involve mucosa of nose, mouth and larynx. Other common sites of involvement include with pulse of 125 and blood pressure of 146/81. He appeared to be in pain with significant soft bone, genitourinary tract or CNS. If untreated, the clinical course can be months to years with tissue swelling, erythema and marked tenderness over the right SCJ. Range of motion of the remissions, exacerbations and progression in size. The rapid method of diagnosis is right shoulder was severely limited due to pain. Initial laboratory evaluation revealed WBCs of visualization of budding yeast in KOH mounts of pus from lesions. Definitive diagnosis is 12.5 k/AL and ESR of 56. Therapy was initiated with imipenem 500 mg IV every 6 hours for by growth of organism in culture. Treatment consists of 6 months of itraconazole in possible SCJ septic arthritis because of history of penicillin allergy. SCJ aspiration was immunocompetent patients. Amphotericin B is used in patients who are pregnant, seriously ill unsuccessful in obtaining any fluid. Computed tomography scan revealed soft tissue swelling & immunocompromised, with CNS infection or progressive disease on itraconazole. Our case around the right SCJ with no evidence of fluid collection. Three-phase bone scan showed stresses the importance of a thorough history and physical for appropriate management increased soft tissue activity and delayed bony uptake involving the right SCJ area. Blood especially in a disease that is known as the great masquerader. cultures drawn on admission grew methicillin- sensitive Staphylococcus aureus and therapy was switched to cefazolin 2 grams IV every 8 hours. Patient reported significant improvement is his symptoms after 3 days of intravenous antibiotics and was discharged home on cefazolin 2 gm IV NECROTISING FASCIITIS. C. Eze1, J. Wiese1; 1Tulane University, New Orleans, LA for total of 4 weeks. Follow-up one week later revealed complete resolution of the soft tissue (Tracking ID #77055) swelling, tenderness and erythema with painless full range of motion of his right shoulder. IMPLICATIONS/DISCUSSION: Sternoclavicular septic arthritis accounts for 1±9% of LEARNING OBJECTIVES: 1. Recognize the signs of deep fascial infections. 2. Use the septic arthritis cases. Predisposing factors include IV drug abuse, DM, central venous catheters physical examination to prompt timely surgical intervention for necrotizing fasciitis. and trauma. Aspiration of the joint can be helpful in confirming the diagnosis and guiding CASE INFORMATION: A 21 year-old Hispanic-speaking man presented with four days of treatment. Unfortunately, the failure rate with this method is high due to the technical left leg pain, swelling and fever after a spider bite. He had a temperature of 103 F, a heart rate difficulty in aspirating the small joint space, as in our patient. Clinical diagnosis requires a high of 128, and a blood pressure of 128/70. His left lateral leg was warm, edematous and tender. index of suspicion in any patient presenting with swelling and pain around the SCJ. Spread of There was a 1 cm ulcer without drainage or necrosis. The , sensation and range of infection can lead to superior vena cava obstruction, mediastinitis and septic shock. Early motion of were normal. A plain film of his leg showed no soft tissue air or bone involvement. diagnosis is critical in order to prevent life threatening complications. His WBC count was 22,000; the remaining laboratory values were normal. Blood cultures were obtained and he was empirically started on gatifloxacin due to a penicillin allergy. After 48 hours, he showed no improvement. Bullae and ecchymosis were noted on the second day; he lost sensation of the overlying skin on the third day. His antibiotic coverage was broadened to PANCREATITIS INDUCED BY ATYPICAL ANTIPSYCHOTICS Ð A NEW MECHANISM. include coverage for MRSA. An MRI revealed fluid collections between the muscle and fascia M. Eskildsen1, K. Lasser1; 1Cambridge Hospital, Cambridge, MA (Tracking ID #74000) consistent with necrotizing fascitis. An emergent fasciotomy and posterior compartment LEARNING OBJECTIVES: 1. To recognize the common side effects of atypical release were peformed. Wound cultures grew group A Strep. and Strep. milleri. antipsychotics. 2. To learn about a previously unreported complication of these drugs. IMPLICATIONS/DISCUSSION: The timely diagnosis of necrotizing fasciitis is important CASE INFORMATION: A 39-year-old man with a history of hepatitis C, schizophrenia, and to preventing tissue damage, systemic toxicity, limb loss or death. Cellulitis not responsive to past alcohol abuse was admitted with worsening abdominal pain and distension over one antibiotics, or the appearance of ecchymosis, bullae or anesthesia should prompt consideration month, accompanied by vomiting and watery diarrhea. He stated that he had been sober for of this diagnosis. The physical examination reflects the deep fascial structured damaged by the two years. His only medications were risperidone at 8 mg daily, and olanzapine at 10 mg daily. advancing infection. Ecchymosis, bullae and anesthesia reflect the damaged vessels, skin planes His psychiatrist had decreased the olanzapine dosage and attempted to discontinue his and nerves. While MRI is useful, establishing a timely pre-test probability prompting surgical prescription one year prior to admission due to poor response, but the patient had refused to exploration is the gold standard for making the definitive diagnosis. The closed space of deep do so for unclear reasons. Physical exam revealed a temperature of 37.8C; and a distended, fascial infections renders them immune from systemic antibiotics; treatment requires diffusely tender abdomen, without signs of ascites or peritoneal irritation. Laboratory immediate surgical release. Antibiotics only buy time for surgical intervention. evaluation was remarkable for triglycerides that were over 3800 mg/dl, our lab's upper limit of measurement, and a lipase of 250 U/l. Serum glucose was 553 mg/dl, with no prior readings in the diabetic range. A computed tomography of the abdomen indicated mild pancreatitis with AUTONOMIC DYSFUNCTION AFTER HEAD TRAUMA. C. Eze1, J. Wiese1; 1Tulane no biliary obstruction. On admission, after discontinuing both medications, we gave him University, New Orleans, LA (Tracking ID #77084) intravenous fluids and nothing by mouth, as well as patient-controlled analgesia with intravenous morphine. Upon discharge, one week later, he was pain-free, and his triglycerides LEARNING OBJECTIVES: 1. Identify the subtle presentation of autonomic dysfunction in and glucose decreased to 308 and 250 mg/dl, respectively. Of his antipsychotics, risperidone the elderly. 2. Recognize the association between autonomic dysfunction and spinal cord alone was resumed before discharge, up to a dose of 8 mg daily two months later. He has lesions. remained without abdominal pain, with serum triglycerides in the 300 range, and persistent CASE INFORMATION: An 81-year-old man presented with acute confusion following six diabetes mellitus treated with metformin. months of progressive lower extremity weakness. He had fallen two weeks prior resulting in a IMPLICATIONS/DISCUSSION: A MEDLINE search yielded two reports of pancreatitis periorbital hematoma. A CT had been obtained on two prior ER visits to exclude a sub-dural associated with olanzapine, and two with risperidone. Hyperlipidemia, including elevated hematoma, and was negative on both occasions. His initial blood pressure was 122/60 mmHg triglycerides, is a side effect of both drugs, although it is more commonly observed with with a pulse of 84. Fifteen minutes later his blood pressure dropped to 64/42 with a pulse of 134. olanzapine. However, this is the first described case of pancreatitis in relation to either of these Intravenous fluids resulted in a blood pressure of 175/104 mmHg with fifteen minutes. Ten two drugs that has been associated with massive hypertriglyceridemia, and we have reported it minutes later his blood pressure again declined to 55/39 mmHg He was placed on an as an adverse event to the FDA. Because he has tolerated risperidone well after discharge, epinephrine drip with an immediate and sustained response of his blood pressure to 169/101 olanzapine seems more likely to have precipitated his pancreatitis, although a synergistic mmHg. His examination was notable for flat neck , no S3, and normal lung sounds. His mechanism between the two drugs is another possibility. This case illustrates the need for close reflexes were absent in both lower extremities without a Babinski's response; his upper extremity monitoring of lipids and glucose in patients taking atypical antipsychotics. reflexes were 1+. His laboratory values, including cortisol, were normal. The EKG revealed atrial fibrillation. There was no on repeat head CT. Owing to the suspicion of autonomic insufficiency, cervical-spine X-ray was obtained, revealing compression fractures involving the C4 to C7 vertebrae. He was admitted to the ICU and neurosurgery was consulted. DOC PLEASE DO NOT CUT MY FOOT OFF! S. Estes1, M. Panda1; 1University of IMPLICATIONS/DISCUSSION: Wide hemodynamics variations should prompt considera- Tennessee±Chattanooga Unit, Chattanooga, TN (Tracking ID #77019) tion of autonomic dysfunction, that should in turn prompt suspicion for an occult spinal cord LEARNING OBJECTIVES: 1. Recognize the varied presentations of Blatomycosis lesion. This is especially true in elderly patients who may not be able to verbalize cervical pain. Dermatidis (BD) infection 2. Recognize the importance of a thorough physical exam. Hypertention and bradycardia may result from spinal cord reflexes unopposed by central JGIM Volume 18, April (supplement 1) 2003 49

regulatory mechanisms. Support of vascular tone with vasopressors is critical to resuscitation. CASE INFORMATION: A 55-year-old male ex-smoker with no significant past medical This case emphasizes the importance of a careful cervical spine evaluation in all falls involving history presented to clinic with paresthesias of the right upper and lower extremities, followed the elderly. by gradual onset of ataxia, diplopia, and dysarthria over a period of five months. The patient also reported weight loss and a chronic dry cough. The patient had no history of toxic exposures or family history of inherited ataxias. Physical exam revealed optical dysmetria, truncal ataxia, finger-to-nose dysmetria, and dysdiadochokinesis. The patient's speech was RHABDOMYOLYSIS, ACUTE RENAL FAILURE AND HEPATITIS SECONDARY TO HIGH severely dysarthric, and sensation was decreased on the right upper and lower extremities. DOSE SIMVASTATIN. D. Fabro1, M. Trexler1; 1Wright-Patterson Air Force Base, Wright- Magnetic resonance imaging (MRI) of the brain was normal. HIV and RPR serologies were Patterson AFB, OH (Tracking ID #76418) negative, and TSH was within normal limits. Lumbar puncture revealed paraneoplastic antibodies, including anti-Hu, anti-P/Q type , and anti-acetycholine receptor. LEARNING OBJECTIVES: To recognize that high dose simvastatin monotherapy, although Computerized tomography (CT) of the thorax demonstrated a 2 cm left hilar mass. having an excellent safety profile, can cause significant rhabdomyolysis, acute renal failure and Bronchoscopy and endobronchial biopsy were negative, but subsequent thoracotomy and hepatitis in the right patient population. To recognize that the addition of a potent or weak biopsy revealed small cell lung carcinoma (SCLC). cytochrome P450 inhibitor is not needed for the significant adverse effects of simvastatin to IMPLICATIONS/DISCUSSION: The differential diagnosis of chronic ataxia includes occur. primary and metastatic neoplasms, paraneoplastic syndromes, progressive multifocal leukoen- CASE INFORMATION: A 62 y.o. woman developed increasing myalgias, malaise, shortness cephalopathy, multiple sclerosis, hypothyroidism, tabes dorsalis, inherited ataxia syndromes, of breath and dyspnea on exertion over 1 week and left lower extremity swelling. Medications vitamin E deficiency, toxic exposures, and stable gliosis due to stroke or demyelination plaque. included simvastatin 80mg daily with normal baseline transaminase levels and diltiazem for the In approximately 80% of cases with paraneoplastic cerebellar degeneration, the underlying past year. CXR revealed mild bilateral pulmonary edema and an ultrasound of the left lower tumor is SCLC. Fifty-one percent of patients with cerebellar degeneration and SCLC have extremity revealed no . Exam revealed in ill appearing female in moderate detectable anti-Huantibodies. Other antibodies foundin paraneoplastic cerebellar degenera- distress secondary to myalgias, mild rhonchi bilaterally, normal heart tones and bilateral lower tion include anti-P/Q calcium channel, anti-Yo, anti-Ma1, anti-Tr, and anti-CV2, but their extremity dependent edema (Lt>Rt). Laboratory studies: alkaline phosphatase 177, AST 1511, exact sensitivities and specificities are not yet known. Therapy is supportive, and symptoms ALT 224, LDH 1396; creatinine 5.6 (baseline 1.4±1.7); BUN 92; potassium 5.6; phosphate usually do not improve with immunosuppression or treatment of the tumor. In conclusion, 6.5; calcium 8.8; creatinine phosphokinase >20,000; troponin <0.05; CKMB 171; TSH wnl; paraneoplastic cerebellar degeneration with paraneoplastic antibodies should be considered in uric acid 8.0. Urinalysis revealed a large amount of blood with only 4±10 red blood cells. all patients with chronic ataxia without other predisposing etiologies. Simvastatin was discontinued. Aggressive treatment with sodium bicarbonate, intravenous hydration and hemodialysis was begun. Over a sixty-plus day hospital course, the patient's renal failure resolved (baseline creatinine now 2.2±2.4) and transaminases normalized. The patient was eventually discharged to home to continue physical rehabilitation with no permanent requirement for hemodialysis. AN UNCOMMON PRESENTATION OF A COMMON ORGANISM. G. Fareau1, R. Pinto- IMPLICATIONS/DISCUSSION: Simvastatin's long term safety profile is excellent. Powell1; 1Dartmouth Hitchcock Medical Center, Lebanon, NH (Tracking ID #76736) Simvastatin induced rhabdomyolysis is reported with low incidence (0.6% in one study involving 80mg of simvastatin) and it is seldom associated with acute renal failure or hepatitis. LEARNING OBJECTIVES: 1. Discuss the presentation of primary bacterial . Myopathy and rhabdomyolysis increases with dose and with concomitant use or addition of 2. Recognize group A beta-hemolytic Streptococcus as a rare but serious cause of primary potent cytochrome P450 3A4 (CYP450) inhibitors, i.e. fibrates, cyclosporine, azathiaprine. A peritonitis. baseline severe renal insufficiency (creatinine clearance by the Cockroft-Gault method, 17cc/ CASE INFORMATION: A 52 year old woman presented to the Emergency Room with a min) and a urinary tract infection treated with a fluoroquinolone 2 days prior, combined to four day history of fevers, chills, and profuse watery diarrhea with associated crampy lower increase the risk of this patient developing rhabdomyolysis. Published reports of simvastatin abdominal pain. She denied any nausea, vomiting, cough, dysuria, or headaches. She denied induced myopathy involve the addition of potent or weak CYP450 inhibitors. Our patient had any recent travel or sick contacts, but noted that the symptoms began hours after having been stable on high dose simvastatin and diltiazem (a weak CYP450 inhibitor) for over 1 year eaten at a Chinese restaurant. Her past medical history was remarkable for a prior prior to presentation and did correlate with the addition of known CYP450 inhibitors. appendectomy, she was on no medications, and her family history was significant only for Additionally unique, this is the first reported case involving the combined toxicities of colon cancer in her mother. Her exam revealed a temperature of 38.7 C, a blood pressure of rhabdomyolysis, acute renal failure and hepatitis with high dose simvastatin monotherapy. 72/40, and a pulse of 112, with abdominal tenderness and guarding in both lower quadrants. Labs showed a white cell count of 5.7 (with a bandemia of 52), a potassium of 2.4, a bicarbonate of 15, a Blood Urea Nitrogen of 52, and a creatinine of 3.7. Liver function tests, amylase, lipase, and urinalysis were all normal. Fecal leukocytes were absent and her EXTRAPONTINE MYELINOLYSIS AFTER RAPID CORRECTION OF HYPONATREMIA. abdominal film showed only a few air-fluid levels. It was the impression of all clinicians G. Falchook1,L.Lu1; 1Baylor College of Medicine, Houston, TX (Tracking ID #74523) involved that the patient's presentation was most consistent with acute infectious diarrhea and profound dehydration complicated by renal failure and electrolyte derangement. LEARNING OBJECTIVES: 1) Review appropriate treatment of severe symptomatic Following aggressive hydration with IV crystalloids, the patient's blood pressure improved hyponatremia. to 120/80 and her heart rate slowed to 88. After blood, urine, and stool cultures were taken, 2) Recognize the dangers of rapid correction of hyponatremia. she was started on IV ciprofloxacin for empiric treatment of her presumed acute infectious CASE INFORMATION: A 56 year-old man with a history of alcohol abuse was admitted to diarrhea. She continued to have diarrhea over her hospital course, but her abdominal pain an outside hospital with altered mental status. On exam, the patient was disoriented, but and temperature curve lessened, and she appeared to be improving clinically. All cultures neurological exam was otherwise nonfocal. Computerized tomography (CT) of the head was (including c. difficle and giardia screens) had returned negative. On hospital day four, her unremarkable. Laboratory results revealed hyponatremia with sodium of 104 mmol/L. The fever and abdominal pain worsened and her abdomen became distended, rigid, and equisitely patient was given hypertonic saline, and the sodium was corrected to 123 within the first 24 tender. An abdominal CT showed diffuse thickening of her colon with ascites and dilated hours. The patient was then transferred to our facility for continuation of his care. Physical loops of small bowel. An emergent exploratory laparotomy was performed and several liters examination on arrival revealed multiple focal neurological findings including bilateral eye of cloudy yellow ascites were drained. A nectrotic mesenteric lymph node filled with pus was deviation to the left, neck deviation to the left, absent gag reflex, and poor motor coordination resected and her abdomen was irrigated with several liters of saline. Gram stains of both the with spastic movement of all extremities. The patient's speech was severely dysarthric and pus from the lymph node and the ascitic fluid revealed gram positive cocci in chains, and she unintelligible. Magnetic resonance imaging (MRI) of the brain showed enhancement of the was promptly started on IV clindamycin. Cultures of the ascites and pus grew group A beta- motor cortex of both cerebral hemispheres and enhancement of the frontal eye fields on the left hemolytic Streptococci, and she was continued on the clindamycin. She continued to with sparing of the adjacent sensory cortex. In consideration of the MRI findings, improve over her hospitalization and made a full and healthy recovery. consultation was sought. The patient's severe dysarthria, dysphagia, ataxia, and optic apraxia IMPLICATIONS/DISCUSSION: Primary bacterial peritonitis occurs as a result of bacterial were attributed to extrapontine (as opposed to central pontine) myelinolysis from rapid infection of the peritoneal cavity and is distinguished from secondary peritonitis by the absence correction of the patient's hyponatremia. of any underlying cause or demonstrable abdominal source. The onset is often rapid and IMPLICATIONS/DISCUSSION: Severe symptomatic hyponatremia should be treated with insidious, and is marked by the appearance of fever, nausea, abdominal pain, and diarrhea. The hypertonic saline, but with a correction in plasma sodium of not more than 1±2 mmol/liter/ patient typically has abdominal rigidity and rebound with features of systemic inflammation hour and a maximum increase of 8 mmol/liter during the first 24 hours. Our patient's sodium (tachycardia, hypotension, tachypnea, etc.) which may progress to frank shock. Streptococcus was corrected from 104 to 123, with an increment of 19 within 24 hours. Rapid correction may pyogenes, or group A Streptococcus, is a very common human pathogen, with up to 15% of result in osmotic demyelination or central pontine myelinolysis, which is characterized by asymptomatic individuals carrying the bacterium (typically in the upper respiratory tract). flaccid paralysis, dysarthria, and dysphagia. Isolated extrapontine myelinolysis is extremely However, primary bacterial peritonitis due to Streptococcus pyogenes is exceptionally rare, with only two cases reported in the literature. The neurologic deficits depend on the uncommon with very few adult case reports documented in the literature. It may be slightly anatomical location of osmotic demyelination. Treatment is supportive, and recovery is slow more common in women, with asymptomatic colonization of the genital tract acting as a portal within weeks to months. Gradual correction of hyponatremia is important because aggressive of entry. The diagnosis is often made only at laparotomy and despite the profound morbiditiy correction can cause not only central pontine myelinolysis but also the unusual manifestation associated with the disease, rapid initiation of the appropriate antibiotics usually results in a of extrapontine myelinolysis. successful cure.

PARANEOPLASTIC CEREBELLAR DEGENERATION AND PARANEOPLASTIC ANTIBODIES IN SMALL CELL LUNG CARCINOMA. G. Falchook1,L.Lu1; 1Baylor EUREKA! A TREATABLE CAUSE OF DIZZINESS. E.J. Favus1,R.Ambrosino1, College of Medicine, Houston, TX (Tracking ID #74527) R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73835)

LEARNING OBJECTIVES: 1) Construct a differential diagnosis of chronic ataxia. LEARNING OBJECTIVES: 1. To recognize and treat non-sustained ventricular tachycardia 2) Review the etiology, presentation, and prognosis of paraneoplastic cerebellar degeneration. (NSVT). 2. To recognize the differential diagnosis of dizziness. 50 Abstracts JGIM

CASE INFORMATION: A 70 year-old male with a history of gout, hypertension, chronic USING THE HEAD AND NECK EXAMINATION TO DIAGNOSE FOCAL NEUROLOGIC renal insufficiency, and hypercholesterolemia presented to his primary care physician DEFICITS. D. Fotino1, N. Parekh1; 1Tulane University, New Orleans, LA (Tracking complaining of intermittent dizziness. He had approximately three episodes per week, each ID #77089) lasting ten minutes, and resolving spontaneously. He described feeling ``lightheaded'' during LEARNING OBJECTIVES: USE THE EXAM SKILLS TO DIAGNOSE FOCAL each episode, and denied a positional component, vertigo, visual disturbances, tinnitus, NEUROLOGIC DEFICITS. history of seizures, aura, post-ictal state, loss of consciousness, palpitations, chest pain, and CASE INFORMATION: A 41 year-old diabetic man presented with a sudden onset of slurred shortness of breath. An EKG shortly after the first episode showed no rhythm speech and left-sided weakness. On examination, he had severe dental caries, slurred speech, abnormalities, ischemia, or infarction. His chronic medications were simvastatin, allopur- and a left facial droop. His tongue deviated to left on protrusion, and he had left upper and inol, and lisinopril. Physical examination revealed a blood pressure of 156/84mmHg, pulse lower extremity weakness. There was tenderness over the right mastoid process. His WBC was 66, and respiratory rate 16. He did not have . Cardiac exam revealed 27,000 with 14% bands. A CT showed subdural fluid collection in the right frontoparietal a non-displaced PMI, regular rate and rhythm, normal S1 and S2 with no murmurs, region. Vancomycin, ceftazidime and metronidzaol were empirically started for a presumptive gallops, or rubs. Holter monitor testing revealed multiple episodes of multifocal ventricular diagnosis of subdural empyema. Shortly after admission, he deteriorated to persistent and ectopy including short runs of ventricular bigeminy, trigeminy, and quadrigeminy with a refractory status epilepticus. The CSF protein was 149; WBC 630 (70% neutrophils); the gram heart rate of 80 beats per minute. He was diagnosed with non-sustained ventricular stain was negative. A repeat CT showed an area of hypodensity and a midline shift, consistent tachycardia (NSVT). A review of the patient's log revealed that each tachyarrhythmic event with subdural empyema. He underwent drainage of the abscess; the cultures grew out correlated with an episode of dizziness. He underwent echocardiography, which showed a pseudomonas aeruginosa. Ciprofloxacin was added to his regimen to double cover the structurally normal heart and an ejection fraction of 55%. He was prescribed metoprolol pseudomonas. His seizure activity relented soon thereafter. 12.5mg po qam, and at a one-month follow-up visit reported improvement in his IMPLICATIONS/DISCUSSION: Sinusitis is the leading cause of subdural empyema, and symptoms. can present with focal neurological signs if intra-cerebral extension occurs. Diabetic patients IMPLICATIONS/DISCUSSION: Dizziness is a common complaint heard by primary are also at risk for malignant external otitis, and empiric coverage for pseudomonas is care physicians, yet only a small percentage of patients receive a firm diagnosis and an warranted at even the lowest level of suspicion. Although this patient's symptoms suggested a effective treatment. In this patient, the discrete nature of these episodes hinted at the cerebrovascular accident, the finding of mastoid tenderness directed the diagnosis towards the possibility of a cardiac arrhythmia. Clinical suspicion for a cardiac problem prompted an infected mastoid sinus and the subdural abscess. In diabetic patients, empiric pseudomonas evaluation by Holter testing. The results showed a temporal relationship between NSVT coverage should be initiated early; double coverage should be instituted when a pseudomonas and dizziness, and provided evidence for a firm diagnosis. Patients with NSVT and a infection is confirmed, as this reduces the mortality of deep tissue infections by 50% when structurally normal heart are not at risk for sudden death, and may be treated with compared to single coverage. A thorough examination of the oro and nasopharyngeal cavities daytime oral beta-blocker therapy to decrease symptoms. Conversely, large studies have can direct and expedite diagnostic testing and prevent grave sequelae of treatable diseases. shown that the combination of NSVT and a structurally abnormal heart is a risk factor for sudden death. Treatment of NSVT with a structurally abnormal heart requires the use of an Automatic Implantable Cardioverter-Defibrillator (AICD). Beyond cardiac arrhyth- A ROCKY SITUATION. F. Francois1, J. Park1, C.T. Tenner2, S. Finkelstein1; 1New York mias, dizziness has many causes. A proper history of the dizzy patient should include University School of Medicine, Brooklyn, NY; 2New York University School of Medicine, New questions about syncope, hyperventilation, anxiety, visual disturbances due to incorrect York, NY (Tracking ID #74431) eyeglasses or diplopia, and . Physical examination should evaluate orthostatic hypotension, hypertension, and peripheral neuropathy. Anemia and hypoxia should be LEARNING OBJECTIVES: 1. Recognize the potential for bowel dysfunction in chronically evaluated by laboratory studies. ill patients 2. Consider the differential diagnosis of lower gastrointestinal bleeding in the elderly population 3. Review the management of stercoraceous masses. CASE INFORMATION: A 72-year-old HIV positive Hispanic male on highly active anti retroviral therapy (CD4 = 612 cells per cubic millimeter, viral load<50 copies per milliliter), was admitted for evaluation of hematochezia. The patient had a history of poorly controlled hypertension and had been hospitalized three weeks prior to this presentation with an acute PUTTING IT ALL TOGETHER: A CASE OF PRIMARY HYPOGONADISM. E.J. Favus1, change in mental status during which he was found to have a basal ganglia infarct. The R.C. Brooks2, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA; 2Pittsburgh VA family reported that the patient had been mainly bed bound since the stroke, and had Healthcare System, Pittsburgh, PA (Tracking ID #73840) intermittently complained of difficulty moving his bowels without any associated abdominal pain, nausea, or vomiting. On physical exam the patient was noted to have a right facial LEARNING OBJECTIVES: 1. To recognize the clinical presentation of male hypogonadism. droop, right-sided hemiparesis, and normal active bowel sounds without abdominal 2. To recognize the differential diagnosis of acquired primary hypogonadism. distention, tenderness, or guarding. On a freely mobile mass was palpated CASE INFORMATION: A 66 year-old male presented with bilateral gynecomastia, in the vault and bright red blood was seen on the glove. Laboratory evaluation was osteoporosis, and erectile dysfunction. Three years ago he was seen by a urologist for significant for a seven-point hematocrit drop from his baseline. On colonoscopy the patient erectile dysfunction and hesitency. He was diagnosed with a low testosterone state was found to have 3 discontinuous areas of ulceration in the rectosigmoid region, with the (laboratory values unavailable), and treated with testosterone. He had improvement of his largest measuring 6cm  2cm. The ulcers were associated with 3 large (4cm in diameter) erectile dysfunction but worsening of his hesitency and was switched to sildenafil. No hard fecal masses (fecalomas). The fecalomas were manually evacuated and the patient was cause was found for urinary hesitancy, but he was treated with tamsulosin without relief. started on a bowel regimen consisting of stool softeners and hydration. The patient's Two years ago he fell and broke his left fourth metatarsal. Dual x-ray absorptiometry scan hematocrit remained stable with no further episodes of rectal bleeding and he was discharged revealed a T-score of À2.7, and he was treated with alendronate. He denied a history of to to the care of his family. glucocorticoid use. One year ago he noticed increased breast tissue bilaterally and a mass IMPLICATIONS/DISCUSSION: Elderly patients may develop bowel dysfunction due to in the right breast. A bilateral mammogram was negative and a breast biopsy was negative diabetes mellitus, hypothyroidism, renal failure, , immobilization, cerebrovascular for malignant cells. His medical history is significant for tinea capitis, treated with 2% accidents, and medications. Once chronic constipation occurs the patients are at risk for fecal ketoconazole shampoo. His medications are sildenafil, alendronate, and ketoconazole impaction and stercoral ulcers (a.k.a. Huntley syndrome). These ulcers result from pressure shampoo. He has no history of alcohol, tobacco, or drug use. Physical examination reveals necrosis on the colonic mucosa by the rock-like fecal mass. Patients may present with rectal a normal thyroid, moderate bilateral gynecomastia without masses, no kyphosis, and bleeding or colonic perforation with peritonitis. In the elderly population, the differential of normal size and shape of the penis, testicles, and prostate. Laboratory tests show total hematochezia as a presenting sign in the setting of a change in bowel habits includes, testosterone 239 ng/dL (241±827ng/dL), free testosterone 5.28 ng/dL (5±21ng/dL), FSH malignancy, infectious colitis, and . Initial management of a stercoral lesion 32.1 mIU/mL (adult male normal range 1.55±9.70 mIU/mL), LH 14.7 mIU.mL (adult involves manual evacuation of the stecoraceous mass followed by a bowel regimen with stool male normal range 0±9.0 mIU/mL), prolactin 13.0 ng/mL (adult male normal range 3.7± softeners along with adequate hydration. Patients with recurrent ulcer bleeding or perforation 17.9 ng/mL), TSH 4.13 uIU/mL (0.35±5.5 uIU/mL), PSA 1.68 ng/mL (0±4ng/mL). may require surgery as definitive therapy. Given his low-normal testosterone and his clinical symptoms, he was re-started on testosterone therapy. IMPLICATIONS/DISCUSSION: The clinical presentation of osteoporosis, erectile SEA-BLUE HISTIOCYTOSIS: A NEWLY REPORTED COMPLICATION OF dysfunction and gynecomastia should provoke a search for a unifying diagnosis of PARENTERAL NUTRITION. S. Frost1; 1Cleveland Clinic Foundation, Cleveland, OH hypogonadism. The medical history of this patient is suggestive of a low testosterone state. (Tracking ID #73897) His serum testosterone level is in the very low-normal range, and the FSH and LH levels needed to maintain this low-normal testosterone level are three times the upper limit of LEARNING OBJECTIVES: 1) Diagnose sea-blue histiocytosis syndrome as a complication normal. High levels of FSH and LH exclude the diagnosis of secondary and tertiary of total parenteral nutrition (TPN). 2) Recognize that bone marrow sea-blue histiocytes are hypogonadism. The low-normal level of testosterone has not been enough for this patient associated with many diseases in which the degradation of lipids and cellular lipid products is to avoid developing clinical disease. Male hypogonadism is defined as a failure of the testes exaggerated. to produce a sufficient amount of testosterone. Hypogonadism can be primary (testicular CASE INFORMATION: A 40 year-old man receiving chronic TPN with lipid emulsion after failure), secondary (pituitary failure), tertiary (hypothalamic failure), or combined primary esophagogastrectomy following caustic ingestion was admitted to the hospital with fever for 5 and secondary. Primary hypogonadism can be either acquired or developmental. Our days, jaundice, hepatitis, and pancytopenia. The patient did not appear ill. The physical exam patient's laboratory values suggest primary hypogonadism. Since he had normal sexual was notable for a clean subclavian Hickman catheter site without erythema or tenderness, development and fathered two children, he likely has acquired primary hypogonadism. hepatomegaly, no heart murmur, and no peripheral stigmata of endocarditis. Laboratory Acquired primary hypogonadism may be the result of amyloidosis, autoimmune destruction, revealed WBC = 3.8 K/uL, hemoglobin = 10 g/dL, platelet = 70 K/uL, AST = 223 U/L, cryptorchidism, leprosy, leukemia, mumps, polyarteritis nodosa, radiation therapy, trauma, ALT=160 U/L, alkaline phosphatase = 339 U/L, and bilirubin = 9.4mg/dL. Investigation for surgery (castration), or drugs such as cancer chemotherapy, ethanol, ketoconazole, bacterial, fungal, mycobacterial, and viral infection was negative. Abdominal sonogram and CT marijuana, or . In this patient, long term administration of ketoconazole scan revealed hepatomegaly without other abnormality. Echocardiogram revealed no shampoo for the treatment of tinea capitis may have resulted in acquired primary vegetations. Upper extremity ultrasound was negative for catheter associated thrombosis. hypogonadism. The Hickman catheter was removed and catheter culture specimens were sterile. Fever JGIM Volume 18, April (supplement 1) 2003 51

persisted despite therapy with piperacillin/tazobactam, vancomycin, fluconazole, and indications for surgical versus medical management may mean the difference between life and amphotericin B. Bone marrow biopsy revealed sea-blue histiocytes. TPN was held and death in patients with EPN. improvement in liver function abnormalities and cell counts began on hospital day (HD) 6 and 7 respectively. Fever dissipated on HD 8, and antimicrobials were discontinued. TPN was restarted without lipid emulsion, and the patient has remained well with resolution of HEPARIN INDUCED MYOCARIAL INFARCTION AND PANCREATIC NECROSIS. hepatitis and cytopenias. J.A. Garcia1; 1Wayne State University, Troy, MI (Tracking ID #74175) IMPLICATIONS/DISCUSSION: Sea-blue histiocytes (SBHs) are macrophages with lysosomal lipid accumulations that appear blue with Giesma staining. The sea blue LEARNING OBJECTIVES: Physicians should be able to recognize early adverse events of histiocytosis syndrome is a typically benign idiopathic disorder characterized by hepatosple- commonly prescribed drugs. nomegaly, purpura, thrombocytopenia, and pulmonary infiltrates. SBHs have also been noted CASE INFORMATION: 56 y/o male, previously heatlhy presented to ER with fever, left calf in association with hematologic disorders such as chronic myeloid leukemia, and metabolic pain and swelling which started after a brief hospitalization for a febrile illness. Lower illnesses such as Niemann Pick disease. SBHs in the bone marrow of patients with extremity dupplex revealed thrombosis involving the Left popliteal and lesser saphenous veins. hepatosplenomegaly, jaundice, and pancytopenia receiving TPN containing lipid emulsions He was started on unfractionated heparin. Labs: WBC 10.2, Hemoglobin 11.7 and Platelets, was first reported in 1996. Lowering the TPN lipid content has been shown to improve 386k. Infectious work up was negative and he was eventually switched to coumadin and pancytopenia. Lipid induced hematopoetic cell membrane alterations triggering macrophage discharged. On the 4th day, he presented with fever and worsening left calf pain. A Lower phagocytosis is one postulated mechanism accounting for TPN related sea-blue histiocytosis extremity dupplex showed progression of the involving the posterior tibial vein. (TPN-SBH). This patient's illness is consistent with prior descriptions of TPN-SBH, except Heparin was restarted. WBC count 16.1, Hemoglobin 9.7 and platelets 240k . The fourth day for fever, which has not been previously reported. However, the resolution of fever coincident of this admission Hb dropped to 6.5 with plts of 150k. On the 9th day, patient developed chest with the improvement in pancytopenia and hepatitis after the discontinuation of parenteral pain. EKG showed ST elevations and he had increased cardiac biomarkers compatible with lipids suggests an association with TPN-SBH. acute lateral Myocardial Infarction. Cardiac catheterization revealed clean coronary arteries. On the 12th day, he complained of constipation, abdominal distension and pain. Abdominal Series showed . Amylase 136, Lipase 73, ALT 21, AST 29, Alkaline Phosphatase 131, Tbili 0.9. WBC 27.2 Hemoglobin 11.7 and Platelets 72k. Because of the dropping platelets and the IT'S BLACK, IT'S HAIRY ... BUT IS IT A PROBLEM? C.C. Fu1, G. Applebaum1; multiple thrombotic events, heparin was held, antibodies drawn, and liperudine was started. 1University of California, Los Angeles, Los Angeles, CA (Tracking ID #74949) Heparin induced platelet aggregating antibodies were positive with ELISA. Abdominal CT LEARNING OBJECTIVES: 1. Recognize the presentation of black hairy tongue. 2. Review showed focal areas of low attenuation with peripancreatic fat stranding compatible with possible predisposing conditions. 3. Emphasize benign nature of this phenomenon. necrotizing pancreatitis. CASE INFORMATION: A 53-year-old Mexican man with no significant medical history IMPLICATIONS/DISCUSSION: Heparin is a widely used medication. Uncommon presented with one month of easy bruising and gum bleeding. The patient's only presentation of HITT should be early recognized to prevent unwarranted management. were occasional aspirin for pain and bayberry extract. Lab results were significant for 2.2 WBCs, Hb 8.2, and 4 platelets. Bone marrow biopsy revealed a hypocellular and fatty marrow consistent with aplastic anemia. The patient's three-week hospital stay was complicated. He WATER INTOXICATION AND DEATH AFTER ECSTASY INGESTION. R. Gardner1; had extraction of an infected tooth and was started on a peroxide-based swish and spit regimen. 1University of California, San Francisco, San Francisco, CA (Tracking ID #76558) Treatment for aplastic anemia was begun with anti-thymocyte globulin and cyclosporine. The patient experienced prolonged neutropenic fevers for which he was treated with ceftriaxone, LEARNING OBJECTIVES: 1. Recognize the common toxicities of ecstasy 2. Diagnose water tobramycin, metronidazole, and vancomycin. During this period, the patient's tongue was intoxication and its complications. noted to develop a dark gray, ``hairy'' appearance, the surface of which could actually be CASE INFORMATION: KD is a 20-year old woman brought into the UCSF ED because she brushed with the end of a cotton swab. developed altered mental status after taking ecstasy. Seven hours prior to admission, she took IMPLICATIONS/DISCUSSION: Black hairy tongue is a rare condition caused by the 1.5 tablets of ecstasy, while her companion took 2 tablets of the same preparation. They elongation of the filiform papillae associated with oral bacterial overgrowth. Black hairy tongue remained at home and ``drank lots of water.'' One hour prior to admission, KD complained of is idiopathic and has been associated with various predisposing factors including alcoholism, severe headache and multiple episodes of vomiting. She then ``stopped making .'' In the systemic illness, immunosuppression, cancer therapy, coffee, antibiotic use, and use of ED, KD was alert and oriented to person and place but appeared agitated and confused. She peroxide-based mouthwash. Our patient was a likely candidate to develop black hairy tongue as then had a generalized tonic-clonic seizure, became apneic, and was intubated. A NCHCT he had been given broad-spectrum antibiotics and used peroxide based mouthwash during showed bilateral uncal herniation with diffuse effacement of the sulci. Significant laboratory immunosuppressive therapy. Treatments for black hairy tongue have included topical retinoin abnormalities included leukocytosis, serum sodium of 124, rhabdomyolysis, and evidence of gel, podophyllum, and attempts at repeated tongue brushing. However, in consideration of our SIADH. A urine toxicology screen was positive only for amphetamines. An ECG showed sinus patient's underlying immunosuppression and profound thrombocytopenia, we chose not to tachycardia with diffuse ST elevations, and a chest radiograph showed bilateral patchy treat the patient's tongue. It is important not to complicate the treatment of an ill patient with infiltrates consistent with pulmonary edema. Repeat physical exam three hours after admission the unnecessary treatment of a benign, albeit strange, condition. documented the absence of brainstem reflexes. She expired 24 hours later, and her organs were harvested for transplantation. IMPLICATIONS/DISCUSSION: Ecstasy, or methylenedioxymethamphetamine (MDMA), FATAL BILATERAL EMPHYSEMATOUS IN A DIABETIC PATIENT is a recreational designer drug popular both for its pleasurable psychological effects and TREATED BY MEDICAL MANAGEMENT ALONE. S. Gala1, D.D. Dressler1; 1Emory for its safe reputation. Acute adverse effects can range from nausea, headache, and myalgias University, Atlanta, GA (Tracking ID #76935) to insomnia, paranoia, and depression. An ecstasy tablet often contains contaminants and other drugs. In addition, the dose of MDMA itself can range from 0 to 200 mg per tablet, LEARNING OBJECTIVES: 1. Recognize the signs of emphysematous pyelonephritis. and the toxic or even fatal dose range overlaps that of recreational use. The pattern of 2. Understanding the indications for surgical versus medical management of emphysematous major physical toxicity is usually hepatic, cardiovascular, hyperpyrexic, or cerebral, pyelonephritis. although DIC, rhabdomyolysis, and acute renal failure also contribute to morbidity. CASE INFORMATION: A 45 year old Mexican female with a history of diabetes mellitus Cerebral toxicity is manifested as seizures or , thought to result from was brought to the emergency room by her family for increasing abdominal pain and a four hyponatremia. In most cases, the low sodium level is hemodilutional; users often sweat day history of nausea, vomiting and diarrhea. There was no recent history of fevers, chills, or profusely and then drink large amounts of free water to rehydrate and to prevent dysuria. Initial examination revealed an ill-appearing woman, moaning in response to painful overheating. Occasionally, SIADH contributes to hyponatremia in this setting. In addition stimuli, but not following commands. Although she was afebrile and normotensive, her to the physical toxicity, ecstasy can also lead to increased risk-taking behavior. Despite the resting heart rate of 119 beats per minute established systemic illness. Her other examination widespread use of ecstasy and the range of potential toxicity, fatalities attributable to the was remarkable for right lower quadrant tenderness in a soft abdomen, but no peritoneal drug are uncommon. KD's demise likely began with ingestion of MDMA, which led to signs. There was evidence of costovertebral angle tenderness bilaterally. Initial laboratory water intoxication and SIADH. Hyponatremia followed, precipitating cerebral edema, results were consistent with diabetic ketoacidsosis (DKA). Leukocytosis and pyuria led to the increased , and then uncal herniation. Respiratory arrest occurred with additional admitting diagnosis of pyelonephritis. Declining mentation led to rapid transfer to compression of the brain stem. The immediate cause of death was hypoxic encephalopathy. the intensive care unit on the day of admission. Computed tomography (CT) of the abdomen Several case reports suggest young women, such as KD, and children appear to be at the showed bilateral emphysematous pyelonephritis, emphysematous cystitis, bilateral perineph- highest risk of poor outcomes associated with hyponatremia. This unfortunate case ric abscesses, and air surrounding the inferior vena cava (IVC). Broad spectrum antibiotics emphasizes the often overlooked and unpredictable morbidity and mortality associated with were initiated. Emergent urology consultation recommended medical management due to casual use of ecstasy. high perioperative mortality risk. Bilateral percutaneous drains were placed under CT guidance. Nevertheless, the patient's condition rapidly deteriorated with development of thrombocytopenia and septic shock, requiring intubation and pressor support. She died the GET YOUR COLONOSCOPY, GET YOUR CURE. D. Garrow1; 1New Hanover Regional following hospital day. Blood, urine and perinephric fluid cultures grew Klebsiella Medical Center, Wilmington, NC (Tracking ID #74301) pneumoniae. IMPLICATIONS/DISCUSSION: Emphysematous pyelonephritis (EPN) is a rare condition LEARNING OBJECTIVES: 1. Present a case of metastatic colon cancer. 2. Provide screening that causes an acute necrotizing parenchymal and perirenal infection due to gas-forming recommendations with colon cancer in a first-degree relative. 3. Discuss genetic factors uropathogens. Bilateral disease is exceedingly rare. EPN occurs predominantly in diabetic implicated in colon cancer. patients and in patients with urinary tract obstruction. E.coli, Klebsiella and Proteus are the CASE INFORMATION: The patient is a 57 year-old female who presented with most frequently identified organisms. Computed tomography is used for diagnosis and dysequilbrium and hand tremor for one month. Head MRI revealed multiple intracranial evaluation of the extent of disease. Antibiotics and percutaneous drains can lead to successful lesions. (fig. 1) Biopsy revealed poorly-differentiated adenocarcinoma. A colonoscopy was outcomes in patients with limited disease. However, nephrectomy is often considered the performed because of the above histology and a family history of colon cancer involving two treatment of choice, especially in patients with extensive disease or multiple poor prognostic brothers and a son. A near-obstructing mass was discovered in the right colon. Patient also had factors. Bilateral disease makes the surgical decision even more difficult. Understanding the liver, spleen and multiple lymph node involvement via PET scan. 52 Abstracts JGIM

CASE INFORMATION: A 63-year-old woman was referred to our center for evaluation of tinnitus in her right ear for 9 months. She described the sensation as, `like the sounds of a steam engine pumping in my ear,' and that it coincided with her heart beat. She noted that applying pressure with fingers over an area in the right retroauricular area would reduce this abnormal noise. Work-up at an outside hospital was negative including, carotid ultrasound, CT scan of mastoid and temporal bone, and MRI of the head and internal auditory canal. Examination was significant only for a loud continuos bruit over the retro-mastoid area. Complete blood counts, serum chemistry, and electrocardiogram was normal. Cerebral angiogram showed an extensive dural (AVF) affecting the distal transverse and sigmoid sinuses with supply through both internal and external carotid arteries as well as right vertebral artery. There was no evidence of cortical venous thrombosis. Thrombophilia work-up was normal. She underwent a combined transarterial embolization and stereotactic radiosurgery using gamma knife. Tinnitus resolved completely after intervention. She remains asymptomatic at the 3-month follow-up visit. IMPLICATIONS/DISCUSSION: Pulsatile tinnitus resulting in audible retro-auricular bruit could result either from systemic diseases, causing alteration in hemodynamic, or due to local disorders within or close to the petrous bone. The most common causes of pulsatile tinnitus includes benign intracranial hypertension, atherosclerotic disease, and glomus tumor. Dural AVF is a rare cause of pulsatile tinnitus (2%).However, 90% of patients with dural AVF present with pulsatile tinnitus. Dural AVF has been reported following trauma, infection, pregnancy related , surgery on the sigmoid and ethmoid sinuses. Cerebral angiogram remains the diagnostic modality of choice. If untreated, a third of dural AVF's develop intracranial bleeding or infarction. Treatment of dural AVF involves transarterial particulate embolization and radiosurgery using a gamma knife .High index of suspicion and thorough physical examination remains crucial in the early recognition of dural AVF.

MANAGING A DIABETIC PATIENT DURING RAMADAN: WHAT A PHYSICIAN NEEDS TO KNOW? P. Chahal1, A.K. Ghosh1; 1Mayo Clinic, Rochester, MN (Tracking ID #73907)

LEARNING OBJECTIVES: 1) Recognize the need for a thorough history taking in the management of patients with chronic medical illnesses. 2) Recognize principles of management of diabetes mellitus during Ramadan. CASE INFORMATION: A 40-year old female immigrant from Somalia with the history of poorly controlled type II diabetes for the past seven years was enrolled in our continuity clinic. She had been on numerous oral hypoglycemic agents without adequate benefit. Her blood glucose ranged from 200±380 mg/dl and glycosylated hemoglobin was 10.7%. She was started Figure 1 on insulin 70/30, 100 units in the morning and 70 units in the evening with addition of oral thiaglitazone agent. During the month of Ramadan her insulin dose was decreased to 50 units IMPLICATIONS/DISCUSSION: The majority of studies have shown a two- to four-fold in the morning and evening and she was advised to take her oral medication in the evening as increase in the incidence of colon cancer in patients with similarly afflicted first-degree most of her meals were spread over night till dawn. relatives. Screening for colon cancer with a positive history in a first-degree relative is advised While accompanying her daughter for routine checkup she complained of feeling of ten years prior to the index case. Hereditary nonpolyposis colon cancer (HNPCC) is a generalized ``shakiness'' which was new to her. We obtained a random blood glucose level, consideration in this patient. The genetic basis for HNPCC is heterogeneous involving which revealed a blood glucose of 37mg/dl. She was treated with supplemental glucose with chromosomes 2, 3, and 7. With the multiple genetic focus of HNPCC, genetic testing is complete resolution of her symptoms. Her insulin regimen was subsequently adjusted further seldom employed. The family is clinically positive for HNPCC as there are more than two and dietary education and hypoglycemia education was given. Frequent telephone calls were cases of colon cancer spanning at least two generations. HNPCC is caused by defective DNA made to adjust her insulin doses and monitor her blood . mismatch repair genes. Afflicted patients develop polyps at a rate similar to the normal IMPLICATIONS/DISCUSSION: Fasting in the month of Ramadan represents a recurring population. However, because of genetic defects, precursor adenoma lesions undergo a more annual event in the life of a Muslim patient. Patients with brittle type I diabetes and poorly rapid progression to carcinomas than usual adenomas. HNPCC typically presents during the controlled type II diabetes could develop complications during month long fasting with change fourth and fifth decades of life. Affected patients are predisposed to a higher frequency of in dietary habits. Physicians should monitor their diabetic patients closely and adjustment in proximal colonic lesions with more advanced pathology, as seen in this case. the insulin regimen should be made to prevent hypoglycemia. Long acting oral hypoglycemics and premixed insulin should be avoided. Dietary principles should be reinforced. Education DIAPHRAGMATIC PARALYSIS AS A COMPLICATION OF SHINGLES. A. George1, regarding home monitoring of blood glucose, hypoglycemia episodes is recommended. After R.D. Hobbs1; 1Oakwood Healthcare System, Dearborn, MI (Tracking ID #76605) Ramadan, patient's therapeutic regimen will need to be changed back with repeat overall education. Obtaining detailed history could help in ascertaining additional cultural factors LEARNING OBJECTIVES: To recognize that shingles, although most commonly thought which could interfere with management of chronic illnesses. of as a sensory problem with a characteristic rash, can cause diaphragmatic paralysis. CASE INFORMATION: A 71 year-old white male with stable hypertension, CHF and COPD, presented to the emergency room with severe dyspnea. He had a 12-year history of ADULT ONSET RECALCITRANT PRURITIS Ð TIME FOR A SERIOUS LOOK. P. Chahal1, chronic elevation of the left hemidiaphragm and had been well except for recent right-sided A.K. Ghosh1; 1Mayo Clinic, Rochester, MN (Tracking ID #74142) neck pain. There was no rash. He was intubated. The following day he developed a classic shingles rash involving the right side of the neck. An EMG revealed a right-sided C3-C4 motor LEARNING OBJECTIVES: 1) Recognize the differential diagnosis of worsening chronic neuropathy. Phrenic nerve function did not return. He died six weeks later when he extubated pruritus. himself at a nursing facility. Autopsy revealed that the chronic elevation of the left 2) Recognize that patients with adult-onset recalcitrant eczema may have underlying non- hemidiaphragm was due to a benign angiolipoma and unrelated to the viral infection. cutaneous lymphoproliferative disorder. IMPLICATIONS/DISCUSSION: Sir William Broadbent first described muscular paralysis CASE INFORMATION: A 38-year old male presented with history of two and a half years of in association with zoster in 1866. In 1949, Halpern and Covner published the first description insidious onset of severe itching involving his feet and gradually spreading and becoming of zoster induced diagphragmatic paralysis. Since then, anecdotal cases have been reported generalized in few months. Subsequently, he developed a rash, which consisted of hard although complete historical data is frequently missing and it has been difficult to elucidate the `bumps', intensely pruritic in nature. He was seen by several physicians and had multiple skin natural history of the condition. Based upon cumulative data from 10 well-documented cases, biopsies demonstrating folliculitis and wound cultures growing Staphylococcus species. several tentative conclusions can be made. The average patient is 69 years of age (range 54±79). Numerous treatment attempts were unsuccessful. The time from rash to paralysis can vary widely from almost immediately to 210 days. In 7/10 Examination revealed hundreds of equally spaced excoriated crusted pink papules measuring cases phrenic nerve function did not recover. In the remaining cases, recovery occurred up to 1 cm diameters. Rest of his systemic examination was normal. between 30 and 540 days later. The right side was affected in 7/10 cases although this is not Investigations revealed a normal complete blood count, hepatitis profile, and complement statistically significant. The ratio between male and female patients is 7/3 but not statistically levels. HIV and fungal serology and PPD test were negative. Skin biopsies showed chronic significant in this series. Pathologically, zoster induces a myelitis that involves the dorsal root dermatitis and the direct immunofluorescence was negative. Chest radiograph revealed ganglia. Why certain individual develop this rare complication is unknown and will require multiple lung masses and subsequent CT scan of chest revealed extensive anterior mediastinal, many further observations. At present, though, the point is clear±herpes zoster can cause bilateral hilar, right paratracheal, and subcarinal adenopathy and multiple bilateral pulmonary diaphragmatic paralysis in the elderly. In such cases the paralysis may develop as a late nodules. CT abdomen was normal. He underwent mediastinoscopy and lymph node biopsy, complication with a poor chance of recovery. which revealed the diagnosis of Hodgkin's Lymphoma, Nodular Sclerosing type. He was started on combination chemotherapy with ABVD. IMPLICATIONS/DISCUSSION: Chronic unexplained eczema and pruritus of adult onset WHAT'S ALL THE BUZZING ABOUT? S.K. Ahlawat1, A.K. Ghosh1, M.T. Cuddihy1; 1Mayo might be associated with underlying lymphoproliferative malignancy. Although pruritus has Clinic, Rochester, MN (Tracking ID #73909) been associated with Hodgkin's disease, the reports of prurigo nodularis' association with LEARNING OBJECTIVES: 1. Recognize the role of history and physical examination in the Hodgkin's lymphoma are rare. Prurigo nodularis is also associated with other malignancies like diagnosis of pulsatile tinnitus. 2. Identify an important treatable cause of pulsatile tinnitus. transitional cell bladder cancer, leukemia and HIV. When an obvious cause like drugs or atopy JGIM Volume 18, April (supplement 1) 2003 53

cannot be identified, a thorough systemic evaluation including careful physical examination mild flaking of the skin persisted. Three months later, the patient presented to the Breast and detailed evaluation maybe warranted. Clinic for evaluation of a mild, but persistent nipple rash. She denied breast lumps, pain or nipple discharge. Breast cancer risks included nulliparity, and use of hormone replacement therapy for nearly 40 years. SHOP 'TIL YOU DROP: A CASE OF HYPOKALEMIC PERIODIC PARALYSIS. B. Taqui1, On examination, there was mild scaling of the skin over the right nipple with no associated L. Kaplan1, A. Ghosh1; 1Temple University, Philadelphia, PA (Tracking ID #75959) induration, erythema or excoriation. On palpation, no dominant mass, nipple discharge, axillary LEARNING OBJECTIVES: 1. Recognize clinical manifestations of hypokalemic periodic or supraclavicular lymphadenopathy was identified. Mammograms revealed increasing micro- paralysis 2. Recognize association of this entity with hyperthyroidism 3. Recognize manage- calcifications in the sub-areolar region of the right breast. Stereotactic biopsy of these ment options for the condition. calcifications was performed and demonstrated high-grade ductal carcinoma in situ (DCIS). Skin CASE INFORMATION: 31 year old Asian male presented with complaint of inability to biopsy of the scaly region revealed Paget disease of the nipple characterized by tumor cells with move his arms and legs. His symptoms began one day prior to admission after walking a large nucleoli distributed singly in the superficial epidermal layers with clusters in the basal significant amount while shopping at a local mall. After leaving the mall, he started to portion of the epidermis. These tumor cells were immunoreactive to anti-cytokeratin 7 and experience numbness and tingling of his arms, legs and abdomen. Later that day, he started carcinoembryonic antigen (CEA) antibodies confirming the diagnosis of Paget disease. In to experience generalized weakness and went to sleep early due to fatigue. When he awoke compliance with the patient's wishes, right mastectomy was performed and on pathologic the morning of admission, he could not walk or move his body. He had to be assisted out of evaluation, residual DCIS was noted around the biopsy site along with Paget disease of the nipple. bed and brought to the emergency room. He had no prior medical problems and was not IMPLICATIONS/DISCUSSION: Paget disease, with an incidence ranging from 0.5 to 2.6%, taking any medications, drugs or supplements. Upon further questioning, he revealed that his presents as a scaly persistent rash, and often mimics eczema, or contact dermatitis of the nipple- mother has had problems with low potassium levels. His review of symptoms prior to this areolar complex. It may or may not be associated with a breast mass. Diagnosis is established by episode was completely negative. Physical exam was unremarkable except for neurological a skin biopsy, revealing characteristic Paget cells. Delay in diagnosis may result when the rash is exam. He was alert and oriented. His cranial nerves and sensory exam were intact. Motor mild in intensity and if unassociated with a breast mass. Clinical management of a patient with a strength was 0/5 in upper extremities and 1/5 in lower extremities. The patient was nipple, or areolar rash mandates continued follow-up. If the rash fails to resolve, a high index of areflexive. Labs: Na 145, K 2.0, Cl 106, CO2 16, creatinine .7, CPK 519, Ca 7.9, Phos 1.3, suspicion for Paget disease of the nipple will enable appropriate work- up and optimal outcome. Mg 1.5, TSH 0.0, T4 total 13.8, T3 total 236.4. His urinary potassium excretion was normal. EKG: low voltage t waves and uwaves. Patient was diagnosed with hypokalemic 1 1 periodic paralysis and treated with oral and intravenous potassium chloride. Within a few BREAST NODULE AFTER PROPHYLACTIC MASTECTOMY. K. Ghosh , K.R. Brandt ; 1Mayo Clinic, Rochester, MN (Tracking ID #75726) hours, his potassium improved to 5.0 and his strength was 5/5. The next day, he was discharged and told to follow up with endocrinology for his hyperthyroidism LEARNING OBJECTIVES: 1. Build awareness among physicians that prophylactic IMPLICATIONS/DISCUSSION: The diagnosis of hypokalemic periodic paralysis is made mastectomy does not completely eradicate the possibility of breast cancer. 2. Emphasize that most easily when is documented during an attack of weakness and other any breast lump after prophylactic mastectomy warrants complete work-up to rule out breast secondary causes are excluded. Attacks begin during the first three decades of life and occur cancer. during the rest period following exercise, stress or high carbohydrate meal. The condition can CASE INFORMATION: A 56 year-old lady with fibrocystic changes in the breast had develop in patients with a familial predisposition (autosomal dominant inheritance) or in those undergone several benign right breast biopsies for mammographically detected abnormalities, with thyrotoxicosis. The latter form is more common in Asian males. Although, the mechanism and finally decided to have bilateral prophylactic mastectomy to prevent the anxiety associated is not entirely understood, it is thought to be related to sudden shift of potassium into cells. with these biopsies. Following the mastectomies, she had bilateral pedicle transverse-rectus- Patients have normal potassium values between episodes and may have decreased magnesium abdominis-myocutaneous (TRAM) flap reconstruction of the breasts with a smooth post- and phosphorus during episodes. Treatment includes oral potassium chloride and correction of operative recovery. She was very satisfied with the outcome of the procedure. Four months thyrotoxicosis. Prevention may include beta blockers, oral supplements, potassium sparing after the surgery, the patient incidentally felt a lump in the left upper breast and when it drugs and low carbohydrate meals. Recognition is important because the condition can lead to persisted for about a month, the patient sought further evaluation. Examination revealed a respiratory muscle paralysis and subsequent death. firm, non-tender, fixed mass with ill-defined margins in the left upper breast. Ultrasound evaluation of the palpable mass revealed a heterogenic echotexture with no evidence of malignancy. Diagnostic left mammogram revealed no evidence of malignancy. Magnetic INFECTED RECURRENT GALACTOCELE Ð A MANAGEMENT DILEMMA. K. Ghosh1, resonance imaging of the breast with dynamic gadolinium enhancement was then M.J. Morton1, D.H. Whaley1; 1Mayo Clinic, Rochester, MN (Tracking ID #74293) recommended and showed benign appearing localized collection of fat lobules and post- LEARNING OBJECTIVES: 1. Emphasize the importance of draining an infected galactocele operative changes. The patient continues to do well on follow-up. and describe a less-invasive modality to achieve this. 2. Highlight follow-up measures in IMPLICATIONS/DISCUSSION: The management of women at high-risk of breast cancer women with a recurrent galactocele. includes the options of surveillance, chemoprevention, prophylactic mastectomy and/or CASE INFORMATION: A 37 year-old lady presented with a non-tender lump in her left prophylactic oophorectomy. Prophylactic mastectomy is an option for risk reduction of breast breast 4 weeks after birth of her fourth child. She was lactating without difficulty and denied cancer, and in women with a strong family history, has been associated with a 90% relative risk redness of the overlying skin or fever. Following clinical examination, she had an ultrasound of reduction. The procedure does not however, eradicate the risk of breast cancer as residual the breast revealing a 3.7cm cystic mass with internal echoes. Ultrasound-guided aspiration was breast tissue may be left behind depending on the surgical technique. Therefore, any breast performed and 30cc of milky fluid aspirated with complete resolution of the mass. However, lump after PM must be evaluated to rule out breast cancer. In general, breast lumps after PM the galactocele recurred within 24 hours but remained asymptomatic otherwise. Three weeks are often benign and related to fat necrosis as was the case in our patient, but the possibility of later, the patient presented with evidence of mastitis, was started on antibiotics, and the malignancy must be borne in mind when evaluating these patients. galactocele re-aspirated. With persistent signs of infection, galactocele-fluid cultures revealing Streptococcus viridans, and re-accumulation of the milk in the galactocele, incision and 1 drainage was contemplated. This was subverted with a less invasive means by inserting an 8 A MAN NEWLY DIAGNOSED WITH HIV REFUSES TO INFORM HIS SPOUSE. C. Gibbs , 1 1 french multiple side-hole pigtail catheter into the galactocele enabling complete drainage and J. Tsui ; Emory University, Atlanta, GA (Tracking ID #74714) healing of the underlying infection. The catheter was removed in 10 days and antibiotics given LEARNING OBJECTIVES: 1.) To appreciate a care giver's ethical and legal responsibilities for a total of 2 weeks. To prevent development of a milk fistula through the drain site, fluid re- when partner notification is refused by a newly diagnosed patient; 2.) To identify various accumulation was monitored with ultrasound and re-aspiration performed at 4 and 16 days partner notification strategies and weigh their advantages and disadvantages. after drain removal. The patient recovered with complete healing of the catheter tract. The CASE INFORMATION: A 36 year-old man presented to the emergency room complaining of galactocele persisted even after cessation of breast-feeding. A mammogram was then performed fatigue, shortness of breath, severe dyspnea on exertion, and cough worsening over several which revealed no findings of underlying malignancy. weeks. The patient had no significant past medical history and denied tobacco, alcohol, or IV IMPLICATIONS/DISCUSSION: A galactocele most commonly presents as a breast mass drug use. He denied any previous history of blood-product transfusions.He stated he had been soon after the cessation of lactation, and an ultrasound evaluation is usually confirmatory. These in a monogamous marriage for the ten years and had had no other sexual partners. Further, the masses usually disappear in few weeks to months. However, the persistence of a galactocele, patient reported a negative HIV test three years ago. Chest X-ray revealed bilateral patchy particularly after repeated aspirations, necessitates further work-up to rule out ductal opacifications without any focal consolidation. Laboratory results were significant for a WBC obstruction from an underlying malignant process. Our patient had another infrequent of 5.1, an LDH of 514, and an ABG of 7.46/39/55. The patient was admitted for community- complication Ð an infected galactocele. The concern of incision and drainage of a galactocele acquired pneumonia and started on ceftriaxone and doxycycline; however, given his clinical was that of a high likelihood of milk fistula. On the other hand, if not drained, infection was likely picture, the patient's sputum was sent for silver stain. It returned positive for pneumocystis to persist and progress to a breast abscess. An alternative was therefore considered of introducing carinii. The patient's medications were changed to trimethoprim/sulfamethoxazole and a pigtail catheter into the galactocele to enable complete drainage while instituting appropriate prednisone, and he was counseled about the likelihood of immunocompromise. At this point, antibiotic coverage. Catheter drainage of breast abscess has been described in the literature, but the patient agreed to HIV testing. He subsequently tested positive for HIV and had a CD4 this is the first report, to our knowledge, of catheter drainage of an infected galactocele. count of 26. Patient education regarding HIV infection and AIDS was initiated. The patient acknowledged the possibility that his wife may have been infected and agreed that she should be notified. Initially, he wished to talk with her himself (self-referral). After a few days, it was NIPPLE RASH Ð THE DICTUM OF ``FOLLOW UNTIL RESOLUTION''. K. Ghosh1, D.R. discovered that the patient had not disclosed his HIV status to his wife. With much Farley1, C.A. Reynolds1; 1Mayo Clinic, Rochester, MN (Tracking ID #75718) encouragement and further education, he agreed to a dual referral approach involving a LEARNING OBJECTIVES: 1. Alert physicians to the possibility of Paget disease of the healthcare provider being present when he notified his wife. However, when the appointed nipple in the case of a non-healing nipple rash. 2. Highlight the diagnostic tests required to meeting day arrived, the patient once again refused. Patient education and support continued. establish the diagnosis of Paget disease of the nipple. As the patient's discharge approached, the medicine team feared that the patient's wife would CASE INFORMATION: A 78 year-old lady reported a ``whitehead like'', non-irritating lesion never be informed of his seropositive status and her potential risk. These concerns were on her right nipple. Watchful waiting was recommended and over the course of the next 3 discussed with the patient and he was informed that if he did not notify his wife, the medicine weeks, this lesion progressed into a rash involving the nipple and areola with a painful central team would act according to state and federal laws and notify her of her HIV exposure and abrasion and crusting. With the use of antibiotic cream, the rash improved in 3±4 days but need for testing. The patient informed his wife within 24 hours. 54 Abstracts JGIM

IMPLICATIONS/DISCUSSION: This case demonstrates various approaches to partner revealing perivascular non-caseating granulomas, which while not diagnostic, will be highly notification and deals with the ethical and legal decisions physicians are forced to make when suggestive in the appropriate clinical context. newly diagnosed HIV patients refuse to participate. Partner notification strategies can be classified into three basic categories: self-referral, dual referral, and provider referral. Each approach has its own advantages and disadvantages. Regardless of the strategy chosen, the FOOLED BY FAT/PERPLEXED BY PROPOFOL. E. Gjersvik Cichowski1, H. Sakowski1, patient's rights to autonomy, trust, confidentiality, and safety must be respected while H. Hashish1, R. Baltaro1; 1Creighton University, Omaha, NE (Tracking ID #74955) balancing the physician's moral and legal responsibility to patients' partner(s), children, and LEARNING OBJECTIVES: 1) Recognize laboratory error in the measurement of serum community. Healthcare providers must recognize their responsibilities, know their federal and bicarbonate. state laws, and act according to individual cases. 2) Utilize the Henderson-Hasselbach equation to indentify blood gas analysis errors. 3) Recognize interfering substances as potential causes of laboratory errors. AN EARLY CASE OF WEST NILE VIRUS MENINGITIS. A.N. Githaiga1, P.K. Han1; CASE INFORMATION: A 72 year-old male was admitted for respiratory distress and 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #74953) confusion, and found to have a right upper lobe lung mass and hypercalcemia. He was intubated on the second hospital day due to worsening of his respiratory status. Propofol was LEARNING OBJECTIVES: 1) To recognize common clinical manifestations of West Nile initiated for sedation and methylprednisolone and levofloxacin were given for a presumed post- Virus infection. 2) To identify meningitis as a possible presentation of West Nile Virus obstructive pneumonia. His initial arterial blood gas after intubation showed a pH 7.38 pCO2 infection. 3) To acknowledge the need for a high index of suspicion for West Nile Virus 38 pO2 143 on an Fio2 of .60. His measured HCO3 was 26 meq/l. Over the next 4 days, his infection in cases of aseptic meningitis occurring in endemic areas. measured bicarbonate progressively dropped to 8 meq/l despite no change in his arterial blood CASE INFORMATION: A 50 year old African American man with no significant past medical gas (pH 7.38 pCO2 36 pO2 103 on an FiO2 of .45). His anion gap was calculated at 19. Serum history presented to the office with malaise, weakness, anorexia, watery diarrhea and mild lactate was normal, and serum ketones were absent. Consultation with the pathology headache of 2 days duration. He was treated conservatively for presumed viral gastroenteritis, department revealed the patient's serum to be grossly lipemic. A review of the chart revealed until he presented to the emergency room 2 days later with increasingly severe frontal headache the patient did receive lipid infusions with TPN 36 and 18 hours prior to this discovery. A lipid and fevers. Physical examination was remarkable for a temperature of 39.6 deg C and nuchal panel was obtained and revealed marked hypertriglyceridemia at 4426 mg/dl. The lipid rigidity, but no focal neurological signs or impaired sensorium. Laboratory studies included a infusions were discontinued, and the propofol was weaned off. The bicarbonate level dropped WBC count of 8800, and analysis which demonstrated a CSF WBC count to a low of 3 meq/l approximately 7 hours after the medication was discontinued. Four hours of 150/mm3 with a differential of 11% neutrophils, 88% lymphocytes, 1% monocytes, and a later, the bicarbonate had corrected to 21 meq/l. The serum, however, remained grossly CSF-protein level of 117 mg/dl. CSF gram stain was negative. The patient was admitted and lipemic. The patient's condition continued to decline with the development of septic shock, placed on empiric ampicillin and cefrtriaxone. Blood cultures and CSF bacterial, fungal and multi-organ failure and ventricular arrythmias. Results of a previous bronchoscopy protozoal studies remained negative. The patient slowly defervesced and his headache demonstrated small cell carcinoma. The patient's family requested no further aggressive improved, and he was discharged to home. Notably, this case occurred at a time when public treatment and he expired later that day. awareness of West Nile Virus infection in Allegheny County, Pennsylvania was just emerging; IMPLICATIONS/DISCUSSION: This patient developed marked derangement in his the virus had been isolated in several dead birds in the area, although there had been no measured bicarbonate levels that did not correspond to his arterial blood gas analysis. A reported cases of human infection. During the hospitalization, serum was therefore sent for laboratory error was hypothesized as the cause. Due to the finding of lipemic serum, the West Nile Virus serologic testing. Following discharge, results of IgM and IgG antibody hypertriglyceridemia was initially suspected as the interfering substance. Upon discontinuing ELISA assays subsequently returned positive, and were later confirmed by plaque reduction the propofol, the serum bicarbonate level normalized, the serum, however remained lipemic. In neutralization test (PRNT). The patient gradually improved, although notably after a review of the literature, neither propofol nor hypertriglyceridemia have been reported as developing a transient morbilliform rash on his chest, back and arms, observed during potential causes of this lab error. Further testing is needed to determine the role of propofol as outpatient follow-up approximately one week after discharge. an interfering substance in bicarbonate laboratory analysis. IMPLICATIONS/DISCUSSION: West Nile Virus infection is a mosquito-borne arboviral illness that is commonest in the United States in late summer and early fall. One of the early clues to an epidemic is the presence of dead birds in the surroundings. Infection is most often DYING TO BE THIN. R.E. Graham1; 1Lenox Hill Hospital, New York, NY (Tracking ID #75181) asymptomatic, and clinical illness is generally mild, presenting with constitutional symptoms much like those of other viral syndromes. Among patients with more serious CNS illness, LEARNING OBJECTIVES: This case demonstrates the limitations of our current knowledge isolated meningitis Ð such as occurred in our patient Ð is relatively less common than about herbal products, particularly in dose-related toxicities, and calls attention to the need for encephalitis or meningoencephalitis. Treatment is supportive, and advanced age is the biggest further studies. This case highlights the need for health care providers to be knowledgeable risk factor for severe neurologic disease. This case illustrates the need to consider West Nile about the herbal products their patients may be using, and to be able to identify potential herb- Virus infection, however, in cases of aseptic meningitis occurring in endemic areas.Diagnosis is associated adverse effects. I hope this case illustrates CAM's prevalence, benefits, and potential by serum or CSF IgM antibodies to West Nile Virus; first-line testing is by ELISA assay, and dangers but most importantly highlights the importance of obtaining a complete medical positive results are generally confirmed by the more specific PRNT. history; including asking our patients if they are using and/or incorporating alternative therapies into their general healthcare. CASE INFORMATION: 26 year old thin female presented to the ED at about 5:15 PM AN UNEXPECTED CAUSE OF FEVER, HEADACHE AND ELEVATED ERYTHROCYTE complaining of a frontal headache, nausea, and feeling weak after fainting. The patient stated to SEDIMENTATION RATE. A.N. Githaiga1, E. Anish1; 1University of Pittsburgh, Pittsburgh, PA the triage nurse that she had eaten Mexican food at about 3:30 PM, went home and took ``a fat (Tracking ID #76143) burner pill'' at about 4PM. She has been on fat burner pills and herbal teas for about one year. Suddenly she began to feel nauseous, developed a worsening headache, then fainted which LEARNING OBJECTIVES: 1) To recognize sarcoid as a cause of central nervous system prompted her to seek medical attention. Initially, the patient was taken to the back of the ED. dysfunction in a patient without other systemic evidence of sarcoidosis. 2) To appreciate the While awaiting physician examination, the patient syncopized and began to have a seizure. The value of performing a brain biopsy to establish a diagnosis of neurosarcoidosis when CSF patient was wheeled into trauma and found to be in Ventricular fibrillation with a potassium of analysis and neuroimaging are nondiagnostic. 2.4. She was defibrillated and then became hypotensive and progressed into asystole, she was CASE INFORMATION: A hypertensive 50-year-old African American woman presented to resuscitated and then intubated. She began posturing without corneal reflexes. After the hospital with a one-month history of retro-orbital headache, recurrent fevers, chills, sweats stabilization the patient was taken to CT; which revealed±Extensive subarachnoid hemorrhage and weight loss. Temperature on admission was 38 deg and her neurologic exam was non-focal. with the presence of intraventricular hemorrhage. Saddly, over the next 48 hours she was Initial labs were significant for WBC-11,800,PLT-610, 000 and ESR-148. A brain CT scan placed on life support and an organ donation referral was made. Soon after she expired. showed old lacunar infarcts. Lumbar puncture showed protein of 111mg/dl, white cell count of IMPLICATIONS/DISCUSSION: Complementary and Alternative medicine (CAM) is one of 3 and 79% lymphocytes. Viral, bacterial and fungal cultures were negative. Autoimmune the fastest growing sectors in health care today. In 1997, Eisenberg & et al JAMA, serological markers were negative. A bone marrow biopsy was negative for malignancy and 1998:280:1569±1575, revealed that 42.1% of Americans (83million) used CAM over the past granulomatous disease. Serum ACE level was normal ( 29 Units/L.). Chest CT scan was normal, year. In the same article Eisenberg, showed that only 38% of patients disclose to their and abdominal CT scan revealed numerous small mesenteric and retroperitoneal lymph nodes physicians their use of alternative therapies when not asked directly. As we continue to see an that were not accessible for biopsy. The patient was started on empiric prednisone therapy for increase in the rate of obesity in the United States, our patients will incorporate both temporal arteritis at 60 mg per day despite negative bilateral temporal artery biopsies. She noted prescription and nonprescription products in hopes of obtaining their desired weight loss. This rapid improvement of her headache and resolution of her fevers and was discharged home. Over current vignette exemplifies the need for the health care provider to first, ask the unasked the next 8 weeks her ESR dropped to 22 and she remained asymptomatic. However, as the question, secondly, to have a basic understanding and knowledge regarding CAM, and finally steroid dose was being tapered, the patient began to experience recurrence of headache and to provide an important role in educating, advising and discussing the potential risks and fevers, as well as gait and cognitive dysfunction. An MRI was performed that revealed multiple benefits of CAM, and the need to closely monitor any use of them. subcortical areas with increased signal. Repeat CSF analysis showed a white cell count of 28 with 89% lymphocytes and increased protein (79 mg/dl). Brain biopsy performed revealed focal perivascular lymphocytic infiltrates with non-necrotizing granulomas. Special stains for AFB MELANOMA FROM WHERE? B. Grigorian1, L. Powell1; 1UCLA±San Fernando Valley and fungus were negative. A diagnosis of neurosarcoidosis was made. Her symptoms steadily Program, Sylmar, CA (Tracking ID #74524) improved with high dose solumedrol and subsequent oral prednisone. IMPLICATIONS/DISCUSSION: This case illustrates the importance of considering a LEARNING OBJECTIVES: 1- Evaluation of diffuse lymphadenopathy in adults. diagnosis of neurosarcoidosis as a cause of fevers and CNS dysfunction in an individual who 2- Recognize the importance of a history and physical in the diagnostic work-up of diffuse does not have other overt manifestations of sarcoid. In 5% of cases, neurosarcoid is the initial lymphadenopathy. presentation of the disease. CNS presentations typically include cranial nerve palsies, 3- Recognize the noncutaneous causes of melanoma. meningitis, optic nerve dysfunction and neuroendocrine disorders (e.g. CASE INFORMATION: 35 y/o white male presented with enlarging , difficulty and central hypothyroidism). CSF findings are nonspecific and include elevated protein and swallowing and 20 pound weight loss. Review of systems was negative for fevers/ nightsweats/ mononuclear pleocytosis. Contrast enhanced MRI may reveal meningeal/cortical masses or shortness of breath. Physical exam showed 6.5X 6.5 cm L firm nontender neck mass, hydrocephalus. As demonstrated in the case presented, neural tissue biopsy may be useful, hepatomegaly, and diffuse lymphadenopathy (LAN), supraclavicular, R axillary, B/L inguinal. JGIM Volume 18, April (supplement 1) 2003 55

Labs revealed normal CBC; ALT 37, AP 570, AST 38, T Br 1.0, LDH 1952 (normal <650). Cr 1.4, and CK 958. There was a noticeable improvement in strength, with ability to stand from CXR showed R mediastinal mass. CT showed diffuse LAN (mediastinal, peritoneal, sitting, ambulate across room and get into and out of bed alone. retroperitoneal) and numerous liver metastases. HIV and hepatitis panel were negative. FNA IMPLICATIONS/DISCUSSION: DISCUSSION: Patients taking colchicine over an of neck revealed atypical lymphoid cells. Excisional biopsy showed anaplastic carcinoma, no extended period of time have been reported to develop a subacute, often severe myopathy in melanin but HMB-45 and melan A (melanocyte markers) were immunostain positive. conjunction with a relatively mild polyneuropathy. Chronic renal failure is a risk factor for this IMPLICATIONS/DISCUSSION: Distinguishing between localized and generalized LAN syndrome. Our patient had been on colchicine for more than a year. In this case an untreated helps guide the appropriate differential diagnosis. Diffuse LAN suggests HIV, mycobacterial myopathy may have resulted in nursing home placement versus a trial of steroids for infection, infectious mononucleosis, SLE, medications (i.e., phenytoin), metastatic carcinoma polymyositis. In our patient, who had pre-existing renal insufficiency worsened by the and lymphoma. dehydration, the clinical presentation and the improvement on discontinuation of colchicine The history and physical exam become crucial in the diagnostic work up of generalized LAN. strongly supports the diagnosis of Colchicine induced myopathy. The history should include signs and symptoms suggestive of infection or malignancy, exposures (cats±cat scratch disease; raw meat±toxoplasmosis; tick bite±lyme disease; unprotected sex or 1 2 1 injection drug use-HIV), constitutional symptoms and medications. A complete physical exam MANAGEMENT OF RAMSAY±HUNT SYNDROME. S. Gupta , O. Melamed ; UCLA 2 should guide the appropriate diagnostic work-up. Patients with generalized LAN should have a School of Medicine, Los Angeles, CA; Olive View±UCLA Medical Center, Sylmar, CA CBC and CXR. If these are normal, consider PPD, HIV test, RPR, ANA, and heterophile test, (Tracking ID #75744) although these tend to be low yield if not specifically indicated. An FNA for cytology is generally LEARNING OBJECTIVES: 1. Clinical presentation and pathophysiology of Ramsay±Hunt the first step due to ease and safety, especially for granulomatous versus malignancy and Syndrome 2. Lack of outcome benefit from head imaging, IV therapy, and surgery for RHS lymphoma versus carcinoma, yet an FNA fails to provide enough material to examine 3. Improved outcome with early treatment. architectural detail or to perform immunostains. This is especially relevant with younger CASE INFORMATION: A 30-year-old female presented to the urgent care clinic for patients where hematologic malignancies or uncommon solid tumors are a consideration. evaluation of left , vertigo, left facial paralysis and small vesicles over the left pinna. The Metastatic melanoma without a known skin primary accounts for around 3% of melanomas. patient's past medical history was significant for chickenpox at the age of eight. On physical Prior to melanocyte-specific immunostains, these cases were considered carcinoma of unkown examination the patient had left ear swelling and erythema with multiple 0.5±1.0 mm vesicles primary. Cases of metastatic melanoma lacking primary skin lesion include primaries of mucosal around the pinna and marked erythema involving the external auditory canal. There was a surfaces (sinuses, oral mucosa, vulva, vagina and anorectum), occular and primary skin lesion positive Bell's phenomenon (the eyeball rolling up and outward on attempting to close the which have regressed. Thus, the lack of skin lesion does not rule out metastatic melanoma. affected eye). A facial paralysis involved the left levator labii and left frontalis muscles. A left No effective systemic therapy exists at this time for metastatic melanoma. Biotherapeutic sensorineural deficit was observed with lateralizing to the right and a positive approaches combining immunomodulators such as IL-2, INF, and vaccines with conventional (normal) bilaterally. The diagnosis of Ramsay±Hunt Syndrome was made. The cytotoxic chemotherapy are currenlty under active investigation. patient was discharged from the clinic on a regimen of Acyclovir and Prednisone. She was instructed to avoid pregnancy, contact with pregnant women or neonates. IMPLICATIONS/DISCUSSION: Clinical presentation of unilateral facial paralysis and a A COURAGOUS CALL: SALINE FOR HEART FAILURE? M. Guidry1, J. Wiese1, J. Wiese1; vesicular rash on the ear (zoster oticus), often accompanied with hearing loss, tinnitus, nausea, 1Tulane University, New Orleans, LA (Tracking ID #77054) vomiting, vertigo and nystagmus was first described by J Ramsay Hunt in 1907. Vestibuloco- LEARNING OBJECTIVES: 1. Recognize the perils of over-diuresis in bi-ventricular heart chlear symptoms were explained by the anatomical proximity of the eighth nerve and the failure. 2. Use disciplined methods of diagnosis to prevent errors in pattern recognition geniculate ganglion within the temporal bone. The pathophysiology of RHS involves the diagnosis. 3. Use the physical examination to predict cardiovascular function. reactivation of varicella-zoster virus (VZV) within the geniculate ganglion and secondary edema CASE INFORMATION: An 80 year-old woman presented with two days of shortness of in the facial nerve resulting in facial nerve palsy. VZV is considered a major etiologic agent of breath and orthopnea. Her blood pressure was 132/65 with a heart rate of 116. She had bi- Bell's palsy. Use of contrast enhanced MRI in diagnosis of RHS does not appear to provide basilar crackles and 3+ pitting bipedal edema. There was an S3, S4, and an inferiorly displaced much information as enhancement of the geniculate ganglion, meatal fundus, and facial nerve is PMI. Her room-air ABG at presentation was pH: 7.44; pCO2:35; pO2:58. She was diuresed observed independent of etiology. Most patients with Bell's palsy tend to recover to complete or with a total of 320 mg of over one day. Her symptoms improved. On the third near normal function even without treatment. One prospective study found that 85% of patients hospital day, she had a sudden worsening of her shortness of breath. Her neck veins were flat showed signs of remission within the first 3 weeks, with 71% recovering complete function, and there were no crackles. A repeat ABG was pH: 7.28; pC02: 57; p02: 81; HCO3:42 Her 13% left with insignificant sequelae, and 16% left with permanently diminished function. BUN tocreatinine ratio increased from 23/1.4 at presentation to 41/2.3 on the third hospital Although most patients with RHS improve, many patients are left with functional and cosmetic day. Diuresis was stopped, and hydration with normal saline was initiated. Her shortness of deficits. Treatment of RHS with oral acyclovir and prednisone (AS therapy) may improve breath improved, with normalization of her acid base values. outcome. Two separate studies showed complete recovery in 75% of patients with RHS treated IMPLICATIONS/DISCUSSION: Dyspnea can result from hypoxia or hypercarbia. This with AS. There has been no evidence of improvement in outcome with intravenous patient initially presented with dyspnea due to congestive heart failure; she was appropriately administration of either acyclovir or prednisone, though many patients are still admitted to managed with preload reduction via diuresis. Continuing diuresis was excessive however. In the the hospital for IV therapy. There is also insufficient evidence for efficacy of surgical facial nerve setting of bi-ventricular heart failure, the over-diuresis resulted in an inadequate right decompression. Evidence for improved outcomes with earlier administration of therapy have ventricular preload, and a subsequent drop in her pulmonary artery pressure. With the alveolar been observed. In one study 75% of patients beginning AS treatment within 3 days of onset of pressure unchanged and the pulmonary artery pressure lowered, the percentage of dead space facial paralysis had complete recovery, compared with 30% of patients beginning therapy after 7 increased. This resulted in a ventilation to perfusion mismatch resulting in hypercarbia. The days. Earlier therapy decreased nerve degeneration and improved recovery of hearing. physical examination was the tell-tale sign, revealing that her volume status was low, instead of high. The ABG confirmed the diagnosis; the rehydration increased the pulmonary artery 1 1 1 pressure, resolving the mismatch, and eliminating the dyspnea. In caring for patients with SEIZURES ON POSTPARTUM DAY SEVEN. K. Gustafson , R. Khurana ; University of biventricular heart failure who are sensitive to preload reduction, it is important to remember Alberta, Edmonton, Alberta. (Tracking ID #76917) that hypercarbia from dead space ventilation can result from aggressive lowering of the LEARNING OBJECTIVES: 1) To recognize that preeclampsia and eclampsia may occur in pulmonary artery pressure. the . 2) Diagnose eclampsia even when it presents without the typical signs of preeclampsia. We describe a case of postpartum eclampsia that was initially misdiagnosed. CASE INFORMATION: A 28 year old woman G2P2 was transferred to our tertiary case COLCHICINE±INDUCED MYOPATHY. K. Gupta1, T.A. Townley1; 1Creighton University, hospital on postpartum day 7 because of seizures. Her pregnancy had been uncomplicated and Omaha, NE (Tracking ID #76577) she had a vaginal delivery at term for a healthy 3515g female infant. Her past medical history LEARNING OBJECTIVES: 1) Review the differential diagnosis of proximal muscle weakness was unremarkable and her blood pressure had remained normal throughout the pregnancy. She in an elderly male 2) Review symptoms and signs of colchicine-myopathy 3) Review the risks presented to a local hospital on postpartum day 7 complaining of severe headache, nausea and factors for colchicine myopathy. vomiting. Her blood pressure was 176/100. She was given analgesia, but then had two CASE INFORMATION: INTRODUCTION: Colchicine has been used for 200 + years, but generalized seizures. She was given magnesium sulfate 5 g intravenously and transferred. When there are few reports of myopathy associated with its use. We present such a case. CASE: Patient assessed, her blood pressure was 150/90. She had no focal neurologic findings, right upper is a 70-year-old male who was hospitalized for abdominal pain/diarrhea. He had fallen on his hip quadrant tenderness, edema or hyperreflexia. Her liver enzymes and platelet count were at home 1 week prior to his admission and became increasingly weak with considerable normal. Urinalysis was negative for protein. Urate was slightly elevated. CT scan of the head reductions in his ADL such as inability to get in and out of bed, stand from sitting and walk. His was normal. EEG was normal. She was seen by the services of Neurology, Internal Medicine PMH includes COPD on home O2, CHF, HTN, DM, CRI (baseline Cr 2.2), obesity and gout. and the Intensive Care Unit. She was diagnosed with seizures of unknown origin and admitted Medications include Oxycodone 5/325mg prn, metoprolol 50mg qd, colchicine 0.6mg qd, for observation. The magnesium sulfate was discontinued. Her blood pressure varied over the allopurinol 100mg qd, furosemide 80mg qd, glipizide 30mg qd, isosorbide dinitrate 30mg qd, next two days from 124/81 to 200/103. On postpartum day 10, she had another generalized fosinopril 40mg qd, ASA 325mg qd, KCl 20mEq qd, Insulin 70/30, MVI qd. His initial physical seizure. MRI of her brain was consistent with hypertensive encephalopathy. She was given a exam was normal except for reduced reflexes in upper limbs 2+/4 and lower limbs 1+/4 with no diagnosis of postpartum eclampsia and treated with intravenous magnesium sulfate and sensory deficits. Lab work revealed acute renal insufficiency on CRI (BUN 69/Cr 2.6), in antihypertensive therapy. She improved over the next few days and all therapy was addition LFT's were twice normal. CK was 1059 with MB fraction <5%. CXR and abdominal discontinued. She remains well with no further seizure activity. series were clear and EKG was unchanged. His abdominal pain resolved, and ARI improved IMPLICATIONS/DISCUSSION: Preeclampsia/eclampsia may worsen or even initially with hydration and discontinuation of ACE-I. Initially his weakness was felt to be secondary to present in the postpartum period. Postpartum eclampsia represents 25% of all cases of intercurrent illness superimposed on chronic illness. However weakness failed to improve and a eclampsia. The majority of these events occur in the first 24±48 hours postpartum, but have repeat CK was 1825 with ESR of 36. His weakness localized to proximal muscles of upper and been reported to occur as late as 4 weeks postpartum. Eclampsia does not always occur in lower extremities, with strength 3/5. Distal muscle strength was 5/5. Colchicine was suspected patients who have the classic triad of preeclampsia (hypertension, proteinuria and edema). as the cause of his myopathy and discontinued. He noticed a significant improvement in his About 20% of patients with eclampsia have no proteinuria. Computed tomography and EEG proximal muscle of 4/5 on the following day. EMG showed myositis with predominantly are often unremarkable, but should be performed to rule out other causes of seizure. When proximal muscle irritability. Repeat labs 5 days after discontinuing colchicine, showed BUN 44/ MRI abnormalities are present, hyperintense signals in cortical and subcortical areas on T2 56 Abstracts JGIM

weighted images may be seen. These are usually in the posterior parietal or occipital lobes. AST 88, ALT 128, ALP 96, GGT 74, albumin 3.7, and total protein 9.8. Other biochemical Management of eclampsia includes delivery of the fetus (if diagnosed antepartum), magnesium profile including TSH, iron studies, ceruloplasmin, a 1 anti-trypsin and a feto protein were all sulfate to prevent recurrent seizures and control of severe hypertension. A high index of within normal limits. ANA and anti thyroglobulin antibodies were positive whereas anti LKM, suspicion is necessary to appropriately diagnose the woman with postpartum eclampsia and anti mitochondrial, anti antibodies were all negative. She had negative serology prevent further morbidity. for EBV, CMV, HZV and hepatitis A, B, and C viruses. The histology was most consistent with . In situ hybridization study for Y chromosome established that immune reactive cells were exclusively of donor origin. There was no evidence of recurrent DIABETIC MUSCLE INFARCTION: AN UNUSUAL CAUSE OF PAIN. D.R. Gutknecht1; chronic myelogenous leukemia. Serum transaminase levels normalized with prednisone 20 mg 1 Geisinger Health System, Danville, PA (Tracking ID #73656) a day but relapsed on dose reduction. Azathioprine was therefore added. Her transaminase LEARNING OBJECTIVES: To recognize focal muscle infarction as an unusual, and levels have been normal for 28 months. sometimes bilateral, cause of severe limb pain in patients with diabetes. IMPLICATIONS/DISCUSSION: This report documents a case of liver dysfunction, CASE INFORMATION: A 55 year-old diabetic woman developed disabling pain in both following SCT, which was indistinguishable from `definite' autoimmune hepatitis (baseline upper legs, with thickening and tenderness of the soft tissues of the right lateral thigh. There diagnostic score > 15) as defined by the modified criteria of International Autoimmune was no evidence of infection. She had neuropathy but sensation in the thighs was normal. Hepatitis Group. To our knowledge, the present case represents the first report of this There was a history of disc disease but an MRI examination of the spine was unimpressive. She complication after allogeneic peripheral SCT. One intriguing feature of this case is that the had arterial disease but ankle/brachial indices were only in the claudication range. There was a target liver cells and immune reactive cells are of different origins. The donor origin of history of venous thrombosis but she was taking warfarin and duplex studies showed no clots. immune reactive cells was clearly established in our female patient by in-situ hybridization Plain films and a bone scan were negative. MRI examination showed diffuse edematous labeling of the Y chromosome. As the term `autoimmune hepatitis' does not accurately reflect infiltration of the subcutaneous fat of both thighs, with increased signal in the right vastus the disease process, we propose the term `alloimmune hepatitis' for this syndrome. lateralis muscle. These findings were consistent with infarction of the vastus lateralis, and conservative treatment was recommended. SUMMER HEADACHE. J. Hafkin1, P. Haidet1; 1Baylor College of Medicine, Houston, TX IMPLICATIONS/DISCUSSION: Diabetic muscle infarction causes pain, swelling, and (Tracking ID #76933) tenderness, most commonly in the thigh, but sometimes in the calf. The opposite limb may be involved, either sequentially, or concurrently, as in this case. The MRI appearance is LEARNING OBJECTIVES: Recognize the key clinical features of viral meningoencephalitis. characteristic and allows the diagnosis to be made without the risks of biopsy. Treatment is Appreciate the increasing incidence of West Nile Virus as a cause of CNS infection. supportive. This rare but important entity must be considered when diabetic patients suffer CASE INFORMATION: A 50 year old white male was admitted to our hospital in July with severe limb pain. three days of fever, chills, headache, and neck stiffness. He worked as an air-conditioner repairman and spent a considerable amount of time shirtless, outdoors in East Texas. Physical examination was significant for fever of 102.4 degrees Fahrenheit, meningismus, and Kernig's A CASE OF SPONTANEOUS BILATERAL CAROTID CAVERNOUS FISTULAS. S. Habib1, sign. The patient was awake, alert, and oriented to person, place, and time. Initial CSF analysis P.K. Han1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76354) revealed WBC 91 with 92% neutrophils and 8% monocytes; protein 81, glucose 68; gram stain LEARNING OBJECTIVES: 1) To recognize the clinical symptoms and signs of carotid revealed few WBCs, and was negative for bacteria; latex agglutination screen was negative for cavernous fistula. 2) To describe an unusual presentation of carotid cavernous fistula. H. influenzae, S. pneumoniae, N. meningitis A, B, C and group B streptococcus. CBC revealed CASE INFORMATION: An 85-year-old woman presented with a 3±4 week history of a WBC count of 10.6 with 70% neutrophils, 20% lymphocytes, and 10% monocytes. Within progressive difficulty with eye opening, poor vision, and tinnitus. She denied headaches, ocular two days of admission, the patient became progressively more lethargic and delirious and was or orbital pain, diplopia, worsening of symptoms with activity, dizziness, focal weakness, or oriented only to person, month, and year. Repeat CSF analysis revealed WBC of 223 with 15% other recent illnesses. She had a history of recent falls, but no head trauma. Her past medical neutrophils, 59% lymphocytes, and 26% monocytes; glucose of 66 and protein of 81. CSF history was significant for hypertension, primary hyperparathyroidism, normocytic anemia, bacterial cultures remained negative. CSF studies for syphilis, tuberculosis, and herpes simplex Paget's disease of bone, and a fifty pack-year smoking history. She was on ferrous sulfate but no virus were negative. CSF IgM was positive for West Nile virus. other medications Physical examination revealed a blood pressure of 168/74 without IMPLICATIONS/DISCUSSION: Until 1999, West Nile virus was found only in Africa, Asia, orthostatic changes, mild conjunctival pallor, and bilateral complete ptosis. There was and the Middle East. Since that time, West Nile virus has infected over 3852 individuals in the chemosis of the right eye and opthalmoplegia, with bilateral palsies of cranial nerves III, IV, U.S. in at least 39 states. West Nile virus is a single-stranded RNA Flavivirus virus that belongs and IV. Both pupils were mid-dilated and non-reactive to light. No other neurological deficits to the Japanese encephalitis complex. Birds are the natural hosts of West Nile virus and were noted. Diagnostic evaluation included a normal CT scan of the brain, while brain MRI mosquitoes, particularly of the culex species, act as vectors. Infection in humans typically demonstrated changes suggestive of bilateral carotid cavernous fistulas. Cerebral angiography occurs in late summer through early fall when mosquitoes are most predominant. Severe was performed, which confirmed the presence of bilateral type A carotid cavernous fistulas. neurologic disease accompanying West Nile virus infection is rare. One out of every 150 The patient then underwent trans-carotid endovascular embolization, which was unsuccessful. infected patients develops meningitis or encephalitis. Age greater than 50, is the major risk Unfortunately the patient developed right-sided hemiparesis a few days later, and subsequently factor for developing life-threatening neurologic disease. West Nile viral encephalitis is similar declined further intervention. to other viral encephalitities and is characterized by fever, headache and an altered level of IMPLICATIONS/DISCUSSION: Carotid cavernous fistula is an unusual problem caused by consciousness. CSF studies typically show a lymphocytic pleocytosis with elevated protein. an abnormal communication between the internal and/external carotid artery and the Early viral encephalitis, however, may demonstrate CSF with a predominantly neutrophilic cavernous sinus. It is classically characterized by the triad of pulsating exophthalmos, ocular CSF pleocytosis, as in our patient. Lymphopenia is a common feature of West Nile virus chemosis and an orbital bruit. Other features include orbital pain or tightness, pulsatile tinnitis, encephalitis and thus it may aid in distinguishing this disease from other forms of viral visual loss due to ischemia of optic nerve and retina, retinal vein congestion, and glaucoma. encephalitis. Definitive diagnosis is obtained through confirmation of blood or CSF IgM to Ophthalmoplegia often results from pressure upon local cranial nerves; CN VI is affected most West Nile virus. Treatment is supportive. The main intervention is prevention by promoting often, and CN III and IV are involved less frequently. Our patient did not present with the the use of mosquito repellant and protective clothing. classic clinical triad, but with bilateral complete ophthalmoplegia and pulsatile tinnitis. Trauma is the most common cause of carotid cavernous fistula although 20 percent of cases are AN UNEXPECTED CAUSE OF PARALYSIS. J. Hafkin1, P. Haidet1; 1Baylor College of non-traumatic. Spontaneous bilateral carotid cavernous fistula, as observed in our patient, is a Medicine, Houston, TX (Tracking ID #77041) very rare entity. Risk factors for carotid cavernous fistulas include older women, mothers during childbirth, hypertension, atherosclerosis and collagen vascular diseases. A four-type LEARNING OBJECTIVES: Appreciate the increasing prevalence of West Nile virus classification of carotid cavernous fistulas based on the anatomy of the lesion has been infection in the United States. Recognize that acute flaccid paralysis is an important neurologic proposed. Our patient had type A fistulas, presumably due to a rupture of an intra-cavernous manifestation of West Nile virus infection. carotid artery aneurysm. Early recognition and intervention is important to prevent permanent CASE INFORMATION: A 64 year old white male presented to our hospital with complaints visual loss and ophthalmoplegia. Endovascular interventions (embolization and balloon of fever, diarrhea, and fatigue. His admission was preceded by two days of watery, non-bloody occlusion) represent a successful treatment option although stroke is a well-recognized stools, fever to 102, fatigue, malaise, and generalized weakness. The patient denied any sick complication in 5±15 % of cases. contacts or travel, although he noted living in a mosquito-infested area of East Texas. On admission, the patient's temperature was 102.2, pulse 69, blood pressure 117/61 and respiratory rate 24. The patient appeared fatigued and exhibited a diffuse, erythematous rash ALLOIMMUNE HEPTITIS FOLLOWING ALLOGENEIC PERIPHERAL STEM CELL and injected conjunctivae. The neurologic examination revealed normal tone and 5/5 strength TRANSPLANTATION. S. Habib1,M.A.Nalesnik1,O.A.Shakil1, J. Ahmed1, throughout. Sensation was intact and reflexes were 2+ and symmetrical in all extremities. The D. BuchBarker1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76772) rest of the physical examination was unremarkable. Within days, the patient developed severe LEARNING OBJECTIVES: 1, To recognize that autoimmune hepatitis is a rare generalized weakness with areflexia and ultimately, respiratory failure requiring mechanical complication following allogeneic stem cell transplantation. 2, To understand the pathophy- ventilation. Analysis of CSF revealed a WBC count of 78 with 55% lymphocytes, 30% siology of auto immune hepatitis folllowing stem cell transplantation. neutrophils, and 5% monocytes; glucose 154, and protein 116. Electrophysiologic studies were CASE INFORMATION: A 43 year-old white female developed Ph-chromosome positive performed and were consistent with a diffuse axonal polyneuropathy. Serologic studies were chronic myeloid leukemia. She received cytoreductive therapy, followed by a 6/6 HLA positive for the West Nile virus. matched allogeneic peripheral stem cell transplant (SCT). Tacrolimus and prednisone were IMPLICATIONS/DISCUSSION: Before 1999, West Nile virus, a single-stranded RNA virus continued for 18 months. One month after tacrolimus dose reduction, her serum AST and belonging to the Japanese encephalitis complex, was found only outside the western ALT levels were 723 and 965 respectively, but bilirubin and alkaline phosphatase were normal. hemisphere. Since then, West Nile virus has infected over 3852 individuals in the U.S. in at An abdominal sonogram was normal. After the tacrolimus dose was increased to its baseline least 39 states. Many clinicians are aware that West Nile virus is associated with encephalitis level, serum AST and ALT levels decreased to 45 and 60. Tacrolimus was then gradually and meningitis, however, the association between West Nile virus infection and acute flaccid reduced and eventually discontinued, which caused a rise in AST and ALT levels. She had no paralysis is less well known. CDC surveillance during the most recent outbreak of West Nile risk factors for . Physical examination was normal except for Cushingoid Virus in Louisiana revealed that almost 20% of patients described as having severe neurologic appearance. CBC with differential were normal. Biochemical tests showed total bilirubin 0.7, disease presented with acute flaccid paralysis. Early reports of patients with West Nile virus JGIM Volume 18, April (supplement 1) 2003 57

acute flaccid paralysis often confused the condition with Guillain-Barre syndrome. Clinicians should be aware that unlike most patients with Guillain-Barre syndrome, patients with West Nile associated acute flaccid paralysis typically have fever, CSF pleocytosis, and electro- diagnostic studies consistent with a predominantly axonal neuropathy. Most patients with Guillain-Barre syndrome are afebrile, have an elevated CSF protein, few if any WBCs in the CSF, and electrodiagnostic studies consistent with a demyelinating neuropathy. The presence of a maculopapular or morbilliform rash, such as our patient had, may also suggest the presence of West Nile virus infection.

PETECHIAE, PLATELETS AND PREDNISONE: IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) IN ADULTS. H.J. Hamrick1; 1UC±San Francisco, San Francisco, CA (Tracking ID #77098)

LEARNING OBJECTIVES: 1. Develop a differential diagnosis for thrombocytopenia in a well-appearing adult. 2. Learn to diagnose and treat ITP in adults using the best available evidence. CASE INFORMATION: A well-appearing 72 year-old Chinese-American man being treated with glipizide for type II diabetes presented to clinic with a petechial rash on his trunk, arms, and legs. A CBC revealed isolated thrombocytopenia (platelet count 23,000). Glipizide was discontinued but thrombocytopenia persisted. His platelet count normalized with a prednisone taper but in the ensuing months, despite splenectomy, he continued to require 5 mg of daily prednisone to maintain a normal platelet count. His diabetes became poorly controlled while on prednisone, and he had one episode of pneumonia requiring antibiotics. The decision was made to stop prednisone. After the initial petechiae he has had no further evidence of bleeding, but his platelet count remains between 10,000 and 40,000. IMPLICATIONS/DISCUSSION: Medications and ITP are common causes of isolated thrombocytopenia in well-appearing adults. Glipizide is among the many medications with published case reports of thrombocytopenia as a side effect. ITP is a clinical diagnosis made in the setting of isolated thrombocytopenia with a normal peripheral smear and no other identifiable cause of low platelets. Experts recommend a bone marrow biopsy in patients over age 60 to rule out myelodysplasia. Anti-platelet antibodies are not specific for ITP. Case series suggest that in adults spontaneous remission occurs less than 10% of the time. Splenectomy is curative in 50±65% of all cases, with better results in patients less than 40 years old. Life- threatening bleeding rarely occurs with a platelet count of greater than 10,000. Prednisone is Erythema Multuforme skin lesions not curative and is most helpful as a supportive measure in patients with platelets under 10,000 or other high bleeding risks (ie: surgery). Asymptomatic patients with platelet counts above IMPLICATIONS/DISCUSSION: Erythema Multiforme is characterized by red iris shaped 10,000 and no other risks for bleeding can most likely be safely managed without steroids. lesions with or without bullae on extremities and around the mouth. It is associated with drugs, pregnancy and infections like herpes simplex and mycoplasma. Treatment includes treatment of primary infection, withdrawal of offending drugs and steroids. A SKIN CONDITION COMMONLY ASSOCIATED WITH HERPES SIMPLEX INFECTION. S. Harigovind1, J. Pino1; 1New Hanover Regional Medical Center, Wilmington, NC (Tracking 1 1 ID #76503) A CASE OF A BAD STOMACH BUG. H.A. Harris ; University of California, San Francisco, San Francisco, CA (Tracking ID #75568) LEARNING OBJECTIVES: Recognize that Erythema Multiforme is commonly associated with herpes simplex and other infections. LEARNING OBJECTIVES: 1. Recognize the role of Helicobacter pylori (H. pylori) in CASE INFORMATION: A 27 year old female with history of recurrent oral herpes simplex various etiologies of dyspepsia 2. Develop an approach for the evaluation of dyspepsia through infections and thrush presented with exacerbation of herpes infection after stopping long term review of the current evidence and recommendations 3. Review diagnostic testing and supressive Valacyclovir therapy. She developed multiple nontender, pruritic bullae on treatment for H. pylori. erythematous iris like lesions on her extrimities and trunk. Labs ANA -ve, PPD -ve, HIV CASE INFORMATION: 46 y/o woman presented with epigastric discomfort and nausea 1±2 non-reactive, Herpes culture of oral lesions -ve, HSV IgG +ve. She was treated with months after she ran out of her cimetidine. Symptoms were similar to ones she experienced 2 Valacyclovir and steroids with improvement in her skin condition and oral herpetic lesions. years prior when she may have had a ``stomach bug'' for which she thought she was given Herpes simplex oral lesions. Erythema Multiforme skin lesions. antibiotics. The patient did endorse drinking 2 beers/day but denied dysphagia, anorexia, weight loss or melena. Physical exam was benign. Symptoms initially improved with reinstituting cimetidine and decreasing alcohol intake. Initial labs demonstrated a normal CBC, LFTs, amylase and lipase, but was impressive for an H. pylori titer 1:87 U/mL. Despite continued cimetidine, the patient's symptoms recurred within months and lansoprazole was initiated. An H. pylori breath test was not pursued due to the patient's reluctance to discontinue medications prior to the test. Subsequent endoscopy revealed 2 small, linear, clean- based ulcers biopsy positive for H. pylori. Symptoms resolved after treatment with amoxicillin, clarithromycin and lansoprozole. IMPLICATIONS/DISCUSSION: Dyspepsia, or chronic and/or recurrent pain or discomfort of the upper abdomen, is a common complaint accounting for 5% of all PCP visits. H. pylori is implicated in several of the etiologies of dyspepsia, thus the management of dyspepsia must involve strategies to appropriately diagnose and treat H. pylori. Testing for H. pylori is recommended only if treatment is intended; however, guidelines regarding the indications for treatment of H. pylori put forth by the American College of (1998) and the Maastricht 2±2000 (European) are conflicting. Both agree on the need to treat in cases of active ulcer disease or gastric/MALT lymphoma, but the Europeans are more aggressive in their recommendations advising treatment in entities such as non-ulcer dyspepsia or concurrent NSAID use. A recent meta-analysis (Laine, et. al. 2001) helps to clarify the issue of non-ulcer dyspepsia Ð which accounts for the majority of dyspepsia Ð suggesting that eradication of H. pylori does not improve symptoms in non-ulcer dyspepsia. Yet the uncertainty regarding the utility of eradication of H. pylori makes the appropriate work up of uninvestigated dyspepsia somewhat unclear. We will review several algorithms for the evaluation of dyspepsia and discuss the current data supporting the most often recommended ``test and treat'' approach with regards to H. pylori and dyspepsia. In addition, we will discuss the range of diagnostic testing available for H. pylori and the appropriate use of these tests during the evaluation of dyspepsia. The topics of treatment and treatment failures will also be addressed.

SYNCOPE IN A 78 YEAR OLD MAN: A COMMON PROBLEM WITH AN UNLIKELY CAUSE. D. Hasselbacher1, T. Montgomery1; 1University of Kentucky, Lexington, KY (Tracking ID #76016)

LEARNING OBJECTIVES: Hypoglycemia as a cause of syncope. CASE INFORMATION: A 78 year-old male with a history significant for atrial fibrillation, Herpes simplex oral lesions congestive heart failure, and transient ischemic attacks presented with a 6-month history of 58 Abstracts JGIM

spells of altered mental status and syncope. The patient's behavior ranged from combative and IMPLICATIONS/DISCUSSION: In this case, caused peripheral arterial agitated to lethargic. These variations in behavior usually occurred early in the morning, lasted ischemia which presented as and weakness. Stroke is the most common neurologic one to three hours, and were associated with diaphoresis, marked confusion, and generalized presentation of aortic dissection, although 10% of patients present with ischemic peripheral weakness. The patient often had no recollection of these events and returned to baseline neuropathies. Although pain describing dissection has classically been taught to be ``ripping or between episodes. This pattern increased in frequency and severity prior to admission. The tearing'', most patients classify the pain as ``sharp.'' Given the high mortality associated with spells were associated with blood sugar measurements in the low forties. The patient was aortic dissection, a high index of suspicion should be maintained for patients presenting with hospitalized for further work up and underwent a monitored fast. Serial lab values were paresthesia and back pain. consistent with insulinoma. Imaging studies to locate a tumor included body CT, ultrasound, endoscopic ultrasound, and nuclear imaging, which were non-diagnostic. Initially the patient's glucose was maintained at normal levels with intravenous 10% dextrose and frequent snacking. ACUTE CHOLESTATIC JAUNDICE AS THE PRESENTING FEATURE OF ACUTE Diazoxide therapy was initiated which allowed the intravenous dextrose to be discontinued; LYMPHOBLASTIC LEUKEMIA. L. Hermiller1,V.Martin1; 1University of Cincinnati, however, even with frequent snacks the patient still had occasional low sugars. With failure of Cincinnati, OH (Tracking ID #73955) medical management the patient underwent exploratory laparotomy with intraoperative LEARNING OBJECTIVES: 1) Illustrate an atypical presentation of Acute Myelogenous ultrasound which did not detect a distinct mass. A distal pancreatectomy was performed, which Leukemia in an adult. 2) Recognize as the result of leukemic infiltration of the liver demonstrated hyperplasia of islet cells. Post-operatively the patient was able to maintain and its resolution after treatment. normal blood sugars without diazoxide. CASE INFORMATION: A 62 year-old white male with unremarkable medical history IMPLICATIONS/DISCUSSION: Nesidioblastosis is a rare cause of hyperinsulinemic presented with acholic stools, dark urine, and constitutional symptoms. Physical examination hypoglycemia that is differentiated by an insulinoma only by pathology. In this case, the revealed a diffuse erythematous, maculo-papular rash of trunk and legs, profound jaundice, patient's hypoglycemia was associated with syncope and altered mental status. liver span of 14cm with a firm edge, no splenomegally and no stigmata of chronic liver disease. His initial outpatient laboratory tests revealed: alkaline phosphatase 413 U/L, total bilirubin 3 THE TWELVE DAY NEUTROPENIC FEVER. E.R. Heinze1, S. Kwunyeun1, A.G. Gomez2; mg/dl, SGOT 510 U/L, and SGPT 515 U/L. Viral hepatitis serologies, an abdominal 1UCLA±San Fernando Valley Program, Sylmar, CA; 2University of California, Los Angeles, ultrasound and CT, and an endoscopic retrograde cholangiopancreatography were unremark- Sepulveda, CA (Tracking ID #75438) able. Three weeks later, the patient underwent a percutaneous liver biopsy at which time his laboratory values were: WBC 1.9 Â 103/3, Hgb 12.6 g/dl, Platelets 62,000, alkaline LEARNING OBJECTIVES: 1) to review neutropenia as a presentation of SLE 2) to discuss phosphatase 706 U/L, total bilirubin 26.9 U/L (direct 21.8 U/L), SGOT 190 U/L, and strategies to avoid misdiagnoses and how to manage lupus neutropenia. SGPT173 U/L. The liver biopsy showed a high-grade malignant leukemic infiltrate. Bone CASE INFORMATION: A 53 y/o Egyptian woman presented with two weeks of fevers marrow biopsy confirmed the diagnosis of B cell/ Burkitt's type acute lymphoblastic leukemia reaching 102±103 degrees F. She denied cough, headache, dysuria, diarrhea, abdominal pain, with flow cytometry showing CD19+/CD10+/CD20-/CD34-/CD13+/HLA DR+ cells. joint pain, oral lesions, rash, weight loss, sexual promiscuity, recent travel, or drug use. She last IMPLICATIONS/DISCUSSION: Acute lymphoblastic leukemia is primarily a disease of visited Egypt four years ago and worked as an apartment manager. She took occasional children; adults only account for approximately 20% of cases and Burkitt's B cell ALL, in turn, Tylenol, no other medication. On examination she had a temperature of 103 degrees F and makes up only 5% of the cases of ALL. Unfortunately, over 60% of adults with ALL are not appropriate tachycardia. No lymphadenopathy, breast masses, abdominal masses/pain, lung cured of their disease. The clinical features of ALL are often nonspecific and primarily crackles, cardiac murmurs, or neurological findings were found. She had a WBC 1.7, 64% constitutional as well as manifestations of cytopenias secondary to the bone marrow PMNs and mild anemia Hgb 11.1. LFT's, TSH, Fe/Ferritin, and chemistry normal. An infiltration. Also, ALL has a predilection for the CNS and symptoms of meningeal leukemia extensive infectious workup was negative including blood and fungal cultures, AFB cultures, or hyperleukocytosis are not uncommon at presentation. Cholestatic jaundice, however, is a urinalysis, CXR, visceral leishmaniasis, malaria, , EBV, CMV, HIV, RPR, PPD. CT much less common presenting feature with a limited number of case reports in the literature. of the chest, abdomen, pelvis, and head found only mild splenomegaly. Transesophogeal echo As demonstrated in this case, one should entertain the diagnosis of acute lymphoblastic revealed no valvular vegetations. The patient continued with daily fevers to 102±103 degrees F, leukemia in those presenting with acute cholestatic jaundice. anemia worsened to a Hgb 8.4, WBC decreased over ten days to a nadir of 0.7 (ANC 60). GCSF was started for neutropenia and empiric Ceftazidime and Tobramycin were begun. Bone marrow biopsy showed normal cell elements and myeloid to erythroid ratio 1:1. Her NEUTROPENIC COLITIS IN AN ELDERLY MALE. N. Hingarh1, A. Gomez1, L. Pinter- mammogram was normal. At this point ANA returned +1:320 as well as Coombs positive. Anti- Brown1; 1UCLA±San Fernando Valley Program, Sylmar, CA (Tracking ID #76495) ds DNA and Anti-Smith was sent. On second day of GCSF patient developed polyarthritis in hands, wrists, , knees, ankles as well as faint malar rash. Follow up CXR revealed small LEARNING OBJECTIVES: 1) Review the potential complications of the treatment of acute left pleural effusion. GCSF was stopped and patient was started on Prednisone with subsequent leukemia. 2) Discuss the presentation of neutropenic colitis and its management. resolution of fevers, rash, and arthralgias. Anti-ds DNA returned +1:80. CASE INFORMATION: A 62 y/o male presented with a 4-week history of progressive IMPLICATIONS/DISCUSSION: Lupus can present in a variety of ways. In this case, the weakness and fatigue with intermittent chest pain on exertion. He also had intermittent initial presentation was neutropenic fever. Only after receiving GCSF did the diagnosis become episodes of gum bleeding, anorexia and shortness of breath. His medications included apparent as it precipitated a lupus flare. The diagnostic criteria for Lupus developed by the ACR Atenolol. On physical exam, his vital signs were stable and he was noted to have pale are 96% sensitive and specific. Non-specific symptoms such as fever, fatigue, and weight loss are conjunctiva, minimal gum bleeding and a non-radiating systolic murmur. His white blood cell common presenting complaints and are often attributed to causes other than lupus leading to count was 1,600 with a normal differential. He had a hematocrit of 14.9 and a platelet count of misdiagnoses. Leukopenia occurs in more than 50% of lupus patients with either 7,000, and lactate dehydrogenase of 794. His remaining lab findings were normal. His granulocytopenia or lymphopenia. GCSF has been used in the treatment of lupus induced peripheral smear showed decrease red blood cells and platelets with normal morphology and neutropenia resulting in a rise in neutrophils within 48 hours, however the elevation is transient no immature white blood cells. Two bone marrow biopsies were both dry taps and confirmed a with return to pretreatment levels within days after withdrawal of therapy. In addition treatment diagnosis of Acute Myelogenous Leukemia (AML) of the Megakaryocyte subtype (FAB with GCSF has been associated with flares in lupus that resolve when the drug is stopped. classification M7). His course was complicated early on by neutropenic fever and broad- spectrum antibiotics were initiated. Chemotherapy was started after a 48-hour period fever- free period with Idarubicin for 3 days and Cytosine-arabinoside for seven days. He tolerated PARESTHESIA IN A MAN WITH ELEVATED PSA. S. Henderson1,J.Messler1, the treatment well, but remained pancytopenic. Two days after completing induction, he D.W. Brady1; 1Emory University, Atlanta, GA; (Tracking ID #75590) became febrile and complained of severe abdominal pain and diarrhea. Broad-spectrum antibiotics for both bacterial and fungal pathogens were started. Imaging of his abdomen LEARNING OBJECTIVES: 1) Recognize the neurologic manifestations of aortic dissection showed bowel wall thickening consistent with neutropenic colitis (typhlitis). Treatment 2) Learn the description of symptoms associated with aortic dissection. initially consisted of broad-spectrum antibiotic coverage and supportive care. His condition CASE INFORMATION: A 63 year old male with hypertension, chronic renal insufficiency, progressively worsened, and both he and family did not want any aggressive intervention. The and peripheral vascular disease presented to the Emergency Department with acute onset of patient passed away shortly thereafter. bilateral lower extremity numbness and weakness. Six weeks prior, he had received an IMPLICATIONS/DISCUSSION: Acute leukemia accounts for about 10% of human cancers arteriovenous fistula in preparation for hemodialysis and was feeling well until the morning of and is the leading cause of death in adults younger than 35 years of age. In our case, the patient admission, when, upon rising from bed, he fell to the ground because of numbness and weakness had poor prognostic factors of age greater than 60 years old and poor functional status. The of his legs. Review of systems was positive for urinary incontinence, ``sharp'' back pain, and treatment of AML consists of supportive care and chemotherapy with induction therapy shortness of breath which had developed at the same time as the paresthesia. Upon reviewing his conducted with an anthracycline and Cytosine-arabinoside (except for subtype M3). medical records, it was discovered that his prostate specific antigen had been elevated at 24.9, Complications from leukemia include those related to immunosuppression and pancytopenia. but the patient had not followed up with the urologist for further evaluation. Physical exam Typhlitis represents inflammation and/or necrosis of the cecum, appendix, and/or ileum and is showed a well-developed male, alert and oriented, in moderate respiratory distress. His a frequent complication of the treatment of AML. Patients usually present with abdominal respiratory rate was 24, blood pressure 142/90, heart rate 82, and temperature 36 C. Other pain, diarrhea and fever. The etiology of typhlitis is unknown, but profound neutropenia and significant physical findings included bilateral crackles, a pericardial friction rub, absent mucosal injury from cytotoxic drugs play important roles in the pathogenesis. The mortality sensation to light touch at an L3 level, 2/5 bilateral lower extremity strength, absent ankle and rate from typhlitis in leukemic patients can be high and the treatment consists of broad patellar reflexes, absent pedal pulses (previously documented), diminished but equal femoral antibiotic coverage, nasogastric suction and supportive care. Surgical intervention is indicated pulses, and an enlarged prostate. Labs showed BUN of 71mg/dl and creatinine of 9.3 mg/dl. if there is bowel perforation or persistent bleeding. Chest radiograph demonstrated mild pulmonary edema. Thorax and abdomen CT without contrast showed a normal . A vascular catheter was placed, and emergent hemodialysis started. The neurology and neurosurgery services were consulted, and plans were made to get an KNEE PAIN, EFFUSION AND FEVER: SEPTIC JOINT OR INTRA-ARTICULAR HYLAN emergent MRI of the lumbosacral spine to rule out cord compression after the patient was COMPLICATION. L.Y. Ho1, E.J. Lee1, K. Barnard1; 1University of Pittsburgh, Pittsburgh, PA stabilized. An hour after dialysis had begun, the patient lost consciousness, and ACLS for (Tracking ID #74197) pulseless electrical activity was initiated. After 25 minutes of unsuccessful resuscitation, the patient was declared deceased. An autopsy was performed which showed hemopericardium from LEARNING OBJECTIVES: Recognize and manage the complications of intra-articular type A aortic dissection which descended to the bifurcation of the aorta. visculosupplementation. JGIM Volume 18, April (supplement 1) 2003 59

CASE INFORMATION: A 74-year-old female, who was previously independent and abdomen/pelvis revealed a without identification of a specific site of ambulating well, presented with a four day history of progressively worsening bilateral knee perforation. Exploratory laparotomy revealed a perforated small bowel mass (7.0 Â 4.0 Â 1.0 pain and swelling. Her past medical history is significant for degenerative joint disease with cm) with infiltrating neoplastic lymphocytes positive for CD 3, 43, and 56 staining. Flow chronic pain in her knees. Her medications included Rofecoxib, Oxycontin, Oxycodone, and cytometry showed a T-cell phenotype with anomalous expression of CD 103 (T-cell mucosal Calcium with vitamin D. The patient had received an injection of Hylan G-F 20 in both knees homing antigen receptor). Staging evaluation did not reveal evidence of metastatic disease. four days prior to presentation for chronic knee pain. A similar injection had been performed The pathology findings in our case are consistent with enteropathy associated T-cell one year previously with relief of pain. The next day she developed fever, chills and the knees lymphoma. Our patient presented with the rarer T-cell CD56 positive variant which has a became warm, erythematous, and swollen, with worsening pain, 10/10 in severity. Upon poorer overall prognosis and aggressive course. presentation, the patient was afebrile and both knees were swollen and tender. The patient was IMPLICATIONS/DISCUSSION: Primary gastrointestinal lymphomas account for 30±40% unable to bear weight, range of motion of the knees was limited to about 30 degrees bilaterally, of extranodal lymphomas, but they are usually of B-cell lineage. Celiac disease, a malabsorption and there was tenderness in the lateral joint line bilaterally. Laboratory results showed a normal disorder related to gluten intolerance, is thought to be a risk factor for developing primary white blood cell count, ESR 70, and C Reactive Protein 20.6. Venous doppler ultrasound was intestinal T-cell lymphoma. Intestinal T-cell lymphoma continues to have a poor prognosis. negative for DVT. Knee x-rays revealed bilateral effusions and evidence of severe CD56 (neuronal cell- molecule) positive tumors have been associated with a more osteoarthritis. Bilateral knee arthrocentesis showed (left/right) white blood cell count, aggressive course. Additional poor predictors include nutritional status at presentation and 11300/10500 with a normal differential, red blood cells 475/38000, and no crystals. Gram presence of a bowel perforation. Survival data for cases presenting with bowel perforation has stain and cultures were negative. The patient was admitted to the hospital for pain management been estimated at 28% and 0% six months and one year post diagnosis. Treatment consists of and transferred to sub-acute rehabilitation for 3 weeks where she responded well to surgical resection of the tumor and adjuvant chemotherapy which consists of cyclopho- corticosteroid injections and physical therapy. sphamide, doxorubicin, vincristine, and prednisone (CHOP) which our patient received. IMPLICATIONS/DISCUSSION: Visculosupplementation involves using intra-articular Systemic chemotherapy is necessary, regardless of stage, because of the malignant clonal injections of high elastoviscous solutions of hyaluronan and hylans in an attempt to restore population of T-cells that exists in the normal gastrointestinal mucosa. Relapse rate is thus the natural mechanical properties of synovial fluid. Complications of intra-articular injections high, even in patients with initial response to chemotherapy. with visculosupplementation occur in 2±4% of injections. Local reactions include joint pain, effusion, and rarely, warmth. Acute pseudogout, granulomatous inflammation, and severe systemic reactions have also been reported. Rest, analgesics, corticosteroid injections, cold PARADOXICAL CEREBRAL EMBOLISM COMPLICATING AN INPATIENT'S packs, and therapeutic arthrocentesis may help relieve symptoms. The presence of fever, HOSPITALIZATION. J. Hutchings1, J. Wiese1; 1Tulane University, New Orleans, LA debilitating pain, and joint effusions in our patient suggested both a systemic and local reaction (Tracking ID #77085) to the supplementation. This impacted her functional status as she became bedridden and she required a prolonged rehabilitation to regain her independent ambulatory status. LEARNING OBJECTIVES: 1. Identify potential complications of indwelling venous catheters. 2. Diagnose systemic embolizations of a venous thrombus to the cerebral vasculature. 3. Appropriately manage new onset stroke. CASE INFORMATION: A 66 year-old woman with recurrent ovarian cancer was hospitalized A GRIM REAPER: LESSONS LEARNED FROM A TRAGIC CASE OF MYXEDEMA and conservatively managed for a partial small . After a second unsuccessful 1 1 1 1 COMA. B. Taqui , P. Huang , L. Kaplan ; Temple University, Philadelphia, PA (Tracking attempt to anti-coagulate her right su-bclavian central venous catheter, the patient developed ID #75537) acute left-sided weakness associated with slurred speech. She denied chest pain but stated she LEARNING OBJECTIVES: 1. Recognize myxedema coma as rare, but important diagnosis was increasing short of breath overnight. Vital signs included a heart rate of 117 beats per in differential for obtunded patient 2. Recognize emergent need for treatment of myxedema 3. minute and a respiratory rate of 26 breaths per minute. Physical exam was remarkable only for Recognize mortality due to the condition and its therapy. a left facial droop, left arm and leg weakness, and dysarthria. An emergent CT scan revealed an CASE INFORMATION: 80 year old Caucasian female with history of congestive heart acute, non-hemorrhagic right-sided cerebral infarct. ECG, duplex scan of the carotid arteries failure, chronic obstructive pulmonary disease, hypothyroidism was found by neighbors to be and chest radiograph were normal. Cardiac isoenzymes were negative for myocardial in obtunded state. In emergency room, her temperature was 95.9 F, blood pressure 108/56, infarction. An arterial blood gas analysis revealed severe hypoxia and an alveolar-arterial pulse 50, respiratory rate 11, glasgow coma scale score 3. Her skin was cool to touch, with oxygen gradient of 42. A ventilation-perfusion scan showed high probability for pulmonary induration and 1+ non-pitting edema of the lower extremities. She had peri-orbital swelling. embolism and a transesophageal echocardiogram revealed a patent foramen ovale. Labs: Na 142, K 4.3, Glc 142, creatinine 2.9, Hgb 9.3, CPK 286, CPK MB 5, troponin I .1, IMPLICATIONS/DISCUSSION: Indwelling catheters can serve as a nidus for thrombus TSH 309, T4 total < 1, T4 free .1. ABG (after intubation, 100% FIO2) pH 7.26 pCO2 52 pO2 formation. Emboli may produce pulmonary sequela with concomitant increased right sided 624. EKG:sinus bradycardia at 50 beats/minute, low voltage. CT head was normal. Blood circulatory pressures. This results in paradoxical emboli entering the arterial circulation though cultures were negative. After labs were drawn, patient was started on nasogastric levothyroxine a right to left shunt, such as a patent foramen ovale, with resultant cerebral ischemia. Patients but continued to deteriorate. The next day, she was switched to and started who demonstrate symptoms of both a cerebral infarct and a pulmonary embolism should be on steroids. Her mental status improved markedly and she was extubated. However, a few days evaluated with a CT scan, carotid duplex, ventilation-perfusion scan and transesophageal later, she was found in asystole and expired. echocardiogram to identify the source and location of the embolus. Treatment involves IMPLICATIONS/DISCUSSION: Myxedema coma is a rare, deadly condition. It should be immediate evaluation for emergent anticoagulation if not contraindicated. Operative closure of a suspected in patients who present with hypothermia and altered mental status. They may also patent foramen is not indicated if the elevation of right sided pressure is related to an acute event. have hypotension, hypoventilation, hyponatremia, hypoglycemia, and cardiovascular abnorm- alities. It may be caused by severe longstanding hypothyroidism or precipitated by infection, infarction, cold weather, narcotics/sedatives. Elderly females are most commonly affected. STILL HAVENT FOUND A DIAGNOSIS: IT MUST BE ADULT STILL'S DISEASE. Therapy should be based on clinical suspicion and started right after drawing TSH, free T4 B. Taqui1, S. Irani1, L.I. Kaplan1; 1Temple University, Philadelphia, PA (Tracking ID #75530) and cortisol levels. Glucocorticoid therapy prevents in cases with associated LEARNING OBJECTIVES: 1. Recognize clinical manifestations of Adult Still's disease adrenal insufficiency. Type of thyroid therapy is controversial. Some prefer T3 because of its 2. Review diagnostic criteria for the disease 3. Manage disease by aiming treatment at joint rapid onset and greater biologic activity. Others prefer T4, which should be given symptoms. intravenously to avoid malabsorption. Careful dosing based on age and weight may prevent CASE INFORMATION: 37 year old Asian female without significant medical history cardiac complications of thyroid therapy. The mortality rate is 30±40% despite adequate presented with ten days of rash, fever, joint pains and stiffness. Rash, which was therapy. Even though intravenous therapy was delayed in this patient, she showed significant erythematous and non-pruritic, began on her thighs and spread to her back and chest. improvement prior to her demise. Thus, her death may have been due to cardiac complications Joint pains spread from her hands and wrists to her shoulders, ankles and knees. Her course of therapy rather than the delay in intravenous therapy. However, definitive cause of death was of illness included high fevers and a sore throat. Physical exam revealed temperature of not determined. Since therapy is controversial and associated with complications, an additional 103.9 F and erythematous, salmon colored maculo-papules on her trunk and proximal lesson is to focus on prevention via recognition and treatment of hypothyroidism. In this tragic extremities. Palms and soles were spared. The rash was exacerbated by fever spikes, which case, the patient had been lost to follow up. usually occurred in the afternoon. Koebner's phenomenon occurred when rubbing caused the rash to appear on previously uninvolved skin. Metacarpophalangial joints, wrists and left shoulder were tender, but without erythema, warmth or effusions. There was no INTESTINAL T-CELL LYMPHOMA PRESENTING AS SMALL BOWEL PERFORATION. lymphadenopathy or splenomegaly. Labs: WBC 22,000 (85% neutrophils, 5% bands). P. Hulick1,H.Tun1; 1Mayo Clinic, Jacksonville, FL (Tracking ID #74266) Blood cultures and tests for HIV, enterovirus, cytomegalovirus, Ebstein-Barr virus, hepatitis, LEARNING OBJECTIVES: 1. Recognize the association of primary gastrointestinal T-cell parvovirus were negative. Anti-streptolysin O titers were negative. LFT, ANA, RF, chest lymphoma and celiac disease 2. Recognize the poor prognosis, especially with +CD56 marker xray, CT chest/abdomen/pelvis, echocardiogram were normal. Skin biopsy showed 3. Treatment must include systemic chemotherapy. perivascular infiltrate, no vascultis. Patient was started on nonsteroidal anti-inflammatory CASE INFORMATION: A 73-year-old white female presented to the emergency department medications and gradually responded to therapy. following an acute exacerbation of abdominal pain that had progressed over the past two IMPLICATIONS/DISCUSSION: Adult Still's disease, although uncommon, should be months. The pain was originally diffuse in nature but became sharp in character with the acute considered in adults with fever, joint pains and rash. The diagnosis requires atleast 5 criteria, presentation. The patient denied radiation to the back while movement exacerbated the pain. including atleast 2 major ones. The major criteria are temperature of > 39 C for atleast 1 week, The patient reported decreased appetite with a fifteen-pound weight loss over the preceding six arthralgias for atleast 2 weeks, typical rash (salmon, maculopapular, evanescent, koebners months, nausea but no vomiting, and intermittent fevers to a maximum of 105F over the phenomenon), WBC > 10,000 (> 80% neutrophils). Minor criteria are sore throat, lymphade- preceding two months. The patient denied other constitutional symptoms. On admission, the nopathy and/or splenomegaly, elevated transaminases or LDH, negative ANA and RF. patient was afebrile with normal vital signs. Diagnosis also requires exclusion of infection, malignancy and other rheumatic diseases. Physical exam was notable for diffuse abdominal discomfort on palpation, decreased bowel Treatment is aimed at joint symptoms because extent and chronicity of arthritis is best sounds of normal pitch, and the absence of generalized lymphadenopathy Laboratory studies predictor of long term consequences. Nonsteroidals, corticosteroids and immunomodulating were Hgb 11.1g/dL, MCV 85 fL, and platelet count of 385,000. Electrolytes, creatinine and drugs are therapeutic options. Choice of therapy depends upon organ involvement and severity liver profile were unremarkable. LDH was 185 u/L. Computed tomography (CT) scan of the of disease. 60 Abstracts JGIM

ADULT INTUSSUSCEPTION: MORE THAN MEETS THE EYE. D. Ishizawar1, R. Granieri2; NEW SEIZURES AND CNS LESIONS IN AIDS PATIENT. S. Issa1, T. Sai1, B. MBA1; 1Cook 1University of Pittsburgh Medical Center, Pittsburgh, PA; 2University of Pittsburgh, County Hospital/Rush University, Chicago, IL (Tracking ID #74053) Pittsburgh, PA (Tracking ID #74292) LEARNING OBJECTIVES: 1. Recognize the clinical presentation of PML. LEARNING OBJECTIVES: 1) To recognize intussusception as a cause of intestinal 2. Recognize the characteristic laboratory findings in PML. obstruction, 2) To recognize that the treatment of adult intussusception differs from pediatric 3. Appreciate the dismal prognosis of PML. cases, 3) To recognize that adult intussusception is often a presentation of underlying CASE INFORMATION: A 24 year old man with severe hemophilia A and AIDS was admitted pathology. to the medical service with new neurological deficits. Eight weeks prior to admission he was CASE INFORMATION: A 53 year old male with a past history of small cell lymphoma started on highly active retroviral therapy (HAART). Six weeks prior to admission he treated three years prior with CHOP chemotherapy and radiation therapy presented to the developed left facial droop and left upper extremity weakness. The patient's family described emergency department with several days of diffuse, unremitting periumbilical abdominal pain. behavioral changes including mood disturbances and aggressive behavior. On the day of He denied melena or hematochezia, and, until recent constipation, his bowel habits were admission the patient experienced two witnessed generalized seizures. On physical examination unchanged. His intake of food was reduced due to bloating, but he denied nausea or vomiting. he appeared chronically ill. Neurological examination revealed a left cranial nerve VII upper He did not experience fatigue, night sweats, fevers, or weight loss. On examination, his motor neuron palsy and left upper extremity weakness. There was no papilledema. An MRI of abdomen was soft and non-distended. He had normal bowel sounds. Despite diffuse the brain revealed multifocal hyperintense signals in the right frontal, left frontal, and right nonspecific tenderness, he did not exhibit guarding or rebound. The spleen and liver were parietal areas predominately affecting the white matter without enhancement or mass effect. A normal size, and no masses were palpated. A rectal exam was normal, and stool hemoccult was subsequent spinal tap revealed a normal opening pressure with 1 white blood cell, 0 red blood negative. Because of his medical history, a CT scan of the abdomen was performed which cells, total protein of 74, and glucose of 54. Evaluation of the cerebrospinal fluid for revealed ileocecal intussusception and resulting obstruction. A barium confirmed an tuberculosis, bacteria, fungus, toxoplasmosis, syphilis, herpes, CMV, and cryptococcus were intussusception but was unable to reduce it. He was taken to the operating room where the negative. JC virus DNA was detected by PCR from the CSF. Based on the clinical surgeons found intra-abdominal lymphadenopathy and ischemia of the proximal colon presentation, radiographic findings and positive JC virus DNA in the CSF, the diagnosis of requiring hemicolectomy. Pathology of the resected tissue revealed follicular B-cell lymphoma progressive multifocal leukoencepholapthy (PML) was made. within the terminal ileum and cecum. IMPLICATIONS/DISCUSSION: PML is a disorder characterized by multiple rapidly IMPLICATIONS/DISCUSSION: Intussusception is a process of gastrointestinal invagina- progressive focal neurological deficits. Hemiparesis, visual field defects, cognitive impairment, tion in which a proximal segment telescopes into a distal portion. While common in children as and cranial nerve deficits are most common. Intracranial pressure usually remains normal. the second leading cause for acute abdomen, adult intussusception occurs in only 5±10% of all Ninety-five percent of all patients with PML have an underlying immunosuppressive disorder cases. Presentation may be either acute or of a chronic indolent nature. It is rarely idiopathic in such as HIV. Conversely, 1±3% of AIDS patients will develop PML. CT or MRI of the brain adults as it is in children, and underlying pathology is readily identifiable in up to 90% of all reveals multiple bilateral, usually asymmetric areas of demyelination. The lesions are usually cases. Common causes include polyps, Meckel's diverticulum, endometriosis, and inflamma- localized to the periventricular area and subcortical white matter. There is no contrast tory bowel disease, but 54%±69% of identified pathology are malignancies including enhancement or mass effect. The diagnosis is made based on the clinical picture of multiple lymphomas. The process of intussusception causes gastrointestinal circulatory obstruction neurologic deficits, characteristic radiographic findings, and isolation of the JC virus from the which can lead to ischemia and bowel infarct. Avoiding delay in surgical intervention preserves CSF. Detection of JC virus from the CSF has a sensitivity of 74±95% and a specificity of tissue. While barium enema is both diagnostic and therapeutic in children, it is less efficacious 92±100%. There is currently no proven effective therapy for PML. HAART therapy has been in adults, and its role in adult therapy is actually controversial. Because of the likelihood of shown to slow the progression of the disease. However, most patients deteriorate rapidly underlying pathology, primary resection is often the treatment of choice. Whether or not to within 6 months. attempt reduction before resection is arguable; some authors have suggested that time spent on barium compromises the integrity of bowel tissue. While uncommon, intussusception should be readily recognized when it occurs. Treatment of the disease requires timely surgical HEADACHES AND VISION LOSS IN A HEALTHY YOUNG MALE. S. Issa1, T. Sai1; 1Rush intervention to preserve bowel tissue. It is paramount to recognize that treatment in adults University/Cook County Hospital, Chicago, IL (Tracking ID #75940) differs from pediatric cases where barium enemas are often successful. Discovery of adult LEARNING OBJECTIVES: 1. Recognize the importance of opthomologic exam in the intussusception must arouse clinical suspicion of underlying pathology which should be differential diagnosis of aseptic meningitis 2. Understand the role of steroid therapy in Vogt- addressed. Koyanagi-Harada Syndrome. CASE INFORMATION: A 24-year-old previously healthy man was admitted to the medical service with progressively worsening generalized headaches, decreased visual acuity, and ETHYLENE GLYCOL TOXICITY: A TALE OF TWO GAPS. D. Ishizawar1, M. Greenwald1, hearing loss for two weeks. The patient reported malaise, but denied nausea, vomiting and R. Granieri2; 1University of Pittsburgh Medical Center, Pittsburgh, PA; 2University of fevers. He had never traveled outside the United States and did not use drugs or alcohol. The Pittsburgh, Pittsburgh, PA (Tracking ID #74948) patient was afebrile. HEENT examination revealed bilateral papilledema and decreased visual acuity and hearing. Neck examination was remarkable for nuchal rigidity. The neurological LEARNING OBJECTIVES: 1) To review the methods of diagnosing ethylene glycol toxicity, exam was otherwise normal. CT scan of the head and orbits confirmed the papilledema but did 2) To review the toxic effects of ethylene glycol, 3) To review the treatment of ethylene glycol not reveal any mass effect. A subsequent spinal tap revealed normal opening pressure, 727 intoxication. white blood cells with 70% lymphocytes, a protein = 81, and glucose = 53. The patient was CASE INFORMATION: A 74 year old male with a history of depression was found begun on broad-spectrum antibiotics and anti-tuberculous therapy without significant unresponsive at home by his wife with an open container of antifreeze nearby. He was taken to improvement. RPR, HIV, ESR, and cryptococcal antigen were negative. Ophthalmologic the local emergency department, which was unable to run ethylene glycol level assays. At the consultation was obtained. Slit lamp examination revealed cells in the anterior chamber outside hospital, he had an anion gap of 25, but an osmolar gap was not measured. He was consistent with uveitis, choroidal inflammation, and depigmentation. The patient was placed on an ethanol drip and transferred to a tertiary care center. A stat ethylene glycol level diagnosed with Vogt-Koyanagi-Harada (VKH) syndrome based on the ophthalmologic returned elevated at 432 mg/dL, and the osmolar gap was 140 mOsm/kg. At this time, although findings, aseptic meningitis and hearing loss. The patient was started on high dose steroids stuporous, he was arousable and conversed appropriately. Unfortunately, urine was not sent for with relatively rapid resolution of the headaches and visual and hearing loss. analysis, but serum creatinine was 1.2 mg/dL. Instead of initiating hemodialysis, the patient IMPLICATIONS/DISCUSSION: VKH is a uveomeningoencephaltic syndrome and appears was placed on intravenous fluids with dextrose and saline and given fomepizole every 12 hours. to be an autoimmune reaction to melanocytes thus making it more common in Asians, Middle- Treatment continued for the next 60 hours until his ethylene glycol level fell within a non-toxic Easterners, and Hispanics than whites. Melanocytes are located in the skin, uvea, retinal range. Clinically, his mental status returned to baseline, and his serum creatinine improved to choriod, membrane of the , and leptomeninges, accounting for the particular pattern 0.8 mg/dL. The patient underwent psychiatric evaluation and after medical clearance was of involvement seen in this syndrome. The ocular findings may include cataracts, glucoma, and transferred to an inpatient psychiatric facility for treatment of his depression. globe atrophy. Meningeal involvement may lead to encephalopathy, seizures, myelopathy, or IMPLICATIONS/DISCUSSION: Ethylene glycol is a sweet liquid found in antifreeze. The other focal signs. CSF findings include a lymphocytic pleocytosis, elevated total protein, and taste has led to accidental intoxication in young children, but ingestion also occurs during normal opening pressure. Other manifestations of VKH include dysacousia, alopecia, poliosis, suicide attempts. It is metabolized into oxalate, which is excreted by the kidneys, through and vitiligo. Although the optimal steroid dosage for treating VKH has not yet been defined it several enzymatic steps beginning with alcohol dehydrogenase. Early toxicity is manifested by is generally accepted to begin therapy with high-dose systemic steroids followed by oral mental status changes ranging from stupor to coma. Renal damage from direct toxicity to the steroids for at least 6 months. Patients typically have a rapid decrease in symptoms. In about kidneys develops later although the rate of occurrence depends on the severity of intoxication. half of the patients, disease recurs within six months of discontinuation of steroids. Presumptive diagnosis, based on a history of ingesting solutions likely to contain ethylene glycol, such as antifreeze, is the first critical step in diagnosis. While ethylene glycol can be measured directly, the laboratory equipment may not be available readily in all emergency NONSTEROIDAL ANTI-INFLAMMATORY DRUG ASSOCIATED LOWER departments. However, diagnosis can be confirmed indirectly with basic laboratory tests. GASTROINTESTINAL TOXICITY. J.T. Jacob1, A.K. Jaffer1; 1Cleveland Clinic Foundation, Ethylene glycol itself causes an increased osmolar gap, and its metabolite glycolic acid creates Cleveland, OH (Tracking ID #74333) the anion gap metabolic acidosis. The end product of , oxalate, can precipitate in urine, and urinalysis may reveal calcium oxalate crystals. Treatment must occur expediently to LEARNING OBJECTIVES: 1) Recognize the lower gastrointestinal (GI) adverse effects of preserve renal and neurological function. This should involve adequate hydration and non-steroidal anti-inflammatory drugs (NSAIDs). 2) Examine the differential diagnosis of inhibition of alcohol dehydrogenase to prevent breakdown of ethylene glycol into its toxic multiple gastrointestinal ulcers. 3) Implement appropriate testing and treatment of NSAID- metabolites. Ethylene glycol is dialyzable, and severe intoxication may require hemodialysis. induced lower GI pathology. However, in most cases, fomepizole, a more efficacious inhibitor of alcohol dehydrogenase CASE INFORMATION: An 80-year-old female with coronary artery disease, hypertension, than ethanol, can be used alone without need for dialysis. If both methods are used the dose of dyslipidemia and osteoarthritis was admitted to the hospital with chest pain and two episodes fomepizole needs to be increased since it is a dialyzable agent. Fomepizole can preserve renal of syncope. Each episode of syncope was preceded by use of sublingual nitroglycerin. Review of function without invasive vascular access required for hemodialysis. Recovery without systems was positive for chronic fatigue, but negative for weight loss, nausea, vomiting, permanent sequelae is possible but requires timely recognition of ethylene glycol intoxication abdominal pain or GI blood loss. Medications were metoprolol, omeprazole, hydrochlor- and familiarity with the treatment methods. othiazide, indomethacin, and gemfibrozil. Exam revealed a BP = 113/60 without orthostasis, a JGIM Volume 18, April (supplement 1) 2003 61

Pulse = 95 and 97% O2 sat. The exam of the abdomen was normal except for guaiac positive called Miller-Fisher syndrome. Plasmapheresis was instituted and after a couple exchanges stool on rectal exam. A CBC showed a hemoglobin of 8.9 g/dl with a normal MCV and RDW. improvement was noted in her motor strength, VC and NIF. She was discharged after An iron panel, B12, folate, LDH, bilirubin, and haptoglobin were also normal. A dipyridamole completing five session of plasmapheresis. 6-weeks post-discharge, her neurological examina- thallium stress test was negative. The syncope was felt to be related to transient hypotension tion was remarkable only for mild residual diplegia. from nitroglycerin in the setting of anemia. She was therefore transfused blood and underwent IMPLICATIONS/DISCUSSION: GBS is an acute ascending inflammatory demyelinating upper and lower endoscopies. Multiple ulcers were noted in the stomach, terminal ileum, polyradiculoneuropathy. The management of GBS requires early recognition because the ileocecal valve, transverse colon and descending colon. Biopsies demonstrated acute non- respiratory muscles can be involved. Elective intubation should be considered when the forced specific inflammation. Gastrin levels were normal. Indomethacin was discontinued, VC falls below 15 mL/kg or when the patient is unable to generate more than 20 cm H2O of acetaminophen was initiated and omeprazole continued. She was discharged home in stable maximal NIF. Initial symptoms include parasthesias with rapid progressive muscle weakness condition with a two-month follow up endoscopy. and areflexia. The Miller-Fisher syndrome is a variant of GBS in which the cranial nerves are IMPLICATIONS/DISCUSSION: Adverse gastrointestinal (GI) effects of NSAIDs are not affected. Autonomic dysfunction with cardiac dysrythmias occurs in one half to two thirds of limited to the stomach and duodenum. Although these sites are most commonly affected, patients. The disease generally has a good prognosis with close cardiopulmonary monitoring. adverse effects related to the large bowel and the distal small intestine are increasingly being Plasmapheresis and IVIG have been shown to alter the natural history of GBS if treatment is recognized in practice. NSAIDs can cause a variety of pathology in the lower GI tract including instituted quickly. erosions, ulcers, diaphragms, strictures, small bowel enteropathy, diverticular bleeding and colitis resembling or exacerbating inflammatory bowel disease (IBD). The pathophysiology of these changes has not been elucidated. Other etiologies of multiple GI ulcers include: viral and THE KIDNEY: A SOURCE OF SEIZURE? T.L. Jarrett1, T. Masud1, D.W. Brady1; 1Emory bacterial infections, vasculitides, IBD and Zollinger-Ellison syndrome. University, Decatur, GA (Tracking ID #76639) Treatment consists of discontinuation and avoidance of all NSAIDs. Gastrin levels should be checked to rule out a . A repeat endoscopy in 6±8 weeks is needed to confirm LEARNING OBJECTIVES: 1. Consider metabolic disorders as a cause of seizures. healing otherwise other etiologies need to be considered. An increase in reporting of these 2. Recognize the clinical presentation and treatment of Gitelman's Syndrome. adverse effects will lead to a better understanding of NSAID induced lower gastrointestinal CASE INFORMATION: A previously healthy, 22 year old male presented for further workup toxicity amongst physicians. after suffering a seizure episode on two separate occasions. 10 days prior to his presentation at the university hospital, the patient experienced a witnessed tonic-clonic event and was taken to a local hospital. The patient was admitted to that hospital and found to have a normal CT, MRI, and EEG. While preparing for discharge home, he had another tonic-clonic event which TYPE 1 DIABETIC WITH INFLAMMATORY BOWEL DISEASE PRESENTING WITH was witnessed by hospital personnel, and he was transferred to the university hospital for LOWER EXTREMITY ULCERS AND KETOACIDOSIS. K. Hahn1, J.T. Jacob2, further evaluation. He complained of feelings of mild generalized weakness over the past few S. Almahameed2, A.K. Jaffer2; 1Hershey Medical School, Pennsylvania State University, months as well as some tingling and numbness in his hands and feet. He denied any recent Hershey, PA; 2Cleveland Clinic Foundation, Cleveland, OH (Tracking ID #74345) trauma or seizure history. He also denied any chills, fevers, nausea, vomiting, or weight loss. LEARNING OBJECTIVES: 1. Outline the preoperative management of diabetes mellitus Past medical history was noncontributory. He denied the use of illicit or prescription drugs, type 1 (DM1). 2. Recognize pyoderma gangrenosum (PG) and the systemic diseases associated tobacco, ethanol, or herbals. On examination, his vital signs were pulse 101, blood pressure with it. 3. Examine the treatment options for PG 146/90, and temp 35.4C. Physical exam was unremarkable including normal neurological CASE INFORMATION: A 42-year-old male with a history of DM1, inflammatory bowel exam. Labs on admission were significant for K of 3.1 meq/L (nl 3.5±5.0), Cl of 96 meq/L (nl disease (IBD) and PG was admitted for ileostomy closure. The patient discontinued his insulin 100±110), CO2 33 meq/l (nl 20±32), Ca 9.0 mg/dl (nl 8.5±10.5), and Mg 1.0 meq/l (nl 1.5± pump the night prior to surgery. The preoperative glucose was 500 and the surgery was 2.4). Records received from the outside hospital showed low Mg and K levels during the time canceled. He was well until three weeks prior when his shin lesions started to get worse after of both wintessed seizures. Patient was repleted with IV Mg and K and placed on phenytoin. minor trauma. Review of systems was otherwise negative. On exam, he appeared lethargic, Repeat MRI and EEG were negative. The patient continued to have low serum magnesium T = 38.3 8C, Pulse = 145, and BP = 110/50 mmHg. The patient had four necrotic shin and ankle levels in spite of aggressive IV and PO repletion. 24 hour urine studies revealed a significantly ulcers with exposed bone and tendon. Labs revealed a serum bicarbonate of 9 mg/dl, potassium elevated urine magnesium excretion of 25 MEq/24hr (nl 6±10 MEq/24hr), as well as a of 4.6 mg/dl, glucose of 527 mg/dl, anion gap of 26 and elevated serum ketones. A blood gas decreased urine calcium excretion of 94 mg/24hr (nl100±300 mg/24hr). Urine screen revealed a pH of 7.24, pCO2 of 17 mmHg, pO2 of 123 mm Hg and HCO3 of 7 mg/dl. Culture was negative. Renin and aldosterone were both elevated at 15.8 ng/ml/hr (nl 0.2±1.6 ng/ml/hr) of the ulcers grew gram positive and negative bacteria. The patient was treated with and 38.4 ng/dl (nl 1.6±16) respectively. The patient was diagnosed with Gitelman's Syndrome intravenous (IV) Insulin, fluids and antibiotics. After the DKA resolved, therapy for PG was and discharged home on magnesium oxide, amiloride, aldactone and potassium supplements. begun using infliximab, topical cromolyn, clobetasol and whirlpool therapy. During infliximab He suffered no further episodes of seizure activity and his weakness improved. infusion the patient developed transient hypotensive and shortness of breath. He was treated IMPLICATIONS/DISCUSSION: Seizures presenting with normal MRIs and EEGs can with diphenhydamine and hydrocortisone with resolution of his symptoms. He was switched to present a diagnostic dilemma for internists. This case emphasizes the importance of oral cyclosporine and discharged home. considering metabolic disorders as a cause of seizures especially in the setting of normal IMPLICATIONS/DISCUSSION: There are two accepted alternatives in the preoperative MRIs and EEGs. Gitelman's Syndrome, an autosomal recessive disorder which usually management of DM1. Patients can hold short-acting insulin on the morning of surgery and presents in early adulthood, is a rare variant of Bartter's syndrome resulting from defects in take one-half to two-thirds of their normal long-acting insulin dose or omit their morning renal tubular function. Unlike Bartter's, Gitelman's patients present with hypomagnesemia and insulin regimen entirely and be administered regular insulin on arrival to the hospital based on hypocalciuria, along with complaints of severe fatigue, cramps, muscle spasms, and . their glucose level. Patients with insulin pumps should continue their pumps at a basal rate until the morning of surgery. PG is an idiopathic dermatosis associated with epidermal and/or dermal inflammation. It is AN UNUSUAL CAUSE OF NAUSEA AND VOMITING WITH FAILURE TO THRIVE. THE most commonly associated with systemic diseases such as IBD, rheumatoid arthritis and IMPORTANCE OF OBSERVATION. J. Jevtic1; 1Medical College of Wisconsin, Milwaukee, lymphoproliferative disorders. These lesions typically involve the lower extremities and are WI (Tracking ID #76703) painful. Treatment is directed at the underlying systemic disease. Systemic steroids were avoided in this patient's case due to concerns for recurrent hyperglycemia. Alternatives include LEARNING OBJECTIVES: 1. Recognize an unusual cause of nausea and vomiting. infliximab, dapsone, thalidomide, azathioprine, cyclophosphamide, 6-mercatopurine, tacroli- 2. Recognize the importance of a good history and physical exam. 3. Consider mitochondrial mus and cyclosporine. Adjunctive therapies include antimicrobials, topical cromolyn, myopathy syndromes when evaluating younger patients with failure to thrive. clobetasol and whirlpool therapy. CASE INFORMATION: A 24 y/o white female with 2 year history of nausea and vomiting with progressive failure to thrive. Three exploratory laparotomies over that time for acute abdomen revealed no pathologic diagnosis. PMH includes asthma, G1P1. P.E. reveals a cachectic, female, 4ft. 11in., 36.1 kg. Evidence of hypotelorism, bilateral ptosis, decreased A WOMAN WITH ASCENDING DEMYELINATING PERIPHERAL NEUROPATHY, lateral gaze with nystagmus at end gaze. Abdominal exam reveals distended and tympanic CRANIAL NERVE PALSY AND CARDIAC DYSAUTONOMIA. S. Almahameed1, epigastrum. Neurological exam reveals normal visual acuity, decreased C.N. 8 bilaterally, J.T. Jacob1, A.K. Jaffer1; 1Cleveland Clinic Foundation, Cleveland, OH (Tracking ID #76224) strength of proximal muscle groups 4/5 with atrophy, while distal muscle groups 5/5 LEARNING OBJECTIVES: 1) Recognize clinical features of Miller-Fisher Syndrome, a bilaterally. DTR's brisk through out. Laboratory studies included CBC, basic metabolic panel, variant of Guillain-Barre Syndrome (GBS). 2) Illustrate the importance of cardiopulmonary thyroid function tests, Vitamin B12, folate, and lactic acid which were normal except monitoring in GBS. 3) Emphasize the role of plasmapheresis and intravenous immunglobulin hemoglobin 9.9g/dl, low iron saturation 11%, ferritin 51. She underwent EGD which was (IVIG) in the treatment of patients with GBS. normal including duodenal biopsies, aspirates and electronmicroscopy of duodenal biopsies. CASE INFORMATION: A 55-year-old female with Crohn's disease on long term TPN Her esophageal manometry revealed hypotensive LES, gastric emptying scan showed presented with shallow breathing, paresthesias involving the extremities and progressive motor prolonged liquid gastric emptying with T 1/2 = 136 minutes (mean is 90 minutes). SBFT weakness over a period of 2 days. Two weeks prior to presentation she was diagnosed with line- showed slow emptying of barium. In consultation with neurology, work up included urine related candidemia; the port was removed and she was treated with intravenous fluconazole. porphyrin studies that were negative, while MRI of brain showed diffuse leukoencephalopathy. Exam revealed a cachectic female who was afebrile, BP = 110/80, HR = 90, RR=22, O2 LP was recommended but nondiagnostic. Fatty acid levels were normal. Ophthalmology sat = 97%. Neurological exam revealed a right facial droop, dysarthria, motor strength was 2/5 evaluation revealed retinal pigmented degeneration while audiometry revealed bilateral in the upper extremities (UE) and 0/5 in the lower extremities (LE) bilaterally. All reflexes were moderate sensorineural hearing loss. Muscle biopsy would be indicated if genetic testing were absent. Brain and spine MRI were unremarkable. The CSF cell count and glucose were normal not available. Pt. had chromosomal karyotyping, as well as mitochondrial DNA and thymidine while the protein was elevated. Blood, urine and CSF cultures were negative. The initial vital phosphorylase levels, which are absent in specific mitochondrial disorders. These confirmed capacity (VC) was decreased to 0.89 L and the negative inspiratory force (NIF) was the diagnosis of a mitochondrial disorder, subtype called mitochondrial neurogastrointestinal unobtainable. EMG revealed features of generalized sensorimotor polyneuropathy with leukoencephalopathy(MNGIE). demyelination and axonal loss. Recurrent asymptomatic episodes of non-sustained ventricular IMPLICATIONS/DISCUSSION: Mitochondrial disorders certainly accounts for <0.1% of tachyarrhythmia were observed on telemetry but cardiac evaluation revealed no structural heart causes of nausea and vomiting. On review of the patient's history and physical exam she also disease. The patient was diagnosed with GBS with cranial nerve involvement, a GBS variant had salient findings of proximal muscle weakness, hearing and eye abnormalities. 62 Abstracts JGIM

Gastrointestinal involvement is an unusual presentation for mitochondrial disorders with only The symptoms and signs of IE often are constitutional and, when localized, result from a 21 reported cases. More typical findings of mitochondrial myopathies are progressive ptosis, complication of IE. Consequently, if physicians are to avoid overlooking the diagnosis of IE, ophthalmoplegia and proximal muscle weakness in young patients. All these findings can be a high index of suspicion must be maintained. This is especially true in cases of IE that have a found on an internists thorough physical exam, as this case illustrates. subacute course. Subacute endocarditis is characterized by an insidious onset and by nonspecific signs and symptoms of chronic illness, such as low grade fever, fatigability, and malaise. Immunologic phenomena occur when the disease is protracted. Musculoskeletal ``I CAN'T TIE MY SHOES. '' ADENOCARCINOMA OF THE LUNG AND symptoms, as was described in this patient, are common. Although fever is the most common PARANEOPLASTIC ANTIBODY ENCEPHALOPATHY: FOLLOW UP 2 YEARS LATER. sign in patients with IE, it is typically low grade. Heart murmurs are noted in 80 to 85 percent K.S. Jorn1; 1Mayo Community Internal Medicine, Jacksonville, FL (Tracking ID #74452) of patients with native value endocarditis (NVE) and are emblematic of the lesion predisposing to IE. Enterococci, which comprise normal gut flora, account for 5 to 15 percent of cases of LEARNING OBJECTIVES: 1. To describe symptoms that may be seen in primary care that NVE. There are no specific clinical manifestations nor is there a single lab test that establishes should prompt evaluation for paraneoplastic limbic encephalopathy 2. To describe the clinical the diagnosis of IE unequivocally. A combination of major and minor clinical findings, outlined course of and paraneoplastic antibody levels in this patient over time 3. To present the concept in the Duke criteria, makes the diagnosis highly probable. In the absence of surgical indication, that paraneoplastic antibody levels may not be cost-effective for surveillance after cancer is optimal therapy for enterococcal endocarditis requires synergistic bactericidal interaction of treated, but additonal study is needed. antimicrobial agents targeted against the bacterial cell wall (penicillin, ampicillin, or CASE INFORMATION: A 47 yo nurse presented for primary care in May 2000 after vancomycin) and an aminoglycoside. recovering from a massive pulmonary embolus in February 2000. Previous medical history was significant only for tobacco abuse and history of depression and anxiety, stable with medical therapy. Evaluation for causes of the embolus revealed only a 1cm coin lesion in her right lung, ``MY MOTHER IS WEAK AND DEPRESSED. COULD IT BE BECAUSE OF HER stable on follow-up CT through June 2001. In Fall-Winter of 2000, the patient, co-workers, MEDICATIONS?'' H. Kaldas1, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA and her supervisors noted a decline in the patient's concentrating ability and documentation (Tracking ID #74568) efficiency. An accusation of diversion of narcotics triggered severe depression and anxiety in December 2000. The patient was receiving medical and psychological therapy for depression LEARNING OBJECTIVES: 1) To recognize the presentation of adrenal insufficiency. 2) To 1 and anxiety when apraxic symptoms such as inability to tie her shoes, loss of direction sense, recognize the glucocorticoid-like activity of megestrol acetate (Megace ), a potential cause for fecal and urinary incontinence, and absence-seizure type episodes were noted in the spring of adrenal insufficiency. 2001. She was felt to have symptoms of limbic encephalopathy. A paraneoplastic antibody CASE INFORMATION: An 81-year-old female was brought to the emergency department by panel revealed an elevated P/Q calcium channel antibody. Thoracotomy with removal of the her son for progressive generalized weakness and lethargy of 4 weeks duration, depression and 1 coin lesion July 2001 revealed it to be bronchoalveolar cell carcinoma. Patient's cognitive frequent falls. She had complained of anorexia for the prior 3 months, for which Megace was function has gradually improved to near-normal levels. Though the elevated P/Q antibody led prescribed. She had no other complaints. Past history is significant for CABG, aortic valve to her cancer diagnosis, the antibody levels have not paralleled her clinical course. replacement, hyperlipidemia, and CVA. Medications included warfarin, furosemide, spirono- 1 IMPLICATIONS/DISCUSSION: Neurologic paraneoplastic antibody syndromes are more lactone, carvedilol, Megace and atorvastatin. On physical exam, she was alert with flat affect. typically associated with small cell lung carcinoma and often involve brain stem, cerebellar, or BP 140/80, without orthostatic changes. No hyperpigmentation was noted. Neuro exam neuromuscular junction dysfunction. There is little literature to guide the follow-up use of revealed right facial droop. Lab studies showed WBC 9, H/H 14/44, platelet 377, glucose 92, paraneoplastic antibody testing after cancer has been treated. This unusual case is characterized BUN 40, Cr 1.1, NA 129, K 5.1, HCO3 22, TSH 3.1. Because of her overall clinical and by cognitive dysfunction in the presence of lung adenocarcinoma and suggests that follow-up laboratory presentation, the pituitary-adrenal axis was evaluated. The AM Cortisol was level paraneoplastic antibody testing does not add much to clinical assessment after treatment of 1.4 and ACTH was 5. Brain MRI and CT abdomen were unremarkable. The diagnosis of 1 cancer. Additional studies are needed to determine if there is prognostic information to be secondary adrenal insufficiency, potentially secondary to Megace , was made. Patient was gained by surveillance with paraneoplastic antibody testing. started on hydrocortisone 20 mg PO qAM, and 10 mg PO qPM. She had marked improvement in her symptoms. Megace1 was discontinued and hydrocortisone was ultimately tapered. IMPLICATIONS/DISCUSSION: Findings in adrenal failure are nonspecific, and, without a EVALUATION AND SIGNIFICANCE OF PERSISTENT ASYMPTOMATIC ELEVATED high index of suspicion, the diagnosis of this potentially lethal but readily treatable disease is BONE ALKALINE PHOSPHATASE. K.S. Jorn1; 1Mayo Community Internal Medicine, missed easily. Symptoms due to cortisol deficiency include anorexia, nausea, vomiting, weight Jacksonville, FL (Tracking ID #74454) loss, weakness, and fatigue. Although orthostatic hypotension is more marked in primary than secondary adrenal insufficiency because of aldosterone deficiency, it does occur in the latter. LEARNING OBJECTIVES: 1. To review a series of cases in which asymptomatic elevated Hyperpigmentation (due to increase ACTH), hyperkalemia and volume depletion (due to bone alkaline phosphatase was discovered, evaluated, and followed. 2. To propose an algorithm aldosterone deficiency) occur only in primary adrenal failure. Hyponatremia is seen in both. In for evaluation of asymptomatic elevated bone alkaline phosphatase. 3. To suggest that patients in whom adrenal insufficiency is merely to be ruled out, plasma cortisol is measured additional study is needed to determine if this algorithm is cost-effective. between 8 and 9 AM. Concentrations of <3 Ag/dl are indicative of adrenal insufficiency and CASE INFORMATION: Asymptomatic elevated liver enzymes are commonly encountered in obviate the need for other tests. Concentrations greater than 19 Ag/dl rule out the disorder. primary care and are well documented in medical literature. Asymptomatic elevated alkaline The short cosyntropin stimulation test is the most commonly used test for the diagnosis of phosphatase (bone subtype) also appears to be common in primary care but there is a lack of primary adrenal insufficiency. Secondary adrenal insufficiency is characterized by low blood guidance in the literature for further evaluation of the abnormality once it is discovered. The cortisol and ACTH levels, a low baseline rate of steroid excretion, and abnormal ACTH and cases presented provide examples of persistently elevated bone alkaline phosphatase and the metyrapone responses. Megace1 is a progestational agent with activity in advanced breast and outcome of the evaluation and followup over three to five years. Diagnoses revealed during endometrial cancer and AIDS-related cachexia. Long-standing Megace1 therapy can result in evaluation of asymptomatic elevated bone alkaline phosphatase include metastatic lung cancer, marked suppression of serum cortisol levels and decreased ACTH .The depressing effect of male osteoporosis, and an apparently benign elevation of the enzyme. An algorithm for megestrol acetate on the pituitary-adrenal axis does not cause clinically evident problems in the evaluation of an asymptomatic elevated bone alkaline phosphatase is proposed. overwhelming majority of cancer patients. However physicians should be aware of the IMPLICATIONS/DISCUSSION: The author hopes that this limited case series will help to possibility of adrenal insufficiency while taking or upon withdrawal of this drug. This is focus additional attention on this relatively common clinical problem, ultimately providing especially important in severely ill patients, in whom the subtle signs and symptoms of adrenal more robust guidance to the clinician in its evaluation and management. insufficiency can be attributed to their primary disease.

THE PATIENT ALWAYS COMPLAINS OF PAIN. COULD IT BE SOMETHING ELSE THIS A RARE CAUSE OF ATAXIA IN THE ELDERLY. A. Kalyanasundaram1, M. Stecker1; TIME? H. Kaldas1, R. Granier1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #74550) 1Geisinger Medical Center, Danville, PA (Tracking ID #76979)

LEARNING OBJECTIVES: 1) To recognize the nonspecific presentations of infective LEARNING OBJECTIVES: 1) To recognize some causes of gait disorder in the elderly 2) To endocarditis (IE). 2) To recognize that patients with chronic pain syndrome can have other recognize the importance of a detailed history and 3) To recognize the role of genetic testing in etiologies for their current illness. 3) To recognize the treatment of enterococcal IE. appropriate elderly patients with gait disorders. CASE INFORMATION: A 34-year-old female with a history of fibromyalgia and penicillin CASE INFORMATION: 64-year-old female patient with past medical history of diabetes, allergy presented several weeks after rectal abscess drainage with malaise, generalized myalgias mild osteoarthritis, and hypercholesterolemia developed gait problems over the last year and a and subjective low grade fever. On the first visit to her physician, the patient was sent home half. She started losing balance around that time and her gait had become slow. She denied with the presumptive diagnosis of fibromyalgia exacerbation. Having continued to experience headaches, seizures, swallowing problems, memory disturbances or any sensory involvement. symptoms that she described as different from her usual ``fibromyalgia pain'', she returned to Her family history is significant for one sister and all male members in her father's family who the office to seek additional medical care. She was afebrile and her physical exam was notable developed gait disorders in their sixties. On examination, slurring of speech was present. Extra- for a diastolic murmur and generalized muscle tenderness. Pertinent labs included H/H of 11/ ocular movements were intact. Strength in all extremities was normal and there was no 39, WBC 14 and ESR 66. Blood cultures were drawn and returned 24±48 hours later, being pronator drift. Sensory examination was intact. Reflexes were symmetric and brisk. Gait was positive for Enterococcus faecalis in 3 out of 3 bottles. TEE demonstrated an aortic valve wide-based and she could not walk on her heels or toes. Her handwriting was small and she had vegetation with regurgitation. The diagnosis of IE was made and she was treated initially with difficulty with rapid alternating movements. An MRI showed mild cerebellar atrophy. Tests for vancomycin and gentamicin. She was successfully desensitized to penicillin and her treatment Lyme disease, rheumatoid factor and anti-nuclear antibody were negative. Vitamin B12 level course with IV penicillin and gentamicin continued for 6 weeks. The patient had gradual and sedimentation rate were normal. Genetic testing revealed that she possessed the CAG/ resolution of her presenting symptoms during her treatment course. CAA repeat expansion mutation associated with spinocerebellar ataxia 17. Genetic counseling IMPLICATIONS/DISCUSSION: Patients with fibromyalgia or chronic pain syndrome can has been offered to her family members. be challenging as they present frequently with multiple nonspecific complaints. It can be IMPLICATIONS/DISCUSSION: There are many potential causes for gait disorders in the tempting to attribute all of their symptoms to these underlying disorders. However, elderly. The most common are related to the presence of a sensory-motor polyneuropathy such physicians should objectively evaluate the patient and entertain other diagnoses when these as seen with diabetes, or strokes related to cerebrovascular disease. Also common are disorders patients present with new or worsening symptoms. In our case, this finally led to the secondary to compressive myelopathy. In this patient the presence of slurred speech made diagnosis of IE. myelopathy and neuropathy unlikely and the absence of structural lesions on MRI suggested a JGIM Volume 18, April (supplement 1) 2003 63

progressive degenerative disorder. Spino-cerebellar ataxia(SCA) type 17 is a rare autosomal syndrome is a variant of sarcoidosis in which acute sarcoidosis often presents with dominant neurodegenerative disease caused by an abnormal CAG expansion in the TATA- constitutional symptoms, polyarthritis, and erythema nodosum. The diagnosis of sarcoidosis binding protein (TBP) gene. SCA 17 was identified in 4 Japanese pedigrees and first reported should be based on a tissue biopsy, but a patient with typical LoÈfgren's syndrome may not need in 2001. Most individuals present between the ages of 20 and 30 with gait ataxia and dementia, biopsy proof. Non-steroidal anti-inflammatory agents usually effectively alleviate sarcoid progressing over several decades to include bradykinesia, dysmetria, dysdiadokokinesis, arthritis and joint symptoms associated with erythema nodosum. In severe acute arthritis and in hyperreflexia, and paucity of movement. Neuroimaging shows cortical and cerebellar atrophy. chronic arthritis, corticosteroids may be required to control the symptoms. Even the small number of SCA 17 patients identified so far suggests that there would be substantial phenotypic variability, probably secondary to incomplete penetrance. This case emphasizes the details of the differential diagnosis of gait disorders in the elderly and the FEVER OF UNKNOWN ORIGIN: YOU'RE NEVER GOING TO GET IT. M. Kanbour1, importance of the family history even in the elderly patient. This has become especially J. Hefner1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76527) important with the greater availability of genetic testing that will provide the basis for genetic counseling. LEARNING OBJECTIVES: 1.) Manage a cost-effective diagnostic workup of fever of unknown origin (FUO) in the elderly; 2.) Assess and treat an elderly patient with an FUO; 3.) Recognize an unusual presentation of an FUO COLA INDUCED HYPOKALEMIC RHABDOMYOLYSIS. A. Kamdar1,G.Stefano1, CASE INFORMATION: A 78-year-old Caucasian female with a history of HTN, presented M. Rich1; 1Summa Health System, Akron, OH (Tracking ID #75779) with a productive cough of white sputum and intermittent fevers, chills and night sweats for 1 month. She also complained of dizziness, weakness, a decreased appetite and a 5 pound LEARNING OBJECTIVES: 1) To review a very unique case of hypokalemic myopathy; weight loss over 4 weeks. She had been treated with antibiotics for 14 days which provided no 2) The importance of a complete history in pinpointing a rare diagnosis; relief. She denied visual changes, head pain, neck stiffness, chest pain, shortness of breath, CASE INFORMATION: A 37 yo white female with no significant PMH presented to the ER dyspnea on exertion, nausea, vomiting, dysphagia, abdominal pain, diarrhea, urgency, dysuria, with a chief complaint of constant, progressive weakness over the past ten days. The patient arthralgias or myalgias. Her medications included hydrochlorothiazide (HCTZ) and lisinopril. initially noted swelling, paresthesias, and muscle tenderness in her legs, followed by progressive On physical exam, she appeared cachectic with dry mucous membranes and decreased skin weakness from the ankles to the hips. She described difficulty in standing from a seated turgor. Temperature was 38.4. Lung exam was clear bilaterally. Cardiac exam revealed a II/VI position, climbing stairs, and ambulating. She denied any alleviating or exacerbating factors or systolic murmur. There was no lymphadenopathy or skin rash. Abdominal exam revealed no similar past symptoms. She had taken only acetaminophen as needed and had no known drug masses or tenderness. She was hydrated and her HCTZ was held. She had multiple episodes of allergies. She denied any ingestions, exposures, or recent travel. On ROS, she denied fever, fever of up to 39.1. At the end of 7 days, her diagnostic testing revealed the following: normal changes in appetite, weight, urine output or color, any GI upset, recent illness, or rashes. She CBC with differential; normal LFT's; 6 blood and 2 urine cultures were negative; Legionella was a smoker, but denied any alcohol or drug use. Exam revealed a thin, well-developed female antigen was negative; non-reactive PPD and a TSH of 2.6. Chest x-ray revealed biapical pleural laying in bed in no apparent distress. Her temperature was 98.28F, pulse was 100, BP was 139/ thickening. ESR was 85. ANA, Rheumatoid factor (RF) and Anti-ds DNA were negative. 82, RR was 20, weight was 115 lbs., and height was 50700. HEENT exam revealed poor Transthoracic echocardiogram (TTE) was negative for vegetation. Chest and abdominal CT dentition, otherwise normal. Cardiac, lung, neck, and abdominal exams were normal. scans revealed no significant findings. Bone marrow biopsy, aspirate and culture were negative. Musculoskeletal exam showed strength to be 5/5 in the upper extremities, 3/5 in the proximal Bilateral temporal artery biopsies revealed severe temporal arteritis (TA). She was discharged lower extremities, 4/5 in distal lower extremities. A positive Trousseau's sign (carpopedal on prednisone and her symptoms resolved after 1 week of therapy. spasm) was noted upon inflation of BP cuff. DTRs were slightly brisk in all 4 extremities but no IMPLICATIONS/DISCUSSION: FUO is defined as a temperature greater than 38.3 on spasticity was noted. Otherwise, neurologic exam was normal. Skin exam showed no rashes. several occasions for more than 3 weeks or after 1 week of thorough diagnostic testing Laboratory evaluation revealed significant hypokalemia of 1.7 mmol/L (normal 3.5±5.0), performed in the out- or inpatient setting. Earlier studies reported that infections represented plasma chloride of 94, plasma CO2 of 31, serum calcium of 7.4, serum magnesium of 1.3, and 41% of all cases. Collagen vascular diseases represented 30% and tumors represented 13%. serum phosphorus of 3.3. Other electrolytes, BUN/Cr, and glucose were normal. Serum CPK Miscellaneous causes represented 2% and in 13% of cases the etiology was not identified. More was significantly elevated at 5,098 U/L (normal 24±170). Urine sodium was 177 mmol/L, recent studies reveal that infections are less common than multisystem disease and this trend was urine potassium was 8 mmol/L, and 24 hour urine potassium was 14 mmol/L. MCV was 104 even more pronounced in patients over 70 years of age. A cost-effect approach in the elderly fL, folate level 3.3 ng/mL, and albumin 3.7 g/dL. Toxicology and diuretic screens were consists of confirmation of fever and a thorough history and physical exam. Laboratory analysis negative. The profound hypokalemia, hypokaliuria, macrocytic anemia, and hypoalbuminemia should consist of a CBC with differential, ESR, TSH, chemistry and liver panel, urine analysis were consistent with the suspicion of a 18 dietary disorder; i.e, low intake vs. eating disorder. and multiple blood and urine cultures. HIV, EBV, CMV, ANA and RF should be considered in The patient consistently denied an eating disorder or distorted body image. Upon obtaining certain cases. Stop all nonessential drugs. Imagining should include a TTE, chest and abdominal further dietary history, the patient's daily consumption of 5±6 L of Pepsi1 stood out as an CT scans. A temporal artery biopsy should be considered if the ESR is more than 40 mm/hr, apparent etiology. The patient stated that she had been drinking caffeinated colas heavily for even in the absence of symptoms. Gallium scan for hidden abscesses and liver and bone marrow several years. Upon cessation of cola consumption and replacement with a total of over 820 biopsies should be considered only in certain cases. Explorative laparotomy is a final resort. meq of KCL, the patient's weakness improved. IMPLICATIONS/DISCUSSION: Colas and other caffeinated beverages have been reported to be causes of significant hypokalemia, likely due to caffeine toxicity and/or phosphate- potassium binding. Although a rare diagnosis, this case of cola induced myopathy was made by ACUTE PHARYNGITIS: AN UNUSUAL PRESENTATION OF TYPHOID FEVER. 1 1 1 1 using fairly simple, bedside physician-patient discussion. C. Kandaswamy ,M.Malik, D. Williams ; Hennepin County Medical Center, Minneapolis, MN (Tracking ID #76080)

PAINFUL RASH. K. Kamjoo1; 1University of California, Los Angeles, Sylmar, CA (Tracking LEARNING OBJECTIVES: Introduction: Typhoid fever is a common disease in the ID #76685) developing countries. Step-wise rising fever, bacteremia, diarrhea associated with abdominal pain and hepatosplenomegaly are the usual manifestations. We report a case of typhoid fever LEARNING OBJECTIVES: 1- To recognize the clinical presentation of sarcoidosis and with sore throat as an integral part of the clinical picture. LoÈfgren's syndrome. 2- To understand that sarcoid is a systemic disease with multi-organ CASE INFORMATION: A 21-year-old immigrant male from Ecuador presented with a involvement and 3- To discuss treatment modalities for sarcoid and sarcoid arthritis. seven-day history of sore throat associated with a foreign body sensation and dysphagia for CASE INFORMATION: A 24 year old male without significant past medical history solid foods. Three days prior to presentation, in addition to his sorethroat, the patient presented to Emergency Department (ED) with complaint of painful rash over both legs for complained of vomiting, diarrhea, mild abdominal discomfort, myalgias, fatigue and subjective 2±3 weeks. Patient is an Argentinean exchange student who traveled to the US approx. six fevers. On examination, his temperature was 94.68F with a pulse rate of 66 beats/minute. The months prior to this presentation. Patient was seen at an outside clinic for the same complaint oropharynx was markedly erythematous. The monospot test and rapid streptococcal screen and was treated with Keflex and Ibuprofen without improvement. Patient reported that few were non-reactive. A diagnosis of acute viral syndrome with pharyngitis was made and he was days after appearance of rash; both of his ankles became swollen and painful. Although patient treated symptomatically with Ibuprofen. He returned to the emergency department two days reported that walking was very painful, he denied any weakness or limitation of movement. In later with worsening sore throat, fever, new onset of low back pain, and mild abdominal addition to the rash, patient admitted that he has been having night sweats and subjective fevers discomfort with nausea. Physical examination revealed a temperature of 103.28F, pulse rate of for the past couple of weeks. Patient also reported a slight dry cough. Initial vitals in ED were: 60 beats/minute, mild peri-umbilical tenderness and splenomegaly. The patient was temp of 38.2, blood pressure of 132/70, pulse of 95, and respiratory rate of 16. On physical hospitalized and started on intravenous fluids and oral Ciprofloxacin 750 mg twice daily. exam patient appeared alert but in mild distress due to leg pain. Heart exam was regular sinus His fever subsided and he showed significant symptomatic improvement on antibiotic therapy. without any murmurs and lungs were clear to auscultation bilaterally. Abdomen was benign. On the fourth day of hospitalization, blood cultures yielded Salmonella Typhi. He was Examination of skin revealed large nodules that were raised, red and tender to touch. Nodules discharged home on day five with two weeks of ciprofloxacin. were warm to touch and distributed randomly all over both legs. Both ankles had non-pitting IMPLICATIONS/DISCUSSION: Conclusion: Once considered an integral part of the edema but they had full range of motion. Ankles were tender to touch and passive range of symptomatology of typhoid fever, sore throat is infrequently reported, perhaps due to motion was painful. Initial lab results showed a serum calcium level of 9.4 and a sedimentation differences in causative strains, less emphasis on documentation of all symptoms and early and rate of 47. Chest x-ray examination revealed bilateral hilar lymphadenopathy and EKG showed effective treatment in the antibiotic era. Physicians should be aware that typhoid fever could a normal sinus rhythm without any conduction abnormalities. Patient was subsequently present as pharyngitis and should be considered especially in immigrants, to aid in early admitted to hospital and placed in respiratory isolation. Patient had negative coccidiomycosis diagnosis and treatment. titers and ruled out for pulmonary Tuberculosis. HIV test was also negative. Patient remained clinically stable but continued to have a low-grade fever. CT scan of chest showed bilateral hilar and sub-carinal lymphadenopathy as well as multiple 1 cm nodules within lung fields. A CASE OF ACUTE HEPATITIS B PRESENTING WITH POLYARTHRALGIA. A. Kapoor1, Subsequently, patient had bronchoscopy with biopsy and pathology report confirmed presence D. McAdams1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73762) of non-caseating granulomatous lesions. Patient was started on 40 mg of prednisone per day and made a remarkable recovery. LEARNING OBJECTIVES: 1. To recognize causes of migratory polyarthralgia. 2. To IMPLICATIONS/DISCUSSION: Sarcoidosis is a multi-system disorder of unknown cause recognize an unusual presentation of acute hepatitis B. 3. To recognize the natural history of characterized by a non-caseating granulomatous reaction in affected organs. LoÈfgren's acute hepatitis B. 64 Abstracts JGIM

CASE INFORMATION: A 27 year old African American female with a past history of the pheochromocytoma. However, there are no reported cases of SCC of renal origin causing human papilloma virus, , and chlamydia presented with two weeks of diffuse joint ectopic ACTH production as was present in our patient. pains. The pain started in her knees and progressed sequentially to include her elbows, shoulders, back, and hips. Her associated symptoms were nausea, fever, and a sallow A CATASTROPHIC COMPLICATION OF . P. Kapoor1, S. Parikh1, complexion. She denied any history of intravenous drug use, but did endorse a history of P. Radhakrishnan1, M. Yungbluth1, D. John1; 1St. Francis Hospital, Evanston, IL (Tracking multiple sexual partners in the past. Physical exam was remarkable for a temperature of ID #75985) 38.3 C, scleral icterus, and jaundiced skin; However, there was no cardiac murmur or hepatosplenomegaly. Musculoskeletal exam revealed no joint effusions, warmth, erythma, or LEARNING OBJECTIVES: 1. Awareness of the association of aortic aneurysm (AA) with tenderness. A pelvic exam was normal with negative gonorrhea and chlamydia testing. Labs giant cell arteritis (GCA) will aid prompt recognition and therapy. 2. To highlight the demonstrated a normal CBC with differential, and an erythrocyte sedimentation rate was 11; significance of using Chest XRay (CXR) as a screening modality in patients of GCA for timely An antinuclear antibody was less than 1:40; Rhuematoid factor, hetrophile antibody, detection of thoracic AA. cytomegalovirus (CMV) IgM, and rapid plasma reagin tests were all negative; AST and ALT were elevated at 605 and 1303, respectively; Bilirubin was 3.3, alkaline phosphatase 204, and albumin 3.3. At this point, work up was initiated for acute hepatitis. While hepatitis A and C serologies were negative, hepatitis B surface antigen and anti-hepatitis B core antigen were positive. HIV testing was negative. A diagnosis of acute hepatitis B was made. It was presumed that the aquisition of hepatitis B in this patient was from sexual contact. Over the next 10 days her AST and ALT peaked at 4500 and 5500 respectively, bilirubin at 10, albumin decreased to 2.0, and INR was 1.9. Treatment was supportive in nature including fluids and pain control. At time of discharge her AST and ALT were trending down toward normal levels and her symptoms were resolving. She was educated about transmission of hepatitis B with attention to safe sex practices. IMPLICATIONS/DISCUSSION: Migratory polyarthralgia has a challenging and broad differential diagnosis. Infectious causes are many and include gonorrhea, syphilis, CMV, Epstein-Barr virus, Lyme disease, and bacterial endocarditis. Viral hepatits is a possible but uncommon infectious cause. Inflammatory causes are a major category and include rhuematoid arthritis, systemic lupus erythematosis, scleroderma, and polymyositis. Post- infectious causes include rheumatic fever and Reiter's syndrome. Crystalline diseases namely gout and psuedogout can also cause polyarthralgias. Joint aspiration and analysis is the key to diagnosis, however our patient had no joint effusions. With the advent of vaccination, acute hepatitis B virus (HBV) infection is now much less common in the United States. However, it remains a major global problem, particularly in developing countries. Signs and symptoms include malaise, fatigue, myalgias, anorexia, nausea, vomiting, abdominal pain, fever, and jaundice. Migratory polyarthralgia, particularly with a benign joint examination, constitutes an atypical presentation of acute hepatitis B. The incubation period for HBV is 1 to 6 months. While 30% of patients who acquire HBV present with acute symptoms, the majority of patients remain asymptomatic with anicteric hepatitis. Ninety percent of cases of acute hepatitis B clear infection and resolve symptoms within 6 months. They remain asymptomatic carriers of HBV. This is demonstrated by disappearance of the heptitis B surface antigen and appearance of the hepatitis B surface antibody. Less than 1% of patients develop acute fulminant hepatitis. The potential outcome of this subgroup is poor and therefore close follow up of synthetic function is warranted during the initial period. Approximately 5 to 10% progress to eventually develop symptomatic chronic HBV infection. Sequelae can include cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Diagnosis of acute HBV is confirmed with serology, and quantification can be done with the polymerase chain reaction. Treatment is mainly supportive in nature, and patients should be educated about disease transmission. Antiviral therapy is not currently recommended or approved for the treatment of acute HBV.

A CUSHY DIAGNOSIS OF FALLS AND WEAKNESS. A. Kapoor1, J. Hefner1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76642)

LEARNING OBJECTIVES: 1.) Recognize an unusual cause of persistent hypokalemia; 2.) Diagnose an atypical presentation of Cushing syndrome; 3.) Recognize the clinical presentation of an ectopic ACTH-producing tumor. CASE INFORMATION: A 77-year-old male with hypertension and Type II diabetes mellitus presented with a 2 month history of fatigue and weakness. He subsequently developed a gait dysfunction and had frequent falls. Outpatient potassium (K) was 1.9 and he was admitted for management of hypokalemia. Physical exam revealed a BP of 180/90, facial plethora and bilateral diffuse rales at the bases of the lungs. Proximal muscle strength was 4/5 in the upper and 3/5 in the lower extremities. Distal strength was 5/5. No moon facies, buffalo hump or abdominal striae were found. His K remained low despite aggressive replacement and secondary causes were investigated. Results of diagnostic testing included a urinary Na 17, K 52, pH 6 (4.8±8), serum Na 140, Cl 95, HCO3 40, BUN 28, Cr 1.4, renin 0.6 (<5 mcg/ml) and aldosterone 5.7 (2±9 mcg/ml). Urinary metanephrines were normal. Cortisol at 8 am was 100 (7±20 mcg/ml) and ACTH 380 (9±52 pg/ml). Post high-dose (8mg) suppression test (DST) cortisol was 118 and ACTH was 126 (2±8 pg/ml). FSH, LH, prolactin and IGF-1 were normal. Brain MRI revealed a normal sized pituitary. Chest CT showed pleural effusions, no masses or lymphadenopathy. Abdominal CT revealed a 3 cm renal mass and bilateral adrenal hypertrophy. Biopsy of the renal mass showed poorly differentiated small cell carcinoma (SCC). Treatment with ketoconazole failed to suppress his cortisol. The patient decompensated and expired. Autopsy revealed numerous nodules in the liver, the right renal mass with focal hemorrhage and no lung masses. Pathology revealed SCC of renal origin with metastasis to the liver. IMPLICATIONS/DISCUSSION: Cushing syndrome is an unusual cause of hypokalemia. Other causes include primary or secondary hyperaldosteronism, Type 2 , Bartter syndrome, Liddle syndrome, diuretic use and VIPoma. Patients with ectopic Cushing secondary to carcinomas often lack the clinical manifestations associated with classic Cushing syndrome±the centripetal fat distribution, moon facies and striae. The metabolic abnormal- ities, however, are more common in ectopic ACTH syndrome namely hypokalemia, metabolic , excessively high cortisol and elevated ACTH levels. Differentiation of ectopic from pituitary dependent Cushing is made by non-suppression of cortisol with the 8 mg DST. There have been reported cases of ectopic ACTH with lung SCC, bronchial carcinoid, medullary carcinoma of the thyroid, gastrointestinal and prostatic adenocarcinoma and JGIM Volume 18, April (supplement 1) 2003 65

CASE INFORMATION: A 75-year-old male presented with acute, severe right upper perforated right ventricle from the pacer wire. Surgical repair was successful but the patient had quadrant (RUQ) pain, radiating to the right shoulder and associated with nausea and vomiting. a very complicated postoperative course and expired. He denied any fever, chest pain, shortness of breath, change in bowel habits or similar episodes IMPLICATIONS/DISCUSSION: Pacemaker insertion is a relatively common and safe in the past. He had a history of coronary artery disease, well-controlled hypertension and procedure and can be lifesaving. Ventricular rupture is a rare, albeit potentially serious, biopsy-proven GCA, diagnosed 15 months ago. Physical examination: afebrile;pulses: 86/min, complication. The elderly, in whom most pacemakers are inserted, are at increased risk of regular and symmetric; BP: 170/108 mm;tenderness in the RUQ with palpable gall bladder complications. The Pacemaker Selection in the Elderly (PASE) study, a prospective 4 cm below the right costal margin; an ejection systolic murmur in the aortic area. The rest of multicenter trial involving 407 patients age 65 years and older, documented a 6.1% the physical examination was essentially unremarkable. Laboratory data: WBC-10000, Hb- complication rate; 4.4% of patients required a repeat procedure. The most common 13.8 and platelets-251,000. The CT scan of abdomen was suggestive of acute cholecystitis. A complications were lead dislodgement (2.2%), pneumothorax (2.0%and observed only in dissection of the superior mesenteric artery (SMA) was also noted. CXR showed aneurysm of those with subclavian venous access) and cardiac perforations (0.98%). Most perforations occur ascending aorta. CT scan of thorax showed a Stanford Type A aortic dissection (AD) with intraoperatively and rarely cause symptoms. However, as in our patient, serious complications, aneursymal dilation of 7 cm. Communication of the true and false lumen suggested chronicity including death, have been reported postoperatively. Complications of pacemaker insertion (see figure). After stabilization of BP, he underwent an emergency laparoscopic cholecys- may masquerade as other less serious entities with symptoms of dyspnea, chest pain, fever and tectomy which led to a resolution of his abdominal pain. Subsequently, he was referred for an weakness. It is paramount that internists be alert to the potential serious complications of elective repair of his asymptomatic, chronic aortic dissection. cardiac rupture and pneumothorax in the patient presenting with these symptoms IMPLICATIONS/DISCUSSION: Horton's syndrome or GCA is the commonest primary postprocedure. Symptomatic patients require surgical intervention. systemic vasculitis in the United States, associated with diverse manifestations and outcomes. The true incidence of aortic involvement is unknown, but is estimated to be 3±15 %. Patients with giant cell may be asymptomatic or may present with aortic arch syndrome, dilation THE LESSER KNOWN 5 P'S: , PIGMENTATION, POOR VISUAL ACUITY, 1 1 of aorta, aortic aneurysm, AD or aortic incompetence. Although, in this patient AD may well PULMONARY INFILTRATES, PUERTO RICAN. A. Kaushal ; Lenox Hill Hospital, New be attributed to atherosclerosis,the history of GCA and segmental involvement of ascending York, NY (Tracking ID #74952) aorta and SMA implicate GCA as a predisposing condition.A high incidence of thoracic aortic LEARNING OBJECTIVES: 1) To learn, diagnose, and manage manifestations of aneurysm has led Evans et al to recommend annual CXR, including lateral views in patients of Hermansky-Pudlak Syndrome (HPS), a tyrosinase positive oculocutaneous albinism. GCA. Since the diagnosis of GCA is commonly made by the internists, awareness of it's CASE INFORMATION: A 53 year-old Puerto Rican male presents with a chief complaint of possible complications helps us manage these patients better. two years of increasing dyspnea on exertion. Past medical history was notable for multiple episodes of pneumonia. Although the patient had been successfully treated as an outpatient during these episodes with oral antibiotics, his chronic baseline dyspnea and decreasing ATRIAL FIBRILLATION IN A 37 YEAR OLD CHINESE IMMIGRANT. A. Karne1; 1New York exercise tolerance continued to worsen. For one of these exacerbations, the patient was University, New York, NY (Tracking ID #74169) admitted to the hospital, where physical exam revealed nystagmus, poor visual acuity, LEARNING OBJECTIVES: 1. Recognize the importance of overcoming language barriers in oculocutaneous albinism, and a bleeding diathesis. Radiological studies revealed bilateral lower patient care. 2. Manage recurrent Grave's Disease in young women. lobe infiltrates and diffuse pulmonary honeycombing fibrosis. The patient improved following CASE INFORMATION: A 37 year old Mandarin speaking woman with no known PMH a ten-day course of IV cefotaxime, gentamycin, and chest physical therapy. presented with chest palpitations for 6 months. Her history was obtained in a crowded, noisy IMPLICATIONS/DISCUSSION: The combination of oculocutaneous albinism, a bleeding ER through a telephone translator, with her husband as a middle translator. She states having diathesis, and pulmonary fibrosis in this Puerto Rican patient raised the suspicion for symptoms for over 6 months with acute decompensation over the last 2 months involving Hermansky-Pudlak Syndrome. HPS is an inherited disease which results in a platelet storage constant fast heart rate, swelling in her face, abdomen, and extremities for 2 months, dyspnea pool defect and lysosomal accumulation of a substance called ceroid lipfuscin. HPS is an when walking 2±3 blocks, a 20 lb unintentional weight loss, poor concentration, and autosomal recessive syndrome found primarily in individuals from the northwestern quadrant constipation. She went to a doctor 1 month ago and was told she has a thyroid problem, but has of Puerto Rico. Patients have legal blindness, nystagmus, iris transillumination, foveal not been taking the prescribed medications. More than 10 years ago in China, she had hypoplasia, decreased number of melanocytes, pulmonary fibrosis, renal disease and problems with her thyroid and was given Western medications for 6 months with granulomatous enteropathic disease. improvements. Otherwise, review of systems was unremarkable. On exam, her pulse was Lab studies in patients with HPS may show an increased bleeding time with a therapeutic irregular, atrial fibrillation, at 125±145, BP 98/64. She was anicteric with swollen eyelids, no response to desmopressin, decreased bone density, and genetic testing showing a mutation on the proptosis. She had an enlarged thyroid, JVD, a hyperdynamic precordium, no heart murmurs, HPS1 gene on chromosome 10q23. The most accurate diagnosis, however, is made by a a distended abdomen, and non-pitting edema in all extremities. Lab studies showed a mild pathognomic platelet morphology diagnosed only by electron microscopy. Management consists transaminitis, negative hepatitis serologies, and positive thyroid stimulating antibodies. She of recognizing the disease, having a lower threshold for admitting individuals for inpatient was diagnosed with Graves disease. Echocardiography showed severe tricuspid regurgitation management, and administration of immunosuppressants and steroids. Current trials of a test and right heart failure without evidence of left sided dysfunction, pulmonary artery drug called pirfenidone are being conducted and offer patients some hope for a treatment. hypertension or septal defects. Her atrial fibrillation was treated with beta blockers and anti- Back to our patient: A careful history taking revealed that the patient presented above had all of coagulation, and she was scheduled for repeat echocardiogram in 2 months to evaluate for valve the above manifestations, even decades prior to his official diagnosis being made. Management disease that may be contributing to her right sided failure. She would like more children, so she of this patient's disease ultimately consisted of various trials of steroids, interferon, and opted for medical therapy with propythiouracil to treat her hyperthyroidism and would methotrexate. While the inpatient stay focused primarily on his pulmonary pathology, consider radioactive iodide or surgical therapy after her thyroid disease is under control. outpatient management consisted of patient education to minimize complications of the IMPLICATIONS/DISCUSSION: 1. Obtaining a complete history in non-English speaking disease and carefully orchestrated care with numerous specialists. patients can be difficult. Despite seeing a private doctor, this patient came to the ER without her primary doctor's support, without her medications, and without the ability to communicate with 1 1 1 hospital doctors. Studies have shown that intepreter services increase cost-effectiveness and HYPOTHENAR-HAMMER SYNDROME. M. Aiyer , H. Kaushal ; University of Illinois quality of care as well as patient understanding and participation in healthcare, despite potential College of Medicine at Peoria, Peoria, IL (Tracking ID #76765) increases in the time and resources to provide such services. 2. Recurrent hyperthyroidism, most LEARNING OBJECTIVES: 1) Identify Hypothenar Hammer Syndrome as one of the work commonly due to Grave's disease, is treated similarly to the initial episode. Anti-thyroid related vascular injuries of the hand. 2) Recognize the common clinical manifestations of this medications are the drug of choice in pregnant women and are not known to effect rare clinical entity. 3) Discuss the diagnostic work up of Hypothenar Hammer Syndrome. reproductivity. Radioactive iodide is contraindicated in pregnancy, although has been shown to CASE INFORMATION: A 42 year old construction worker presented with a 3 week history have no effect on reproductivity in the long term. Surgery is effective, although has no of progressive pain and swelling in his left index finger after an attempt to straighten an iron advantages and has been associated with increased fetal losses if done during pregnancies. pipe with this left hand. Past medical history was significant for a similar episode involving his right index finger after trauma that resolved with symptomatic treatment. Patient had a 50- pack year history of smoking. The rest of his review of systems was unremarkable. DELAYED VENTRICULAR RUPTURE BY A PACEMAKER LEAD: RECOGNITION OF AN Physical examination was unremarkable except for a swollen and tender left index finger with a UNCOMMON COMPLICATION OF A COMMON PROCEDURE. S. Katsev1, R. Granieri1; gangrenous tip. The left ulnar pulse was absent. His radial pulses were intact in both 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #74178) extremities. LEARNING OBJECTIVES: (1) To recognize the potential complications of pacemaker Laboratory data including ANA and sedimentation rate were within normal limits. An placement. (2) To recognize the diagnosis and management of myocardial rupture post arteriogram of the left upper extremity revealed thrombosis of the distal ulnar artery and pacemaker placement. occlusion of digital arteries of the second digit that were thought to be secondary to embolic CASE INFORMATION: A 74 year old male was brought by his friend to the emergency room events from the ulnar artery thrombus. Duplex ultrasound also revealed a thrombosed with a four week history of gradually progressive shortness of breath that began 2±3 days after pseudoaneurysm in the left ulnar artery at the hypothenar eminence. Diagnosis of Hypothenar dual-chamber pacemaker placement for Mobitz II heart block and symptomatic bradycardia. Hammer Syndrome (HHS) was made. The procedure was without any immediate complications. CXR post-precodure was negative IMPLICATIONS/DISCUSSION: HHS is a rare clinical entity that results from repetitive for pneumothorax. He currently denied chest pain, cough, fevers, chills, sweats, lightheadedness, palmar trauma leading to damage of the ulnar artery as it passes over the hammate bone. The or dizziness. PMH was significant for, in addition to Mobitz II heart block, coronary artery syndrome usually manifests as unilateral digital ischemia caused by embolic digital artery disease, severe aortic stenosis and hypertension. Medications included felodipine 10 mg PO qd, occlusion from the thrombosed palmar ulnar artery. It is predominantly seen in males around simvastatin 10 mg PO qd, and lisinopril 20 mg PO qd. He had a remote history of tobacco use the age of 40. In a small study of 21 patients, 12 out of 13 who had arteriography of both upper and was a former steel mill worker. On physical examination, VS: HR 105, RR 26, BP 150/90, extremities had bilateral palmar ulnar disease (1). Diagnosis is made on clinical features and pulse ox 92% (on room air). Pertinent findings included no JVD, a II/VI SEM at the right upper confirmed by angiography that shows a palmar ulnar artery abnormality and digital artery sternal border radiating to carotid arteries, laterally displaced PMI, decreased breath sounds on occlusion. Treatment may include surgery involving excision of abnormal palmar ulnar artery the left 2/3 up the lung fields, no organomegaly and 1+ pretibial edema. CXR showed a free segment. flowing large left pleural effusion. The patient was admitted to the hospital and a thoracentesis Reference: 1. Ferris BL, Taylor M, Oyama K et al. Hypothenar Hammer Syndrome: Proposed was performed from which serosanguinous fluid was obtained. CT of the chest demonstrated a etiology, Journal of vascular surgery; 31(1 part 1):104-113. 66 Abstracts JGIM

ACUTE PUSTULAR PSORIASIS: RECOGNITION, DIFFERENTIATION, AND and/or aplasias, varices and a variety of lymphatic abnormalities. Vascular malformations may MANAGEMENT. D.C. Kendrick1, C.G. Kendrick2; J. Wiese1; 1Tulane University, New involve visceral organs such as the bowel, liver, kidneys, and lungs and can, uncommonly, cause Orleans, LA; 2Louisiana State University, New Orleans, LA (Tracking ID #77071) complications in those organs. Treatment of KTWS is supportive and/or cosmetic unless orthopedic or bleeding complications arise, at which point surgery is generally indicated. LEARNING OBJECTIVES: To recognize and manage pustular psoriasis and to differentiate it from other causes of erythroderma. CASE INFORMATION: DP is a 58-year-old African American male who presented with an METFORMIN AND DEPRESSION: A POTENTIALLY LETHAL COMBINATION. S. Kesler1, exfoliative erythroderma and pustules in the palmar-plantar areas that had coalesced to form R. Shapiro1; 1Hennepin County Medical Center, Minneapolis, MN (Tracking ID #77020) ``lakes of pus.'' The patient noted a similar but milder eruption 3 months earlier in which he was treated at another facility with oral prednisone with some improvement. He reported that LEARNING OBJECTIVES: 1) Consider the potential for a fatal overdose of Metformin the pustules had started on his hands, progressing rapidly over several days to affect the entire when treating diabetic patients who are at risk of commiting suicide. body. Erosions later appeared in the mouth. He complained of an intense pruritus and burning 2) Recognize the constellation of signs that are consistent with a Metformin overdose. sensation along with a fetid odor. At the time of presentation he was noted to be febrile with a 3) Recognize the need to quickly and aggressively treat a Metformin overdose and its medical leukocytosis. A skin biopsy showed spongiform pustules in the upper epidermis with numerous consequences. PMNs present. Inpatient management included a combination of actretin, IV vancomycin, and CASE INFORMATION: A 42 year-old woman with a history of diabetes, hypertension and topical mid-potency steroids, with rapid improvement in the patient's condition. schizoaffective disorder was found obtunded in her apartment and admitted to the MICU. She had recently been hospitalized for suicidal ideation. Empty pill bottles of a benzodiazepene, an atypical antipsychotic, a SSRI and Metformin were found. Six hours after admission, the patient developed lactic acidosisand a severe sepsis-like syndrome consistent with Metformin overdose. She subsequently became critically-ill, and had a clinical course which included severe ARDS and anuric renal failure. Support was withdrawn at the request of her family following a prolonged course of aggressive treatment. IMPLICATIONS/DISCUSSION: Metformin is commonly used in primary care and its potential for lethal side effects is well known in the setting of medical illness. This case demonstrates how Metformin also has potential for great harm in the setting of an overdose. Physicians should be aware of the risks of prescribing Metformin to diabetic patients with depression or a history of impulsive behavior.

A RARE CAUSE OF ACUTE ABDOMINAL PAIN. H. Khalid1, I. Vassileva1; 1New Hanover Regional Medical Center, Wilmington, NC (Tracking ID #76489)

LEARNING OBJECTIVES: 1. Recognize rectus sheath hematoma to be a complication of anticoagulant therapy especially following trauma. 2. Understand rectus sheath hematoma as a cause of acute abdominal pain. 3. Value of conservative management in rectus sheath hematoma. CASE INFORMATION: A 49 year old female with recent diagnosis of pulmonary embolism due to oral contraceptive use presented with acute onset of left sided abdominal pain associated with nausea but no vomiting, diarrhea or constipation or changes in urinary habits. Patient's medications were warfarin, ibuprofen prn, home O2 and amitryptiline. Had 25 pack year smoking history. On examination, she seemed to be in moderate distress with severe tenderness on left side of midline from epigastrium to suprapubic region, worse with any movement associated with mild fever. Vital signs were stable otherwise. Stools hemoccult negative. Lab studies revealed a wbc count of 12,700, Hb of 10.7, noted to be reduced from previous admission. Creatinine 0.7 mg/dl, lipase 94 mg/dl, PT 23.1, INR 3.73 with normal liver function tests and normal UA. Contrast enhanced CT revealed acute hematoma of left rectus sheath, 20cm  6cm with active bleeding. Patient's Hb further dropped so eventually transfused, coumadin stopped and surgery consulted. They suggested conservative treatment with analgesia and rest and later on, IVC filter placement. Repeat CT Scan showed stable hematoma. Patient clinically better with stable Hb. So, again started on low dose coumadin and sent home with caution not to smoke and avoid trauma as on further questioning, eventually, patient provided history of fall. ``Lakes of pus'' IMPLICATIONS/DISCUSSION: Left sided abdominal pain and fever can be mistaken for number of causes of acute diseases of abdomen. But, due to advent of CT, an unusual diagnosis is IMPLICATIONS/DISCUSSION: A presentation of erythroderma should prompt the relatively easy to make. But, since rectus sheath hematoma is one of the reported complications physician to consider pustular psoriasis, pemphigus foliaceus, pityriasis rubra pilaris, of anticoagulation therapy, this diagnosis should always be kept in mind. Once diagnosis is underlying leukemia/lymphoma, severe atopic dermatitis, ichthyoses, drug induced erythro- established and if this hematoma is not causing severe symptoms, the condition can be managed derma, diffuse seborrheic dermatitis, scabies, and staphylococcal scalded skin. Pustular nonoperatively with bed rest and analgesics. Ideally, anticoagulation should be discontinued. It psoriasis can be differentiated by sudden onset of acral pustular lesions, fever, intense pruritis, is rarely necessary to reverse the coagulation defect if operation is not undertaken. As in our case, and occasionally, hypocalcemia and mucous membrane lesions. Patients will often have a patient was clinically improved so it was decided to manage her conservatively and avoid surgery. personal or family history of plaque psoriasis and/or psoriatic arthritis. Treatment of choice is She was restarted on anticoagulation because risk of pulmonary embolism is greater than acitretin (a second generation retinoid). Topical steroids are often helpful, but systemic hematoma. It was made sure to counsel her about any trauma as it increases risk of hematomas in steroids should be avoided. future. Patient continued to do well on further follow ups.

MASSIVE LOWER GI BLEED FROM ILEAL AND COLONIC VARICES IN A PATIENT AN UNUSUAL CAUSE OF ASCITES: A CASE OF EOSINOPHILIC GASTROENTERITIS. WITH KLIPPEL-TRENAUNAY- WEBER SYNDROME. M. Kennedy1,C.V.Mueller1; M. Khalil1, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73745) 1University of Cincinnati, Cincinnati, OH (Tracking ID #77195) LEARNING OBJECTIVES: 1. To recognize ascites as a complication of eosinophilic LEARNING OBJECTIVES: 1) Learn about the vascular malformations seen in Klippel- gastroenteritis (EG) 2. To diagnose and treat EG. Trenaunay-Weber Syndrome. CASE INFORMATION: A 50 year-old female with no significant PMH presented with a 2 CASE INFORMATION: A 25 yo Caucasian male originally presented to an outside hospital month history of epigastric pain that was associated with nausea and decreased appetite. She with bright red blood per rectum. He denied associated abdominal pain, nausea, vomiting, reported the pain to be constant and exacerbated with food, but mildly relieved with a bowel fever or prior history of rectal bleeding. Initial systolic blood pressures were in the 80-90's with movement. She denied any vomiting, melena, hematochezia, fever, chills, recent travel, change a heart rate in the 130's. Work up at the outside hospital included flexible that in diet or alcohol abuse. Two weeks prior to admission, she developed non-bloody, watery revealed nonbleeding internal hemorrhoids, a negative tagged RBC scan and an unremarkable diarrhea, increased abdominal girth, and 12 lb. weight gain, despite the poor appetite. CT of the abdomen. Upon transfer to our facility, he was hemodynamically stable, but found Outpatient evaluation with abdominal ultrasound was unremarkable and an upper GI series to have a hemoglobin of 7.5 with a baseline of 13.5. The morning after admission, the patient revealed dysmotility of the lower esophagus with tertiary contractions. Treatment with developed massive hematochezia associated with diaphoresis and tachycardia. He was urgently rabeprazole provided minimal relief. Physical examination upon admission was remarkable for a sent for tagged RBC scan that showed distal ileal bleeding. Subsequent mesenteric mildly distended and diffusely tender abdomen with positive shifting dullness but no rebound, angiography did not identify any active bleeding or . The patient again guarding or organomegaly. The remainder of physical exam was normal including heme decompensated and was taken for exploratory laparotomy that revealed bleeding ileal and negative stool. Lab work was significant for WBC of 14,000 with 30% eosinophils. Liver colonic varices. He underwent ileocecectomy without complications and had no further function tests were normal. Serum albumin was 2.4 and ascitic fluid analysis showed: pH 7.31, episodes of bleeding. He required a total of 20 units of PRBC's during his hospitalization. albumin 1.8, negative cytology, and WBC of 4700 with 96% eosinophils. Stool culture and IMPLICATIONS/DISCUSSION: KTWS is classically described as a venous monoangio- sensitivity, ova and parasites were negative. Further workup with abdominal ultrasound with dysplasia, but is actually associated with a variety of vascular malformations including: Doppler showed patent vessel and normal direction of flow. Upper endoscopy revealed erythema subcutaneous hemangiomas, cavernous hemangiomas, AV fistulas, deep vein malformations of the antrum. Colonoscopy was normal. CT scan of the abdomen and pelvis showed diffuse JGIM Volume 18, April (supplement 1) 2003 67

small bowel thickening without fat stranding and moderate ascites. Trans-vaginal ultrasound HUS because most present with the same symptoms, have identical pathologic changes, and was negative for ovarian mass. Bone marrow biopsy was normal. The patient refused surgical receive the same treatment. The classic pentad of thrombocytopenia, microangiopathic bowel biopsy and diagnosis of EG was established on the basis of exclusion. She was started on hemolytic anemia, neurologic abnormalities, renal abnormalities and fever is present in few oral dose of prednisone for 6 weeks and discharged to home. Follow up visit and blood work patients. The diagnosis is made primarily by the presence of thrombocytopenia and showed 0% eosinophils, resolution of ascites, resolution ofabdominal pain, and good appetite. microangiopathic hemolytic anemia. The etiology is a deficiency of von Willebrand factor IMPLICATIONS/DISCUSSION: EG is an uncommon disorder characterized by gastro- (vWF) cleaving protease, which results in the accumulation of unusually large vWF multimers, intestinal symptoms, blood eosinophilia, and eosinophilic infiltration of the gastrointestinal causing platelet aggregation. wall. The signs and symptoms of EG are related to the layer and extent of the bowel involved Causes of TTP-HUS include E. coli 0157:H7 and medications such as ticlopidine, with eosinophilic infiltration. Patients with subserosal infiltration may develop eosinophilc cyclosporine, and . Most adult cases, however, are idiopathic. ascites. The diagnosis of EG is confirmed by a full thickness biopsy of the bowel in the absence Treatment is plasmapheresis, the mechanism of which is not completely understood. 10 to of intestinal parasitic infection. Treatment of EG is empiric because no prospective, 20% of patients have an incomplete response; steroids, vincristine or IVIG can be added in randomized clinical trials are available to guide treatment. Prednisone (20 to 40 mg/day) is these cases, but are not alternatives to pheresis. Some studies show improvement with recommended for two weeks and should be tapered over the next two weeks. Improvement splenectomy, especially in conjunction with pheresis and steroids. usually occurs within two weeks of therapy. Despite the rarity of EG, it should be suspected in 30 to 50% of patients have exacerbations of thrombocytopenia and hemolysis when pheresis is a patient with any GI symptoms associated with peripheral eosinophilia because this treatable tapered. Relapse is defined as recurrence after 30 symptom-free days without treatment. Both disease can disguise itself as the . are treated with reinstitution of daily pheresis. It is essential that physicians involved in the care of the patient with TTP-HUS recognize that many patients may have worsening disease with tapering of pheresis and to be aware of PULMONARY HYPERTENSION IN SYSTEMIC LUPUS ERYTHEMATOSUS: alternate life-saving treatments if this occurs. CONSEQUENCE OR COINCIDENCE? T. Khoo1, A. Ghosh1, S. Dhillon1; 1Mayo Clinic, Rochester, MN (Tracking ID #74630) NOT YOUR TYPICAL ATYPICAL: A CASE OF EOSINOPHILIC PNEUMONIA. J. Kim1, LEARNING OBJECTIVES: 1) Recognize that pulmonary hypertension is not uncommon J. Sethi1, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #74685) patients with SLE; 2) Recognize that primary pulmonary hypertension in SLE patients often presents earlier than pulmonary hypertension from a secondary cause. LEARNING OBJECTIVES: 1. Recognize the presentation of eosinophilic pneumonia (EP) 2. CASE INFORMATION: A 21-year-old woman was transferred to our hospital for Identify causes of EP 3. Manage patients with EP. management of her pulmonary hypertension (PHT) and systemic lupus erythematosus CASE INFORMATION: A 61 year-old female presented with 4 weeks of malaise, a dry (SLE). She initially presented a year ago with progressive cough and pleuritic-type chest pain. 8 cough, and recent high fevers. She also had night sweats for the 6 months since she started months prior to admission, she underwent an echocardiogram which revealed a pulmonary hormone replacement therapy. She had no pets and no recent travel history. Though exposed artery pressure (PAP) of 27 mm Hg. Four months later, she was admitted to a community to tuberculosis as a child, she had never been tested or treated for it. She had begun hospital for congestive heart failure and was found to have positive anti-Smith, anti- just over a month earlier for rosacea and was on loratidine for seasonal allergies. phospholipidand anti-nuclear antibodies, and was diagnosed with SLE. Her symptoms She did not drink alcohol and quit smoking 5 years prior. Physical exam was notable for high gradually progressed to dyspnea on exertion, paroxysmal nocturnal dyspnea and Raynaud's fever, tachypnea, pulse oximetry of 96% on room air, inspiratory crackles at the right base and phenomenon. She was subsequently readmitted to that hospital 2 weeks prior to transfer to us dullness at the left base. Labwork: WBC 15.2 with 84% neutrophils; blood eosinophilia for worsening of her symptoms. There, she had a generalized seizure and was initiated on increased over several days to 15%. ESR was 70. Chest radiograph showed small bilateral plasmapheresis treatment. Examination revealed a thin, anxious lady in mild dyspnea and an effusions, no cardiomegaly, and bilateral, peripheral, apical alveolar infiltrates. PPD was obvious malar rash. Cardiac auscultation revealed a loud and palpable P2, and a II/VI systolic negative. Her fevers persisted and the left pleural effusion increased on intial therapy for murmur at the tricuspid area. She had a non-tender hepatomegaly and mild bilateral pedal community-acquired pneumonia. The effusion was transudative, with 1755 WBCs, 12% edema. Echocardiogram revealed a PAP of 76 mm Hg, with evidence of right heart neutrophils and 10% eosinophils. A bronchoalveolar lavage (BAL) and transbronchial biopsies enlargement and mild tricuspid regurgitation. A chest CT scan with angiography and a were performed; BAL fluid contained 63% eosinophils and biopsies revealed focal aggregates ventilation-perfusion scan showed no signs of a pulmonary embolism. A right heart of eosinophils around the airways, consistent with eosinophilic pneumonia. Oral prednisone catheterization was done as well showing moderate PHT and a moderate response to was started and both symptoms and eosinophilia resolved 48 hours after her first steroid dose. epoprostenol challenge. Workup for lupus cerebritis was negative. She was initiated on IMPLICATIONS/DISCUSSION: EP is characterized by eosinophilic pulmonary infiltrates. It prednisone and Cytoxan for SLE. Plasmapheresis was discontinued. Diltiazem, Valsartan and presents as an acute febrile illness with dyspnea, night sweats, weight loss, dry cough, crackles or Warfarin were initiated to control her pulmonary hypertension. She tolerated the medications wheezing on lung exam, increasing blood eosinophilia and bilateral, peripheral patchy infiltrates well and was discharged with outpatient follow-up, with the consideration of using on chest radiograph. The ESR is often elevated. Etiologies include common medications, epoprostenol in the future should her condition worsen. including minocycline, parasitic infections, HIV, and fungal infections. A high index of IMPLICATIONS/DISCUSSION: Prevalence of PHT in SLE ranges from 5% to 14%. A suspicion, confirmed by BAL fluid eosinophilia and diffuse eosinophilic infiltration of the lung third of SLE patients have positive antiphospholipid antibodies, although the significance of on biopsy, leads to the diagnosis. The response to steroids is dramatic, as was seen in our patient, this in the development of PHT is unknown. In one study of SLE patients, 5.9% were found to with symptoms, eosinophilia, and lung infiltrates decreasing within 48 hours. Treatment is have pulmonary hypertension, of which 48% of them had no identifiable cause, the rest found continued for 3 months to prevent relapses, which respond to re-intitiation of steroids. to have a secondary cause. For the subgroup with secondary hypertension, 50% of them were due to valvular abnormalities. The primary pulmonary hypertension tended to present far earlier after diagnosis of the SLE compared to secondary PHT, 8.8 versus 43.2 months. YOUR BLOOD'S NO GOOD HERE: A LESS COMMON CAUSE FOR REJECTING A 1 2 1 Raynaud's phenomenon in secondary hypertension is associated with a more severe pulmonary POTENTIAL BLOOD DONOR. J. Kimberly , R. Watkins ; Wake Forest University Baptist 2 artery pressure. These patients seem to respond to epoprostenol therapy although there have Medical Center, Winston-Salem, NC; Wake Forest University, Winston-Salem, NC been documented cases of fatal thrombocytopenia. (Tracking ID #76222) LEARNING OBJECTIVES: 1) Be able to counsel patients with evidence of infection with HTLV-I and 2) appreciate associated diseases. BEYOND THE DIAGNOSIS OF THROMBOCYTOPENIC THOMBOTIC PURPURA: CASE INFORMATION: A 43 year old African American female with a history of MANAGEMENT AFTER INITIAL PHERESIS FAILS. J. Kim1, R. Granieri1; 1University of hypertension, diabetes, and treated syphillis presents to clinic reporting that she fears she Pittsburgh, Pittsburgh, PA (Tracking ID #74501) may have contracted HIV disease. She recently donated blood and subsequently received a LEARNING OBJECTIVES: 1. Recognize the presentation of thrombocytopenic thrombotic letter stating she could no longer donate blood ``because of an infection like AIDS.'' The purpura-hemolytic uremic syndrome (TTP-HUS). patient presented the letter which notified her of the presence of HTLV-I/II antibodies with 2. Manage patients with TTP-HUS, including relapse or refractory disease. Western Blot confirming HTLV-I infection. ELISA for HIV 1 and 2 was performed and was CASE INFORMATION: A 39 year-old female with rheumatoid arthritis, hypertension, and negative. The patient was initially fearful and had many questions regarding HTLV-I seizure disorder presented with two days of hematuria. She denied fevers, dysuria, urinary infection: How did she get infected and was it sexually transmissible or contagious via other frequency, headaches, visual changes, or cough. Her last seizure was two weeks prior to routes? Would she develop immunosuppression similar to that seen with HIV disease? Were presentation. Medications included , phenytoin, methotrexate, and amlodipine. There there any other possible adverse effects on her health? was no fever and her physical examination was otherwise negative for lymphadenopathy, hepa- IMPLICATIONS/DISCUSSION: HTLV-I is a retrovirus endemic in parts of Japan with tosplenomegaly or petechiae/purpura. Initial workup revealed a platelet count of 7,000, H/H of other clusters of high prevalence including the southeastern US. The virus is transmitted by 7.3/24, WBC of 8.2, LDH of 900, and Cr of 3.5. Peripheral smear demonstrated schistocytosis. three known routes: 1) from mother to child, especially through breast feeding, 2) through The patient was diagnosed with TTP-HUS and began daily plasmapheresis and prednisone, sexual activity, and 3) through blood, either from contaminated needles or transfusion. In areas during which her platelet count improved to 130,000 and her LDH normalized. She was where HTLV-I is endemic, many inflammatory and autoimmune diseases have been attributed discharged to continue outpatient pheresis but was readmitted one week later with fever (1038 to the virus though causation has only been shown for two diseases. HTLV-I is clearly linked F) and a platelet count of 78,000. She was begun on plasmapheresis with cryoprecipitate-poor to adult T-cell leukemia/lymphoma (ATL), classically an aggressive, usually deadly, plasma, vincristine, and steroids. She responded well; her pheresis was decreased to every other hematogenous malignancy characterized by rapid progression of skin lesions, pneumonitis, day and prednisone was tapered. She was discharged with a platelet count of 398,000 to hypercalcemia, and lymphocytosis. The second disease with a clear association with HTLV-I continue outpatient pheresis and vincristine, which were discontinued after one month. infection is tropic spastic parapesis or HTLV-I-associated myelopathy (HAM) which, unlike One month later, the patient had a platelet count of 70,000, LDH of 1,186, and schistocytes on ATL, is characterized by an insidious onset with symptoms often including stiffness or peripheral smear. Plasmapheresis and prednisone were restarted, and a splenectomy was weakness in one or both legs, back pain, urinary incontinence, and mild sensory changes. One- performed. Discharge platelet count was 199,000. Two weeks later, her platelet count was third of patients are bedridden by ten years. Both ATL and HAM occur in 2-5% of HTLV- 57,000. Pheresis and vincristine were restarted with good response. infected patients. ATL is slightly more common in infected males and usually occurs after IMPLICATIONS/DISCUSSION: TTP and HUS are diseases with abnormalities in multiple 20-30 years of infection whereas HAM is more prevalent among females and can occur just a systems. Classically, TTP is described as having more severe neurologic disease, whereas HUS few years after infection. More than 95% of patients with ATL and HAM have evidence of has more of a renal component. Clinically, however, patients are described as having TTP- HTLV-I infection. The patient under discussion was educated about the nature of HTLV-1 68 Abstracts JGIM

and how it differed from HIV, and counselled to practice ``safer sex'', avoid donating blood, out of a chair. At presentation she could not walk. She had a dusky, almost dirty appearing rash and, should she become pregnant, avoid breast feeding. She was also informed of the risk, albeit on her chest and around her eyes. An erythematous rash was noted on the dorsal surface of the a fairly low one, of ATL and HAM. MCP and PIP joints of her hands. She could not lift either thigh off the bed. Laboratory values: CK 14,245, RF 273, ANA + >1:640 (speckled pattern), AST 605, ALT 207, ALK PHOS 95, LDH 150. Hepatitis B CAb +, Hep Sab +. Anti-RNP, Anti-Jo, Anti-SSA, Anti-SSB and anti- EOSINOPHILIC GASTROENTERITIS: AN UNUSUAL CAUSE OF CHRONIC DIARRHEA DS DNA were all negative. A presumptive diagnosis of dermatomyositis was made, a AND ASCITES. A.L. Kinderman1, T.L. Shim1; 1Rush Medical College, Chicago, IL (Tracking confirmatory muscle biopsy performed and prednisone begun. Malignancy workup was ID #76496) negative. She improved slightly and was discharged to a rehabilitation facility. IMPLICATIONS/DISCUSSION: Dermatomyositis (DM) is a rare idiopathic inflammatory LEARNING OBJECTIVES: 1) Recognize the clinical presentation of eosinophilic gastro- myopathy that has a 2:1 female preponderance and presents most commonly in the fifth . decade. The incidence of DM is 1:100,000. Pathogenetically, DM is associated with immune 2) Identify the diagnostic criteria for eosinophilic gastroenteritis. complex deposition in a perivascular and perifasicular distribution. The etiology is unknown 3) Understand the management and prognosis of eosinophilic gastroenteritis. although viruses have been implicated. The typical presentation of DM is proximal muscle CASE INFORMATION: A 38 year-old woman presented to the ER with vomiting and weakness in association with classic dermatological findings. Gottren's papules, as seen in our diarrhea for four weeks. She experienced 6-8 watery, non-bloody stools per day; vomiting after patient, are the most commonly seen skin rash. The classic heliotrope rash is the most specific consuming any food or liquid; and a ``pulling sensation'' across the lower abdomen. One week manifestation of DM but is only rarely seen. Other findings include acanthosis nigricans, after the onset of symptoms the patient was admitted to the hospital, rehydrated, and ``mechanics hands,'' diffuse flat erythema in a shawl like distribution, and periungual erythema. discharged with a diagnosis of acute gastroenteritis. The symptoms worsened soon after The elevated liver enzymes in this patient are problematic since DM alone can raise discharge, and the patient was readmitted to the hospital. Evaluation included routine stool parenchymal liver enzymes. The hepatitis B profile is not suggestive of an acute infection and cultures and ova and parasites. The patient was treated empirically with levofloxacin and unlikely to be causing the elevated liver enzymes. Hepatitis B, however, has been implicated in metronidazole and was discharged home. Stool cultures were later found to be negative. The the pathogenesis of some cases of DM and raises the question of a delayed slowly progressive patient's symptoms quickly worsened and she presented again to the ER. Past medical history humorally mediated immune reaction. The relationship between the two conditions is was remarkable for asthma and lactose intolerance. On physical examination, BP = 115/62, unknown although a few select reported cases suggest it may be more than coincidental. P = 110, and T = 99.18F. revealed a moderately distended abdomen with shifting dullness and mild tenderness to palpation in the upper abdomen. The remainder of the examination was unremarkable. The white blood cell count was 15,600 with 55.3% 1 1 1 1 eosinophils; the hemoglobin was 8.9. CT of the chest, abdomen, and pelvis revealed a FOOLED BY A CASE OF FLU. R.M. Krishnan , R. Granieri , S. Duncan , U. Kannapadi ; 1 thickened terminal ileum and cecum, ascites, and bilateral small pleural effusions. Paracentesis University of Pittsburgh, Pittsburgh, PA (Tracking ID #74160) was performed. The peritoneal fluid revealed 1,920 white blood cells with 3 neutrophils, 12 LEARNING OBJECTIVES: 1) Recognize influenza pneumonia as a cause of acute lymphocytes, and 85 eosinophils. Ascites fluid albumin was 3.3; the serum-ascites albumin respiratory failure in high-risk patients. 2) Identify hemolytic uremic syndrome (HUS) gradient was 1.2. Upper and lower endoscopy revealed only melanosis coli. Biopsy of the complicating influenza. duodenal mucosa revealed lymphocytic and eosinophilic infiltration. The patient was treated CASE INFORMATION: An 82-year-old male with coronary artery disease and ulcerative with prednisone. Her symptoms improved and she was discharged home. colitis presented last February with 3-day history of shortness of breath, cough, and fever. IMPLICATIONS/DISCUSSION: Eosinophilic Gastroenteritis (EG) is a rare disease whose There was no history of smoking, travel, or prolonged immobilization. His ROS was otherwise etiology is unknown, though it may be a Type I hypersensitivity reaction. Patients with EG negative. His medications were aspirin, metaprolol, lisinopril, and sulfasalazine. After initial present a range of symptoms from nausea, vomiting, and diarrhea, to ascites and bowel treatment for pulmonary edema at an outside hospital, he was transferred to our institution. He obstruction. The symptom complex is determined by the degree of eosinophilic infiltration of was intubated due to worsening hypoxia. A bronchoscopy was performed: bronchoalveolar the gastrointestinal tract. The diagnosis of eosinophilic gastroenteritis requires the presence of lavage (BAL) was bloody. VS: Temp - 378C, BP -124/60 mmHg, HR -110/min, SaO2 - 98% gastrointestinal symptoms, eosinophilic infiltration of one or more areas of the gastrointestinal on assist control ventilation. Exam was notable for bilateral rales and absence of S3 or JVD. tract on biopsy, absence of eosinophilic involvement of multiple organs outside the Initial labs revealed Na-127, creatinine -1.0, CK-MB -15, Troponin I -10.2. EKG was normal; gastrointestinal tract, and absence of parasitic infection. Eosinophilic gastroenteritis without CXR showed interstitial pulmonary edema. Echocardiogram showed EF of 35%. A high- ascites is treated with cromolyn; the presence of ascites requires glucocorticoid treatment. More resolution chest CT showed ground glass appearance consistent with ARDS. He was treated than 90% of patients respond quickly to treatment. The relapse rate is high with cessation of with ceftriaxone and azithromycin. His hospital course was complicated by right middle and treatment (>33%). Those who relapse often require maintenance therapy with glucocorticoids. anterior cerebral artery ischemic stroke, ARF (BUN/Cr 118/3.3), anemia and ultimately shock. He expired on the ninth hospital day. Autopsy reports confirmed thrombotic consistent with HUS. BAL culture subsequently grew influenza A. 1 1 1 A CURIOUS CASE OF CYANOSIS. C.T. Ko , N. Spell ; Emory University, Atlanta, GA IMPLICATIONS/DISCUSSION: Influenza, occurring as outbreaks in winter seasons, is (Tracking ID #76425) usually self-limited; but causes increased morbidity and mortality in high-risk populations. LEARNING OBJECTIVES: 1. Recognize methemoglobinemia as a cause of cyanosis, even Such high-risk group includes patients with underlying cardiac, pulmonary, and immunosup- without G6PD deficiency. 2. Diagnose and treat methemoglobinemia by understanding its pressive diseases, nursing home residents and older than 65. Primary viral pneumonia is the mechanism of action. 3. Recognize the drugs that can cause methemoglobinemia. most severe pulmonary complication that tends to occur in individuals with elevated left atrial CASE INFORMATION: A 26-year-old African-American female with HIV presented filling pressures, and pulmonary diseases. Systemic complications include rhabdomyolysis, complaining of worsening shortness of breath, headaches, and generalized weakness. Her CD4 Reye syndrome, transverse myelitis, and myocarditis. Other rare complications, such as count was 11/mm3. She had been discharged from the hospital one week prior with treatment hemolytic uremic syndrome and toxic shock syndrome worsen the clinical outcome. Apart for presumptive Pneumocystis carinii pneumonia. Her discharge medications included from the tissue culture, the virus can be detected in throat swabs and by serologic methods. clindamycin and primaquine. On physical exam, she was a thin, cachetic, pleasant female in This high-risk patient presented with acute severe respiratory failure from primary influenza A mild respiratory distress. Vital signs included a temperature of 102.5F (39.2C), blood pressure pneumonia complicated by HUS leading to renal failure and anemia. Increasing the pretest 90/50 mm Hg, pulse 124 beats/minute, and respiratory rate 24 breaths/minute. Her pulse probability by clinical evaluation will be helpful in initiating treatment earlier in the course oximeter reading was 85% saturation on room air and 89% saturation with a 100% non- rather than be fooled by the flu. breathing oxygen mask. She had conjunctival and mucosal pallor as well as cyanosis of her nail beds, diffuse shoddy lymphadenopathy, and tachycardia with no associated murmurs/rubs/ gallops. Lung fields were clear to auscultation with adequate airflow. Laboratory evaluation TALCOSIS IN A PATIENT WITH FACTITIOUS DISORDER. J.W. Krzewinski1, R. Barnes1; revealed white blood cells 3400/mm3 (47N, 46L, 6M), hemoglobin 7.0 g/dl, hematocrit 1Virginia Mason Medical Center, Seattle, WA (Tracking ID #75749) 20.2%, platelets 130,000/mm3, and reticulocytes 1.4%. Her hematocrit one week prior was LEARNING OBJECTIVES: 1. To recognize the clinical and pathologic presentation of 35.5%. Chemistry profile showed total bilirubin 1.0 mg/dl, LDH 1374 U/L, and G6PD 10.6. talcosis, also known as foreign body granulomatosis. To recognize the sequelae of talcosis, All other chemistry values were within normal limits. Chest X-ray was unchanged from her specifically panlobular emphysema, acute pulmonary hypertension, ARDS, and spontaneous previous films with minimal bilateral reticular prominence likely secondary to mild interstitial pneumothorax. 2. To recognize signs and symptoms of factitious disorders (Munchausen's). 3. scarring. Arterial blood gas on room air showed pH 7.40, pCO2 28 mm Hg, pO2 73 mm Hg, To discuss differences between factitious disorders, somatoform disorders and malingering. oxyhemoglobin 73%, carboxyhemoglobin 0.2%, and methemoglobin 25%. Primaquine was CASE INFORMATION: A 50 year-old Oregon man with an extensive past medical history discontinued, and methylene blue was administered. Methemoglobin level was 13.6% within including chronic pain syndrome involving his hip, knee, and groin, total hip replacement one hour. One week later in outpatient follow-up, methemoglobin level was 2.6%. surgery with multiple revisions and post-surgical complications presented with a recent history IMPLICATIONS/DISCUSSION: Methemoglobinemia causes cyanosis that is unresponsive of hypertensive episodes and syncope. He was referred to VMMC for evaluation of a possible to oxygen therapy. In addition, pulse oximeter readings are not accurate when there is pheochromocytoma. In addition to syncope, the history and physical revealed an antecubital methemoglobin in the blood. Etiologies of methemoglobinemia include medications, chemical abscess and fevers. The patient was admitted and an Infectious Disease consult ordered. He agents, and hereditary causes. The goal of therapy in methemoglobinemia is to reduce heme reported that In March, 2002, he developed increasing frequency of attacks characterized by iron in order to restore normal oxygen transport. chill, abrupt fever, hypertensive episodes, and syncope. In mid-March, he noted swelling, redness and warmth in his right antecubital fossa and continued to have fever every few days. The patient's hospital course was complicated by multiple episodes of fever >39 oC, witnessed PROGRESSIVE WEAKNESS AND RASH IN A PATIENT WITH ELEVATED LIVER and unwitnessed syncopal episodes, frequently infliltrated intravenous lines, polymicrobial ENZYMES. P. Koneru1, S. Madishetty1, M.D. Hannis2, R.D. Hobbs1; 1Oakwood Healthcare blood cultures, increasing oxygen needs, infected PICC, and atrial fibrillation. His medical System, Dearborn, MI; 2Dearborn, MI (Tracking ID #76623) work-up was extensive. He ultimately underwent a chest CT which showed multiple 2-3mm, LEARNING OBJECTIVES: To recognize the etiologic dilemma posed by elevated liver bilateral pulmonary nodules. The patient had thoracoscopic lung biopsy of several nodules. enzymes in a patient with both dermatomyositis and positive hepatitis serologies. The pathology revealed near complete occlusion of small and medium vessels by extracellular CASE INFORMATION: A 57 year-old Asian-American woman presented with three weeks of refracticle material. The patient was confronted with these findings and confessed to having progressive muscle weakness. She had difficulty combing her hair, lifting her arms or getting crushed and injected oxycontin on several hundred occasions. JGIM Volume 18, April (supplement 1) 2003 69

IMPLICATIONS/DISCUSSION: TALCOSIS- FOREIGN BODY GRANULOMATOSIS- diagnosis of this syndrome is essential, as patients with paraneoplastic impingement may not Occurs when tablets are pulverized and injected. The most common fillers used in tablets are regain function beyond the deficit at presentation. talc, cornstarch, cellulose. These fillers cause an initial arteritis which is associated with rapid influx of neutrophils around the intravascular foreign body. The influx of neutrophils is followed shortly thereafter by granuloma formation as talc particles migrate through the vessel HE SAID, SHE SAID: GENDER DIFFERENCES IN THE PRESENTATION OF ACUTE wall to the surrounding perivascular and interstitial tissue. The most common radiographic CORONARY DISEASE. E.J. Lee1, K. Barnard1; 1University of Pittsburgh, Pittsburgh, PA finding is widespread, 2-3mm well defined nodules typically in the mid lung. The clinical (Tracking ID #75596) presentation is typically non-specific and may mimic URI with: cough, dyspnea, increased LEARNING OBJECTIVES: Recognize gender differences in the presentation of myocardial sputum. Sequelae of talcosis includes: panlobular emphysema, acute pulmonary hypertension, ischemia and consider microvascular spasm as a cause for chest pain in women with ARDS, and spontaneous pneumothorax. Treatment options are limited but include: angiographically normal coronary arteries. Dexamethasone and D-penicillamine. Steroids appear to have a limited (if any) role. CASE INFORMATION: A 54 year-old Asian-American woman with history of chronic back Vasodilatation with hydralazine may help those with pulmonary hypertension. FACTITIOUS pain presented with retrosternal chest pain. The pain was sharp, radiated to her left arm, DISORDER- A form of feigned illness which differs from malingering (which has a external awoke her from sleep, and lasted for one hour. She had had similar pain the previous day, incentive- avoiding work, financial gain) in that it has no other incentive other than to be a lasting an hour before spontaneously resolving. Neither episode was associated with nausea, patient and experience the sick role. Both factitious disorder and malingering differ from vomiting, diaphoresis, or exertion. Another similar episode occurred one year ago. somatoform disorders in that they are voluntarily produced. Munchausen's Syndrome is the Echocardiogram at that time showed mild hypertrophy and normal overall function, while most extreme (and highly publicized) form of factitious disorder. Patients with factitious coronary catheterization revealed normal coronary arteries and an ejection fraction of 65%. disorder often appear more comfortable than their condition would warrant. They may be The patient had no history of diabetes, hypertension, hyperlipidemia, smoking or family pleasant, cooperative and receptive to ANY intervention- even if painful and risky. Nurses often history of coronary artery disease. On initial evaluation in the Emergency Department, the note that they often have no visitors/phone calls suggesting anti-social or isolating behaviors. patient was without chest pain. Her electrocardiograph showed normal sinus rhythm with no They may also give a medical history that is unbelievable or ``too good to be true''. Be suspicious ischemic changes. Chest radiograph was normal. Total CPK was 71 and troponin was less when pt's deny youthe right to access old records or speak with previousproviders. than 0.2. She was admitted to rule out myocardial infarction. Shortly after being admitted, the medicine house staff were called to evaluate the patient for ``seizure-like activity.'' The patient was found in severe emotional distress with taut extension of her upper and lower UNFAITHFUL OR NOT?- A CASE OF TRICHOMONAS VAGINALIS. G.C. Lamb1; extremities, and clawing of her hands bilaterally. She was alert, oriented, and able to follow 1Medical College of Wisconsin, Milwaukee, WI (Tracking ID #76052) commands throughout this episode which resolved within minutes. Electrolytes showed a calcium of 9.7, magnesium of 1.7, phosphate of 3.3, and potassium of 3.8. An LEARNING OBJECTIVES: 1) Describe the epidemiology of Trichomonal vaginal electrocardiograph at this time showed ST depression in leads II, III, and AVF. Repeat infections. 2) Recognize that acute trichomonal vaginitis does not necessarily mean a recent electrocardiograph showed a similar pattern of ST depressions. The patient was transferred to sexual exposure. the cardiac step-down unit with a presumptive diagnosis of unstable angina and started on CASE INFORMATION: The Call: She was in tears, barely understandable over the phone. anticoagulation therapy. Aspirin and beta-blockers were held due to reported allergies. Yesterday she had been seen in the clinic and diagnosed with trichomonas vaginitis. The Subsequent electrocardiographs showed normal ST segments in all leads. Second and third resident had dutifully told her that this was a sexually transmitted disease and that both she and sets of cardiac enzymes were negative. Cardiac catheterization the following day revealed her husband needed to be treated simultaneously. Unfortunately, because of her husband's normal coronary arteries and an ejection fraction of 60%. The patient was discharged home health they had not had sex in over ten years. Now her husband was accusing her of infidelity, a the following day in good condition. fact she denied vehemently. The Case: The patient is a 59 year old white woman with a 1 week IMPLICATIONS/DISCUSSION: There is abundant data to suggest there are gender history of burning on urination and a mild vaginal discharge, described as thin and clear. She differences in the risk factors, presentation, and management of cardiac disease. It has been denied fever or flank pain. Her social history was significant for part-time work as a shown that negative affect and emotional distress may increase risk of ischemic heart disease housekeeper which took her out of the house periodically. Her husband had been disabled for and interfere with effective cardiac rehabilitation. Mental stress has been known to cause 10 years with a back injury and there had been no sexual activity since the injury. The pelvic ischemic changes on electrocardiograph and abnormalities in regional and global left examination was remarkable only for a thin watery discharge with a mild odor. Cervix and ventricular function. These effects have been associated with microvascular spasm. A mental adnexa were benign. A wet prep revealed numerous trichomonads. stress-induced ischemic episode may have occurred in this patient. A coronary catheterization IMPLICATIONS/DISCUSSION: Trichomonas vaginalis infection classically presents as a that showed normal coronary flow would not be uncommon in such a case. It is important to vaginitis/cervicitis with a thin, yellow, frothy, foul smelling discharge often times associated realize that despite angiographically normal coronary arteries, this may be an atypical with dysuria. Nevertheless, up to 40% of infections are asymptomatic. The association with presentation of true underlying coronary disease. sexual activity is well documented. As an illustration of this, the incidence of infection in the general population has been reported as high as 5-10%, while in venereal disease clinics the incidence jumps to 25% and up to 70% among prostitutes. However, unlike other sexually transmitted diseases, the age distribution of of trichomonas infection is bimodal. For example, THROMBOTIC THROMBOCYTOPENIC PURPURA-HEMOLYTIC UREMIC SYNDROME 1 1 1 most women with gonorrhea are in their early 20's, with less than 2% over the age of 40. (TTP-HUS) AFTER A SINGLE DOSE OF QUININE. J. Lee , M. Krasnoff ; Dartmouth Trichomonas infections also peak during years of maximal sexual activity but there appears to be Hitchcock Medical Center, Lebanon, NH (Tracking ID #74449) a second peak around the time of menopause. Indeed, >30% of patients are over the age of 40. It LEARNING OBJECTIVES: 1. Identify a potentially fatal complication of a commonly has been hypothesized that this represents women infected at an early age who harbored the prescribed therapy for nocturnal leg cramps. 2. Recognize quinine as the most common cause trichomonas asymptomatically but present with symptoms at a time when the vaginal milieu of drug-associated TTP-HUS. changes (eg. menopause) allowing the trichomonas to propagate. There are several reported CASE INFORMATION: The patient is a 66 year old previously healthy female who presented cases of newborns and apparent virgins with trichomonas. These likely represent either to the emergency department with the acute onset of nausea, vomiting, abdominal pain, transmission from infected mothers at the time of birth or a nonsexual source. Studies from the diarrhea, and disorientation 2.5 hours after taking a single dose of 260 mg of quinine for British literature (Burgess,1963; Whittington 1957) establish that trichomonas can survive for nocturnal leg cramps. Over the next few hours, she developed severe hypotension, requiring up to 45 minutes on a toilet seat, although transmission by this route has never been proven. Has pressors. Labs were notable for WBC 3.6 Plt 123,000 Bun 25 Cr 1.9 T bili 1.7 PTT 75 she been faithful? Clearly there is valid justification to believe that she is telling the truth. PT > 100. A CT scan of the abdomen and pelvis was unremarkable. The patient was admitted to the ICU with a presumed diagnosis of sepsis of unclear etiology; she was started empirically on IV ampicillin/sulbactam. Over the next few days, the patient developed microangiopathic hemolytic anemia, severe thrombocytopenia (Plt 12,000), and acute renal failure (Cr 8.4). PROGRESSIVE LOWER EXTREMITY WEAKNESS. J. Lane1, J. Hutchings1, J. Wiese1; Cultures of sputum, urine and blood showed no growth. Her clinical diagnosis was felt to be 1Tulane University, New Orleans, LA (Tracking ID #77002) TTP-HUS; her antibiotics were stopped and she was begun on daily plasmapheresis. Dialysis LEARNING OBJECTIVES: 1. Use the physical examination to distinguish peripheral was instituted. After two weeks of therapy, the patient's anemia, thrombocytopenia, renal neuropathy from the cauda equina syndrome. 2. Understand the importance of a timely failure, disorientation, and coagulopathy were all improving or resolved. An adverse event diagnosis of cauda equina syndrome. report was sent to FDA MedWatch. CASE INFORMATION: A 49 year-old man presented with a five weeks of bowel and bladder IMPLICATIONS/DISCUSSION: Nocturnal leg cramping is a common complaint incontinence and parethesias of the lower extremities. He had a history of diabetes mellitus and encountered in the primary care setting. Despite quinine being frequently prescribed, its HIV. Two weeks prior he had presented for evaluation of urinary hesitancy and paresthesias of potential for severe adverse reactions is largely underrecognized. Quinine is the most the lower extremities. He was diagnosed with diabetic peripheral neuropathy and released. On common cause of drug-associated TTP-HUS. Common presenting symptoms include the this admission, his neurological examination revealed decreased sensation in the lower acute onset of abdominal pain, nausea, vomiting, diarrhea, fevers and chills. The symptoms extremities, absent ankle reflexes, an ataxic gait, saddle anesthesia, and decreased anal sphincter usually begin abruptly, several hours after the ingestion of quinine. A single tablet is tone. An MRI of the spine revealed an extradural mass extending from L4 to S4. Biopsy sufficient to cause TTP-HUS. In addition to the expected findings of TTP-HUS, low-grade confirmed the neoplasm to be Burkitt's lymphoma. DIC and leukopenia can also be seen. The mechanism of quinine-associated TTP-HUS is IMPLICATIONS/DISCUSSION: Although spinal cord compression is a medical emergency, presumed to be caused by drug-dependent antibodies. Treatment involves avoidance of access to an MRI may be limited. The physical examination is instrumental in establishing the quinine exposure, plasmapheresis and supportive therapy. While available by prescription, diagnosis and expediting appropriate therapy. Although diabetes and HIV are common causes quinine is also found in beverages, such as quinine water, tonic water, and gin and tonic. In of peripheral neuropathy, they are not causes of the cauda equine syndrome (CES). A addition, there is an extensive list of herbal remedies containing quinine including cinchona methodical physical examination detected saddle anesthesia and sphincter impairment, tree, peruvian bark, and china bark. Physicians should carefully question any patient with establishing the diagnosis of CES. Compression of the roots can be caused by a ruptured TTP-HUS for quinine exposure, especially since patients may not report it among their disk, infection, fracture, or tumor. HIV patients are at increased risk for tumors associated with medications. In addition, physicians need to counsel patients regarding future avoidance of co-sexually transmited viral infections such as HHV6 and HHV8. CES is a neurosurgical all quinine-containing compounds, since repeat ingestion of quinine may cause relapse of emergency, requiring immediately operative decompression of the spinal canal. A timely TTP-HUS. 70 Abstracts JGIM

TUBERCULOSIS PRESENTING AS A PROSTATIC-RECTAL FISTULA IN AN HIV and 1.0 respectively. An initial urinalysis revealed protein level of greater than 300 mg/dl and PATIENT. D. Lehman1, J. Mills1, C. Sorensen1, J. Whitesel1, R. Reves1; 1Denver Health . A subsequent 24-hour urine collection revealed 7.6 grams of protein and Hospital Authority, Denver, CO (Tracking ID #75102) confirming a diagnosis of . The differential diagnosis of nephrotic syndrome with eosinophilia includes lymphoma and various parasite infections. While parasitic LEARNING OBJECTIVES: To recognize that tuberculosis can present with unusual clinical serologies were pending, chest and abdominal CT scans were normal ruling out a diagnosis of manifestations, often sub-acute or chronic, especially in the immunocompromised context, lymphoma. A showed membranous glomerulonephritis with diffuse IgG deposits such as HIV infection. in the subepithelium. Subsequent peripheral blood smears showed obvious microfilariae of the CASE INFORMATION: 48 y/o male with heterosexually acquired HIV infection and a CD4 Loa loa species, indicating active infection. Further laboratory studies revealed the absence of count of 306, presented with a 1-month history of penile and and 1 week of no urethral other conditions associated with membranous glomerulopathy. Therefore, it was concluded voiding. He noted urine coming from the rectum with feces. Voiding cystourethrogram showed a that the nephrotic syndrome and the membranous glomerulonephritis were most likely caused prostatic-rectal fistula and a Foley catheter was placed. He was born in Mexico and had a negative by the filarial infection. The patient was treated with metolazone and lisinopril to treat the PPD 10 years earlier. Four months earlier he had presented with dysuria, an enlarged prostate, anasarca/ nephrotic syndrome and given ivermectin to treat the filariasis. At follow-up two pyuria and microscopic hematuria. CT scanning then showed a 2.7 by 3.0 cm hypodensity within months later, the edema had resolved and his urinalysis had almost normalized. an enlarged prostate that, in the absence of fever and toxicity, appeared clinically not consistent IMPLICATIONS/DISCUSSION: Loa loa is one of eight filarial species and occurs mainly in with a prostatic abscess. No urine culture was done, but he received 10 days of levofloxacin. the rain forests of Africa. Adult worms develop and mate to form microfilariae, which appear in Fistula evaluation by GI with colonoscopic biopsy showed chronic inflammation and necrosis. the blood. Whereas other filarial species cause the classic symptoms of , the loaisis Transrectal ultrasound showed a large prostate with prostatic calculi with no cyst or abscess. species is more commonly associated with pruritus and localizd areas of subcutaneous swelling. Granulomas and acid-fast bacilli (AFB) were found in biopsies obtained during an unsuccessful Various nephropathies, including nephrotic syndrome, are rare and likely result from immune surgical attempt to repair the fistula. Bilateral infiltrates were found on a post-operative chest complex deposition within the glomerulus. In tropical countries, infectious diseases are X-ray. AFB were found in urine and sputum and cultures grew Mycobacterium tuberculosis common causes of the nephrotic syndrome. As demonstrated in this case, one should consider (TB). Standard 4-drug therapy for TB was successful and the fistula closed without further the diagnosis of filariasis in patients that present with anasarca and/or nephrotic syndrome and surgery after 6 months of directly observed treatment and Foley drainage. who have a history of travel to endemic countries for filariasis. IMPLICATIONS/DISCUSSION: Delayed and missed diagnoses of active pulmonary and extrapulmonary TB are common due to the relative rarity of the disease and a lack of familiarity with its protean manifestations. TB of the genitourinary tract accounts for about 1% PATHOLOGIC RUPTURE OFA NORMAL-SIZE SPLEEN IN ACUTE MYELOID LEUKEMIA. of reported cases of TB in the US. Extrapulmonary forms (27% of US cases) are more common Y.Y. Li 1, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73694) among children and patients with HIV-infection or other disorders of immunity. The keys to earlier recognition of active TB are awareness of: 1) the manifestations of the disease, 2) risk LEARNING OBJECTIVES: 1) Recognize an unusual complication of acute myeloid factors for previous exposure and latent TB infection, and 3) risk factors for progression from leukemia; 2) Diagnose and manage pathologic splenic rupture; 3) Recognize the mechanisms latent TB infection to active disease. In retrospect this patient had all three of these features. of pathologic splenic rupture. The clinical features of active TB, both pulmonary and extrapulmonary are variable, but CASE INFORMATION: A 63 year-old white female with a history of von Willebrand disease chronic and sub-acute presentations are common. Signs of systemic toxicity are helpful if presented with 3 weeks of severe fatigue. She denied history of trauma or abnormal bleeding present but are commonly absent. TB of the urinary tract should be suspected in patients with although she reported easy skin bruising. On physical examination, her temperature was 37.4 unexplained ``sterile'' pyuria and/or hematuria and in those with unexplained chronic degrees Centigrade and BP 102/72 mmHg. She appeared thin and pale. Neck was supple, inflammation and fibrosis. This patient had a common risk factor for infection, having been without thyromegaly. Lungs were clear. Heart was regular, without murmurs or gallops. born in Mexico, and had HIV infection as a risk factor for progression to active TB. Although Abdomen was benign without masses, tenderness or hepatosplenomegaly. Extremities had no the GU tract is a relatively common extra-pulmonary site for TB, there is little mention in the cyanosis, clubbing or edema. Neurological examination was non-focal. CBC revealed a literature of fistula as a complication of TB prostatitis. The most likely etiology of a prostatic- hemoglobin of 10g/dl, platelet of 33,000/mm3, and WBC of 3500/mm3 with 13% blasts. Bone rectal fistula is surgery, rarely by infection. marrow biopsy found 40% blasts with positive CD33 and CD34. She was diagnosed with acute myeloid leukemia. Chemotherapy with cytarabine was started. Five hours later, she developed severe stabbing left upper quadrant abdominal pain radiating to the back and left shoulder, CRYPTOCOCCAL IN A HYPOGAMMAGLOBULINEMIC PATIENT. aggravated by body movement, only slightly relieved by intravenous hydromorphone. One 1 1 1 1 A. Lentz , J. Chanez , L. Hunter ; Methodist Hospitals of Dallas, Dallas, TX (Tracking hour later she became hypotensive with a BP of 90/50 mmHg. Hemoglobin dropped from 9.0 ID #76196) to 7.1g/dl in 4 hours. Electrocardiogram showed sinus tachycardia and no acute ischemic LEARNING OBJECTIVES: To evaluate cryptococcal meningoencephalitis in non-HIV changes. Abdominal series was unremarkable. An abdominal CT scan was reported infected individuals. To discuss hypogammaglobulinemia as a possible predisposing factor. To unremarkable initially, but further review demonstrated blood surrounding the spleen. discuss transient CD4 lymphopenia. Emergent laparotomy found acute rupture of a normal sized spleen (8.0 Â 5.5 Â 2.3 cm). CASE INFORMATION: A 48 year-old African American man with no past medical history Splenectomy was performed. She was transfused a total of 6 units of packed red blood cells. presented with headache and malaise. Radiological studies revealed what appeared to be a solid Hemoglobin remained stable after the surgery. She developed acute respiratory distress posterior occipital mass consistent with a malignant lesion and surgical intervention was syndrome and died of respiratory failure and cardiac arrest within a week. pursued. At craniotomy he was found to have an abscess; smears revealed yeast forms and IMPLICATIONS/DISCUSSION: The spleen is an immunologic organ commonly involved cultures grew Cryptococcus neoformans. CSF results were WBC 255, protein 112, glucose 27 in hematologic diseases. Splenic rupture can be classified into 1) traumatic; 2) spontaneous; and and cryptococcal antigen 1:64. Serum cryptococcal antigen was 1:128. He disclosed no risk 3) pathologic. Pathologic splenic rupture occurs in a spleen affected by a disease without factors for immunodeficiency which was confirmed by negative studies for HIV-1 and 2 previous trauma. The presentations of splenic rupture are the result of intra-abdominal antibody, HIV-1 and 2 PCR, HTLV-1 and 2 antibody and HTLV-1 and 2 PCR. Of note, his hemorrhage, hypotension, tachycardia, peritoneal irritation signs, and fever. The abdominal CD4 count was 79 and his total IgG, IgG1 subclass and IgG2 subclass levels were low. IgA and pain could radiate to the left shoulder (Kehr's sign). Pathologic rupture of a spleen affected by a IgM levels were at the lower limits of the normal range. He received two weeks of amphotericin hematologic malignancy is a rare event and it is especially unusual for a normal sized spleen to B and improved appropriately. Lumbar puncture at that time revealed: WBC 440, protein 111, rupture. The risk of splenic rupture increases with age and size of the spleen. The release of the glucose 30 and cryptococcal antigen 1:2. Repeat CD4 count was 191 and serum cryptococcal enzymatic content of cells shortly after induction chemotherapy may lead to splenic damage, antigen was 1:64. His therapy was changed to fluconazole and he continued to improve. followed by rupture of the spleen. The present patient had received cytarabine just 5 hours IMPLICATIONS/DISCUSSION: Although possible in immunocompetent hosts, crypto- before the abrupt onset of abdominal pain. Other risk factors of bleeding such as coccal meningoencephalitis presents most commonly in patients with HIV infection, drug- thrombocytopenia and von Willebrand disease might also have contributed to her catastrophic associated immunosuppression, leukemia and complement deficiency. This infection has rarely event. The diagnosis of pathologic splenic rupture begins with a high index of suspicion. A been reported in cases of hypogammaglobulinemia. Cryptococcus neoformans infects through patient with risk factors presenting with left upper abdominal pain should be observed closely aerosolization producing a primary respiratory infection that spreads hematogenously to and investigated. Plain abdominal X-ray, ultrasound and CT scan are valuable tests. Aspiration distant sites. In hypogammaglobulinemia of the type shown in this patient, the proposed host of blood by abdominal puncture could confirm the diagnosis. For insidious rupture, liver- defect stems from dysfunctional T-cell activity resulting in fundamental difficulties with spleen scintigraphy is of value. The only therapy is splenectomy. complement fixation, opsonization and reduction of circulating antigens. We propose the possibility that the hypogammaglobulinemia facilitated the development of this patient's CNS SUBACUTE ONSET OF ATAXIA IN A PREVIOUSLY HEALTHY MALE. Y.Y. Li 1, J. Hefner1, disease. These immunosuppressed patients present with fever, headache and malaise similar to, R. Granieri1, A. Tulsky1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73876) but typically more intense and shorter in duration than infections in the immunocompetent host. Response to treatment with amphotericin B and fluconazole are similar to those in LEARNING OBJECTIVES: 1) Recognize the unusual presentations of lung cancer; 2) immunocompetent hosts.Close monitoring and medication adjustments per clinical response Diagnose anti-Huantibody associated paraneoplastic encephalomyelitis (PEM); 3) Recognize are essential. Thus, this case provided an unusual initial presentation of hypogammaglobu- the treatment of large cell neuroendocrine carcinoma and PEM. linemia as cryptococcal meningoencephalitis. CASE INFORMATION: A 67-year-old male was well until 6 weeks prior to presentation, when he developed diffuse extremity deep aching pain and difficulty with walking, maintaining his balance and doing buttons. He denied diplopia, but had trouble looking to the left. He NEPHROTIC SYNDROME AS A RARE PRESENTATION FOR FILARIASIS. denied weakness, numbness, sensory loss, trouble with speech or articulation, or bowel or K. Leuenberger1,V.Martin1,B.Mathis1; 1University of Cincinnati, Cincinnati, OH bladder dysfunction. On physical examination, he had normal vital signs. He was alert, (Tracking ID #73960) cooperative, but somewhat slow. A 2 Â 2 cm non-tender supraclavicular lymph node was LEARNING OBJECTIVES: To recognize filariasis in the differential diagnosis of nephrotic palpable. Heart, lungs and abdomen were unremarkable. Extremities had no cyanosis, clubbing syndrome. or edema. Eyes could not move past the midline on leftward gaze. Motor strength was 5/5 in all CASE INFORMATION: A 46 year old man who had recently emigrated from West Africa muscle groups tested. Vibratory sense was diminished distally in the right lower extremity. A presented with a three month history of lower extremity pitting edema. His physical heel-to-shin testing was ataxic. He could not sit nor stand unaided. Romberg's sign was non- examination was significant for anasarca. Laboratory data revealed a white blood cell count of interpretable even with the eyes open. Plantar responses were flexor bilaterally. Cerebral spinal 9900 with 58% eosinophils, an albumin level of 1.2 g/dl as well as a BUN and creatinine of 16 fluid reveaked glucose 93, lymphocyte 4, IgG 15.1, and protein 100. Anti-Hu antibody was JGIM Volume 18, April (supplement 1) 2003 71

positive. Brain MRI showed a small old lacunar infarct. Chest CT scan identified a 1 ± 2 cm EARLY RECOGNITION OF AN UNCOMMON PATHOGEN: VIBRIO VULNIFICUS. right suprahilar pulmonary nodule, 3 right upper lobe nodular densities less than 1 cm each, G. Loukatous1, J. Wiese1, J. Aliota1; 1Tulane University, New Orleans, LA (Tracking and a prominent 3.5 cm nodule in the right pretracheal area. EMG and nerve conduction ID #77080) studies demonstrated a sensory motor polyneuropathy. Lymph node biopsy showed neoplastic LEARNING OBJECTIVES: 1. Identification of the clinical signs and symptoms of Vibrio cells staining with synaptophysin and chromogranin, supporting the diagnosis of large cell Vulnificus infection 2. Recognition that early and aggressive intervention is essential to optimal neuroendocrine carcinoma. The patient was treated with carboplatin and etoposide for three patient outcome doses and IVIgG for five doses. The symptoms were stabilized. CASE INFORMATION: A 42-year-old Vietnamese man presented with a two-day history of IMPLICATIONS/DISCUSSION: Paraneoplastic encephalomyelitis (PEM) is a frequent fever and a painful left leg. He denied trauma or stasis involving the leg. His pulse was 110; blood remote effect of cancer characterized by neuronal loss and inflammatory infiltrates in the pressure 110/50; temperature 38.0 C. There was a 10 cm eccyhmotic lesion on his left lower leg. nervous system. The onset is usually subacute and causes severe neurological dysfunction Despite therapy with cefazolin his condition deteriorated. Over 12 hours, the ecchymosis which antedates the diagnosis of cancer. The presenting neurological syndrome is usually extended as the skin lesion rapidly developed multiple fluid-filled bullae. General surgery was sensory neuropathy, cerebellar dysfunction and cortical encephalitis. Diagnosis of the primary consulted for surgical debridement. Upon further questioning, the patient noted a recent history cancer remains challenging and requires a high index of suspicion. Usually, it is made by the of raw oyster ingestion. Wound and blood cultures returned positive for Vibrio vulnificus. He demonstration of specific paraneoplastic antibodies. Anti-Huantibody recognizes a family of was started on . Although he subsequently developed multi-organ failure, he RNA-binding proteins expressed in the nuclei of neurons and cancer cells. It has been used as a recovered after 22 days of aggressive medical treatment and continued surgical debridement. diagnostic marker, but no evidence suggests it causes neuronal damage. Effective treatment of IMPLICATIONS/DISCUSSION: Early diagnosis and treatment is the critical component of the tumor with chemotherapy is an independent predictor for stabilization of PEM. Large cell a successful outcome from a Vibrio vulnificus infection. The key to diagnosis is combining an neuroendocrine carcinoma is a highly aggressive tumor that usually occurs in smokers, and may astute history with an observant physical examination. In sea-side cities, the consumption of be either central or peripheral. It has been suggested that surgically resectable tumors be oysters or exposure to the water may be so common as to preclude the patient from thinking to excised and that advanced stage lesions be treated with combination chemotherapy. offer this historical clue unless prompted. Recognizing the appearance of Vibrio, then, is the Immunotherapy has been proven effective in some patients in tumor regression and PEM key to diagnosis. Erythematous and ecchymotic skin lesions that rapidly evolve to hemorrhagic stabilization or improvement. The prognosis is poor, with a median survival of 11 months. vesicles and bullae should alert the physician to the possibility of a Vibrio infection. Like necrotizing faciitis, vibrio invades the deep fascia, destroying the facial structures as it rapidly extends. Ecchymosis, bullae and anesthesia reflect the loss of vessels, skin partitions and nerves. PERITONEAL TUBERCULOSIS VERSUS METASTATIC OVARIAN CARCINOMA: A Early intervention with appropriate antibiotic therapy and aggressive wound debridement is DIAGNOSTIC CHALLENGE. K. Lin1, A. Monferre1; 1Temple University, Philadelphia, PA essential in such cases. Even with early intervention, bacteremia from V. vulnificus carries a (Tracking ID #75850) 50% mortality that increases to 90±100% in the presence of hypotension. LEARNING OBJECTIVES: Recognize that the clinical manifestations and radiologic findings of peritoneal tuberculosis (TB) may mimic ovarian carcinoma. Recognize that an elevated CA-125 level may be more suggestive of tuberculous peritonitis than ovarian PNEUMOCYSTIS CARINII PNEUMONIA WITHOUT THE HUMAN IMMUNODEFICIENCY carcinoma in certain populations such as young women, HIV-infected women and women VIRUS. H. Ly1, M. Decker1, S.E. Sherman2; 1UCLA-San Fernando Valley Program, Sylmar, from areas endemic for tuberculosis. CA; 2University of California, Los Angeles, Sepulveda, CA (Tracking ID #75462) CASE INFORMATION: A 29 year-old Vietnamese woman with no significant past medical LEARNING OBJECTIVES: To recognize Pneumocystis carinii pneumonia (PCP) in non- history presented to the emergency department with a 10 day history of fever, non-productive HIV infected patients. cough, abdominal pain, and increasing abdominal girth. A PPD placed as an outpatient was CASE INFORMATION: A 34 year old non-smoking, HIV-negative Hispanic male, who reactive to 16mm. She emigrated from Vietnam ten years prior, had no recent travel history, and received his last dose of chemotherapy for lymphoma 1 week prior, presented with 3 days of had no recent sick or TB contacts. Family history was negative for cancer. On physical increasing cough, dyspnea on exertion, and fever. He denied any sick contacts, TB exposure, examination, the patient was febrile to 102.6F with a pulse of 111 BPM. Pulmonary exam was recent travel, or pet exposures. His vital signs were:T 99.6 F, BP 115/78, P 100, R 20, and Pulse clear to auscultation. Abdominal exam was significant for mild distention, and tenderness in the Ox 96% on room air. Respiratory exam showed unlabored breathing and clear lungs. His studies epigastric and right upper quadrant regions without rebound or guarding. Gynecologic exam was showed: WBC 1.9 (N 51%, L 12%, M 35%), Hb 9, Hct 25.9, Plt 44, and LDH 1461. Chest x- normal. Chest x-ray was normal. A CT scan of the abdomen and pelvis showed diffuse intra- ray showed bilateral hilar fullness not seen on prior films. Differential diagnosis on admission abdominal ascites with omental caking, strongly suggestive of metastatic disease from ovarian was pulmonary infection (community acquired, atypical, and fungal pneumonia; TB; PCP) carcinoma. Pelvic ultrasound was negative for adnexal masses. Ascitic fluid analysis showed a versus recurrence of lymphoma. Hospital course:Ceftriaxone and azithromycin were empirically predominantly lymphocytic exudate. There were no malignant cells, acid-fast bacilli (AFB) or started on Day 1. By Day 2, the patient remained febrile and showed signs of decompensation other organisms detected in the fluid. Fluid culture yielded no growth. Multiple sputum smears with decreasing BP and increasing oxygen need to 4 liters. A room air ABG at that time showed: were negative for AFB. A CA-125 level was elevated to 546 U/ml. A CT guided biopsy of the pH 7.49, pCO2 36, PO2 43, saturation 83%. Chest CT showed progression to diffuse bilateral omentum revealed granulomatous inflammation and well-defined granulomas with central alveolar infiltrates without adenopathy. Trimethoprim/sulfamethoxazole was added empirically necrosis ± histology consistent with tuberculous peritonitis. The patient was started on a regimen for PCP. The patient was then transferred to the ICU for prophylactic intubation and of isoniazid, rifampin, ethambutol and pyrazinamide. On follow-up two weeks after discharge, diagnostic bronchoscopy showing positive Pneumocystis carinii direct fluorescent antibody on the patient reported feeling well with complete resolution of the fever and abdominal pain. lavage. All other studies (biopsy, brush, and sputum/blood samples) were negative for bacterial, IMPLICATIONS/DISCUSSION: Peritoneal tuberculosis is an uncommon entity. The fungal, and malignant processes. Prednisone was subsequently added. The patient improved common clinical presentation is ascites or an abdominal mass. The elevated CA-125 and dramatically with extubation on Day 3 and discharge within the week. radiologic appearance of the omentum, as in the case of our patient, can be highly suggestive of IMPLICATIONS/DISCUSSION: PCP is usually seen in AIDS patients with CD4 counts ovarian carcinoma. However, it is well established that many other conditions, including <200 without chemoprophylaxis. Unfortunately, it may not be readily considered in the peritonitis can elevate the CA-125. When these features are present in a patient who is at high differential in immunosuppressed, non-HIVpatients. The above vignette serves to remind us to risk for developing tuberculosis and who is at low risk for developing ovarian cancer then the not exclude PCP in the differential because a delay in evaluation could be fatal. Our patient fared diagnosis of tuberculosis must be considered. Establishing the diagnosis of peritoneal well because we recognized his predispositions (hematologic malignancy and immunosuppres- tuberculosis can be difficult as ascitic fluid is rarely positive for AFB and even culture of biopsy sion from chemotherapy) early in his hospital course which led to prompt treatment. The specimens may be negative. Diagnosis is often made on the basis of suggestive histopathology calculated absolute lymphocyte count was 228, making the CD4 count likely <200. and clinical features. Clinicians must maintain a high index of suspicion for tuberculous peritonitis in patients presenting with ascites and abdominal masses, especially in young women (in whom ovarian carcinoma is uncommon), HIV-infected patients and patients from areas endemic for tuberculosis. In these cases, empiric antituberculosis therapy can be considered SWOLLEN HEAD: MORE THAN AN EGO PROBLEM. A.C. Maio1, H. Sakowski1, while further workup is pending. CA-125, while nonspecific for peritoneal tuberculosis, can be A. Bewtra1; 1Creighton University, Omaha, NE (Tracking ID #77073) useful in monitoring response to therapy and would be expected to return to normal levels. LEARNING OBJECTIVES: Formulate a differential diagnosis of facial swelling using clinical and laboratory data. Initiate early and aggressive treatment based on the presumed diagnosis of facial swelling. CHRONIC SINUSITIS AND BEYOND. A. Loewen1; 1University of Calgary, Calgary, Alberta, Recognize that individuals with recurrent severe infection should be tested for immunode- Canada (Tracking ID #77075) ficiencies. LEARNING OBJECTIVES: To review an approach to the patient with chronic infection. To CASE INFORMATION: A 19 year old male was admitted in August, 2001 with face and lip discuss the manifestations of Wegener's Granulomatosis. swelling and pain. He has no significant past medical history or family history. He smokes CASE INFORMATION: A 33 year old male with a 4 month history of chronic sinusitis which is cigarettes, drinks alcohol, and uses cocaine and marijuana. On physical exam he is afebrile, with refractory to antibiotics, and an episode of suppurative otitis media, presents with left sided Bell's a pulse of 132, respirations of 20 and a BP of 110/70. Oxygen saturation initially was 100% on palsy and multiple boils. There is microscopic hematuria with normal renal function. Drainage room air. His left face, mouth, and neck are swollen and firm, his left eye was swollen shut and and biopsy of sinuses demonstrates necrotizing granulomatous inflammation. Anti PR3 level is his tongue was swollen. He had no cervical adenopathy and clear lung fields. Initial impression 18.5 kEu/L. A diagnosis of Wegener's granulomatosis is made. The patient later develops was and treatment involved epinephrine, solumedrol, and with worsening hemoptysis while on therapy with prednisone and cyclophosphamide. respiratory status, intubation. Fever climbed to 103.3, treatment was started with ampicillin- IMPLICATIONS/DISCUSSION: An approach to the patient with apparently chronic sulbactim and clindamycin. With positive blood cultures the diagnosis was now thought to be infection must include infectious causes, underlying immunosuppressed states and non- necrotizing fasciitis. Supportive care including TPN continued until he was extubated and infectious causes. Wegener's granulomatosis is a vasculitis of small arteries and veins and discharged after 3 weeks. Patient never followed up and was readmitted in May, 2002 with a usually presents as a pulmonary-renal syndrome. In this case it presented with upper airway similar presentation and was found to have common variable immunodeficiency. Upon involvement, pyoderma gangrenosum and cranial nerve palsy, butpulmonary and renal discharge, he still has not followed up and is not being treated. symptoms were minimal. A broad differential diagnosis can lead to the correct diagnosis, IMPLICATIONS/DISCUSSION: Necrotizing infections of the skin and fascia involve tissue avoiding unnecessary interventions, and hasten administration of appropriate therapy. destruction, systemic toxicity, and a high mortality rate. There is a tendency to underestimate 72 Abstracts JGIM

the severity and extent of infection. We now see more angioedema and might miss this clinical SEPTICEMIA DUE TO PASTEURELLA MULTOCIDA. M.S. Marcu1, E.H. Elbadawy2; presentation. Normal complement studies make hereditary angioedema unlikely and normal 1University of Cincinnati, Cincinnati, OH; 2Fairview Hospital, Cleveland, OH (Tracking tryptase makes angioedema from other causes unlikely. Treatment of necrotizing fasciitis ID #73629) involves airway control, IV antibiotics, and early, aggressive surgical debridement. Individuals LEARNING OBJECTIVES: 1- To recognize liver cirrhosis and alcoholism as predisposing with common variable immunodeficiency frequently present with recurrent infections with factors for Pasteurella multocida sepsis. 2- To recognize the importance of detailed history encapsulated bacterial pathogens as in our patient. Those with recurrent infections should be taking in formulating a preliminary diagnosis and guiding further management. checked for the disorder and treated with IV immunoglobulin. CASE INFORMATION: A 57-year-old Caucasian male presented with one day history of fever, chills, malaise, lightheadedness and confusion. Symptoms started 5 days after a cat bite. Laboratory Data His medical history was significant for hypertension, atrial fibrillation, alcoholism and Tryptase 2.4 ug/l diagnosed 3 months prior to this admission. His medications included C4 23 mg/dl spironolactone, lasix, folic acid, carvedilol and digoxin. On physical examination he appeared ill CH50 98 u/ml with temperature of 103.4, blood pressure of 89/67 and heart rate of 130. Both hands showed Blood cultures + for Group A Strep multiple linear lesions with scabbing with no evidence of inflammation or lymphadenopathy. HIV Negative The remainder of examination was remarkable for jaundice, spider nevi, irregularly irregular IgG 555 mg/dl rhythm, tender hepatomegaly and bilateral pedal soft pitting edema. There was no abdominal IgA 238.5 mg/dl guarding or rigidity, no splenomegaly or ascites on examination. Laboratory evaluation IgM 142 mg/dl showed; white blood cells 25.7 k/AL (4.8±10.8), hemoglobin 10.4 gm/dL (14±18), platelets 78 k/AL (150±400), prothrombin time 22.2 seconds (10±13), INR 2.3, AST 112U (7±40), ALT A LOW K IS NOT OK. A. Mallouk1, R. Cader1, E.F. Yee2; 1UCLA-San Fernando Valley 51U (30-60), Total bilirubin 15.2 mg/dL (0.1±1.0) and albumin of 2.7 g/dL (3.5±5.0). After Program, Sylmar, CA; 2Albuquerque VA/University of New Mexico, Albuquerque, NM obtaining blood cultures patient was started on intravenous ampicillin/sulbactam 3 gm every 6 (Tracking ID #75441) hours and oral ciprofloxacin 500 mg twice daily. Next day his blood cultures grew Pasteurella multocida in 4 bottles out of 4. Treatment was continued with ampicillin/sulbactam for total of LEARNING OBJECTIVES: 1. Recognize primary hyperaldosteronism as a cause of 14 days and he was discharged home in stable condition. hypokalemia 2. Review the workup and management of primary hyperaldosteronism. IMPLICATIONS/DISCUSSION: Pasteurella multocida is a gram-negative coccobacillus that CASE INFORMATION: A 56-year-old man with a 10 year history of hypertension presented constitutes part of the normal oral flora of many animals. Systemic infections with P. multocida for a routine clinic visit. He had no chest pain or palpitations and took nifedipine for his blood are rare, but they are more common in patients with liver dysfunction, particularly in patients pressure. He had no other significant past medical history. Physical exam was unremarkable with . Splenic hypofunction secondary to cirrhosis or alcoholism might except for BP 176/94. Labs showed K 2.71, CO2 32.7, BUN 13, Cr 1, Mg 1.9. The patient was play an important role in the pathogenesis of the disease. Preliminary diagnosis of P. multocida not on diuretics nor NSAIDS and did not abuse alcohol. He had never been told he had infection in patients with liver disease and history of cat bite is important even in the absence of hypokalemia before. He had no muscle cramps, weakness, or diarrhea. A repeat lab confirmed cellulitis as in our patient. the low potassium. Because of the hypertension, alkalosis, and hypokalemia without an obvious source, the patient had additional testing including urine lytes showing K 43 (high), and serum aldosterone to renin activity ratio and 24 hour urine aldosterone level which were both VALPROIC ACID AS A STIMULANT FOR HIV REPLICATION. S. Martin-Schild1, J. Wiese1; elevated. Urine and serum cortisol were normal. He was started on spironolactone for 1Tulane University, New Orleans, LA (Tracking ID #77088) suspected primary hyperaldosteronism. An abdominal CT scan was obtained that showed no LEARNING OBJECTIVES: 1. Recognize that valporic acid may stimulate HIV replication. adrenal enlargement or asymmetry. An MRI found no hyperplasia or masses. The patient was 2. Recognize the drug interaction of valproic acid with anti-retroviral therapy. referred to renal, and additional testing is pending (adrenal vein sampling). CASE INFORMATION: A 53 year-old man with a history of traumatic intra-cerebral IMPLICATIONS/DISCUSSION: In the outpatient setting, hypokalemia may be discovered hemorrhage was diagnosed with HIV/AIDS. His initial CD4 count was 180; his HIV viral load on routine labs in asymptomatic patients or may present with weakness, muscle cramps or was 144,000 copies. He was started on Combivir and Nelfinavir with rapid improvement in CD4 arrythmias. Patients should be asked about the presence of emesis, diarrhea, diuretic, , count to 228 and decline in his viral load to undetectable. A recurrence of his complex partial or NSAID use, and alcohol abuse. An elevated urine K+ level indicates renal rather than GI seizures prompted therapy with valproic acid. The dose of valproic acid was gradually increased losses. On exam, an elevated blood pressure differentiates hyperaldosterone states from other over eighteen months to a dose of 2250 mg/day. During this period, the patient's CD4 count conditions such as RTA, , Bartter's and Gitelman's syndromes. In this was stable and his viral load remained undectectable. However, further increases in valproic acid case, hyperaldosteronism was suspected because of the patient's hypertension, hypokalemia and were necessary due to incomplete control of seizures. Within 2 months of increasing the dose to . Hypertensive patients with otherwise unexplained hypokalemia should be 4500 mg/day, his viral load increased to 90,000 copies and then, one month later, to 240,000 worked up for primary hyperaldosteronism. Other patients in whom the diagnosis should be copies. The dose of valproic acid was decreased to 3000 mg/day. His viral load declined to 883 pursued include those with severe or resistant hypertension. The workup includes a serum copies. During this period of 48 months, he was continuously taking Combivir and Nelfinavir aldosterone/plasma renin activity ratio and a 24 hour urine aldosterone level. Primary and compliance was confirmed by computerized record keeping of refill requests. hyperaldosteronism is caused by adrenal hyperplasia in about 70% of the cases, adrenal IMPLICATIONS/DISCUSSION: Valproic acid accelerates the cytochrome P450 system, adenoma in 30% and rarely by adrenal carcinoma. CT scan or MRI of the abdomen is needed establishing a potential for reducing other drugs metabolized through this pathway. to exclude adenomas, which are treated with surgical resection. Hyperplasia is treated with Subtherapeutic levels of Aanti-retroviral medications can result. Valproic acid has also been spironolactone. In this patient, additional testing (adrenal vein sampling to measure demonstrated in in vitro studies to stimulate HIV replication in a dose-dependent fashion, aldosterone) may help distinguish between hyperplasia and adenoma. Sampling is helpful if independent of other drugs. The concentration noted to stimulate HIV replication is within the there is no adrenal abnormality on imaging. range used for normal seizure prophylaxis. Due to intracerebral infections, seizures are common in patients with HIV. Valproic acid should be used with caution in HIV-infected individuals until the clinical significance of the interaction between valproic acid and HIV-infection is THE POTATO DIET. S. Agresta1, U. Manhare1; 1Tulane University, New Orleans, LA determined. HIV viral load should be followed closely with any changes in valproic acid dosing. (Tracking ID #76992)

LEARNING OBJECTIVES: 1. Understand the three components of coagulation. 2. GOT MILK! (COPE'S SYNDROME). M.W. Martinez1, K.G. Lim1; 1Mayo Clinic, Rochester, MN Recognize the signs of vitamin C deficiency. (Tracking ID #76172) CASE INFORMATION: A 28 year-old obese woman presented with six weeks of lower extremity edema, ecchymosis and a petechial rash. The lesions progressed from one-millimeter LEARNING OBJECTIVES: This case report illustrates a rare diagnosis and an often petechial lesions to a confluent ecchymosis. She also noted a history of bleeding gums. There overlooked complication of a benign therapy. Prompt diagnosis is essential to preventing long was no history of trauma, heavy menstrual bleeding, transfusions, or a family history of term sequelae. bleeding disorders. She used no drugs or alcohol; her diet was limited to meat and boiled CASE INFORMATION: A fifty-four-year-old man presented with nausea and vomiting for potatoes. Her heart rate was 110; blood pressure 110/65; temperature 38.2 C. Her conjunctiva one month. He was having more than five non-bloody emeses per day, often within 10 minutes of were pale; her gums were erythematous. A non-blanching palpable ecchymosis extended from eating. Emesis was not always associated with eating. He stated that he was unable to keep down her buttocks to her left posterior thigh and calf. There were perifollicular hemorrhages and any food. He denied fevers, chills, rigors, or night sweats. He described low-grade headaches edema of both lower extremities. The platelet count, PT and PTT were normal. Her vitamin C with associated tinnitus, an 18-pound weight loss and generalized weakness with increased level was 0.1 mg/dL (normal >1 mg/dl). She was started on daily vitamin C and multivitamin somnolence as well as new onset erectile dysfunction. He complained of intermittent epigastric supplements. The ecchymosis resolved after one week of therapy. abdominal pain, and had had a previous laparotomy for abdominal pain approximately five years IMPLICATIONS/DISCUSSION: There are three components to hemostasis: platelets, ago. He is a lifetime non-smoker and denied taking any medications. Evaluation revealed total coagulation factors, and vasospasm. Vasospasm depends upon vessel integrity, which in calcium of 16.6 with ionized calcium of 7.7 and a creatinine of 4.9. Unenhanced CT revealed a turn depends upon adequate collagen synthesis. Vitamin C is a cofactor in collagen formation band of calcification in the midline of the anterior abdominal wall measuring approximately 6 cm important for normal blood vessel integrity. Cutaneous and gingival hemorrhages result from in length and 1.4 cm in diameter. In addition, there were numerous small mesenteric and fragile blood vessels; gingival hemorrhage occurs only in those with teeth. Perifollicular retroperitoneal lymph nodes along with a 1cm node in the suprapubic anterior abdominal tissue. hemorrhages result from malformed hairs causing hemorrhages within the follicle. Symptoms He had a tiny stone in the left kidney and all the bones were noted to be hyperdense. His may develop as early as three months after decreased vitamin C intake. The cost-effective hemoglobin was 11.7 with a normal peripheral smear, erythrocyte sedimentation elevated at 38. evaluation of a bleeding diathesis should begin with an evaluation of coagulation factors (PT, B12/folate, LDH and T- and B cell surface markers were normal. PTH-RP was non-detectable PTT) and the platelet count. If these are normal, platelet function (bleeding time) and and PTH was appropriately suppressed. He was treated with IV fluids, furosemide and disorders of vascular integrity should be investigated. A careful dietary history should include pamidronate, with normalization of his calcium at time of dismissal. Upon further questioning, the types and methods of food preparation, as boiling can destroy vitamins. As in this case, this discovered that he was ingesting 6 to 7 grams of calcium per day for the last 20 years. history may increase the pre-test probability for vitamin deficiency, and expedite the diagnosis. IMPLICATIONS/DISCUSSION: These findings were consistent with milk-alkali syndrome. Other vitamin deficiencies should be evaluated or empirically treated. Importantly, obesity The recent emphasis on calcium therapy for prevention of osteoporosis and the availability of does not exclude . calcium carbonate has made milk-alkali syndrome the third leading cause of hypercalcemia. JGIM Volume 18, April (supplement 1) 2003 73

This presentation is consistent with the subacute form of milk-alkali syndrome referred to as IMPLICATIONS/DISCUSSION: The incidence of tuberculous lymphadenitis (2±5% of Cope's Syndrome. These patients are exposed intermittently for many years and present with tuberculosis cases) is increasing amongst the homeless and immigrant populations, accounting for symptoms of both acute and chronic hypercalcemia. This patient responded to therapy and his 31% of extra-pulmonary tuberculosis cases in the United States. This case demonstrates a creatinine remained minimally elevated at 1.8 at a six-month follow-up visit. particular vulnerability in caring for underserved populations. Although this patient's initial smearswerenegative,hisculturesultimatelyturnedpositive.Thisphenomenonisnotuncommon; cultures may turn positive up to eight weeks after smear negative AFB stains. Because of his homelessness, he was lost to the medical system, and was unable to be notified by public health officials. The course of tuberculous lymphadenitis exacerbated the problem: scrofulusually presents as a painless neck mass. Its progression is indolent and without constitutional symptoms; HIV positive patients may be symptomatic two to twelve months prior to diagnosis. Integrating the patient's social needs is an important step in preventing complications from disease.

EOSINOPHILIC GASTROENTERITIS. T. Mason1, A. Andablo1; 1Cook County Hospital, Chicago, IL (Tracking ID #76966)

LEARNING OBJECTIVES: 1. Understand the importance of eosinophilia in the differential diagnosis of gastroenteritis. 2. Recognize the clinical presentation, diagnosis and treatment of eosinoiphilic gastroenteritis CASE INFORMATION: A 38-year-old female with a history of ``anemia'' presented to the emergency department after three weeks of intractable nausea, vomiting, diarrhea and abdominal cramps. She denied fever, chills, cough, headache, or dysuria. She had no recent travel history and denied alcohol and drug use and was employed as a nurse. On physical exam the patient was afebrile and tachycardic. Abdominal exam was remarkable for distension, left lower quadrant pain on palpation, and shifting dullness. Laboratory findings included a serum WBC count of 18 with a differential of 30% polys, 11% lymphs and 55% eosinophils. Stool for ova and parasites, and clostridium difficile, was negative. CT scan of the abdomen confirmed a moderate amount of peritoneal fluid, with thickened stomach and small bowel wall. Peritoneal fluid revealed WBC count of 1,920 with a differential of 3 %polys, 12% lymphs, and 85% eosinophils. Colonoscopy with cecal and ascending colon biopsies along with EGD, with biopsies demonstrated severe chronic inflammatory tissue involving the serosal layer with eosinophilia consistent with eosinophilic gastroenteritis. The patient was then started on oral steroids with progressive resolution of symptoms. IMPLICATIONS/DISCUSSION: Eosinophilic gastroenteritis (EG) is characterized by tissue eosinophilia that can involve different layers of the gut wall. The term, however is a misnomer; the disease may involve any area of the gastrointestinal (GI) tract, from the esophagus to the rectum. The cause of EG is unknown and the pathogenesis is poorly understood. Recent data suggest that in EG eosinophils may directly damage the GI tract wall. The most prevalent form involves the mucosal and submucosal layers; symptoms typically include colicky abdominal A FIFTY-SEVEN YEAR OLD FEMALE PRESENTING WITH AGRAPHIA FROM pain, nausea, vomiting and diarrhea. Patients with muscular layer disease typically present with 1 1 1 CEREBRAL EMBOLISM OF UNUSUAL ETIOLOGY. E. Martorell , P. Abraham ; Mayo pyloric or intestinal obstruction. The rarest form is serosal layer disease; the entire bowel wall Clinic, Jacksonville, FL (Tracking ID #75540) is usually involved, and these patients typically present with eosinophilic ascites. The diagnosis LEARNING OBJECTIVES: 1) To describe an unique presentation of a cardiac myxoma. is made based on clinical presentation, characteristic lab findings and with biopsy. Peripheral 2) To recognize cardiac myxomas in the differential diagnosis of acute embolic cerebrovascular eosinophilia is found in approximately 80% of cases. In all cases, stool studies must be done to accident in adult patients. 3) To assess, diagnose and manage cardiac myxomas early in order to rule out parasitic infestation. The treatment of EG is dependent on the bowel layer involved. In prevent potential mortality and morbidity. patients with mucosal layer disease it is reasonable to attempt dietary manipulation, a trial of CASE INFORMATION: A 57-year-old right-handed woman presented to the emergency sequential elimination of milk beef, eggs, and gluten can be tried. Steroids are the mainstay of department with a three-hour history of new onset writing difficulty without additional therapy in patients who fail to respond to dietary manipulation and for those with obstructive symptoms. On physical exam her vitals were normal except for an elevated blood pressure of symptoms or eosinophilic ascites. 156/73. Her head, eye, mouth, neck, skin, cardiovascular and pulmonary examinations were 1 unremarkable. Her neurological examination was completely unremarkable with the exception MINIMAL SYMPTOMS IN BILATERAL SADDLE PULMONARY EMBOLI. U. Mason , 1 1 1 of a mild impairment of finger to thumb movements (apraxia) on the right hand. She was able J. Brinckerhoff , J. Fisher ; University of Colorado Health Sciences Center, Denver, CO to write her own thoughts, but had difficulty due to significant agraphia. MRI demonstrated (Tracking ID #76175) multiple acute and sub-acute ischemic as well as hemorrhagic lesions without surrounding LEARNING OBJECTIVES: 1) Recognize the presentations of pulmonary emboli. 2) edema. Electrocardiogram and chest films were normal. Baseline CBC, coagulation studies, Emphasize the value of a high clinical index of suspicion. chemistry studies and rheumatologic serologies were within normal limits. Carotid duplex CASE INFORMATION: A 34 year old male with bipolar disorder was admitted complaining showed mild stenosis of the carotid arteries bilaterally. A tranesophageal echocardiogram of dyspnea with minimal exertion (walking 20 feet) for one week. He denied a URI, chest pain, revealed a large multilobulated, motile left atrial mass affixed via a stalk to the left interatrial syncope or shortness of breath at rest. The patient's blood pressure was 109/64, heart rate 88, septum consistent with atrial myxoma. The patient subsequently underwent urgent respiratory rate 20, 97% saturation on room air. He was in no acute distress and his lungs were thoracotomy. A mucinous dark red polypoidgelatinous 5cm  2cm  1cm mass was resected clear. He had no abdominal tenderness and no lower extremity edema or pain. Laboratory from the left atrium. Biopsy revealed a benign cardiac atrial myxoma. The patient remained revealed a normal CBC. His serum CO2 was slightly decreased at 19 and an anion gap elevated neurologically stable and was discharged home on day #10. at 19. His INR was 1.14 with PTT of 36.5. EKG revealed sinus tachycardia with a rate of 104, IMPLICATIONS/DISCUSSION: Myxomas are twice as common in women as in men and normal axis and T-wave inversions in V1-V6. Chest radiograph revealed hyperexpansion with most frequently develop between the third and sixth decades of life. About 1% of ischemic enlarged pulmonary arteries. High resolution CT scan demonstrated bilateral saddle strokes in young people are caused by atrial myxomas. Although embolic complications from pulmonary emboli. Doppler evaluation of lower extremities revealed a new right DVT in myxoma most often affect the brain in more than two third of cases, our patient is unique his distal superficial femoral vein. V/Q scan revealed multiple clots in both lung fields. The because of her mild, single neurological deficit and absence of the typical presenting signs and patient's echocardiogram was consistent with elevated RV pressure and hypertrophy of the symptoms characteristic of this tumor such as obstructive cardiac signs (54±95%) and right ventricle, indicating chronicity of his elevated pressures. The patient was treated with constitutional symptoms (90%). Systemic emboli occurs in 10±45% of myxoma patients. heparin. An IVC filter was placed on day #2 because of large clot burden and concern for Cardiac myxoma should always be considered in the differential diagnosis of embolic stroke in further pulmonary emboli. Given his right ventricular hypertrophy and likelihood of future adult patients because rapid diagnosis allows curative surgical resection and prevents further pulmonary emboli, the patient was discharged on life-long therapy with coumadin. morbidity and mortality. IMPLICATIONS/DISCUSSION: The incidence of pulmonary emboli in the US approximates 400,000 cases a year, with another 800,000 cases remaining undiagnosed. In one large series of A PREVENTABLE CASE OF SCROFULA. C. Mason1, J. Wiese1; 1Tulane University, New patients with no pre-existing pulmonary disease, the incidence of dyspnea was 73%, pleuritic Orleans, LA (Tracking ID #77012) chest pain 66%, cough 37%, tachypnea 70%, tachycardia 30% and rales 51%. Laboratory, EKG and CXR findings are routinely nonspecific. The untreated mortality for PE is ~30%, while the LEARNING OBJECTIVES: 1. Diagnose extra-pulmonary tuberculosis. 2. Integrate the mortality in treated cases ranges from 2 to 8%. It is imperative that clinicians maintain a high patient's social needs in follow-up evaluation. index of suspicion for pulmonary emboli when evaluating the patient with dyspnea. CASE INFORMATION: A 35-year-old HIV-positive homeless man presented with five days of a painful, actively draining left posterior cervical neck mass. He reported associated fevers, ALOPECIA FOR THE INTERNIST. J.A. Maughan1, A.G. Gomez1; 1University of California, night sweats, and malaise but no weight loss or hemoptysis. He first noted the six cm mass four Los Angeles, Sepulveda, CA (Tracking ID #75139) months earlier following a protracted (two month) febrile, respiratory illness. Pulmonary tuberculosis had been considered at the beginning of his symptoms, but excluded based upon LEARNING OBJECTIVES: 1) Recognize diffuse nonscarring alopecia as a presentation of sputum negative AFB smears. A fine needle aspiration (FNA) was performed that revealed systemic disease. suppurative necrotizing lymphadenitis. AFB smears and culture of the aspirate were positive for 2. Identify various categories of hair loss, including diffuse and nonscarring alopecia; focal and Mycobacterium tuberculosis. He was started on rifabutin, isoniazid, pyrizinamide, and nonscarring alopecia; and scarring alopecia. ethambutol and showed improvement. 3) Recognize the subtypes of alopecia that merit prompt referral to dermatology. 74 Abstracts JGIM

CASE INFORMATION: A 38 year old woman hospitalized for alcoholic hepatitis 5 months menopause: black chosh and soy±category 2, because the evidence supports safety and possibly prior presented with diffuse scalp hair loss over 2 months. She acknowledged diffuse joint efficacy; Dong quai, evening primrose oil, red clover, vit E, acupuncture±category 3, because pains, thirty-pound unintentional weight loss, increasingly brittle hair and nails, and a four- evidence on efficacy is inconclusive but likely safe. We would advise regular exercise and good month period of amenorrhea. She denied a butterfly facial rash, pleuritic pain, oral ulcers, nutrition to promote overall health and calcium and vitamin D supplements. Thus far, there photosensitivity, Raynaud's phenomenon, or seizures. She also denied insomnia, heat or cold are no CAM therapies that we would recommend strongly for treatment of menopause. intolerance, changes in bowel habits, or tremors. Additionally, she denied poor nutrition or use References: 1 Kronenberg F. Complementary and alternative medicine for menopausal of herbal supplements. Physical examination demonstrated diffuse thinning of terminal hairs symptoms: a review of randomized, controlled trials. Ann Intern Med. 2002. 137 (10) 805-813. throughout the scalp. The hair loss included the anterior hairline and was not localized to the 2. Weigner WA. Advising patients who seek complementary and alternative medical therapies crown or the temples. Five telogen stage hairs were dislodged on hair pull test. Absent were: for cancer. Ann Intern Med. 2002. 137(11) 889-903. malar or discoid rash, perilimbic injection, oral ulcers or Wicke's striae, joint swelling, hirsutism, acne, loss of lateral third of eyebrows, tremors, thyromegaly, nail changes, skin lesions or other BECHET'S DISEASE PRESENTING AS INFLAMMATORY BOWEL DISEASE. rashes. Lab results revealed Hgb 12.8 g/dL, Hct 38.1 %, plt 180 k/uL, Na 136 mmol/L, K 3.8 R. Mediwala1, E. Warm1; 1University of Cincinnati, Cincinnati, OH (Tracking ID #73969) mmol/L, Cr 0.8 mg/dL, glucose 76 mg/dL, ALT 24 u/L, TSH 1.37 uIU/mL, ANA negative, RPR and MHA-TP negative. An HIV test was negative. After an initial evaluation in primary LEARNING OBJECTIVES: 1. Differentiate and diagnose the gastrointestinal manifestations care clinic, pt was referred to dermatology. The dermatologist diagnosed Telogen Effluvium of Bechet's disease versus inflammatory bowel disease. 2. Manage the gastrointestinal secondary to stress from her prior hospitalization for alcoholic withdrawal. Three months later, manifestations of Bechet's disease. the patient had regained her former hair density without medications or other interventions. CASE INFORMATION: Bechet's disease is a rare inflammatory disease diagnosed by IMPLICATIONS/DISCUSSION: A patient may first present with ``hair loss'' to the internist. syndromic classification. The pathological enteral manifestations may be indistinguishable from Physical examination will demonstrate either localized or diffuse, scarring or non-scarring inflammatory bowel disease. We report a case of Bechet's initially diagnosed as . alopecia. Any patient with scarring alopecia or focal nonscarring alopecia warrants prompt A 34 year old African American man with a past medical history of deep venous thrombosis, referral to dermatology. oral aphthous ulcers, and biopsy of the colon for rectal bleeding consistent with inflammatory In cases of nonscarring alopecia such as ours, the disorder is often a presenting symptom of bowel disease presented for new onset genital ulcerations. These multiple, painful, shallow systemic disease. The differential diagnosis includes thyroid abnormalities (both hypo and ulcerations had been occurring over the last two months. The lesions were 1±2 cm in diameter, hyperthyroid), systemic lupus erythematosis, nutritional deficiencies, anemia, syphilis, HIV, located in on the scrotum and the penile shaft, and would resolve over 5±10 days with some telogen effluvium, alopecia areata, and androgenetic alopecia. Only when history, physical, and scarring. No history of sexually transmitted diseases, or recent sexual contacts was elicited. laboratory evaluation rule out a systemic disease is a referral to dermatology warranted. Our Viral cultures from the lesions were negative. He denied symptoms of diarrhea or melena. He case was diagnosed as Telogen Effluvium. Physiological or emotional stress can precipitate did complain of painful oral ulcers first noticed one year ago. During the course of his early entry of hairs into telogen, or shedding, phase. The patient usually sheds these hairs hospitalization, it was noted that he developed erythema at the sites of blood draws. Given all approximately 2 to 5 months after the precipitating event. Telogen Effluvium is a self-limited of these findings the patient was diagnosed with Bechet's disease. and reversible disorder. Patient education and reassurance are mainstays of treatment. IMPLICATIONS/DISCUSSION: Bechet's disease is a clinical diagnosis based on a history of recurrent oral ulcerations and two other criteria that may include recurrent genital ulceration, eye lesions, skin lesions, and pathergy. Patients with Bechet's are also more prone to deep DIAGNOSIS AND TREATMENT OF PULMONARY EMBOLISM VIA AN INTERNET CAFE. venous thrombosis secondary to activation of platelets and endothelial cells. In fact, between 7 M.E. Mayer1, G. Kaur1; 1Cleveland Clinic Foundation, Cleveland, OH (Tracking ID #74387) and 38% of patients have large venous or arterial lesions. The histologic manifestations of Bechet's are similar to that of inflammatory bowel disease and must be distinguished by the LEARNING OBJECTIVES: To recognize that email from a patient, though not ideally other clinical features of Bechet's, including pathergy. Interestingly, the enteric manifestations suited to urgent communication, may require heightened awareness and decisive action. To of Bechet's are currently treated with the same regimen as a patient with inflammatory bowel demonstrate this point, we describe diagnosis and treatment of a life-threatening pulmonary disease, but further research is needed for more effective and targeted treatment. This case embolism (PE) in a patient travelling in a remote area, using email as a communication tool. underscores the need to keep alternate diagnoses in mind for patients diagnosed with an CASE INFORMATION: A 53 year old man developed left leg tightness after a flight to Costa inflammatory bowel disease, especially those who present with recurrent mucosal ulcerations. Rica. Three days later, he developed shortness of breath and had a syncopal spell in a mountain rainforest. He was taken to a local hospital, and reports having had cardiac enzymes drawn, and having been released the next day. He described his symptoms, including ongoing shortness of ADULT POLYCYSTIC PRESENTING WITH A RUPTURED 1 1 1 breath, in an email to his physician (MM) from an ``Internet Cafe'' the following day. I advised CEREBRAL ANEURYSM. C. Meier , L. Coberly ; University of Cincinnati, Cincinnati, he obtain a leg ultrasound and/or lung scan to check for deep vein thrombosis (DVT) and/or OH (Tracking ID #75961) PE. He replied that he was unable to get these tests (hospital ultrasound technician was away LEARNING OBJECTIVES: -to recognize the connection between cerebral aneurysms and for a week). I advised that he self-administer low molecular weight heparin (LMWH) if Polycystic Kidney Disease -to become aware of screeing recomendations and modalities for available, and specified dosage. He was able to obtain 2 days' doses of fraxaparin, then cerebral aneurysms in patients with Adult Polycystic Kidney Disease enoxaparin on the day he departed for the U.S. On arrival to the U.S., he went to our CASE INFORMATION: A 43-year-old African American male with a negative past medical emergency department, where a lung scan verified multiple bilateral pulmonary emboli. He history except for hypertension was admitted with a subarachnoid hemorrhage. Cerebral was hospitalized and placed on heparin and warfarin, until his INR was therapeutic. He angiography revealed an aneurysm of the left posterior communicating artery. On physical exam, reported having felt less short of breath over the three days after beginning LMWH in Costa bilateral palpable abdominal masses were discovered. Laboratory studies revealed a BUN of 40 Rica. He was told that his oxygen saturation was 80% when hospitalized in Costa Rica, 89% mg/dL and a creatinine of 3.2 mg/dL. A renal ultrasound showed massively enlarged kidneys after heparin overnight there (unfortunately, he was released after a day with no further with multiple cystic areas consistent with advanced Adult Polycystic Kidney Disease. The patient treatment, until he obtained the LMWH). His oxygen saturation was 94% on presentation to had no prior history of kidney disease. His father, on the other hand, died of an unknown kidney our hospital, three days into self-administered LMWH therapy. disease in his mid-forties. Several paternal aunts and uncles also suffered of kidney disease. IMPLICATIONS/DISCUSSION: DVT and PE are known potential consequences of air IMPLICATIONS/DISCUSSION: Adult Polycystic Kidney Disease is inherited in an travel, with long flights conferring greater risk. Access to diagnosis in remote areas may be poor. autosomal dominant pattern. Progressive growth of cysts in both kidneys frequently leads to The current vignette describes the use of email from an ``Internet Cafe'' a continent away, with renal failure. Screening of individuals with a positive family history of APKD is with renal effective doctor-patient communication, resulting in ``cyber-diagnosis'' and treatment. This ultrasound or CT. Cerebral aneurysms are an extrarenal complication of APKD, with rupture underscores the importance of empiric treatment of PE while awaiting diagnostic testing, and causing 11% of deaths in theses patients. The prevalence of cerebral aneurysms increases with demonstrates the value of the Internet as a communication medium for medical care. age, averaging around 10% in this population. Patients with a family history of subarachnoid hemorrhage or cerebral aneurysm are at greatest risk. In one study, asymptomatic cerebral MENOPAUSE: ADVISING PATIENTS ON COMPLEMENTARY AND ALTERNATIVE (CAM) aneurysms were found in 22% of patients with a family history, versus 5% of patients with no THERAPIES. A. McCaffrey1; 1Harvard Medical School, Boston, MA (Tracking ID #74947) family history. Risk of rupture increases with size of the aneurysm and with location in the posterior circulation, with values ranging from 0.5 to 4% per year. As the size of the aneurysm LEARNING OBJECTIVES: 1. Review evidence of CAM for menopause. 2. How to advise is directly related to age, it is rare to detect an aneurysm in patients younger than age 30. patients on CAM for menopause. Magnetic Resonance angiography is the recommended method of screening. APKD should be CASE INFORMATION: A 59 year-old woman asks ``is there anything natural I can take for considered in patients with a strong family history of renal disease. Screening for cerebral menopause?'' She reports hot flashes up to 5 times a day, insomnia, and fatigue. She had been aneurysms in patients with APKD is controversial. Many investigators recommend screening using HRT for 4 years, but recently stopped due to concerns about the long term effects. She after the age of 30. Other authors recommend screening only for patients with a family history had good relief while on HRT, but now her hot flashes and sleep problems have recurred. A of cerebral aneurysms. Recommended screening intervals vary from every 3 to every 10 years. friend advised her to take a combination of black cohosh, vit E, and dong quai. She has a past medical history of HTN. She is not currently taking any medicines, and has no known TRANSIENT MYOCARDIAL DYSFUNCTION IN A 20 YEAR OLD PATIENT WITH TOXIC allergies. She is a non-smoker, and drinks 2 glasses of wine per week. On physical exam, she is a SHOCK SYNDROME. M. Mendiola1, S. Davies1, S. Goldsmith1, D. Williams1; 1Hennepin thin, white woman; the rest of her exam is normal. County Medical Center, Minneapolis, MN (Tracking ID #76855) IMPLICATIONS/DISCUSSION: In July 2002, results from the Women's Health Initiative revealed that the overall risks of long-term estrogen with progestin outweigh the benefits. LEARNING OBJECTIVES: 1. Transient myocardial dysfunction has been described in many According to these results, estrogen with progestin increases the risk of cardiovascular disease, non-cardiac illnesses, including sepsis, subarachnoid hemmorhage (SAH), Acute Respiratory blood clots, and breast cancer. The US Preventive Services Task Force now recommends Distress Syndrome (ARDS), and and post operatively in non cardiac patients. 2. Mechanisms against the use of estrogen and progestin for the prevention of chronic conditions in include oxygen supply and demand mismatch, circulating myocardial depressants, and calcium postmenopausal women. Women are turning to CAM for relief of menopausal symptoms; last overload secondary to catecholamine surges. 3. Resolution is usually complete over ten to year the sales for OTC menopause remedies reached $100 million. A recent meta-analysis (1) fourteen days, but elevated troponins may be a predictor of imcomplete recovery. reviewed existing evidence of CAM for menopause. Using a guide on how to discuss CAM CASE INFORMATION: The patient is a 20 year old previously healthy college student who therapies with patients [scale: 1 recommend, 2 accept and consider recommending, 3 accept presented to the emergency department with a three day history of increasing myalgias, sore but do not recommend and, 4 discourage] (2), we rate the following CAM therapies for throat, and diffuse erythematous rash with of her finger tips. She rapidly JGIM Volume 18, April (supplement 1) 2003 75

developed multi system organ failure, and required temporary mechanical ventilation, CPK and creatinine. Imaging studies are most helpful in type one, where gas formation occurs. continuous veno-venous hemodialysis, and high doses of three pressors for blood pressure MRI may overestimate deep tissue involvement. Thus, the only way to make a definitive diagnosis support. We had high clinical suspicion for toxic shock syndrome, which was later confirmed by is via surgical exploration. Surgery is indicated for severe pain, toxicity, fever and elevated CPK. positive TSST-1 antigen. On hospital day #3, she developed a wide complex tachycardia. Her Early surgery may improve the outcome, but mortality rates are high even in cases of optimal ejection fraction was estimated at 15±20% by echocardiogram. Serial troponins peaked at 33.3. therapy. Repeat explorations and debridement should be performed until all necrotic tissue has By the time of discharge, 2 1/2 weeks later, her ejection fraction had increased to 34±40%. Her been removed. Additional therapies include antibiotics and intravenous immune globulin. ejection fraction was 30% at four weeks, and 30% at 4 months after initial presentation. She is maintained on a beta blocker, and an agiotensin converting enzyme inhibitor. NON-HODGKIN'S LYMPHOMA PRESENTING AS FLANK PAIN. K.Y. Miskel1; 1Hospital of IMPLICATIONS/DISCUSSION: Transient myocardial dysfunction has been described in a the University of Pennsylvania, Philadelphia, PA (Tracking ID #73961) multitude of non-cardiac illnesses, including subarachnoid hemmorage (SAH), Acute Respiratory Distress Syndrome (ARDS), trauma, sepsis, and post operatively in non-cardiac LEARNING OBJECTIVES: 1) Recognize an atypical presentation of lymphoma surgical patients. It is a common complication of sepsis. A variety of non-coronary artery 2) Recognize that systemic non-Hodgkin's lymphoma is a common HIV-related malignancy related mechanisms have been proposed, icluding oxygen supply and demand mismatch, CASE INFORMATION: A 33 year old healthy male with no significant past medical history circulation of various myocardial depressants such as cytokines, and high catecholamine surges presented with three weeks of bilateral flank pain. His flank pain was intermittent but had leading to calcium overload. While transient myocardial dysfunction has been described in progressively worsened, with radiation to his groin. The pain was associated with movement. both ARDS and severe sepsis, there is only one other case report in the literature specifically He denied fevers/chills, nausea/vomiting, dysuria, or hematuria. Social history was negative for related to toxic shock syndrome. The usual course of sepsis-related myocardial dysfunction is tobacco, alcohol, or illicit drugs. He was homosexual and involved in a long-term monogamous complete resolution over ten to fourteen days. The fact that this patient had an elevation in relationship. He had a family history of nephrolithiasis. On initial exam, he was afebrile with a troponin, and that she still had a depressed ejection fraction four months after presentation, benign abdominal exam, no costovertebral angle tenderness, a normal rectal exam, and guiac suggests that she may have experienced some degree of ischemic myocardial injury. The negative stool. A urinalysis was significant for +++blood and no leukocyte esterase or protein. magnitude of the persistence of the myocardial insult attests to thd dangers of toxic shock An abdominal xray showed a normal bowel gas pattern with no renal calculi. He was presumed syndrome, even in patients who recover from the acute sepsis and respiratory failure. to have radiolucent nephrolithiasis and was advised to follow-up closely. Five days later, he presented to the emergency room with unremitting flank pain, new suprapubic pain, dysuria and fevers to 103±104 F. His only medications were ibuprofen and percocet (prescribed NATURE'S JEST: DYSPHAGIA LUSORIA. J. Messler (PY)1; 1Emory University (PY), recently for his flank pain). On exam, he appeared uncomfortable, had a T 99.2 F, oral thrush, Atlanta, GA (Tracking ID #75862) and bilateral cervical/axillary lymphadenopathy. His abdomen was soft, mildly distended, and LEARNING OBJECTIVES: Objectives 1. To identify the symptoms and signs of subclavian diffusely tender to palpation, particularly in the suprapubic area. He had scattered papules with steal syndrome 2. To appreciate the disorder of dysphagia lusoria and an aberrant subclavian central umbilication on his face, buttocks, and thighs. Laboratory studies were significant for a artery WBC 5.6, hemoglobin 11.9, creatinine 2.6, AST 124, ALT 158, alkaline phosphatase 627, and CASE INFORMATION: CASE: A 52 year old homeless male presents with multiple total bilirubin 1.5. Abdominal CT scan showed bulky retroperitoneal and pelvic lymphadeno- complaints. He last saw a doctor ten years ago. His main complaints include right hand pathy, bilateral , and a circumferentially thickened bladder wall. Bone marrow numbness and weakness, particularly while he's working. Additionally, he reports occasional biopsy and bladder wall biopsy confirmed the diagnosis of stage IV immunoblastic non- dizziness and headaches. On further review of systems, he describes claudication symptoms, Hodgkin's lymphoma involving the bone marrow, GI tract, liver, spleen, and bladder. HIV was difficulty swallowing, especially solid foods, but denies weight loss. His past medical history positive with a CD4 count of 138 and a viral load of >500,000. includes diabetes and hypertension. However, he last received medications over ten years ago. IMPLICATIONS/DISCUSSION: Non-Hodgkin's lymphoma occurs in 10-30% of AIDS He does drink alcohol daily and smokes cigarettes. On exam, his blood pressure reads 150/100 patients, the most common type being high-grade diffuse large B cell (immunoblastic variant) in the left arm and 130/70 in the right arm. His heart rate is 76, respiratory rate is 6, and he is or Burkitt's-like. Patients usually present with stage IV disease and frequently have afebrile. Significant findings on exam include right carotid, right subclavian, and right and left involvement of the bone marrow, CNS, liver, and gastrointestinal tract. Although HIV femoral bruits. He also has diminished pulses in the right radial and right brachial arteries, as associated systemic lymphoma frequently presents with rapid nodal enlargement and B well as decreased pulses in his feet. An EKG suggests enlarged left ventricle hypertrophy. He symptoms, it has no pathognomonic features. This previously healthy male had HIV risk eventually received an angiogram, specifically to see if his subclavian bruits and right hand factors as well as molluscum contagiosum and oral thrush that suggested the diagnosis of HIV symptoms were significant. His right subclavian artery was aberrant and appeared to wrap infection. In addition to chemotherapy, immune reconsitution with highly active anti-retroviral behind his esophagus. He also had a severe stenosis of his right subclavian artery proximal to would be necessary for effective treatment. the right vertebral take-off. Furthermore, an exam of the lower extremities revealed severe stenosis in his right iliac artery that received angioplasty. Given the stenosis on angiogram and ALPHA-INTERFERON THERAPY AND DELIRIUM. D. Misra1, S. Young1, C. Schleupner1; evidence of flow-reversal, it appeared that subclavian steal syndrome accounted for several of 1New Hanover Regional Medical Center, Wilmington, NC (Tracking ID #75477) his symptoms, such as the dizziness, headaches, right hand claudication, and exam findings. Coincidentally, the aberrant subclavian seemed to explain his symptoms of dysphagia. Although LEARNING OBJECTIVES: Recognize delirium as one of the neuro-psychiatric adverse the diagnosis of subclavian steal syndrome can be deduced by his history and exam, the aberrant effects of alpha interferon therapy. We intend to share our experience because it may pose as a subclavian was unexpected, but along with his stenosis, accounts for many of his symptoms. diagnostic challenge for clinicians. IMPLICATIONS/DISCUSSION: DISCUSSION: Subclavian stenosis can cause symptoms CASE INFORMATION: We present the case of a 57 yr old caucasian male who had previously related to subclavian steal. The vertebral artery on the side of the stenosis creates retrograde been diagnosed with malignant melanoma. He had undergone local excision and was found to blood flow from the brain stem by essentially stealing blood from the contralateral vertebral have positive lymph nodes. He was started on adjuvant alpha interferon therapy, initially at a artery. The prevalence of an aberrant right subclavian has been reported as 0.5%-2.9%. The dose of 40 million units a day which he could not tolerate primarily because of constitutional finding of dysphagia has also been reported. This is termed dysphagia lusoria, and was symptoms. His symptoms included severe arthralgias, myalgias and headaches. He received this originally described in the 18th century. It translates as jest of nature. The treatment is surgical dosage for only 4 days, which was then discontinued and subsequently started back on a reduced resection if it causes significant symptoms. dose of 20 million units a day after a drug free interval of one week. He tolerated the lower dose without any side effects. The following week, he was started back on 40 million units a day of interferon which he received for five days. Within a couple of days, pt was experiencing severe DEEP GRATIFICATION: SUCCESSFUL OUTCOME OF TYPE 2 NECROTIZING headaches along with myalgias and arthralgias. This became worse and patient presented with FASCIITIS. B. Taqui1, L. Min1, L. Kaplan1; 1Temple University, Philadelphia, PA (Tracking delirium, agitation and combativeness. He required intravenous sedation and eventually ID #75569) endotracheal intubation for airway protection. His workup including blood counts, basic LEARNING OBJECTIVES: 1. Distinguish between two types of necrotizing fasciitis 2. metabolic panel; urinalysis, drug screen, CT scan of the head and CSF examination were all Recognize clinical manifestations of necrotizing fasciitis 3. Recognize management of within normal limits. Serum transaminases were mildly elevated but this was unchanged since suspected necrotizing fasciitis the beginning of interferon treatment. His stay in the intensive care unit lasted 24 hours. The CASE INFORMATION: 59 year old African American male with history of hepatitis c and following day, he was back to his baseline cognitive level and was discharged home. right femoral deep venous thrombosis presented with one week of increasing right lower IMPLICATIONS/DISCUSSION: Alpha interferon is a glycoprotein produced by leukocytes extremity pain causing difficulty with ambulation. He also reported subjective fevers and chills. which has broad spectrum antiviral, immunologic and antiproliferative properties. Therefore, it He admitted to intravenous drug use, using his right thigh for access. His temperature was 101 is commonly used in treatment of hairy cell leukemia, hepatitis, renal cell carcinoma and malig- F, pulse 110, blood pressure 90/60. His right thigh was erythmatous, edematous and tender, nant melanoma. The spectrum of side effects is wide and depends on various factors including the with 10 Â 8 centimeter posterolateral area of fluctulance. The rest of the exam was dose of the drug, age of the patient and the type of interferon. Our literature search revealed very unremarkable. Labs: WBC 50,000 (93% neutrophils), hemoglobin 7.1, CPK 104, creatinine few case reports of interferon induced delirium. Neuro-psychiatric adverse effects occur with 5.9. Blood and wound cultures were drawn. MRI showed necrotizing fascittis of posterior/lateral doses higher than 30 million units per day. The temporal relationship of the onset of delirium thigh with overlying cellulits, no osteomylelitis. Surgical exploration revealed necrotic skin and with high dose interferon treatment in our patient stands out prominently. We believe that this subcutaneous tissue extending down to muscle and fascial level, involving half the circumference occurrence should be brought to the notice of physicians prescribing interferon so that patients of thigh. Wide excisional debridement of thigh was performed. Blood and wound cultures grew presenting with neuro-psychiatric manifestations are diagnosed and managed appropriately. group A streptococcus sensitive to cefazolin. After antibiotic treatment and two subsequent debridements, the patient improved. Upon discharge, his WBC and creatinine were normal. FULMINANT HEPATIC FAILURE COMPLICATING HIGH DOSE AMIODARONE LOADING. IMPLICATIONS/DISCUSSION: There are two types of necrotizing fascittis. Type one, S. Mitz1, M. Sheffield1; 1Methodist Hospital of Dallas, Dallas, TX (Tracking ID #75995) which is caused by mixed aerobic and anaerobic bacteria, is associated with diabetes mellitus, cervical necrotizing fasciitis, and fournier's gangrene of perianal area. Type two necrotizing LEARNING OBJECTIVES: 1) Recognize the clinical features of fulminant hepatic failure. fasciitis, due to group A streptococcus, is associated with history of blunt trauma, varicella, 2) Diagnose the cause of hepatic failure. 3) Manage the complications of patients with hepatic intravenous drug use, penetrating injury and possably with nonsteroidal antiinflammatory drugs. failure. Necrotizing fasciitis should be suspected in patients with severe unexplained pain increasing over CASE INFORMATION: A 51 year-old man with an ischemic cardiomyopathy presented to time, skin changes (erythema, red-purple discoloration, blisters, bullae), fever, systemic toxicity, the emergency department after experiencing multiple shocks from his automatic implantable myalgias, diarrhea and anorexia. Lab tests show leukocytosis with marked left shift and elevated cardiac defibrillator (AICD). In the ED, the patient developed ventricular tachycardia at a rate 76 Abstracts JGIM

of 162 bpm with a BP of 132/102. His AICD began antitachycardia pacing and DC CASE INFORMATION: The patient is a 42 year-old male who ingested 90 500 mg tablets of countershocks without success. The patient was loaded with amiodarone and placed on a 2mg/ valproic acid following an argument with his wife. The exact time of ingestion was unclear, but min infusion of amiodarone. Sinus rhythm was restored. Lab values included normal liver was felt to be 6 to 8 hours prior to presentation. The patient's wife assumed that he was function tests and a creatinine of 2.1. The patient stabilized. After 24 hours, the amiodarone sleeping, but when found to be unresponsive again several hours later, he was brought to the infusion was reduced to 1 mg/min. Twelve hours later, the patient developed confusion and emergency department. On physical examination, the patient was unresponsive, hypotensive, severe dyspnea. Lasix was given without improvement. The patient developed fever, and without hyperreflexia or clonus on neurological examination. Laboratory values revealed hypotension, and became lethargic. The exam showed a quiet, tender abdomen. The HCO3 normal liver function tests, hypocalcemia, valproate level of 1157 (ref 50±150 ug/ml), and an had fallen to 6 meq/L, and the creatinine had risen to 3.2 mg/dl. The ALT was 1947 U/L, the ammonia level of 270 (ref 9±33 umol/L). The patient's electrocardiogram was notable for QT AST was 2629 U/L, the bilirubin was 4.2, and the PT was 16.9s (INR 2.8). The patient was prolongation. CT scan of the head and lumbar puncture were unremarkable. Intravenous fluids diagnosed with fulminant hepatic failure. Dopamine and a bicarbonate infusion were begun. were administered and dopamine was initiated for blood pressure support. The patient's Antibiotics were started. The patient was intubated and vitamin K was given. Amiodarone was respiratory status declined, he was unable to protect his airway and therefore intubated. considered to be a possible cause of the fulminant . Thus, 72 hours after admission, Carnitine was administered for the hyperammonemia on a daily basis. The valproic acid and the amiodarone infusion was stopped despite persistent ventricular ectopy. The patient's status ammonia levels declined over the next 48 hours and his mental status improved. He was declined and he died on the fifth day from complications from a liver biopsy. extubated after approximately 72 hours. The patient did well and was transferred to . IMPLICATIONS/DISCUSSION: Fulminant hepatic failure develops in less than 2 weeks IMPLICATIONS/DISCUSSION: Hyperammonemia results when valproic acid is metabo- after an insult to the liver. The diagnosis of liver failure should be entertained in the presence lized to propionic acid, which inhibits carbamyl phosphate synthetase, the first enzyme involved of encephalopathy associated with jaundice, coagulopathy, acidosis, fever and hypotension. In in the urea cycle. Valproic acid also binds to carnitine, a molecule important in the metabolism this patient, clinical suspicion was confirmed by the rapid change in the liver function tests. of long-chain fatty acids and ketoacid analogues of various amino acids, thereby depleting serum The viral hepatidities and drug/toxin exposure are the most common etiologies of fulminant concentrations of carnitine. Valproic acid also causes increased renal production of ammonia by liver failure. In this patient, the leading considerations were ischemic and drug/toxin exposure. reducing the synthesis of glutamine. Administration of exogenous carnitine is thought to A review of the literature revealed at least twenty fatalities from acute hepatic failure following decrease ammonia levels by binding to valproic acid, and also by relieving the inhibition of the administration of high dose parenteral amiodarone over the last twenty years. The carbamyl phosphate synthetase and thus urea synthesis. Management of valproic acid chronology of exposure and onset of hepatic failure were consistent with amiodarone induced intoxication is largely supportive. Patients who present early may benefit from gastric lavage hepatotoxicity in this patient. Regardless of the cause, the treatment of and a single dose of activated charcoal; however, multiple-dose activated charcoal does not requires removal of the exposure and supportive care for the expected complications. Despite increase the elimination of valproic acid. Other interventions may involve blood pressure aggressive support, mortality remains at 60-90% without transplantation. support with intravenous fluids and vasopressors, correction of electrolyte abnormalities, and correction of acid/base disorders (commonly an anion gap metabolic acidosis). Mechanical RECURRENT SKIN ULCERS WITH PATHERGY CAUSED BY A BROWN RECLUSE ventilation may be necessary in patients who require airway protection. In the majority of cases, SPIDER BITE. T. Mohmed1, S. elAchkar1, K. Vorenkamp1, R. Meade1, C. Treadway1, this management strategy results in favorable outcomes. Hemodialysis and charcoal R.D. Hobbs1; 1Oakwood Healthcare System, Dearborn, MI (Tracking ID #76600) hemoperfusion are additional treatment options. Typically, extracorporeal removal is employed in patients with renal abnormalities, hypotension refractory to all supportive measures, severe LEARNING OBJECTIVES: To recognize that brown recluse spider bites may cause metabolic abnormalities, active seizure, or those who are persistently comatose. However there pyoderma gangrenosum and pathergy due to persistent mediated injury. are no controlled trials that demonstrate an improvement in outcome with these measures. CASE INFORMATION: A 47 year-old woman presented with a six month history of recurrent, painful, nonpruritic ulcers on the dorsa of both wrists and the right calf. Past history 1 revealed that six months prior, while cleaning debris from an old tavern, she was bitten on the DISEASE COMMON IN THE 2ND DECADE SEEN IN THE 6TH DECADE. O.I. Nesheiwat , 1 1 1 1 1 hand by a spider. The spider was captured and identified as a brown recluse spider. Within S. Warshafsky , C. Karmen , C. Carosella , S. Peterson ; Division of General Internal hours she was ill with nausea, vomiting, malaise and fever. She improved with supportive Medicine, Department of Medicine, New York Medical College, Valhalla, NY (Tracking treatment. The lesion cleared but weeks later, began to reoccur following minor trauma such as ID #75137) that caused by mosquito bites. On physical examination we discovered pyoderma gangrenosum LEARNING OBJECTIVES: To review the causes and epidemiology of secondary like lesions that were confirmed by biopsy. Long-term therapy with dapsone was started. hypertension. IMPLICATIONS/DISCUSSION: Pyoderma Gangrenosum was first described by Brunsting CASE INFORMATION: A 65 year old female initially presented to her primary physician 5 et al in 1930. The etiology is unknown in fifty percent of the cases but associated with years ago with a blood pressure of 159/98. Repeat readings were similar and she was started on Ulcerative Colitis and Behcet's Disease. Spider bites rarely lead to pyoderma gangrenosum and hydralazine 25 mg. There was a modest effect from hydralazine, but control was never acheived. even more rarely lead to recurrent lesions and pathergy. Brown recluse venom has been Four months later hydralazine was changed to losartan 50 mg. No significant lowering was purified and studied and is known to persist in some wounds for a relatively long time. The obtained. Losartan was increased one month later to 100mg and two months later precise mechanism of the lesions is not known although neutrophil inhibitors such as nitrogen hydrochlorothiazide 25 mg was added. Her blood pressure stabalized to 140/90 for 6 months. mustard and dapsone can mitigate or prevent the reaction. The development of new lesions at Then a gradual increase in her blood pressure was noticed, so diltiazem was added. Her physical distant sites from the inciting lesion is unexplainable and suggests an immune mediated exam and lab values were unremarkable. Due to failure of multiple antihypertensive response and not a local reaction. The observed clinical response to dapsone suggests an medications,a magnetic resonance arteriogram of the renal artery was conducted which revealed ongoing neutrophil mediated injury. Currently dapsone is being carefully tapered. It is renal artery stenosis. An angiogram was conducted showing segments of stenosis and dilatation unknown if the lesions will persist and argue for a permanent ongoing cell mediated injury or of the right renal artery, consistent with the diagnosis of fibromuscular dysplasia. Renal artery cease and suggest a self limited condition as remaining venom is cleared. angioplasty was performed, and follow up blood pressure normalized on two medications. IMPLICATIONS/DISCUSSION: This is an elderly female with hypertension refractory to PLASMAPHERESIS FOR THE TREATMENT OF HYPERTRIGLYCERIDEMIA. medications. A secondary cause was sought out with an imaging study, which showed a C. Carosella1, C. Karmen1, S. Warshafsky1, Y. Murray1; 1New York Medical College, unilateral fibromuscular dysplasia of the right renal artery. It is unusual for a women in this age Valhalla, NY (Tracking ID #76460) group to present with this type of secondary hypertension. Patients with fibromuscular dysplasia respond well to angioplasty. LEARNING OBJECTIVES: To recognize the value of plasmapheresis in the treatment of triglyceride-induced . CASE INFORMATION: A 50-year-old Hispanic woman with a history of insulin-dependent HYPERVENTILATION AND SEVERE HYPOPHOSPHATEMIA IN A PATIENT WITH A diabetes mellitus, coronary artery disease and hypertriglyceridemia presented to the emergency TRACHEALTRANSPLANT T. O'Brien1, L. Coberly1; 1University of Cincinnati, Cincinnati, OH room with severe abdominal pain, nausea, vomiting and poor oral intake all gradually worsening (Tracking ID #75253) over the prior two weeks. She had been treated with a combination of atorvastatin, gemfibrozol, and niacin with only marginal success in controlling her lipid levels. Physical exam revealed an LEARNING OBJECTIVES: 1. The reader should be able to list three common causes for ill-appearing woman complaining of abdominal pain. Bowel sounds were hypoactive, and the hypophosphatemia. 2. The reader should be able to explain why phosphate repletion is abdomen was diffusely tender. The serum was grossly lipemic. Laboratory studies revealed a typically not be necessary for hypophosphatemia from respiratory alkalosis. glucose of 1321 mg/dl, amylase of 1008 mg/dl, lipase 2001 mg/dl, and triglycerides 9198 mg/dl. CASE INFORMATION: Hyperventilation can precipitate life-threatening alkalosis and CT scan of the abdomen was consistent with acute pancreatitis. Her condition rapidly severe hypophosphatemia that does not require phosphate repletion. A 36 yo female who was deteriorated with respiratory failure, requiring ventilator support, and renal failure, requiring status post cadaveric tracheal transplant and multiple stent placements presented with dialysis. She was transferred to the University Hospital for plasmapheresis. One plasmpheresis suspected stent re-stenosis, complaining of dyspnea, increased work of breathing, and inability treatment with continuous infusion of heparin lead to a substantial and sustained reduction of to clear secretions. Her respiratory rate was 30±34 with normal oxygenation. Emergent triglyceride level to less than 150 mg/dl. The patient steadily improved with decreased bronchoscopy revealed only minimally occlusive concretions, however peri-procedure labs dependence on the ventilator, increased urine output, and decreased swelling of the pancreas. revealed an arterial blood pH of 7.71 and a phosphate of 0.6 mg/dL. The patient reported Unfortunately, the patient suffered a cardiac arrest on the sixteenth hospital day. weakness and paresthesias in all four extremities plus arthralgias in her hands. The patient was IMPLICATIONS/DISCUSSION: Plasmapheresis has been used to treat hypertriglyceridemia started on a NaPO4 infusion @ 0.6 mmol/kg over 6 hrs. She was given supportive care and when adequate diet and drug therapy fail. In this case plasmapheresis was highly effective in reassurance for her hyperventilation. After only three hours, the PO4 was 3.3 mg/dL and the removingthetriglyceridesandmayhaveledtothepatient'ssteady,albeittemporary,improvement. infusion was stopped. Repeat ABG showed a pH of 7.49, with improvement in pCO2 from 14 to 27 mmHg. The patient's symptoms resolved. IMPLICATIONS/DISCUSSION: Severe hypophosphatemia, defined as a serum PO4 <1.5 HYPERAMMONEMIA IN THE ABSENCE OF HEPATIC FAILURE: VALPROIC ACID mg/dL, has been reported in 0.22±2.15% of adult hospital admissions. It occurs more commonly INTOXICATION. D. Nataraj1, J. Atwood1, R. Granieri1, J. Akhtar1; 1University of Pittsburgh, in alcoholics and malnourished patients and has a variety of causes, including respiratory Pittsburgh, PA (Tracking ID #73714) alkalosis. In respiratory alkalosis, carbon dioxide readily diffuses from the intracellular space LEARNING OBJECTIVES: (1) to recognize hyperammonemia due to acute valproic acid resulting in higher intracellular pH. This activates glycolysis and the formation of phosphate- intoxication (2) to manage hyperammonemia due to acute valproic acid intoxication by containing compounds. Phosphate is used from the circulating inorganic phosphate pool, understanding its mechanism. depleting extracellular stores. This process induces relative hypophosphatemia. This contrasts JGIM Volume 18, April (supplement 1) 2003 77

with metabolic alkalosis where excess extracellular bicarbonate is only poorly diffusible and alcohol drinking behavior. Insufficient evidence-based studies exists to guide clinicians does not significantly raise intracellular pH. Severe hypophosphatemia can be a life- regarding the optimum management of peri-operative AWS and until such time, alcohol threatening disturbance but may not represent total body phosphate depletion or require treatments will continue to be used. supplementation. An understanding of the basic physiology guides therapy.

CLINICAL CHALLENGES IN THE OBESE PATIENT. E. Ong1; 1Santa Clara Valley Medical COMPARTMENT SYNDROME: AN UNCOMMON SEQUELAE OF A COMMON Center, San Jose, CA (Tracking ID #75786) INFECTION D.M. Olkon1; 1Hennepin County Medical Center, Minneapolis, MN (Tracking ID #76457) LEARNING OBJECTIVES: To diagnose nephrotic syndrome in a diabetic. To assess the clinical complications of nephrotic syndrome. To recognize the clinical challenges of the obese LEARNING OBJECTIVES: Identify signs and symptoms of compartment syndrome patient. Recognize compartment syndrome as a possible complication of cellulitis CASE INFORMATION: A 52 year old morbidly obese male presented to his primary care CASE INFORMATION: R.H. is a 67 year old male initially seen in the emergency room five physician with four days of facial and upper extremity edema. He had developed orthopnea, days before admission for right lower extremity redness, pain and swelling. He was given pain paroxysmal nocturnal dyspnea, and dyspnea with exertion. His past medical history included medication and sent home. He returned the following day and two days later with persistent poorly controlled diabetes, chronic lower extremity edema, and untreated obstructive sleep symptoms and was given appropriate oral antibiotics for presumed cellulitis. An ultrasound apnea. An initial chest CT demonstrated pleural effusions and a soft tissue mediastinal mass showed no thrombosis. After his fourth ER visit he was admitted for intravenous antibiotics. thought to be compressing the superior vena cava. Mediastinoscopy of the mass demonstrated Additionally, over the past three months he had noted bilateral lower extremity pain with no tissue findings; a repeat chest CT, with dye injected in both arms simultaneously, revealed walking over one block. Work up to date included normal resting and exercise ankle/brachial the mass was likely lipomatosis. Further workup of the pleural effusion included an indices a CT scan of the lumbar spine, which showed disc bulges at L3-4 and L4-5 with mild unremarkable echocardiogram and an ultrasound-guided thoracentesis. The pleural effusion spinal stenosis. When we met him, he complained of severe pain despite oral narcotics and also was transudative and negative for cytology. The patient's urine revealed 3+ proteinuria and oval endorsed difficulty with his gait over the past week. On physical exam, temperature was 98.60 fat bodies, and a spot urine protein/creatinine ratio demonstrated over 4 grams of protein. and the right lower extremity had diffuse anterior erythema without distinct borders. There These findings, along with hypoalbuminemia, were consistent with nephrotic syndrome. The were no breaks in the skin but onychomycosis was present on bilateral toes. There was 2+ patient's symptoms improved with furosemide diuresis. However, the patient was rehospita- edema on the right and none on the left. Dorsalis pedis pulse was noted only by doppler on the lized a week later, complaining of acute shortness of breath. He was already known to be right, but was intact on the left. Neurologic exam revealed significant difficulty with hypoxic, probably from obstructive sleep apnea. A ventilation perfusion scan was performed, dorsiflexion of the right foot which was presumed to be secondary to pain or possibly related to and demonstrated a new lingular mismatch of intermediate probability for a pulmonary his known spinal stenosis. Labs revealed a normal white blood cell count, elevated C-reactive embolism. The patient stayed in the hospital until five days of oral coumadin overlapped with a protein, small blood in the urine with 0±5 red cells and a creatinine slightly above his baseline. heparin drip, as his obesity prevented accurate dosing of low-molecular-weight heparin. Plain radiographs were normal. Broad spectrum intravenous antibiotics, elevation and pain IMPLICATIONS/DISCUSSION: Diabetes is a common cause of nephrotic syndrome. The control were initiated at admission. After two days, the redness and swelling improved but a diagnosis can be made by quantification of urine protein excretion; oval fat bodies suggest foot drop and pain persisted. Neurology felt his foot drop could be consistent with his known hyperlipidemia from a fall in oncotic pressure and decreased clearance of very low density disc disease but also suggested surgical evaluation. Anterior compartment syndrome was lipoproteins. Clinical symptoms include peripheral edema, pleural effusions, and hypercoagul- subsequently diagnosed based on a direct compartment pressure reading of 45 mmHg. Because able conditions like pulmonary embolism. The pathophysiology of these clinical symptoms of the delay in diagnosis, the fact that pulses were present and that there was no tissue necrosis may be due to sodium retention from renal disease and hemostatic abnormalities such as or abscess seen on subsequent scanning, the decision was made not to operate. The patient's urinary loss of antithrombin III. The diagnostic workup was made more difficult for this pain and swelling gradually resolved over weeks but he was left with a permanent foot drop. patient due to complicating conditions related to his morbid obesity, such as the lipomatosis IMPLICATIONS/DISCUSSION: Compartment syndrome is a surgical emergency that must and obstructive sleep apnea. As obesity increasingly becomes a public health epidemic, be detected early to avoid potential serious sequelae. Causes are many and include closed generalists need to recognize the extensive clinical challenges for the obese patient. trauma (most commonly), vascular injury and reperfusion, burns, prolonged surgery or traction, overexertion/exercise, and infection. It occurs most commonly in the arm or leg but can be seen in the foot, abdomen, retroperitoneum and mediastinum. Recognition depends on THE ACCIDENTAL PATIENT: A CASE OF HYPOGLYCEMIA. M. Ong1; 1University of clinical suspicion and can be remembered as the five P's: pain (severe and out of proportion to California, San Francisco, San Francisco, CA (Tracking ID #75589) injury); pulselessness, paralysis (excluding concomitant nerve injury); paresthesia and pallor. LEARNING OBJECTIVES: 1) To discuss the differential diagnosis of hypoglycemia. Laboratory may show myoglobin in the urine or elevated creatine kinase. Imaging studies may 2) To recognize that accidental sulfonylurea ingestion is a cause of hypoglycemia in adult help rule out other causes but direct measurement of compartment pressures are needed for nondiabetics. diagnosis. Also well described is the syndrome of chronic compartment syndrome, which is 3) To recognize that polypharmacy issues are common and are not limited to a patient's own typically thought of as an overuse injury in runners but remains as an interesting possible prescriptions. explanation for this patient's claudication history. CASE INFORMATION: An 80 year old male on multiple medications presented with severe hypoglycemia. He had no prior history of diabetes and never used alcohol. During his initial INTRAVENOUS ETHANOL AND TREATMENT FOR ALCOHOL WITHDRAWAL hospitalization, the patient was found to be hypogonadal and diagnosed with cholangitis. 1 2 2 SYNDROME IN THE PERIOPERATIVE PERIOD. J. Olstein , A. Gordon , J. Conigliaro ; Diagnosis was based on hypothermia, choledocholithiasis and ductal dilatation although blood 1 2 University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh, VA Pittsburgh Healthcare cultures were negative and initially there was no leukocytosis. Cortisol levels were normal and System, Pittsburgh, PA (Tracking ID #76617) no abdominal tumors were found by CT. Insulin levels and c-peptide levels were elevated. The LEARNING OBJECTIVES: Early recognition and treatment of Alcohol Withdrawal patient's medications did not include any associated with hyperinsulinism. The patient's Syndrome (AWS) may reduce perioperative morbidity and mortality. Intravenous Ethanol glucose normalized after two days of treatment with a glucose drip, antibiotics, and stone (IVE) is still used for the peri-operative management AWS. This case illustrates the importance extraction with sphincterotomy. Upon discharge, the leading diagnosis was sepsis-induced of 1) identifying patients who require AWS treatment and using evidence-based treatments early hypoglycemia. The patient was rehospitalized five months later with another episode of to prevent AWS peri-operative complications, 2) exploring the use of alcohol to treat peri- hypoglycemia. A sulfonylurea level was sent and returned positive for glipizide. It was then operative AWS, and 3) discussing optimum treatments of AWS with patients and family prior to discovered that the patient was erroneously taking his wife's glipizide. The patient has had no surgery. further episodes of hypoglycemia. CASE INFORMATION: T.O. is a 65 year-old man with history of hypertension, congestive IMPLICATIONS/DISCUSSION: The differential diagnosis of hypoglycemia includes heart failure and peripheral vascular disease with bilateral thigh claudication admitted for aorto- hormone deficiencies, enzyme defects, acquired liver disease, malnutrition, sepsis, malignancy, bifemoral bypass. Initial documentation of alcohol use consisted of an admission nursing note medications, and hyperinsulinism. Hyperinsulinism can be caused by sepsis, insulinoma, stating that the patient drank alcohol. After an uncomplicated surgery, he was successfully autoantibodies and medications. These medications include exogenous insulin, sulfonylureas extubated and on post-operative day (POD) 2 was transferred to a general surgical bed. On POD and other sulfa drugs, and also quinine and pentamidine. Hypoglycemia due to accidental oral 3, he became increasingly agitated and combative. AWS was suspected and Lorazepam 1±2 mg sulfonylurea ingestion in non-diabetics is more common in the pediatric rather than the PRN was ordered. Over the next three days he did not improve and was returned to the SICU for internal medicine literature. Drug-induced hypoglycemia should be considered whenever the re-intubation for airway protection and IV benzodiazapine treatment. After being informed of patient has potential access to hypoglycemia-inducing agents. Polypharmacy is a well- his clinical condition, the patient's son requested his father receive alcohol to prevent delirium recognized cause of adverse drug events among the elderly. However, estimates of tremens since his father had not consented to ``detoxification''. A 10% ethanol drip was begun to polypharmacy are limited to an individual's medications obtained by prescription or over- 100 cc/h on POD 8 and on POD 9 he was successfully extubated. Although he became more the-counter. It should be recognized that individuals with multiple medications may alert and interactive, attempts to wean his IVE caused increased agitation. On POD 11 he was inadvertently consume medications other than their own. transferred to a general surgical bed, his IVE was discontinued, and he was ordered 12 ounces beer PRN. On POD 12, he continued to be confrontational and was discharged to home. A CASE OF ASCITES AND UNILATERAL LEG SWELLING. B. Taqui1, D. Oxman1, IMPLICATIONS/DISCUSSION: AWS is a complex constellation of signs and symptoms L. Kaplan1; 1Temple University, Philadelphia, PA (Tracking ID #76436) related to autonomic hyperactivity in alcohol dependent patients whose alcohol intake is decreased or discontinued. Severe AWS includes life-threatening delirium tremens that may be LEARNING OBJECTIVES: 1. Recognize iliac vein compression (May-Thurner) syndrome exacerbated by the stress of surgery. Pre- or peri-operative detoxification from alcohol may also as rare cause of left leg swelling in patient with negative venous dopplers 2. Recognize potential increase surgical morbidity. Symptom triggered, appropriate dosing of benzodiazapines are for endovascular damage and thrombosis resulting from condition 3. Recognize endovascular effective first line treatment for AWS. However, intravenous and oral alcohol use continues to stenting as potential cure be used in the perioperative period. Although multiple case reports exist detailing the use of CASE INFORMATION: 38 year old Caucasian male with history of alcohol abuse presented IVE or oral alcohol to prevent withdrawal symptoms, no clinical trials exist to demonstrate its with three days of abdominal pain and increasing abdominal girth. Serum lipase was markedly efficacy in management of peri-operative AWS. The use of IVE in the perioperative period is elevated and paracentesis showed ascitic fluid consistent with pancreatic ascites. He was started complicated by electrolyte disturbances, pancreatic complications, and difficulty in objectively on total parenteral nutrition. He subsequently developed left leg and scrotal swelling. Lower measuring treatment efficacy. Use of oral alcohol may also reinforce unhealthy outpatient extremity venous duplex imaging was negative for deep venous thrombosis, but contrast 78 Abstracts JGIM

venography revealed compression of the iliac vein by the right iliac artery. The patient underwent gravitational effect on the pulmonary circulation, caused by his prolonged assumption of the endovascular stenting of the femoral vein with complete resolution of leg and scrotal swelling. Trendelenberg position as part of the management of his diabetic foot problems. His swelling has not recurred since then. His pancreatitis and ascites also gradually resolved. IMPLICATIONS/DISCUSSION: Pulmonary edema presents classically with bilateral IMPLICATIONS/DISCUSSION: The potential for obstruction of the left common iliac vein parahilar alveolar shadows producing a bat wing appearance on CXR. In situations by the overlying right common iliac artery against the pelvic brim was first noted by Virchow. characterized by gravitational effects or alterations in lung perfusion, as in COPD or Later, May and Thurner described the ``iliac compression syndrome.'' In this patient, it was pulmonary embolism, pulmonary edema may present in less typical ways. Acute mitral believed that the ascites coupled with intravascular volume burden of parenteral nutrition led regurgitation has been reported as causing right upper lobe pulmonary edema and unilateral to the patients symptoms. The syndrome, which can be acute or chronic, predisposes patients pulmonary edema has been attributed to the gravitational effects of posture. These atypical to thrombosis. Thus, contrast venography should be considered in patients with unilateral left presentations can be confused with pneumonia and aspiration. To make the correct diagnosis lower extremity swelling and negative duplex imaging. Therapy with endovascular stenting of in patients with atypical CXR's, clinicians must rely on other clinical and radiologic signs of femoral vein offers patients the chance of cure. heart failure and take a careful history.

CALL-FLEMING SYNDROME: A RARE CASE OF REVERSIBLE CEREBRAL BLASTOMYCOSIS DISGUISED AS AUTOIMMUNE DISEASE AND VICE-VERSA. A.S. Pai ISCHEMIA IN A YOUNG ADULT. K. Pachipala1, J. Hosey1; 1Geisinger Medical Center, Panandiker1, P.A. Schlesinger1; 1Hennepin County Medical Center, Minneapolis, MN Danville, PA (Tracking ID #74226) (Tracking ID #76956)

LEARNING OBJECTIVES: Recognize that Call-Fleming syndrome is a rare cause of TIA or LEARNING OBJECTIVES: Recognize the generalized nature of presenting signs and stroke in a young adult. symptoms of blastomycosis and that confirmation with careful testing is possible. CASE INFORMATION: A 39-year old woman with a history of Crohn's disease was admitted Recognize the similarity between clinical features of blastomycosis and autoimmune disease. with three episodes of painless transient numbness of the left upper extremity, each lasting Distinguish between red cell ghosts engulfed by macrophages and blastoconidia; untrained 10±15 minutes. She had no appreciable history of recurrent headache or migraine. CT scan, assessment may lead to misdiagnosis. MRI/MRA/MRV of the brain, carotid doppler, and TEE were normal. She had no clinical or CASE INFORMATION: In 1989, a 29 year old female with a prior clinical diagnosis of serologic evidence of vasculitis. Thrombophilic work up was negative. A 4-vessel cerebral systemic lupus erythematosus with anti-phospholipid antibody syndrome, residing in a region angiogram showed a beaded segmental narrowing involving the right internal carotid artery endemic to blastomycosis, presented with fevers, breathlessness and a non-productive cough. from the bifurcation to the base of the skull. Fibromuscular dysplasia was considered, but a Workup revealed pulmonary infiltrates, anemia with left-shift, and a sputum KOH preparation repeat angiogram 3 days later showed that the vessels had returned to normal. The patient was demonstrating round, non-staining elements felt to be consistent with blastomycosis. After discharged on a calcium channel blocker and coumadin. four days of intravenous amphotericin, the patient developed progressive pulmonary infiltrates IMPLICATIONS/DISCUSSION: Stroke in young adults is usually due to cardiac embolism, requiring ventilatory support. Subsequent evaluation with broncho-alveolar lavage revealed dissection of arteries, vasculitis, and conditions associated with hypercoagulable states. alveolar hemorrhage and red cell ghosts within macrophages; these findings were consistent `Reversible cerebral segmental vasoconstriction' also known as Call-Fleming syndrome is a rare with a vasculitic rather than an infectious disease process. cause of stroke or TIA and is characterized angiographically by multiple areas of reversible Eleven years later, the patient presented with hemoptysis, fatigue and arthralgias leading to segmental arterial narrowing. Symptom onset can be spontaneous, but has also been associated initiation of immunosuppresants for presumed autoimmune disease. After discharge, however, with pregnancy, migraine, and use of sympathomimetic drugs. Most patients present with sputum cultures grew Blastomyces dermatitidis, and followup chest CT revealed bibasilar headache. Symptoms can last from few minutes to 6 months. The mechanism of vascular consolidation with cavitary changes prompting a reduction in steroid dose and initiation of narrowing is not understood. Repeat angiogram may be needed to demonstrate the reversible anti-fungal therapy. nature of the angiographic changes. IMPLICATIONS/DISCUSSION: The literature contains multiple cases of blastomycosis mimicking a variety of illnesses, from neoplastic to autoimmune disease. Certain confounding factors can limit the differential diagnosis: (i) the indolent course of blastomycosis with non- SCURVY PRESENTING AS PSEUDO-VASCULITIS IN A PATIENT WITH specific presenting symptoms may catch the unwary off-guard, (ii) blastomycosis may present SCHIZOPHRENIA. K. Pachipala1, D. Gutknecht1, A. Mirza1; 1Geisinger Medical Center, Danville, PA (Tracking ID #74391) in a manner similar to a variety of disease processes, (iii) and finally, blastomycosis may be superimposed upon another illness, clouding both diagnosis and management. LEARNING OBJECTIVES: 1. Consider scurvy in the differential diagnosis when patients appear to have vasculitis, especially in populations at high risk. 2. Appreciate that early ACUTE TUBULOINTERSTITIAL ASSOCIATED WITH CLOPIDOGREL. diagnosis, facilitated by taking a good dietary history, is important, as scurvy is potentially fatal. N. Palanichamy1, C. Kumar1; 1Oakwood Healthcare System, Dearborn, MI (Tracking CASE INFORMATION: A 54-year-old schizophrenic man presented to rheumatology clinic ID #76611) with a vasculitis-like skin rash, joint swelling and tenderness, edema of a lower extremity and poor dentition. He was a chronic smoker and had a history of alcoholism. He was not on any LEARNING OBJECTIVES: To describe clopidogrel induced acute renal failure, a previously medication other than haloperidol on a prn basis. An extensive work up for vasculitis was unreported drug reaction. negative. The patient was referred for biopsy of his skin lesions and scurvy was clinically CASE INFORMATION: An 89 year-old white male presented with hematuria and acute renal suspected and confirmed with a low vitamin-C level. Biopsy did not show evidence of vasculitis. failure. His Medications were aspirin, plavix, metaprolol, prinivil, lasix and flomax. He was The patient's symptoms and signs resolved rapidly with oral vitamin-C. placed on clopidogrel two weeks prior. He stopped the drug the day before admission. His IMPLICATIONS/DISCUSSION: Scurvy is a disorder caused by vitamin C deficiency. Its creatinine level was 3.9 mg/dl (baseline creatinine 1.3 mg/dl). Urinalysis showed proteinuria, protean manifestations include petechiae, ecchymoses, hyperkeratoses, arthralgias, malaise, leukocytes and erythrocytes. 24-hour protein excretion was 756 mg. A renal ultrasound showed fatigue, impaired wound healing, hair with corkscrew deformity and swollen, red purple gums. no obstruction. Over the course of the next week his renal function deteriorated (creat 8.9 mg/ Our case is unusual because our patient presented predominantly with joint symptoms and a dl). Renal biopsy showed a widened, edematous interstitium with moderate lymphocytosis, vasculitic-appearing rash. The diagnosis was missed by the rheumatologist, but was later made plasma cells and regenerative tubules and was compatible with tubulointerstitial nephritis based on a dermatologist's suspicion. Scurvy is rare in industrialized nations but can occur in (AIN). Dialysis was started and the patient was placed on steroids. With treatment the certain high-risk groups because of poor intake of vegetables and fruits or an increased need for creatinine decreased to 2.6 mg/dl, the dialysis stopped and the steroids tapered. Based on the vitamin C. High-risk groups include the elderly, pregnant and lactating women, infants, the history and presentation clopidogrel was thought to be the etiology of the nephritis in this case. urban poor, the malnourished, food faddists, alcoholics and those with cancer. Scurvy has also IMPLICATIONS/DISCUSSION: To our knowledge, this is the first case of clopidogrel been reported in psychiatric patients with depression, schizophrenia and anorexia nervosa. induced acute tubulointerstitial nephritis. The rapid deterioration in the renal function two Schizophrenic patients are predisposed to abnormal dietary patterns, food fads and self neglect weeks after starting clopidogrel and the absence of confounding factors suggests the diagnosis which subject them to a risk of scurvy. Our patient was at risk because of underlying in the presence of the biopsy findings. Clopidogrel affects platelet aggregation by inhibiting the schizophrenia, a history of alcoholism, and malnutrition, which predisposed him to poor intake. ADP receptor and the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa His smoking history probably contributed to his deficiency by increasing vitamin C needs. complex. The precise mechanism of the renal dysfunction is unknown but, like ticlopidine, a chemically similar drug with known adverse renal effects, may be caused by cell-mediated ATYPICAL RADIOLOGIC PRESENTATION OF CARDIOGENIC PULMONARY EDEMA: injury. Guerciolini et al. (1985) demonstrated a positive lymphocyte stimulation test in explaining agranulocytosis associated with ticlopidine. The other known mechanism of drug THE IMPORTANCE OF A CAREFUL HISTORY. K. Pachipala1,D.Bulaloiu1,L. induced AIN, antibody mediated injury and circulating immune complexes are less likely Adhikesavan1, D. Gutknecht1; 1Geisinger Medical Center, Danville, PA (Tracking ID #74394) causes insofar as the immunoflorescent studies in our case were nonspecific. In addition to the LEARNING OBJECTIVES: Recognize that pulmonary edema is one of the many causes of more commonly known side effects of clopidogrel physicians now need to realize that in rare localized upper lobe infiltrates, especially when patients at risk for heart failure have been in instances it may cause renal dysfunction. dependent positions for prolonged periods of time. CASE INFORMATION: A 52-year old man with type-2 diabetes and severe atherosclerotic LEUKEMOID REACTION WITH MALIGNANT FIBROUS HISTIOCYTOMA. S. Parikh1, cardiovascular disease, who had had a toe amputated for an infected ulcer two days before, was V. Molagavalli1, P. Radhakrishnan1; 1St. Francis Hospital, Evanston, IL (Tracking ID #76515) admitted with a 3-day history of orthopnea and dyspnea on exertion. He had been on prolonged bed rest to facilitate healing of his foot. On admission he was hypoxic, with coarse LEARNING OBJECTIVES: Think about malignancy in the differential diagnosis of crackles at the apices of the lungs and decreased breath sounds at the lung bases. There was no leukemoid reaction. elevation of JVP and the rest of the cardiovascular exam was unremarkable. CXR showed upper CASE INFORMATION: A 68 year old Caucasian male with no significant past medical lobe alveolar shadows bilaterally with bilateral pleural effusions and Kerley B lines. Spiral CT history presented with complaints of swelling of both legs, vague abdominal pain, watery of the chest done to rule out pulmonary embolism showed bilateral pleural effusions and diarrhea and increased urinary frequency of 6 weeks duration. He also reported a weight gain of bilateral nodular upper lobe infiltrates without evidence of embolism. Atypical pulmonary 50 pounds over the past 6 months. On physical examination, he was afebrile, pulse was 81/min edema was suspected and the patient was propped up in bed, and given furosemide. His and blood pressure was 145/82 mm Hg. He had pallor and massive lower extremity edema symptoms and CXR abnormalities resolved in 2 days. Natriuretic peptide was found to be extending upto the scrotum. There was no lymphadenopathy. Abdominal examination revealed markedly elevated at 857 pg/ml and an echocardiogram confirmed LV dysfunction with an EF a large hard mass extending anteriorly from the right lumbar region to the opposite flank and of 20%. The atypical presentation of this patients pulmonary edema was explained by a pelvis. Laboratory data- Hb 8.7gm/dl, Total WBC 74,800/cumm, Differential±40% JGIM Volume 18, April (supplement 1) 2003 79

neutrophils, 56% bands and 4% monocytes, platelets 195 K/cu mm, LAP score 217. Urinalysis louse). They belong to the order Anoplura, the sucking lice that feed on blood approximately 5 was normal. Alkaline phosphatase 144 IU/L, total serum protein 6.3 g/dl, C-reactive protein times per day for approximately 40 minutes each time. Hemorrhagic macules or papules 13.3 mg/dl. Both blood and urine cultures were negative. Peripheral smear±leukocytosis, develop at the sites of feeding lice, and vertical excoriations due to scratching and mature granulocytes and band forms, no blasts. CT scan of the abdomen showed a large, postinflammatory hyperpigmentation are common (aka, vagabond's disease). These lice can lobulated retroperitoneal mass extending to the posterior aspect of the right kidney, measuring be transmitted directly from person to person. They are also a potential vector for transmission 9Â8Â15 cm and another left sided pelvic mass, 14Â10Â17 cm, contiguous with the urinary of diseases such as typhus, louse-borne relapsing fever, and endocarditis. Bacterial super- bladder and pressing on the IVC. Multiple low-density lesions were also noted in the liver and infection at the sites of infestation is also common. Zoonotic pediculosis (louse infestation) has spleen. Bone marrow biopsy revealed a myeloid predominant hypercellular marrow, no blast been reported as a major cause of anemia in domestic animals. This possibility, however, has cells. A CT guided biopsy from the hypodense lesion in the liver revealed a metastatic, poorly not been reported in humans. Our case presents a homeless male wtih severe iron-deficient differentiated malignant fibrous histiocytoma (MFH), pleomorphic type, positive for vimentin anemia associated with chronic pediculosis. This case supports the hypothesis that louse and negative for cytokeratin and alpha-fetoprotein on immunostaining. The IL-6 and IL-2 infestation is an uncommon cause of anemia in humans. To our knowledge this is the first case levels were normal. The patient was started on chemotherapy with cyclophosphamide, report of its kind (Internet and Medline search from 1960 to present). dexamethasone, adriamycin and dacarbazine. He developed disseminated intravascular coagulation on the 5th day of chemotherapy and expired. IMPLICATIONS/DISCUSSION: This case is unique because of the association of malignant CHEST PAIN AND SYNCOPE IN A YOUNG WOMAN. D. Parrish1, S. Khasani1, J. Wiese1; fibrous histiocytoma with leukemoid reaction (LR). Several cases of soft tissue sarcomas with 1Tulane University, New Orleans, LA (Tracking ID #77066) leukocytosis have been reported, but less than 15 cases of MFH with this phenomenon were LEARNING OBJECTIVES: 1. Develop a cost-effective approach to diagnosis of pulmonary found in the review of literature. The relationship between cytokine levels and LR has not been hypertension. 2. Diagnose primary pulmonary hypertension. consistently demonstrated in the cases reported. Although, in our patient, serum cytokine levels CASE INFORMATION: A 23 year-old woman presented with chest pain and syncope after were noninformative and histologically, the metastatic component of the tumor was not exertion. The chest tightness was associated with shortness of breath, nausea, and diaphoresis. significantly different from the ``non-inflammatory'' fibroxanthosarcomas, the absence of any She first experienced exertional angina at age 18 during military training. The episodes had other cause of leukocytosis highlights its association with MFH. The prognostic significance of increased in frequency since. Her vital signs were normal. The was normal leukocytosis with these tumors is yet to be defined, an added survival benefit of the with the exception of a a left-sided heave and a loud, persistently split S2 that widened with inflammatory component is debatable. inspiration. An electrocardiogram demonstrated normal sinus rhythm, right axis deviation, and T-wave inversion in the inferior and anterior leads. Three troponin assays were negative. PULMONARY NODULAR AMYLOIDOSIS DIAGNOSED BY TRANSBRONCHIAL LUNG Echocardiography revealed right ventricular enlargement, dilated pulmonary arteries with BIOPSY. J.S. Park1, R.L. Smith2, C.T. Tenner2; 1New York University School of Medicine, pressures of 50 mm Hg, normal chamber sizes, normal valves, and no septal defects. A New York, NY; 2VA New York Harbor Healthcare System, New York, NY (Tracking ID #76845) ventilation/perfusion scan, ANA and RF were normal. A right heart catheterization confirmed pulmonary artery hypertension with a systolic pressure of 70 mmHg and a normal wedge LEARNING OBJECTIVES: 1. Assess the differential diagnosis of pulmonary lesion pressure. A bubble study looking for small septal defects was normal. Angiography confirmed 2. Recognize and review the clinical features and management of pulmonary amyloidosis CASE INFORMATION: Case 1: A 69 year-old male with a history of 30 pack-year tobacco the presence of dilated pulmonary arteries without evidence of thromboembolic disease. IMPLICATIONS/DISCUSSION: Primary pulmonary hypertension is a diagnosis of use and positive tuberculin test, presented with nonproductive cough and night sweats for several months. Physical exam was normal. Serum immunofixation tests and acid fast stains of exclusion, with a prevalence of one to two people per million. Because of its low incidence and protean nature, the most cost effective strategy is to exclude common etiologies of sputum were normal. Pulmonary function test (PFTs) showed moderate obstructive airway pulmonary hypertension such as pulmonary embolism, valve disease, lupus, CREST and left disease, and transthoracic echocardiogram was unremarkable. Chest x-ray (CXR) exam heart failure. Right heart catheterization is the best diagnostic test. The median survival after revealed a rounded opacity in the right lung apex. Computed tomography (CT) showed a diagnosis is 2.5 years. Intravenous epoprostenol is the drug of choice, but oral vasodilators are 2.5 cm right apical mass and multiple small nodules seen in both lung fields. Transbronchial biopsy of the apical mass was consistent with pulmonary nodular amyloidosis. Follow-up CT also used. Anticoagulation has been shown to prolong life; some patients may also respond to oral vasodilators. Anticoagulation improves mortality by decreasing thombosis and throm- imaging showed no significant change after one year. boembolism. This patient was started on a trial of oral bosentan and warfarin. Since primary Case 2: A 73 year-old Caucasian male with a history of 40 pack-year tobacco use, had a CXR pulmonary hypertension has no cure, an exhaustive search for secondary causes is warranted in for preoperative evaluation for blepharoplasty. He denied cough, weight loss, and night sweats. any patient with this diagnosis. Physical exam and laboratories were all within normal limits. PFTs were consistent with mild obstructive airway disease. CXR exam showed an incidental finding of a round density in the right middle lung field. CT revealed a 1.5 cm round opacity in the right middle lobe. Transbronchial lung biopsy of the mass was consistent with pulmonary nodular amyloidosis. THE ALCOHOLIC PATIENT IS NOT ALWAYS INTOXICATED WITH ALCOHOL. C. Passero1, P. Hasley1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76788) Follow-up CT imaging showed no significant change after one year. IMPLICATIONS/DISCUSSION: Pulmonay amyloidosis may present in one of three ways: LEARNING OBJECTIVES: 1. Recognize the signs and symptoms of ethylene glycol (1) diffuse, interstitial process associated with primary, systemic amyloidosis and a median poisoning. 2. Distinguish the diagnostic tools used to confirm the presence of ethylene glycol survival of 16 months after diagnosis; (2) Endobronchial amyloid causing obstruction that is poisoning. usually amenable to treatment with laser therapy; and (3) isolated, pulmonary nodular CASE INFORMATION: A 44 year old male with a history of depression and heavy alcohol amyloidosis that is not associated with systemic disease and follows a benign course. Our two use developed slurred speech and unsteady gait. Later he was found unresponsive and lacked cases are examples of pulmonary nodular amyloidosis. Pulmonary disease is uncovered as an appropriate airway reflexes requiring intubation in the field. In the emergency room he was incidental finding with one or more nodular opacities seen on chest imaging suggesting a found to have a pulse of 125, systolic blood pressure of 165 and a respiratory rate of 33. A CXR malignant process. Transbronchial lung biopsy may establish the diagnosis with light showed mild pulmonary edema. An arterial blood gas had a pH of 6.99, pCO2 of 26, and a pO2 microscopy showing amorphous, extracellular deposits that stain pink with hematoxylin and of 114. His sodium was 138, chloride 105, bicarbonate 6.1, BUN 13, Cr 1.2 and glucose 158. eosin. Under polarized light, amyloid produces apple-green birefringence. In our two cases of His anion gap was calculated to be 24 and his measured osmolarity was 324 resulting in an primary nodular amyloidosis, elevated monoclonal proteins were not found, consistent with the osmolar gap of 36. His serum alcohol level was non detectable. Urinalysis revealed calcium absence of systemic involvement in this presentation of disease. Further, follow-up chest oxalate crystals, proteinuria and hematuria. He was treated with fomipazole, pyridine and imaging has revealed no change in the pulmonary nodular opacities, reflecting the benign thiamine. He developed acute renal failure requiring dialysis. When his medical issues resolved course of this disease. he was transferred to inpatient psychiatry for treatment of depression. IMPLICATIONS/DISCUSSION: This case demonstrates the typical signs and symptoms of A CASE OF HUMAN LOUSE INFESTATION ASSOCIATED WITH SEVERE ANEMIA. ethylene glycol intoxication including central nervous system effects of ataxia, slurred speech, J.S. Park1, C.T. Tenner2; 1New York University School of Medicine, New York, NY; 2VA New and somnolence; cardiopulmonary effects of tachycardia, hypertension and congestive heart York Harbor Healthcare System, New York, NY (Tracking ID #76937) failure; and renal insufficiency with hematuria, proteinuria, and oliguria. A patient with alcohol-like inebriation, a negative serum ethanol level, and a history of depression raises the LEARNING OBJECTIVES: 1. Assess the differential diagnosis of altered mental status and suspicion for possible ethylene glycol poisoning. Laboratory tools can aid in the diagnosis. anemia in homeless patients 2. Distinguish the clinical presentations and potential Ethylene glycol and its metabolites contribute to a high anion gap metabolic acidosis combined complications of pediculosis 3. Recognize the importance of clinical observation and scientific with a serum osmolar gap. When a serum test for ethylene gylcol is unavailable, diagnosis may reasoning in development of hypotheis in genenral medicine be confirmed by identification of calcium oxalate crystals in the urine. The metabolites of CASE INFORMATION: A 40 year-old homeless male with a history of untreated ethylene glycol cause the life threatening effects. Therapy prevents the destruction of ethylene Schizophrenia was brought in for evaluation of fatigue and altered mental status. On glycol into its metabolites and increases excretion of unaltered ethylene glycol. Fomipazole, an presentation, the patient was noted to be disheveled and confused with initial BP 128/61, P88, alcohol dehydrogenase inhibitor, and ethanol, a high affinity competetive substrate, block the RR 17, and T99.9. Physical exam was remarkable for numerous nits on hair and clothing, and enzyme alcohol dehydrogenase that degrades ethylene glycol. Thiamine and pyridine skin with innumerate number of excoriated, hemorrhagic papules. Rectal exam revealed no administration block oxalic acid formation by converting glycolic acid into nontoxic masses but guaiac negative brownish stool. Initial laboratories included: WBC 13.7, HGB 3.7, metabolites. Hemodialysis enhances elimination of unmetabolized ethylene glycol, corrects HCT 11.5, PLT 375, MCV 72, RDW 16, and 71% PMN. Gastric lavage was negative for metabolic acidosis, and reverse in the patient who develops acute renal failure. occult blood. Computed tomography of head and a diagnostic lumbar puncture were normal. Serum anemia work-up was remarkable for low ferritin (11) and iron (76). Folate and vitamin B12 levels were normal. The remaining laboratories, imaging studies, and cultures were all MULTIPLE CRANIAL NEUROPATHY: AN ATYPICAL PRESENTATION OF LYME within normal limits. He was treated for pediculosis with permethrin and received blood DISEASE. M. Patel1,S.Patel1,J.Feng1,F.Garafalo1, H. Cortes1,C.Buckner1; transfusion with an appropriate increase in blood counts. His mental status and leukocytosis 1NewYork Methodist Hospital, Brooklyn, NY (Tracking ID #74274) significantly improved as pediculosis and anemia were treated. Blood counts has remained stable after treating pediculosis. LEARNING OBJECTIVES: To recognize that Lyme disease, although most commonly IMPLICATIONS/DISCUSSION: The 3 most common arthropod exoparasites in humans presents as erythema migrans accompanied by flu-like symptoms, neurological abnormalities are Pediculus capitis (head louse), Pediculus corporis (body louse), and Phthirus pubis (pubic may be the initial manifestation. To underscore this point we describe a case of Lyme disease 80 Abstracts JGIM

that had an uncommon presentation with multiple cranial neuropathies including trigeminal nerve involvement. Her MRI also showed some distinct abnormalities which have been rarely reported. CASE INFORMATION: A 51-year old woman, who had been well otherwise, presented in November 2001 with the sudden onset of facial asymmetry. She developed right-sided trigeminal neuralgia on the second day of hospitalization. There was no history of fever, headache, vomiting, muscle weakness. She did not recall any tick bite or rash. She had frequently visited Dutchess County in upstate New York during the past two years in relation to construction work on her house. On admission, she was found to have monocular diplopia of the right eye, of her right ear and right lower motor neuron (LMN) facial palsy. Other than these findings, her neurological examination was unremarkable. MRI of the head revealed multiple foci of hyperintensities in the white matter; bilateral enhancement of the tentorium and cranial nerves III, V, VII; and unremarkable orbits (Fig 1,2,3). Cerebrospinal fluid (CSF) revealed a protein level of 600 mg/dl; WBC 210/uL (lymphocytes 95%) and glucose 91 mg/dl. Serum and CSF were positive for Lyme antibodies on ELISA. The result was confirmed by western blot assay on the CSF. The patient was started on intravenous ceftriaxone 2 gm every 24 hrs. On the 4th day of antibiotic therapy, she developed left sided LMN facial palsy. After 4 weeks, a repeat CSF study showed significant improvement: the protein level fell to 82 mg/dl and WBC count to 33/ul. Six weeks after ceftriaxone therapy, the diplopia, trigeminal neuralgia and facial palsy resolved completely. IMPLICATIONS/DISCUSSION: Though facial palsy is a relatively common presentation of Lyme disease, multiple cranial neuropathies may be the initial manifestation and must be borne in mind. The diagnosis can be easily missed in such cases without any antecedent history of tick bite or rash. A history of travel or residence in an endemic area is a useful clue. In addition, MRI may play an important role in the diagnosis. Our patient's MRI at admission revealed bilateral enhancement of meninges and cranial nerves III, V and VII indicating evidence of inflammation that preceded the full clinical expression. To our knowledge, multiple cranial neuropathies as the initial manifestation and evidence of gadolinium enhanced MRI lesions of WALDENSTROM'S MACROGLOBULINEMIA AND HEART FAILURE. R. Pearl1, the involved cranial nerves have been rarely reported. Recognizing these subtle imaging J. Wiese1; 1Tulane University, New Orleans, LA (Tracking ID #77006) findings, combined with high clinical suspicion is the key to diagnosis and allows early treatment which can help prevent further complications. LEARNING OBJECTIVES: 1. Use the physical examination to determine cost-effective use of echocardiography 2. Use an understanding of physiology to guide diagnostic procedures 3. Diagnose infiltrative cardiomyopathy. CASE INFORMATION: A 73 year-old man presented with right-sided chest pain and shortness of breath. The shortness of breath had worsened over two weeks, with new onset three-pillow orthopnea and lower extremity edema. His vital signs were normal. He had a soft S1, a normal S2, and an S4. Although he had bilateral crackles and an elevated JVP, there was no S3 or inferiorly displaced PMI. His edema was initially ascribed to hypo-albuminemia (Albumin = 2.) although his pit recovery time was greater than 90 seconds. Based upon a suspicion of a restrictive cardiomyopathy, an echocardiogram was obtained. This showed left ventricular hypertrophy and an E-to-A mitral-flow reversal consistent with diastolic dysfunction. His ejection fraction was 20% despite ventricular hypertrophy. A bone marrow biopsy was performed that confirmed the diagnosis of Waldenstrom's macroglobulinemia. IMPLICATIONS/DISCUSSION: The physical examination in concert with an under- standing of the physiology underlying disease is the foundation for cost-effective identification of occult diagnoses. The silent S1 suggested a low ejection fraction, and while the S4 without an S3 or inferiorly displaced PMI suggested a non-compliant hypertrophic ventricle. Both of these conclusions were confirmed by echo. A low ejection fraction despite ventricular hypertrophy suggested an infiltration of the ventricular wall. LaPlace's law states that wall tension is a function of the pressure and radius of a chamber, divided by the thickness of the chamber's wall. Because wall tension is proportional to afterload (like a spring, the ventricle must overcome the weight that has stretched it) a thick ventricle wall should lower wall tension, thereby decreasing the ventricular afterload. The ejection fraction should increase proportional with the wall thickness. Failure to do so suggests that the thickness is due to infiltration with a non-contractile substance. The history of chronic renal insufficiency and anemia suggested the diagnosis of amyloidosis due to Waldenstrom's macroglobulinemia. This clue was instru- mental in prompting the bone marrow biopsy that confirming the diagnosis. The finding of a speckled myocardium on echocardiogram is a classic, though late state finding of the disease.

A COMMON PRESENTATION AT AN ODD TIME W. Pease1, M. Aiyer1; 1University of Illinois at Chicago, Peoria, IL (Tracking ID #76819)

LEARNING OBJECTIVES: 1. Recognize the increasing incidence of post partum precelampsia and eclampsia. 2. Identify the presenting signs and symptoms of post partum preclampsia and post partum eclampsia CASE INFORMATION: A 37 year-old Afro-American female (G4P4),16 days post partum, presented with progressive abdominal pain and headache of 8 days duration. Review of systems was positive for blurry vision, chest pain, orthopnea, exertional dyspnea and bilateral pedal edema. Physical exam revealed a blood pressure of 120/84, a pulse of 40, and respiration rate of 16. Abdomen was diffusely tender. Lower extremities had 3+ edema. Rest of the physical exam including cardiac was normal. Laboratory data revealed elevated transaminases, LDH, uric acid and proteinuria. 2D Echo showed mild left ventricular enlargement with an ejection fraction of 50±55%. Lower extremity dopplers, V/Q scan, CT of abdomen and pelvis were all normal. During the hospital course the patient's symptoms continued to worsen with significant elevation of blood pressure. The diagnosis of postpartum preeclampsia was entertained and patient was started on intravenous MgSO4. The patient diuresed, with normalization of her blood pressure and pulse rate. Within 24 hours all her clinical symptoms resolved along with normalization of laboratory data over the next few days. This case represents a classical presentation of postpartum preeclampsia. Older age, and African-American race placed her at higher risk for preeclampsia. IMPLICATIONS/DISCUSSION: Improvements in prenatal and perinatal care have led to a relative increase in the rate of postpartum eclampsia that now accounts for up to 50% of cases (1) The symptoms can occur from within 48 hours postpartum to as late as 3±4 weeks. Headache, vision changes, nausea and vomiting, and epigatric pain are the the four most common presenting symptoms of post partum eclampsia. Internists taking care of post partum JGIM Volume 18, April (supplement 1) 2003 81

patients need to be aware that these symptoms can be heralding late postpartum eclampsia. associated medication risk factors of hydroxychloroquine therapy and corticosteroid with- Early intervention and treatment can prevent adverse complications. drawal that likely acted as the inciting event. References: Leitch CR, Cameron AD, Walker JJ. The changing pattern of eclampsia over a 60- year period. Br J Obstet Gynaecol 1997;104:917±22. IDIOPATHIC ACQUIRED VON WILLEBRAND'SDISEASE(VWD).J.H. Petkova1, P. Radhakrishnan1; 1St. Francis Hospital, Evanston, IL (Tracking ID #76592)

MALFUNCTIONING CHEST TUBE? A. Pervez1, S. Akhtar1, U. Ahmad1, R. Chaudhry1, LEARNING OBJECTIVES: 1. Diagnose acquired vWD. I. Ghobrial1; 1UPMC McKeesport, PA (Tracking ID #77014) 2. To understand the associations and clinical manifestations of Acquired vWD. LEARNING OBJECTIVES: Giant Empysematous Bullae May Mimic Pneumothorax on CASE INFORMATION: An 80-year-old male, during pre-operative workup for a routine Chest X-Ray total knee replacement, was found to have a prolonged bleeding time (11 min) and mild CASE INFORMATION: A 37 y/o African American male presented with a generalized tonic elevation of the PTT (53.7 min). His past medical history included coronary artery disease, for clonic seizure. His past history only included epilepsy, for which he was non-compliant with which he underwent bypass, 6 years ago without any complications. There was no history of treatment. Although he was a heavy smoker, there was no known history of COPD and his any abnormal bleeding episodes in the past. Laboratory Data: CBC, PT/INR and metabolic review of systems was negative. His vitals on admission were normal and physical examination profile- normal. Mixing studies showed correction of the PTT to 40.5 on addition of plasma. was only remarkable for tracheal deviation to the right with hyper resonance to percussion and In the quantitative assays of the coagulation factors done, the von Willebrand's factor was markedly decreased breath sounds on the left side of the chest. The CBC and basic metabolic mildly elevated (132%). The multimeric fraction of vWF was diminished. Serum Protein profile were within normal limits and the chest x-ray as reviewed by both clinicians and Electrophoresis±polyclonal elevation of globulins with no spike. Peripheral smear-normal. radiologists was reported as a 90% left sided pneumothorax with mediastinal shift. A CBC, PT and PTT (6 years ago)-normal. A diagnosis of acquired von Willebrand's disease was preliminary diagnosis of pneumothorax was reached and a chest tube was inserted. The left made. The patient received FFP prior to surgery and did not have any significant bleeding lung however failed to expand despite attempts to reposition the tube. A CT Chest was then during or after the surgery. obtained which revealed a giant bulla occupying the entire left hemithorax. The alpha-1 anti- IMPLICATIONS/DISCUSSION: vWD is the most common inherited bleeding diathesis. trypsin was normal. A thoracotomy was performed and the bullous lesion was resected. Follow However, acquired factor deficiency is uncommon. While there is no true estimate of the up chest X-rays showed expansion of the left lung. prevalence of the acquired form, a recent study suggested that it might range from 0.004 to IMPLICATIONS/DISCUSSION: Giant emphysematous Bullae which mimic massive 0.13%. In an international registry of 211 cases, all were associated with an underlying cause, pneumothorax on chest X-ray with a mediastinal shift, may be found even in patients with commonest being a malignancy (Wilm's tumor, cdrenal cancer), myeloproloferative states, no previous history of COPD. Physicians should be aware of this and therefore avoid autoimmune diseases (SLE, hypothyroiditis), cardiac anomalies (patent ductus arteriosus, overzealous attempts to reposition chest tubes. angiodysplasis, aortic stenosis), or drugs (valproic acid, ciprofloxacin, hydroxyethyl starch). Most of the cases reported were discovered during the work up of the underlying disease or developed malignancy shortly after. To our knowledge, this is the first reported case of truly DYPHAGIA IN A DIABETIC. T.A. Pestana1, M. Landry1, T. Conrad1; 1Tulane University, idiopathic vWD. To date, the patient has not developed any signs of malignancy. In summary, New Orleans, LA (Tracking ID #77042) it is important for the internist and surgeon to be aware of the acquired vWF deficiency, its associations, to rule out possible underlying causes. LEARNING OBJECTIVES: 1) Recognize diabetes mellitus as an immunocompromised state. 2) Recognize the differential diagnosis for dysphagia. 1 CASE INFORMATION: A 52 year old male presented with nausea, vomiting, abdominal pain, WOUND BOTULISM Ð A DARK SIDE TO BLACK TAR HEROIN USE. T.T. Pham , 1 1 1 1 and poor oral intake. He had poorly controlled diabetes mellitus, and had not recently tested his P.P. Balingit , D. Yick , C. Nguyen ; UCLA San Fernando Valley Program, Sylmar, CA blood glucose levels. On examination, the patient appeared ill, showing dry oral mucosa (Tracking ID #76163) without lesions, tachycardia, and tenderness in the right upper quadrant. Serum electrolytes LEARNING OBJECTIVES: 1. Recognize the clinical manifestations of wound botulism revealed a glucose of 409 mg/dl, an anion gap of 19, and ketonemia. Glycolated hemoglobin (WB). 2. Appreciate the difficulty in differentiating WB from other forms of neuromuscular was 13.2%. Diabetic ketoacidosis resolved, however, the patient's nausea and vomiting weakness. 3. Review the diagnostic approach and management of WB. persisted. Upper gastrointestinal series showed delayed gastric emptying and pylorospasm. CASE INFORMATION: A 46 year old male with a history of black tar heroin use, diabetes, Metoclopromide and erythromycin were initiated for gastroparesis with improvement. Ten and hypertension reported one day of acute onset dysarthria, blurred vision, diplopia, and days later, the patient returned with continued nausea, vomiting, and dysphagia with solids and generalized weakness. His BP was 158/96. Though alert and oriented, exam revealed bilateral liquids. Abdominal radiography showed no obstruction, and video fluoroscopy showed normal eyelid ptosis and the inability to gaze laterally or upward. Pupils were sluggish but reactive to peristalsis. Abdominal CT scan demonstrated a thickened esophageal wall suggestive of light. Mild facial droop and tongue deviation to the right, an ataxic gait, and diminished DTRs . Endoscopy revealed a white coating of the esophagus, and brushings yeilded were noted. Gross motor strength and sensation were preserved. Also present were several Candida albicans. Treatment with fluconazole was successful. indurated skin lesions over sites where the patient had injected black tar heroin. CBC, IMPLICATIONS/DISCUSSION: may be asymptomatic, but can electrolytes, ESR, CPK, and head CT were normal. HbA1c was elevated at 10.9. The initial cause dysphagia or odynophagia. Endoscopically, lesions appear erythematous, edematous, diagnosis of lacunar infarction vs. profound diabetic neuropathy was made. Respiratory failure ulcerative, or as focal white plaques. Esophageal candidiasis is often linked with severe soon ensued, requiring mechanical ventilation. Though alert and able to communicate using immunodeficiency, but occurs in patients with uncontrolled diabetes secondary to impaired written responses, he developed loss of DTRs, intermittent loss of proximal extremity strength, leukocyte function. This patient had no other risk factors for immunocompromise, and was and was unable to open or move his eyes. His disease process was then felt to be consistent with HIV negative, but his uncontrolled diabetes predisposed him to an opportunistic infection. the Miller Fischer variant of Guillain Barre syndrome (MFGBS) and IVIG was given with no Thus, recognition of diabetes mellitus as an immunocompromised state is vital in evaluating response. Antibody testing for MFGBS revealed negative GQ1B titers and CSF studies were acute illness in diabetic patients. normal. Administration of neostigmine did not produce improvement. He then developed fever, and given the presence of skin abscesses, the diagnosis of WB was pursued. Serological and murine bioassay testing confirmed the diagnosis and wound debridement was performed. DEVELOPMENT OF PUSTULAR PSORIASIS IN A PATIENT UNDERGOING The patient clinically improved after antitoxin administration. IMMUNOSUPPRESSANT THERAPY FOR LEUKOCYTOCLASTIC VASCULITIS. IMPLICATIONS/DISCUSSION: C. botulinum is a heterogeneous group of Gram positive, 1 1 1 J. Peterson , E. Warm ; University of Cincinnati, Cincinnati, OH (Tracking ID #73971) rod-shaped, spore-forming bacteria that causes a toxin-mediated neuroparalytic disorder. The LEARNING OBJECTIVES: 1) Recognize atypical presentation for psoriasis. 2) Minimize toxin irreversibly inhibits presynaptic acetylcholine release from peripheral nerves. Roughly antibiotic use for noninfectious skin lesions. 3) Recognize potential complications of steroid 110 cases of botulism are reported annually in the US, 72% of which are infant botulism, 25% withdrawal. are food borne and 3% are WB. Recently, the number of WB cases has increased significantly, CASE INFORMATION: A 54-year-old male with a history of leukocytoclastic vasculitis was especially among black tar heroin users. After 10±14 days of incubation, WB manifests as noted to have a diffuse erythematous rash while being admitted for an unrelated endoscopic symmetric, descending motor weakness with blurred vision, diploplia, dysarthria, and procedure. The rash first developed two weeks prior in the patient's right groin and gradually xerostomia. Ophthalmoplegia, ptosis, and mydriasis may also be present. Evaluation should spread to include both legs and his right arm. It had not responded to a course of levofloxacin exclude such entities as GBS, myasthenia gravis, stroke, tick paralysis, and electrolyte or over the counter topical ointments. In the month prior to admission the patient had been abnormalities. Diagnosis is confirmed by the presence of toxin in serum. Management includes tapered from 15 milligrams to 12.5 milligrams of prednisone. On admission the patient had equine antitoxin administration and wound debridement. Mechanical ventilation should be warmth, erythema, and mild tenderness to the affected areas. Numerous 1 to 5 millimeter initiated if even mild respiratory distress is noted as respiratory failure can be sudden and life pustules also were present on the erythematous base. The patient was afebrile and had a mildly threatening. elevated white count of 11 thousand. Gram stain and culture of the pustules revealed no bacteria. Fungal elements were not seen. A punch biopsy was taken and returned consistent BEWARE: PYOMYOSITIS. S. Pillai1; 1New Hanover Regional Medical Center, Wilmington, with pustular psoriasis. Acitretin therapy was initiated. NC (Tracking ID #75428) IMPLICATIONS/DISCUSSION: Psoriasis is a relatively common dermatologic disorder that occurs in approximately 1% of the North American population. While generally benign, LEARNING OBJECTIVES: 1. Present a case of pyomyositis. 2. Report the patient psoriasis can present in an atypical and potentially life threatening manner. Pustular psoriasis populations most susceptible to pyomyositis. 3. Detail physical exam findings and differential can occur in varying degrees of severity with distinct subtypes. These include the relatively diagnoses. limited form of palmoplantar pustulosis to the more severe generalized von Zumbush type. If CASE INFORMATION: A 45 year old female with history of HIV & Hep C antibody untreated, disruption of the skin's barrier can lead to large amounts of volume loss and positivity presented with right sided hip pain for seven days duration after an initial fall. She secondary bacterial infections. Systemic involvement including arthritis, heart, liver, and reported an intermittent subjective fever over the previous two days. On examination the has been associated with advanced cases. Triggering events are often unknown, patient was febrile to 100.4 degrees Farenheit. Her right hip was extremely painful on but there has been an association with pregnancy, concurrent infections, and medications. extension and abduction. Initial right hip x-rays were normal. CT scan revealed abnormal Given the nonspecific somatic complaints and laboratory abnormalities, successful diagnosis diffuse thickening and low attenuation within both the right iliacus and piriformis muscles. A requires recognition of the pustular areas on the erythematous base. Our patient had two single gas bubble seen in the iliacus muscle was consistent with myositis. 3 cc of purulent fluid 82 Abstracts JGIM

was obtained from the area. This subsequently grew Staph. aureus. The patient received MANAGING ANTICOAGULATION DURING PREGNANCY: A NEW TECHNOLOGY oxacilllin IV for one week and was discharged on tmp/smx DS po BID for 14 days. R. Ranpuria1, P. Hasley1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76799) IMPLICATIONS/DISCUSSION: Pyomyositis was at one time believed only to be endemic LEARNING OBJECTIVES: 1. Manage women who are pregnant and need anticoagulation. to the tropics. However it is seen in the continental US predominantly in immunocomprimised 2. Recognize the teratogenic effects of coumadin, unfractionated heparin and low molecular patients and diabetics. Symptoms may be confused with muscle strain, contusion, weight heparin. thrombophlebitis, appendicitis, and pelvic pathology. Local muscle pain, redness and swelling CASE INFORMATION: A 30 year old pregnant female with a PMHx of congenital cyanotic are postivie signs when peripheral muscles are affected. An intraabdominal abscess may vary in heart disease was s/p St. Jude aortic valve replacement. When her pregnancy was discovered presentation. It is often diagnosed via CT scan and ultrasound, although MRI is the most she was changed from coumadin to subcutaneous heparin ( 3Â/day). On this regimen she sensitive. In 75% of cases, a single abscess is present. The suppurative stage is seen 10±21 days developed three episodes of right facial and extremity weakness, right arm stiffening and after symptoms begin. In 95% of cases the organism is Staph. aureus. Treatment in the abnormal eye movements. An MRI scan showed a left frontoparietal infarct. A transesophageal suppurative stage is by drainage of abscess. Medical management is with oxacillin or methicillin echocardiogram showed a small clot on the aortic valve. The patient was started on a for 2 to 6 weeks. Blood cultures are only positive in about one-third of cases. There sometimes continuous heparin infusion and arrangements were made for continuous unfractionated is a history of recent trauma. The key to the early diagnosis of pyomyositis is to beware of the heparin infusion via a subcutaneous pump. risk groups for the disease and to evaluate early with radiographic imaging. IMPLICATIONS/DISCUSSION: t is a challenge to manage pregnant patients who require anticoagulation for prosthetic valves. Coumadin is the drug of choice for anticoagulation, however because it freely crosses the placenta it is not considered safe to use in pregnant 1 1 1 NOT ALL THAT IS COPD! S. Pudur , J.L. Mitchell ; Medical College of patients. The teratogenic effects of coumadin usually occur between the sixth and ninth weeks Wisconsin, Milwaukee, WI (Tracking ID #75309) of gestation. The most common abnormalities occur in bone and cartilage development. In the LEARNING OBJECTIVES: 1. Consider tracheobronchomegaly (TBM) in the differential second and third trimesters one can develop abnormalities of the fetal central nervous system, diagnosis of atypical COPD exacerbation or recurrent pneumonias 2. Describe clinical and optic atrophy, microcephaly, mental retardation, spastisity and hypotonia. Unfractionated radiologic features of TBM 3. Manage TBM heparin does not cross the placenta because of its high molecular weight. Since it does not cross CASE INFORMATION: A 55 year old male presented with 10 days of worsening shortness of the transplacental barrier it lacks teratogenic effects and will not anticoagulate the fetus. Low breath, productive cough with yellow sputum, and fever. Previous antibiotic treatment did not molecular weight heparin is another anticoagulant that should be considered in these patients. help. PMH includes COPD, yearly pneumonias for many years, and exposure. He However, its use in pregnancy is not well studied. The ideal treatment for a pregnant woman smoked a 1/2 ppd for 35 years but quit 5 years ago. In the ED, he was afebrile, RR 16, POx requiring anticoagulation would be to switch from coumadin to heparin prior to conception. 89%, and exam was remarkable only for bibasilar crackles. Admission labs were normal. Chest The patient shold be hospitalized until she is therapeutic on heparin. The three approaches x-ray showed right lower lobe consolidation and tracheal enlargement. Chest CT showed right that are recommended include: 1. Dose adjusted unfractionated heparin throughout upper and lower lobe consolidation plus diffuse bronchiectasis and significant dilation of the pregnancy. Heparin is given subcutaneously every 12 hours and then dose adjusted to trachea (4.2 and 3.2 cm in sagittal and transverse diameter) and main stem bronchi (CT maintain two times the normal PTT, or anti-Xa levels of 0.35 to 0.70 U/ml. 2. Dose adjusted available to view). Pulmonary function tests showed a FEV1/FVC ratio of 55% and FEV1 46% low molecular weight heparin throughout the pregnancy so as to keep a four hour post of predicted. He responded to a course of gatifloxacin. On follow-up, he was doing well on injection anti-Xa level at 1.0 U/ml. 3. Unfractionated or low molecular weight heparin therapy prophylactic doxycycline on days 1±7 of each month. until the thirteenth week, with a change to coumadin until the middle of the third trimester and IMPLICATIONS/DISCUSSION: Tracheobronchomegaly (TBM) or Mounier-Kuhn syn- then restarted on unfractionated or low molecular weight heparin until delivery. An emerging drome is a clinical syndrome resulting from dilation of the trachea and major bronchi. Fewer technology in the form of a continuous subcutaneous heparin infusion pump would provide than 100 cases have been reported in the world literature, but the incidence is probably higher simple, convenient monotherapy that would eliminate the need for daily subcutaneous as the clinical symptoms mimic chronic bronchitis and bronchiectasis. Many patients carry the injections. diagnosis of COPD, as in this case. The disease is more common in men. The pathogenesis of TBM is unclear. The disease may be congenital, as it is associated with Ehlers-Danlos syndrome, or, it may be acquired, since almost 50% of patients show no symptoms until third WHEN SINUSITIS DOESN'T SMELL RIGHT: DIAGNOSING WEGENER'S 1 1 decade of life. A variant has an autosomal recessive pattern of inheritance. TBM is diagnosed GRANULOMATOSIS. J. Ravenell ; Hospital of the University of Pennsylvania, by its clinical features of repeated respiratory infections and by radiographic confirmation of Philadelphia, PA (Tracking ID #76272) dilated trachea and bronchi. A dilated trachea has a diameter of more than 3.0 cm, the left main LEARNING OBJECTIVES: 1. Recognize the clinical manifestations and diagnosis of bronchus more than 2.3 cm and right main bronchus more than 2.4 cm. In TBM, there is a Wegener's Granulomatosis 2. Appreciate that the classic clinicopathologic triad of Wegener's return to normal bronchial size at the fourth or fifth bronchial generation. Because of repeated may not present simultaneously infections, CT scans often reveal parenchymal scarring. The severe inflammation of the CASE INFORMATION: A 74-year-old male presented to his primary care physician with left tracheobronchial mucociliary system leads to decreased mucus clearance, in turn leading to frontal sinus pain and bloody mucous discharge. He was treated with five weeks of antibiotics infection and more inflammation, and then bronchiectasis and emphysema. Saccular diverticula and was eventually admitted to the hospital for intravenous antibiotics and steroid therapy for form, causing pooled secretions and recurrent infections. Management is difficult. Therapy for painful recalcitrant sinusitis. CT scan of the sinuses at that time revealed acute left frontal acute infections is postural drainage and antibiotics. Bronchoscopy may be required for sinusitis, and left ethmoid mucosal thickening. Chest X-ray obtained at that time revealed a clearance of secretions and prophylactic antibiotics may be helpful to reduce baseline bacterial right lower lobe patchy infiltrate consistent with pneumonia. He underwent a surgical sinus counts. In particularly recalcitrant cases, tracheostomy may be required. drainage procedure for chronic sinusitis and was treated for pneumonia. Over the course of the next year the patient had intermittent hip pain, knee pain, costochondritis and sinus pain. He later developed acute unilateral sensorineural hearing loss followed by diffuse myalgias. He A CASE OF HEMOPTYSIS AND HEMATURIA. M. Qadeer1, G. Wajida1, P. Radhakrishnan1; presented to the emergency department after onset of fever, chills and cough. Physical 1St. Francis Hospital, Evanston, IL (Tracking ID #76152) examination was only remarkable for a temperature of 101.3F. Chest X-ray revealed a right apical density not seen on the prior study. Laboratory studies revealed a mild normochromic LEARNING OBJECTIVES: 1. To know the differential diagnosis of a patient presenting normocytic anemia, ESR of 70, creatinine of 1.0 and urinalysis only significant for RBC of 10. with hempotysis and hematuria. All cultures were negative. ANA, RF, C3, and C4 were normal. ANCA testing showed a 2. To interpret the clinical and the laboratory data with an open mind. diffuse, cytoplasmic pattern (C-ANCA), identified by enzyme immunoassay as anti-PR3 CASE INFORMATION: A 64-year-old white male presented to his primary doctor with a antibodies consistent with Wegener's Granulomatosis. A lung biopsy revealed granulomatous history of chronic cough of two months, two episodes of streaking hemoptysis and mild vasculitis and fibrinoid necrosis consistent with Wegener's Granulomatosis. difficulty in breathing. Prior to this visit, he had been in good health all his life except for IMPLICATIONS/DISCUSSION: Wegener's Granulomatosis is a systemic necrotizing recurrent sinusitis. Later on during the work up, he had an episode of painless hematuria. He granulomatous vasculitis of the medium and small vessels. Wegener's classically includes the did not take any medications. There was no history of alcohol intake, smoking or drug abuse. triad of upper and lower respiratory tract involvement and renal manifestations, but often He worked in a chemical plant for years and was exposed to unknown chemicals. He is married presents with ocular, aural, central nervous system, cardiac and cutaneous manifestations. The and has two children. There was a strong family history of cancer including the lung and colon diagnosis is based on clinical features and confirmed by C-ANCA (which is 99% specific with cancers. Physical examination was normal. modern testing modalities) and tissue (biopsies from the respiratory tract have higher Laboratory data: Hemoglobin 10 gm%, RBC 4.82 million/cumm, MCV 70, and RDW 20. diagnostic yield than renal biopsy). This patient had Wegener's characterized by chronic The iron saturation was 8.7%. Sodium 138, potassium 4.0, chloride 100, BUN 23, creatinine sinusitis, migrating pulmonary infiltrates, mild renal involvement, joint involvement and 0.9 and calcium 8.7. Chest x-ray showed multiple lung nodules. Urine analysis showed RBC of hearing loss all presenting at different times. The classic triad is present at initial presentation 8 and 2+ proteins. CT scan of chest confirmed the presence of multiple nodules. Biopsy of the only 30% of the time, which often makes the diagnosis elusive as in this case. Since Wegener's peripheral lung nodule showed adenocarcinoma. Subsequent CT scan of abdomen revealed most commonly presents with sinus involvement, it should be suspected in cases of recurrent or irregular left renal mass. Nephrectomy specimen revealed renal cell carcinoma. Bone scan was chronic sinusitis that begin in the fourth or fifth decade and are associated with other systemic normal except for sinusitis. manifestations. IMPLICATIONS/DISCUSSION: The association of hemoptysis and hematuria along with a history of sinusitis initially led us to assume that this patient had Wagener's granulomatosis or some other form of vasculitis. While the clinical symptoms fit the criteria of pulmonary±renal A SARCASTIC RASH IN AN IMMIGRANT FORM SOUTH SUDAN. S. Ravilla1, I. Shendrik1, syndrome, the absence of renal insufficiency and the presence of lung nodules prompted us not T.A. Townley1; 1Creighton University, Omaha, NE (Tracking ID #76403) to disregard other causes of hemoptysis and hematuria. Nodular lesions on chest x-ray have been well described in Wagener's granulomatosis, infective endocarditis (presenting as septic LEARNING OBJECTIVES: 1) Recognize the cutaneous manifestations of sarcoidosis emboli) and metastases from solid or hematological malignancies and all of them can have 2) Review the differential diagnosis of a nodular cutaneous lesion in a immigrant from pulmonary and renal involvement. subsaharan africa 3)Review the pathophysiology of cutaneous sarcoidosis This case illustrates the need to keep an open mind while making a clinical diagnosis and CASE INFORMATION: A healthy 21 year old South Sudanese woman, 4 weeks post-partum, interpret laboratory data so as to order the relevant investigations before embarking on an who had spent 2 years in an Ethiopian refugee camp before immigrating to the U.S one year expensive workup, which may ultimately lead to a delay in the diagnosis. ago, presented with a rash on her left cheek of over 2 years duration. She had noticed the rash JGIM Volume 18, April (supplement 1) 2003 83

first back in Sudan and had persisted during her refugee camp stay. She reported that the rash was found that she received an injection of Kenalog 40 mg to the right shoulder from another had been non-pruritic, non-exudative, indolent and asymptomatic. She had no history of MD six weeks prior to presentation. Without any other exogenous sources of steroid, it was photosensitivity, exposure to chemicals or insect bite. A week's trial of anti-fungal topical concluded the pt had experienced cushingoid symptoms from the Kenalog injection followed application was unsuccessful. Her recent pregnancy was uneventful including negative HIV, by secondary adrenocortical insufficiency at presentation. Hep.BSAg and VDRL serology. Her PMH was negative for major medical illnesses and prior IMPLICATIONS/DISCUSSION: Therapy with pharmacological doses of glucocorticoids is eruptive lesions. She did have a history of positive PPD 1 year ago with negative CXR the most frequent cause of secondary adrenocortical insufficiency. The usual presentation is following immigration to the U.S. She had not been treated with anti-tuberculous agents. Her similar to that of primary adrenocortical insufficiency, with two important exceptions. Since ROS was otherwise unremarkable. Exam revealed a hyperpigmented nodular lesion pituitary secretion of ACTH is deficient, the characteristic hyperpigmentation of Addisons approximately 1cm wide and 4 cms long in a semi-circular distribution over the left malar disease is absent. The clinical features of mineralocorticoid deficiency are usually absent in the area. The rash was further noted to be non-tender, normothermic with mild induration. unstressed state, and therefore volume depletion, dehydration, and electrolyte abnormalities Physical exam revealed a healthy 21 year old woman with normal cardiac, pulmonary, are usually absent. Hypotension is also less severe, except in acute presentations. Hyponatremia gastrointestinal and neurological exam, with no evidence of lymphadenopathy and a similar can be present, and is usually due to water retention and inability to excrete a water load rather rash elsewhere. Her CBC was within normal limits. Given the patient's ethnicity and travel than to sodium loss. The clinical features of ACTH and glucocorticoid deficiency are history, leishmaniasis and cutaneous mycobacterial infections were included in the differential. nonspecific and consist predominantly of weakness, lethargy, easy fatigue, anorexia, nausea, Consideration was also given to Sarcoid and variant discoid lupus. (Syphilis was considered and occasionally, vomiting. Patients may also describe arthralgias, myalgias, and exacerbation unlikely, given recent negative serology). A diagnostic excisional biopsy revealed sarcoid-like of allergic responses. With acute decompensation, severe hypotension or shock may occur and granulomas surrounded by mild chronic lymphocytic infiltration. Special stains (including be unresponsive to vasopressors unless glucocorticoids are administered. AFB, giemsa, PAS, Fite, Giemza and warthin-starry) did not reveal pathogenic microorgan- isms. Patient was initiated on a local topical steroid application (clobetasol propionate) for two weeks with dramatic resolution of the rash. A diagnosis of Sarcoidosis was therefore made by exclusion and dramatic response to treatment. UNRECOGNIZED GRAVES' DISEASE IN A PATIENT WITH A HISTORY OF COCAINE 1 1 IMPLICATIONS/DISCUSSION: The protean manifestations of Sarcoidosis include a) ABUSE. C. Reznikoff ; Hennepin County Medical Center, Minneapolis, MN (Tracking Erythema nodosum (most common, although non-specific lesion). b)Lupus pernio (classically ID #76901) involving the rim of the nose and associated with infiltration of the nasal mucosa causing LEARNING OBJECTIVES: 1. Recognize the large prevalence of cocaine abuse. ulcerations or even fatal airway obstructions). c) Papules, nodules or plaques (as seen in the 2. Diagnose and treat underlying medical conditions that may be masked or mimicked by above patient). d) Psoriasis like rash. e) lesions in scars and tattoos. The learning objectives of cocaine intoxication. this presentation are to review the cutaneous manifestations of Sarcoidosis, the differential 3. Provide health care to patients resistent to treatment of cocaine addiciton. diagnosis of nodular cutaneous lesions in an imigrant population and the pathophysiology of CASE INFORMATION: Mr J is a 53 year-old man who presented to the Emergency Cutaneous Sarcoidosis. Considering the growing immigrant population in the U.S, the Department (ED) with chest pain in January of 2002. At that time he also described shortness of differential of an indolent chronic rash should include parasitic infestations. However, in breath, insomnia, anorexia, and a sense of anxiety. The exam revealed an agitated but otherwise patients of African decent, the extremely variable masquerading rash of sarcoidosis should be well-appearing man with tachycardia. Mr J had a positive urine cocaine screen. He was admitted considered as an important part of the differential. and ruled-out for myocaridal infarction (MI) with serial troponins and electrocardiogram. Two months later, Mr J returned with similar complaints. Again his urine was positive for cocaine and his serum was negative for troponins. Over the next three months he returned to the ED four NOT EVERY ``OA'' IS DUE TO ``DJD'' Ð HEMOCHROMATOSIS PRESENTING AS ``OA''. more times with a new resting tremor and a weight loss of over sixty pounds. Cocaine screens S.U. Rehman1, J.N. Basile1, E.B. Clyburn2, A. Shakaib2; 1Ralph H. Johnson V.A. Medical remained positive. The patient refused treatment for substance abuse and expressed Center/Medical University of South Carolina, Mount Pleasant, SC; 2Medical University of dissatisfaction with the quality of care he received. Finally in September of 2002 a Thyroid South Carolina, Mount Pleasant, SC (Tracking ID #76965) work-up was performed, demonstrating a TSH <0.1 and a free thyroxine >6.5. A radioiodide uptake scan confirmed the diagnosis of Graves' disease. The patient had symptomatic relief with LEARNING OBJECTIVES: 1. To recognize the differential diagnosis of OA (Osteoarthritis) beta blockade and propylthiouracil. He is currently scheduled for thyroid ablation. especially in a young patient. IMPLICATIONS/DISCUSSION: An estimated 1.5 million Americans (0.7%) abuse cocaine 2. To diagnose hemochromatosis in a patient presenting with OA. chronically. In 1998, cocaine contributed to Emergency Department visits on 152,000 3. Recognize that a genetic screening test can diagnosis hemochromatosis before systemic occasions (1). Cocaine abuse is a potentially life-long chronic disease. involvement occurs. Acute cocaine intoxication may mimic other diseases, preventing or delaying their diagnosis. CASE INFORMATION: A 39 year-old white male presented with a 3-year history of bilateral An easy explanation for Mr. J's tremor, weight loss and agitation were already available, thus a knee pain. Previously diagnosed as DJD. Review of systems was negative. His mother thyroid work-up was delayed. Cocaine abuse may draw the physician's attention to conditions developed osteoarthritis at a young age, and his uncle died of liver cancer at the age forty-two. caused by chronic abuse rather than unrelated medical problems. MI should be ruled out, but Examination was unremarkable. ALT and LDH were slightly elevated, all other labs were not without considering hyperthyroidism. In one study of 165 patients with cocaine normal. Serum iron and ferritin were high. Knee radiolographs showed DJD. Liver biopsy was intoxication and psychotic symptoms, only 18% were given the proper diagnosis of negative for hemochromotosis. Gene testing confirmed homozygous hemochromotosis. schizophrenia on the initial evaluation (2). Finally, some physicians may perceive substance Weekly phlebotomy treatment resulted in a complete relief. abuse as a primary and overriding health care problem. Mr. J did not wish to address his IMPLICATIONS/DISCUSSION: Knee pain is a common presentation in the primary care cocaine abuse and still rightly expected treatment of his other medical problems. In conclusion, arena. If the radiologist reports OA, generally it is considered DJD and treated as such. This many misperceptions may cloud the diagnostic process with patients who abuse cocaine: case highlights the importance of expanding the differential diagnosis of OA, especially in a confusion of symptoms with drug effects, distraction from unrelated medical conditions and young person. Etiologies includes Metabolic disorders (hemochromatosis,Wilson's disease); prioritizing abstinence above other medical care. Endocrine disorders (acromegaly, hypothyroidism);Collagen vascular diseases (RA,SLE); 1. Caulkens J American J of Public Health 09/2001 p1446 Metabolic Bone disorders(Paget's disease); Dysplasias, which form a vast group; and Endemic 2. Shaner A Psychiatry Serivices 05/1998 p684 osteoarthritis (Mselini disease, Kashin±Beck disease, and Malnad disease). Hemochromatosis is the most common adult . Early diagnosis enables rapid treatment and an improved prognosis. The first clinical manifestation is represented by arthropathy in 45% of the cases. The articular THINK IT'S MONONUCLEOSIS, BUT IT'SNOT:STILL'S DISEASE. T.M. Rohr- features of are often nonspecific and associated with a delay in diagnosis that may compromise Kirchgraber1, M. de la Cruz1; 1State University of New York Upstate Medical University, outcome. Treatment of the arthritis with analgesics is often disappointing, but identification of Syracuse, NY (Tracking ID #74876) the underlying disease permits institution of life-saving phlebotomy therapy. The aim of this LEARNING OBJECTIVES: 1.) Review the Criteria for Diagnosing Mononuclesois report is to highlight the fact that patients with premature osteoarthritis should alert the 2.) Review Still's Disease physician to screen for hemochromatosis in order to formulate the correct diagnosis before the CASE INFORMATION: Case Report: 19 yo previously healthy male c/o arthralgias and fever development of severe internal organ involvement. >4 weeks with fevers to 103, with diaphoresis,chills, rigors, mild sore throat, cough, fatigue, arthralgias, joint swelling and morning stiffness. At 3 weeks his Monospot and ASO were +, CBC, UA and SMA-7 were wnl. Diagnosed with Mononucleosis and given ibubrofen for pain SECONDARY ADRENOCORTICAL INSUFFICIENCY AFTER ONE STEROID INJECTION he worsened. ROS: poor appetite with a wt loss of 68 pounds/5 weeks. PE: 63.6 Kg, bp 104/ TO SHOULDER JOINT. A. Remington1, J. Derby1; 1Creighton University, Omaha, NE 107 hr 90 rr 18 ht 6600 T 36.5 C. Nodes: +cervical adenopathy. No HSM. Joint tenderness and (Tracking ID #76276) effusion was noted in multiple joints. A salmon-colored macular rash was noted that became LEARNING OBJECTIVES: 1. Recognize clinical presentation of secondary adrenocortical more prominent over the next hour. In addition he developed rigors and chills. On further insufficiency. 2. Learn that even a single small dose of steroids can cause secondary questioning, he described the rash as intermittent over 5 weeks, blanching, non-puritic and adrenocortical insufficiency. painless. CASE INFORMATION: A 53 year old Caucasian woman with history of hypothyroidism, IMPLICATIONS/DISCUSSION: Discussion: Adult Onset Still's disease is a rare type of depression, and right rotator cuff tendinitis, presented to clinic with a six week history of Rheumatoid Arthritis occurring primarily in young adults. Diagnosis depends on exclusion of weakness in the lower extremities, vomiting, anorexia, facial swelling, as well as overall malaise other diseases. Major criteria: T > 39 C x >1 week, leukocytosis, a salmon-colored evanescent and fatigue. She is on thyroid and estrogen replacement as well as treatment for depression. Pt rash appearing in the trunk and extremities, and arthralgias >2 weeks. Minor criteria: sore denies any use of herbal supplements. On exam her vitals are P 84, RR 12, BP 120/84. She throat, adenopathy, splenomegaly, liver dysfunction, and negative RF and ANA. Infectious appears cushingoid with the typical facies, and increased abdominal girth. Thyroid, heart, Mononucleosis (IM), may manifest with symptoms that overlap those of Still's disease. lungs, and nerves are normal. Lab results show TSH 1.96, FT4 normal, LH undetectable, FSH Arthralgia and rash may be present with IM although rarely. +Monospot can be indicative of normal, prolactin normal at 16.1, serum ACTH very low at 2pg/ml, serum cortisol IM and rheumatoid arthritis. Both IM and Still's share common symptoms such as fever, sore undetectable, urine cortisol undetectable, normal hemogram, normal electrolytes and LFTs. throat, arthralgia and rash. However, while a sore throat is a prominent feature of IM, it is a MRI of the head was done to rule out pituitary masses and was normal. After extensive review it minor symptom of Still's. Arthralgia and rash are very common in Still's disease but rare in IM. 84 Abstracts JGIM

The most impressive part of his case was his presentation. He moved like a ``little old man'' fatigue, and night sweats. He denied using tobacco or intravenous drugs. On physical when getting on to the exam table and the rash ``grew'' in front of our eyes. The patient tells examination, he had orthostatic hypotension and a new 2/6 systolic ejection murmur. He did you want he has it is up to us to recognize it. not demonstrate peripheral stigmata associated with endocarditis (Osler's nodes, Janeway lesions, or splinter hemorrhages). Pertinent labs for the hospitalization included a hemoglobin of 10.2 g/dL, hematocrit of 30.1%, and mean corpuscular volume of 81.9 fL (further labs confimed iron deficiency). An erythrocyte sedimentation rate (ESR) was 35; C-reactive protein DISSEMINATED COCCIOIDOMYCOSIS PRESENTING AS LOW BACK PAIN. was 12.5 and albumin was 2.0. WBC, BUN, creatinine, liver function tests, chest radiograph, M. Roschewski1; 1Eisenhower Army Medical Center, Augusta, GA (Tracking ID #75192) and EKG were normal. PSA, TSH, and morning cortisol levels were normal. PPD and HIV LEARNING OBJECTIVES: 1) Recognize the importance of a complete travel history screening were negative. Esophagogastroduodenoscopy and colonoscopy did not show any 2) Diagnose Coccidiomycosis when presenting as disseminated disease abnormal pathology. CT scans of the head, neck, chest, abdomen, and pelvis were 3) Recognize the importance of preventive strategies for Coccioidomycosis infection in unremarkable except for a small pericardial effusion and an old ischemic left cerebellar endemic areas infarct. On day six of his hospital stay, the patient had a fever with a Tmax of 39.0 and a CASE INFORMATION: C.S. is a 27 y/o African-American active duty soldier with no bandemia of 14% with a normal WBC count. Two sets of blood cultures were drawn and significant medical history who developed persistent lumbar back pain approximately 1 month diphtheroids, identified as species other than Corynebacterium jeikeium, grew in all specimens. after a traumatic fall. Six months prior, he was deployed along the Arizona-Mexico border A transthoracic echocardiogram revealed an aortic valve vegetation, moderate aortic performing road construction duties as a heavy equipment operator. Radiographic studies regurgitation, and an ejection fraction of 60 to 65%. A diagnosis of subacute bacterial identified lytic bone lesions of the bilateral iliac bones and left sacroiliac joint. The patient endocarditis was made and the patient was treated with a four week course of intravenous underwent a left posterior pelvic surgical debridement. Incisional biopsy confirmed the ampicillin. Surveillance cultures drawn five days after starting antibiotics were negative and the diagnosis of coccidioidomycosis and he was treated with 4 weeks of amphotericin B, followed patient remained afebrile for the rest of his hospital stay. by oral itraconazole. Approximately 4 weeks later, the patient described new thoracic and left IMPLICATIONS/DISCUSSION: Bacterial endocarditis is a common entity encountered in shoulder pain. Coccidioides immitis antibody levels (complement fixation) had increased from the hospital setting. The diagnosis may be missed as it can mimick a variety of conditions due 1:256 titer to 1:2048 titer. Bone scan revealed the presence of disease involving the thoracic its protean clinical manifestations and the diversity of pathogens associated with it. spine, sternum, and left clavicle. He again underwent surgical debridement of affected areas Recognition of these signs and symptoms can enable the clinician to make an early diagnosis followed by 10 weeks of treatment with amphotericin B lipid complex (Abelcet). C. immitis and pave the way for intervention and further reduction in morbidity and mortality. These antibody titers have fallen to 1:64, and the patient has been enrolled in a compassionate-use include constitutional symptoms such as fever, fatigue, and weight loss; new and/or changing trial of the new oral antifungal SCH 56592 (posaconazole). murmurs; embolic phenomenon such as Janeway lesions, mycotic aneurysms, and peripheral IMPLICATIONS/DISCUSSION: This case illustrates several important features of this emboli to multiple organs; and immune complex mediated phenomena such as glomerulone- disease for primary care providers. Coccidioidomycosis is an endemic disease of the phritis, Osler's nodes, and arthritis. Elevated ESR and C-reactive protein, and a positive Southwestern United States and should be considered in anyone who recently has traveled to rheumatoid factor often accompany these presentations. Anemia is present in 70 to 90% of these areas with symptoms of a non-specific respiratory illness. African-Americans, Asians, and cases. Weight loss is found in up to 25% of cases and often leads to an exhaustive work up for Latinos, as well as pregnant females are at increased risk for disseminated forms of the disease, malignancy, tuberculosis, and other chronic diseases. If there is a high index of suspicion, which may present with other common complaints such as back pain, headache or blurry vision. diagnosis can be made by positive serial blood cultures or the presence of valvular vegetations Diagnosis is often delayed in other areas of the country because adequate travel history to these on echocardiogram. Streptococci, enterococci, and staphylococci are isolated in the vast areas is not sought. Management of sequelae such as osteomyelitis often involves combined majority of cases. Other pathogens are rather uncommon and include the HACEK group surgical and medical therapies and often requires lifelong suppressive triazole therapy. (Hemophilus, Actinobacilus, Cardiobacterium, Eikenella, and Kingella), Coxiella, Neisseria, Pseudomonas, Salmonella, Streptobacillus, Bacteroides, Corynebacterium and other anaerobic gram-negative bacilli. There are case reports of native and prosthetic valve endocarditis caused by diptheroids including C. jeikeium, C. urealyticum and C. striatum. Of the nondiphtheriae STREPTOCOCCUS AGALACTIAE ENDOCARDITIS AS A COMPLICATION OF OFFICE- corynebacteria, C. jeikeium is the most worrisome as it is resistant to multiple antibiotics and BASED ENDOMETRIAL SAMPLING. M. Rossing1, E. Warm1; 1University of Cincinnati, warrants treatment with vancomycin. Diagnosis of the causative organism is imperative for Cincinnati, OH (Tracking ID #74025) initiation of therapy with appropriate antibiotics and possible surgical intervention. LEARNING OBJECTIVES: Recognize the potential for endocarditis after an endometrial sampling procedure. CASE INFORMATION: Antibiotic prophylaxis is not recommended prior to endometrial COLONIC ULCERS SECONDARY TO A SELECTIVE CYCLOOXYGENASE-2 1 1 sampling procedures or even dilation and curettage because of the very low risk of infectious INHIBITOR NONSTEROIDAL ANTIINFLAMMATORY DRUG. D.W. Rudy , R.A. Parks ; 1 complications. We report a case of acute bacterial endocarditis caused by Streptococcus University of Kentucky, Lexington, KY (Tracking ID #76601) agalactiae following endometrial sampling in a woman with no known valvular abnormalities. A LEARNING OBJECTIVES: After listening to this vignette presentation the leaner will: 59-year-old woman with a history of abnormal uterine bleeding who had undergone office 1. Recognize the importance of NSAID-induced adverse effects in the lower GI tract. 2. Add based endometrial biopsy about two weeks earlier was found unresponsive at home and was NSAIDs (including the selective COX-2 inhibitors) to the differential diagnosis of rectal brought to the hospital. She was noted to have a temperature of 102.5 degrees Fahrenheit; she bleeding and intestinal strictures. was awake, but did not speak and withdrew her left side more than her right side to painful CASE INFORMATION: A 58 year old female with a history of GERD treated with a proton stimuli. She also had petechiae in her conjunctiva, fingers and toes. Laboratory evaluation pump inhibitor, hypertension, hyperlipidemia, and hypothyroidism was prescribed celecoxib showed white blood cell count of 21,400 cells/mm3, normal electrolytes and glucose, and 200mg/day for mechanical low back pain. After approximately a month of therapy she normal liver enzymes. CT scan of the head was normal at presentation. On hospital Day 3, presented with bloody diarrhea. She denied fever or chills. There was only minor abdominal blood cultures from admission grew beta-hemolytic Group B Streptococcus from all samples. cramping. The patient has a strong family history of colon cancer and had undergone a Transthoracic and transesophageal echocardiograms demonstrated a 4Â3 cm lesion on the surveillance colonoscopy 2 years ago. This was normal except for a few small diverticula. posterior leaflet of the mitral valve with moderate mitral regurgitation. Repeat CT of the head Abdominal examination was unremarkable. Rectal exam revealed a small external demonstrated a large left middle cerebral artery infarction, but no evidence of abscess. The and no masses, red blood was found on the exam glove. Stool culture, ova and parasites, and patient responded to antibiotics, but died of complications before valve replacement surgery WBCs was negative. The patient discontinued the celecoxib and the bleeding diminished. A could be performed. flexible sigmoidoscopy demonstrated a few 5 mm ulcers in the descending and transverse IMPLICATIONS/DISCUSSION: Endometrial assessment by means of biopsy or sampling of colon. Biopsies revealed nonspecific acute and chronic inflammation. No granulomas or crypt endometrial cells is a minimally invasive alternative for dilation and curettage or hysteroscopy. abscesses were seen. The bloody diarrhea completely resolved. The patient remains off of the Techniques using the Pipelle endometrial sampling device are the most popular due to high celecoxib. Her back pain remains problematic. sensitivity and specificity compared to other office based procedures, and low rates of IMPLICATIONS/DISCUSSION: Upper GI tract ulceration with hemorrhage is a well- complications. In dilation and curettage, studies show transient bacteremia in 5% of patients recognized complication of NSAIDs. This serious side effect prompted the development of the and up to 0.34 in 100 patients have fever complicating their procedure. We hypothesize that selective COX-2 inhibitors which are touted as being safer in this regard. (However, this claim our patient's endocarditis was caused by bacteremia resulting from her endometrial sampling, has recently been questioned.) Less known important GI adverse events attributed to NSAIDs making this a very unusual complication of a common procedure. There is no data supporting include strictures and ulcerations of the small and large intestine. This case demonstrates the use of antibiotic prophylaxis for office based (i.e. Pipelle) or operating room (i.e. dilation symptomatic ulcerations of the colon attributed to celecoxib, a COX-2 specific NSAID. The and curettage) endometrial sampling. Unfortunately for our patient, mortality rates for Group patient's clinical presentation, and histology are consistent with that described with non- B Streptococcus endocarditis approach 40%, similar to those associated with staphylococcal selective NSAIDS. Clinicians must consider NSAIDs in the differential diagnosis of lower GI species. tract bleeding, ulceration, or strictures. Studies are needed to determine if COX-2 specific inhibitors are safer than non-specific NSAIDs regarding the lower GI tract. This may become especially relevant in assessing the role of COX-2 inhibitors in the prevention of colon cancer. WEIGHT LOSS WITHOUT WORKING OUT: WORK UP LEADING TO BACTERIAL ENDOCARDITIS. A. Roy1, D. McAdams1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73880) NON-KETOTIC HYPEROSMOLAR SYNDROME ASSOCIATED WITH OLANZAPINE USE IN A NON-DIABETIC PATIENT. S.W. Russell1, C.V. Mueller1; 1University of Cincinnati, LEARNING OBJECTIVES: 1. Recognize that weight loss can be the primary presentation of Cincinnati, OH (Tracking ID #77161) endocarditis. 2. Recognize signs, symptoms, and uncommon causative organisms of bacterial endocarditis. 3. Recognize that exclusion of Corynebacterium jeikeium as the pathogen in LEARNING OBJECTIVES: 1) Learn risks of atypical anti-psychotics 2) recognize association diphtheroid endocarditis is crucial for appropriate antibiotic therapy due to its multiple drug of hyperglycemia/DKA with these medications. resistance. CASE INFORMATION: A 51 year old non-diabetic female with hypertension and Major CASE INFORMATION: A 55-year-old white male with a history of alcohol abuse presented Depressive Disorder with Psychotic Features presented to the hospital complaining of blurry with an unintentional weight loss of 65 pounds over three months with associated malaise, vision and polyuria associated with fatigue for the last several days. She had been taking JGIM Volume 18, April (supplement 1) 2003 85

olanzapine 10 mg daily for the last 14 months and 45 mg for the last four months. patients. Arrhythmias are a common clinical manifestation in patients in the chronic phase of Although she had a family history of diabetes, a previous fasting glucose before beginning Chagas disease. olanzapine was 85 mg/dL. Her exam was significant only for a non-obese, dehydrated Although this patient's atrial fibrillation may not directly related to her Chagas' disease, there appearing female who was orthostatic and tachycardic. Total glucose was 1122 mg/dL and may be some benefit to treatment of the subacute phase to prevent late complications of the measured serum osmolality was 320 mOsm/kg. A venous blood gas showed pH 7.38 and pCO2 disease. 41. Other labs included positive serum ACE test, trace urine ketones, and (in mEq/L) serum HCO3 23, sodium 122 and potassium 5.4 (anion gap of 19). IMPLICATIONS/DISCUSSION: As early as 1926, patients with schizophrenia have been 1 2 1 known to have an increased risk of developing hyperglycemia, a process which was exacerbated THE CASE OF THE ``HARD'' BELLY BUTTON. M.G. Salaita , M. Panda ; University of 2 with the introduction of phenothyiazines in 1956 and the atypical anti-psychotics in 1994. Tennessee, Chattanooga, Chattanooga, TN; Society of General Internal Medicine, Increasingly, non-schizophrenic patients taking atypical anti-psychotics are demonstrating Washington, DC (Tracking ID #76692) increased episodes of hyperglycemia and the complications thereof. One proposed mechanism LEARNING OBJECTIVES: Recognize the work-up of dyspepsia and the varied presentation for this hyperglycemia is through drug interference with cellular glucose transport proteins of gastric cancer. leading to increased insulin resistance and impaired glucose utilization in the periphery. This CASE INFORMATION: A 31 year old white male presented to a walk-in clinic in July'00 effect is not dose dependent and has its onset from 10 day to 18 months after the initiation of with complaints of ``heart burn''. His father had gastric cancer and the patient admitted to the drug. The literature is replete with examples of DKA in schizophrenic patients taking moderate alcohol and tobacco use. His physical exam was normal. He was prescribed H2 atypical anti-psychotics but does not specifically report the development of non-ketotic blockers and referred to a gastroeneterologist. He underwent panendoscopy in October `00 hyperosmolar syndrome. Additionally, patients taking atypical anti-psychotic medicines for which revealed active pyloric ulceration and mild esophagitis. Empiric treatment for HPylori diagnoses other than schizophrenia±including bipolar disorder and major depression with and follow-up endoscopy in 2 months was recommended. Patient reported to the clinic in ±risk developing hyperglycemia. January 01complaining of constant epigastric pain, intermittent and melena, nausea ,vomiting, 30 pound weight loss, and a ``hard belly button'' for several weeks. Exploratory laporatomy showed gastric outlet obstruction with evidence of linitus plastica, A CASE OF STAPHYLOCOCCAL COLITIS PRESENTING AS TOXIC SHOCK carcinomatosis involving the peritoneum, omentum and liver. Pathology report of omentum 1 1 1 SYNDROME. T. Rutkoski , C. Mueller ; University of Cincinnati, Cincinnati, OH (Tracking and abdominal wall implant showed metastatic signet ring cells secondary to primary gastric ID #77132) carcinoma. Patient opted for hospice management. LEARNING OBJECTIVES: 1) Recognize the presentation of toxic shock syndrome. IMPLICATIONS/DISCUSSION: The highest incidence of gastric carcinoma occur in Japan, 2) Realize its occurrence in males and nonmenstrual females. Central and Eastern Europe. Globally the incidence of distal stomach cancers has decreased CASE INFORMATION: MZ was an 18 y.o. caucasian female with a PMH of depression and but the incidence of proximal stomach and esophagogastric junction cancer has increased. Mass PTSD who presented to the ER with complaints of fever, rash and abdominal pain. Outpatient screening programs in Japan for persons 50 years of age or older via radiography or endoscopy medications included only quetiapine. The patient was currently living in a women's shelter b/c have been effective in decreasing deaths. However, this approach does not appear to be of reported sexual abuse and she denied tobacco, alcohol, and drugs. Initial PE was significant warranted in the U.S. where the incidence of gastric cancer is the lowest. Current for fever, hypotension, conjunctival injection, rash, diffuse abdominal tenderness, and a recommendations include empiric medical therapy plus a trial of anti Hpylori therapy if negative pelvic exam. Labs revealed an elevated WBC count, a renal panel with elevated AG, non-invasive testing is positive for patients <45 years of age with new onset dyspepsia alone. mild LFT abnormalities, negative CSF tap, negative tox. screen, and a contaminated U/A with Those who fail therapy or present with more serious symptoms (dysphagia, weight loss, ketones. The patient was initially treated with ceftriaxone and aggressive fluid management. vomiting) should be referred for prompt endoscopy. Patients over the age of 45 with new onset She did develop anemia and mild pulmonary edema. Her illness gradually improved. She was dyspepsia should be referred directly to endoscopy. Common initial symptoms at diagnosis of discharged home and follow up in the office 5 days later revealed desquamation of her hands. gastric carcinoma are weight loss and abdominal pain. Ulcer type symptoms are seen in 17%. Her infectious w/u was negative except for a stool cx growing S. aureus. Toxic Shock Symptoms suggestive of metastasis include ascites, fistulae, lymphatic extension i.e Staphylococcal Toxin-1 was negative, but Staph aureus B toxin was positive. periumbilical nodule (Sister Mary Joseph's node) as in our patient or left supraclavicular IMPLICATIONS/DISCUSSION: The initial cases of staphylococcal TSS were described in lymphadenopathy (Virchow's node). More than 90% of malignant stomach neoplasms are young menstruating females in the late 1970's. Much was learned about this disease in a short adenocarcinomas. Poorly organized clusters or solitary signet ring cells and a diffusely time. Soon an association was found between highly absorbent tampons and TSS. These infiltrating growth pattern characterize the diffuse type which tends to occur more frequently tampons were removed from the market in the early 1980's. Since then the number of cases of in women and younger patients and carries a poorer prognosis. This case demonstrates an TSS has declined greatly. Today, however the number of reported cases is relatively stable. aggressive course of gastric carcinoma in a young white male who presented with the common These cases can be found in the menstruating and nonmenstruating female, the young and old, symptom of heartburn. It illustrates the need for aggressive workup of a common symptom in a and the male and female patient. There are very few cases of Staph TSS secondary to colitis in patient with risk factors or with no response to conventional therapy. the literature. Overall disease mortality has also improved throughout the years but remains as high as 15% in some studies (although more likely 2±5% by most accounts). It is therefore important to think of this disease in the differential diagnosis and treat it appropriately. ISOLATED ESOPHAGEAL ASPERGILLOSIS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSIS. M. Salaita1, M. Panda1, C. Schmitt1; 1University of Tennessee± Chattanooga Unit, Chattanooga, TN (Tracking ID #77030) AN UNCOMMON CAUSE OF ATRIAL FIBRILLATION: A CASE OF CHAGAS' DISEASE. LEARNING OBJECTIVES: 1. Recognize atypical infections in secondary immunodeficiency R. Saavedra-Romero1, M. Walsh1; 1HCMC, Minneapolis, MN (Tracking ID #77061) states. 2. Recognize the varied presentations of aspergillosis. LEARNING OBJECTIVES: 1. Understand Chagas' disease as a big public health problem in CASE INFORMATION: A 27 year-old black female was referred for endoscopy in October Latin America and the potential for this disease in U.S. immigrant populations. `01 secondary to a subjective report of one episode of hematochezia. The patient has a history 2. Identify the clinical manifestations of chronic chagas' heart disease. of steroid dependent SLE, end stage renal disease on hemodialysis and small bowel resection 3. Become familiar with the diagnostic work-up and treatment of Chagas' disease for gastrointestinal hemorrhage three years ago. Endoscopy revealed polypoid masses involving CASE INFORMATION: A 32 year old woman from El Salvador living in the United States the esophageal mucosa and external hemorrhoids. Biopsy was consistent with acute on chronic for the past 5 years presented to the ER with intermittent palpitations accompanied by candida esophagitis. Treatment with flucanazole was initiated without complaints. Followup dizziness, shortness of breath, and anxiety for three days. She reported one previous admission endoscopy in April `02 revealed normal mucosa mixed with yellow nodules with an exudate. for atrial fibrillation successfully electrically cardioverted one year prior to this presentation. Biopsy revealed fungal elements with septate hyphae and acute angle branching consistent with An echocardiogram revealed atrial fibrillation with a rapid ventricular response at a rate of 189 aspergillus. Complete blood count with differential at that time showed a total WBC of 4.2 beats per minute. Chest x-rays, electrolytes, serial cardiac enzymes and thyroid function tests TH/MM3 and 81.2% nuetrophils. Chest CT only revealed baseline mild cardiomegaly and were normal. An echocardiogram showed mild left atrial enlargment with normal left splenomegaly. Patient was treated with itracanazole. Repeat endoscopy in August `02 ventricular ejection fraction with no wall motion abnormality. continued to reveal nodularity of the esophageal mucosa with a lesser degree of exudate. The patient was started on a diltiazem drip for rate control and advanced to metoprolol for Biopsy was consistent with candida without evidence of aspergilus. long term management. She was also started on aspirin for thrombus prophylaxis. No IMPLICATIONS/DISCUSSION: Aspergillosis encompasses a variety of manifestations of underlying etiology for her arrhythmia was identified. However, an extensive review of the infection. The major entities include invasive disease, acute bronchopulmonary aspergillosis patient's family history revealed that her father had been diagnosed with heart failure secondary (ABPA) and pulmonary aspergilloma. Disease due to aspergillus organisms is uncommon and to Chagas' disease back in El Salvador. A sample of the patient's blood was sent for serology for usually occurs in the setting of immunosuppression for which neutropenia (ANC < 1500 TH/ Chagas' disease and returned positive with a titer of 1:512. The patient was placed on MM3) and corticosteroids are the most common predisposing factors. The most common nifurtimox. Although it was believed that she may have been in the subacute phase of her manifestation of invasive aspergillosis involve the lung and contiguous structures. The central illness, treatment was initiated as a means of preventing advancement of her disease to chronic nervous system and gastrointestinal system (especially esophagus and bowel) are the first and illness. second most common target of dissemination respectively. Symptoms of aspergillus esophagitis IMPLICATIONS/DISCUSSION: Chagas' disease is a protozoan infection due to Trypano- are usually consistent with severe odynophagia similar to those of candidiasis. Isolated soma cruzi and is primarily related to three problems: ; ; and cardiac esophageal aspergillosis is very rare. There are two case reports published describing this disease. Chagas' myocarditis is the most common form of cardiomyopathy in Latin-American unusual presentation, one involving a patient with acute leukemia and another occurred in a countries and therefore has become a considerable public health problem for many areas. It is patient 25 days post bone marrow transplantation. This case is of interest because though our estimated that over 750,000 years of productive life are lost annually because of premature patient was steroid dependent she was not neutropenic prior to and at the time of presentation deaths due to this disorder. (ANC > 1500 TH/MM3). Further she was asymptomatic in regards to her fungal infection and The presentation of Chagas' disease consists of an acute and chronic phase, separated by an did not have evidence of aspergillus involvement at other sites. In addition esophageal indeterminate phase. The latter describes a patient who has positive se-rology, but no involvement usually occurs as a secondary complication of severe invasive lung disease. To our symptoms, physical signs, or laboratory evidence of organ involvement. The intermediate knowledge, this is the first case to describe isolated esophageal aspergillosis in a patient without phase usually lasts 10 to 30 years, but, for unknown reasons, persists throughout life in most the overt risk factors for invasive aspergillosis. 86 Abstracts JGIM

DEVELOPING AND IMPLEMENTING A MEDICAL INTERPRETER TRAINING INR = 1.26, and APTT = 50 sec. Vitamin K was discontinued and he was discharged home after PROGRAM AT ACADEMIC HEALTH CENTERS TO IMPROVE PATIENT PHYSICIAN psychiatry consultation. COMMUNICATION. D. Salas-Lopez1,A.Natale-Pereire1,V.Barba1,M.Soto- His epistaxis and bruising of skin returned after 1 week resulting him to revisit ER. Patient Greene1, C. McLauglin1, 1University of Medicine and of New Jersey, Newark, denied any further intake of anticoagulant since discharge, however confirmed that the NJ (Tracking ID #73826) anticoagulant he had ingested 4 weeks ago with suicidal intent was infact superwarfarin (rodenticide) subsequently identified as brodifacoum. His blood studies revealed Hbg 7.9 g/dl, STATEMENT OF PROBLEM/QUESTION: 1. Assess the capacity and needs of an PT >200 sec, INR = 397.5 and APTT = 95.3 sec. He was again treated with FFP, blood Academic Health Center's language programs. 2. Develop a medical interpreter training transfusion and Vitamin K. This time he was discharged on long term high dose (100 mg/day) program based on a needs assessment. 3. Implement a cost-effective medical interpreter oral Vitamin K and out patient follow-up. program that is sustainable. IMPLICATIONS/DISCUSSION: Superwarfarins were developed in 1970's to overcome OBJECTIVES OF PROGRAM/ INTERVENTION/ WEB SITE: Because of the increasing warfarin resistance in rats. They are long acting, fat-soluble anticoagulants, and 100 times number of patients of diverse racial, cultural, linguistic, and religious backgrounds there is a more potent than warfarin. Their half-life varies from 16 to 69 days compared to 37 hours for need to produce culturally competent providers that appreciate and incorporate the patient's warfarin. Brodifacoum is the most commonly used superwarfarin thus the commonest cause of world view into management decisions. It is expected that minority populations including superwarfarin poisoning. Its poisoning is mostly accidental however it can result from suicidal Hispanics, African Americans, Asians, and other people of color will grow from 28% of our attempt, industrial exposure or deliberate self-poisoning with denial (Munchausen syndrome). population currently to 40% of our population by the year 2030. Many minority Americans, Clinical features of brodifacoum poisoning are varied and include epistaxis, hematurea, especially those with limited English proficiency, face barriers to accessing health care and gastrointestinal bleeding, ecchymosis, hemoptysis, spontaneous abortion and intracranial obtaining appropriate treatment. Addressing the needs of an increasingly diverse population has bleeding. PT, INR and PTT are usually severely prolonged but correct on mixing study. The become a major challenge to clinicians, health systems, medical schools, and public diagnosis may be confirmed by detecting brodifacoum in blood however it is usually missed on policymakers. Recognizing the importance of cultural competency and medical interpretation the initial screening test for superwarfarin and may need a special assay. we developed New Jersey's first Medical Interpreter Training Program Ð ``Bridging the Physicians must have a high index of suspicion of superwarfarin exposure when patients have Language and Cultural Gap.'' The purpose of this program was to develop a best practice model prolonged unexplained coagulopathy resistant to vitamin K replacement and FFP, along with based upon a curriculum that was practical, cost-effective, and relatively easy to implement. undetectable warfarin levels and depletion of vitamin K dependent coagulation factors. ``Bridging the Language and Cultural Gap'' provides a comprehensive ``train the trainer'' model After correction of initial life threatening coagulopathy by transfusion of blood products these to enable institutions, such as Academic Health Centers, train medical interpreters for the patients should be placed on long-term high dose Vitamin K therapy and closely followed in delivery of quality medical interpretation services and culturally competent care. outpatient clinic. DESCRIPTION OF PROGRAM/ INTERVENTION/ WEB SITE: FINDINGS TO DATE/ EVALUATION OF WEB SITE: As a result of this program, physicians and patients report high levels of satisfaction with our trained interpreter services. The State of New Jersey's Office of Minority and Multicultural Health is now moving forward in STRONGYLOIDES HYPERINFECTION SYNDROME IN AN IMMUNOSUPRESSED 1 1 1 fostering high quality language programs that will help eliminate racial and ethnic disparities in TRANSPLANT PATIENT. M. Schaeffer , E. Warm ; University of Cincinnati, Cincinnati, healthcare and will promote access to optimal healthcare for all. Legislation has been introduced OH (Tracking ID #74228) into the State legislature regarding cultural competency training and additional recommenda- LEARNING OBJECTIVES: 1) To understand that patients undergoing solid organ tions to the State are being drafted to expand this model program. Our hospital is now transplantation require immunosupressive medications and should undergo thorough implementing an on-going training program for all interpreters and staff prior to enlisting their evaluation for infectious diseases with consideration of subclinical parasitic infections. 2) To services, have hired bilingual greeters for the hospital, and a bilingual patient advocate. We have understand that patients taking glucocorticoids have compromised cell-mediated immunity also initiated a cumulative and ongoing series of research projects in the field of cross-cultural and are susceptible to life-threatening infections by organisms that typically cause mild or no disease in healthy individuals. CASE INFORMATION: Solid organ transplant patients require immunosuppression and are 1 NOT EVERY RECTAL MASS IS A PRIMARY RECTAL CARCINOMA. Q.U. Saleheen , susceptible to many life-threatening infections. We report a case of fatal fulminate infection 1 1 P. Radhakrishnan ; St. Francis Hospital, Evanston, IL (Tracking ID #76613) with Strongyloides stercoralis 3 months following orthotopic heart transplantation. A 54-year- LEARNING OBJECTIVES: 1. To emphasize the need to keep an open mind while making a old male underwent orthotopic heart transplantation for ischemic cardiomyopathy. Over the clinical diagnosis 2. To understand the different presentations of prostatic carcinoma. next 6 weeks he required increasing doses of prednisone, tacrolimus and mycophenolate CASE INFORMATION: A 66-year-old Oriental man presented with complaints of cramping mofetil for graft rejection. 8 weeks after transplant he suffered a perforated colonic abdominal pain, tenesmus (immediately after eating) and constipation with pellet like stools of diverticulum, and underwent emergent surgery. On postoperative day 14 he developed 3 weeks duration. His past history included Coronary Artery Disease and Radical hypotension, respiratory failure and decreased mental status. S. stercoralis was identified in Prostatectomy for Prostate Carcinoma 8 years ago with regular follow up. Physical stool and bronchoalveolar aspirate, and Gram negative bacteremia was found. LP revealed examination was normal except for an irregular rectal mass partially occluding the lumen of motile S. stercoralis larvae in CSF and Gram negative meningitis. Brain MRI revealed multiple the rectum. A preliminary clinical diagnosis of rectal carcinoma was made. Flexible areas of signal change consistent with extensive new infarcts. After 10 days of supportive care sigmoidoscopy showed a cauliflower like ulcero-nodular mass occupying the lumen of the and antibiotics, treatment was withdrawn at the family's request and the patient died. rectum. Biopsies of which were consistent with Adenocarcinoma. CT scan of the pelvis showed IMPLICATIONS/DISCUSSION: Strongyloides Hyperinfection Syndrome (SHS) occurs a mass adherent to the posterior wall of urinary bladder in the region of trigone, partially when massive infestation by S. stercoralis occurs in the lungs, GI tract and rarely in the central obstructing lumen of the rectum and also causing bilateral hydroureters and bilateral nervous system (CNS). Strongyloides stercoralis is a helminthic parasite endemic to the hydronephrosis. A subsequent serum PSA was 138 ng /ml, the previous value being 22 ng/ml. southeastern region of the United States. S. stercoralis has a complex life cycle in the human Based on this data a diagnosis of prostate carcinoma was made. Because of the extent of disease involving the skin, , lungs, and gastrointestinal tract. Compromised host and underlying heart disease palliative measures were chosen for management including the defenses leads to susceptibility to SHS. Along with this massive invasion of S. stercoralis, stents in rectum and bladder to relieve obstruction. secondary Gram-negative bacteremia and sepsis are common. CNS invasion is not common IMPLICATIONS/DISCUSSION: Finding a rectal mass on clinical examination is not but has devastating consequences, as seen in our patient. Perhaps the most damaging aspect of uncommon. Our case is unusual in that the rectal mass was of prostatic origin, presenting 8 CNS invasion by S. stercoralis occurs when bacteria cross the blood-brain barrier attached to years after initial diagnosis. Though rectal involvement by prostatic carcinoma is present in the parasite or within the gut of the worm leading to secondary bacterial meningitis. Although 0.56% to 11.5% of cases on postmortem studies, the presence of Denonvillier's Fascia usually pre-transplant patients infection screening occurs, thorough assessment for parasites is often inhibits it. Commonest modes of involvement of rectum are a bulging prostate mass with intact lacking. In patients in endemic areas and with risk factors for subclinical parasitic infestation, rectal mucosa or an annular stricture, ulcerating masses being the rarest and accounting for less consideration should be given to further evaluation prior to surgery and initiation of than 1% of these cases. Knowledge of this is important as it can avoid a misdiagnosis of primary immunosupressive medications. Overall mortality of SHS is greater than 80%. rectal cancer, especially in patients who do not have a history of Prostate cancer or those with a history of prostate cancer who have received radiotherapy. NEUROSYPHILIS PRESENTING AS . E. Schmidt1, B. Mathis1, E. Warm1; 1University of Cincinnati, Cincinnati, OH (Tracking ID #74057) A CASE OF PROLONGED COAGULOPATHY FROM SUPERWARFARIN OVERDOSE. LEARNING OBJECTIVES: 1) Recognize various manifestations of tertiary syphilis. S. Sarin1, H.B. Mukhtar1, A. Mirza1; 1Geisinger Medical Center, Danville, PA (Tracking 2) Recognize treatment benefits of neurosyphilis. 3) Recognize that cases of tertiary syphilis ID #73793) may increase in prevalence in the clinic setting following the rise in cases of early syphilis seen LEARNING OBJECTIVES: 1. To recognise that superwarfarin causes prolonged coagulo- in the past two decades. pathy needing high dose Vitamin K treatment for weeks to months CASE INFORMATION: A 66 year-old African American male with history of treated syphilis 2. To suspect superwarfarin overdose as a cause of coagulopathy resistant to vitamin K and at age 25 presented to an outpatient clinic following a hospital stay for recent subcortical stroke fresh frozen plasma treatment and non-Q wave myocardial infarction. He reported fecal and urinary incontinence and CASE INFORMATION: A 50 years old gentleman with a past medical history of depression subjective memory deterioration for an undetermined amount of time. On exam he was found and recurrent suicidal attempts presented to emergency room (ER) with history of hematuria, to have no anal sphincter tone and was unkempt. The patient was admitted to the hospital, and epistaxis and bruising of skin after suicidal attempt with anticoagulant ingestion. Physical had a spine MRI that was negative for any lesions. He was found to have a SED rate of 117 examination revealed widespread ecchymosis of skin and heme positive stool but was otherwise mm/h, a positive RPR with a 1:1024 titer, and a positive serum FTA-Abs. Lumbar puncture unremarkable. Laboratory studies revealed hemoglobin (Hbg) 4.8 g/dl (13.7±16.5 g/dl), revealed a pleocytosis with a predominance of lymphocytes, an elevated protein at 152 mg/dL, prothrombin time (PT) >50 sec (11.5±14.3 sec), INR too high to be reported, and activated and a positive VDRL at 32 dilutions. The patient was treated for neurosyphilis with 14 days of partial thromboplastin time (APTT) >150 sec (21±37 sec). intravenous penicillin G, 24 million units per day. He subsequently was found to be HIV Patient was thought to have ingested warfarin, the most commonly available anticoagulant. His positive. On clinic follow up, the patient had improved anal sphincter tone, improved physical anemia was corrected with blood transfusion and coagulopathy treated by fresh frozen plasma appearance, and improved subjective cognition. His weight improved by 13 pounds and his (FFP) and Vitamin K. After 6 days of treatment his Hbg was12.2 g/dl, PT = 14.7sec, RPR had decreased to a titer of 1:512. JGIM Volume 18, April (supplement 1) 2003 87

IMPLICATIONS/DISCUSSION: The patient described above had clear benefit of treatment prostate. Pertinent laboratory testing showed a mild microcytic anemia with a normal leukocyte with apparent reversal of some of the neurologic sequelae of his tertiary syphilis. There is lack count, glucose 275 mg/dl, hemoglobin A1C 11.7%, and a normal PSA. Urinalysis revealed no of data in the literature supporting reversibility of the neurologic complications of this disease, pyuria and urine cultures were negative. However, cultures of prostate secretions, and four blood especially the dementia, that is thought to be related to fibrosis, and therefore the thought of cultures obtained before the initiation of antibiotics, were positive for MRSA. A transrectal the RPR as a screening test for reversible causes of dementia has been questioned. It has been ultrasound showed large, solid, nodules in the right and left prostate likely representing an proposed that there may be an increase in the number of cases of tertiary syphilis in light of the infectious process. A biopsy of the prostate revealed severe acute and chronic prostatitis. increased number of primary syphilis cases seen in the past two decades, as well as an increase Cultures of the prostate tissue grew MRSA. Notably, sensitivities from all MRSA cultures were in the HIV population. There must be a heightened level of suspicion for this process in identical. The patient was treated with intravenous vancomycin and his clinical status improved. anyone with neurologic findings and history consistent with this diagnosis. IMPLICATIONS/DISCUSSION: Coagulase negative Staphylococcus is known to cause chronic prostatitis. Additionally, methicillin-sensitive Staphylococcus aures can cause chronic prostatitis, especially prostatic abscesses. However, we are unaware of prior cases of MRSA ENDOCARDITIS AS A RED-HERRING. N. Schmidt1, R. Witzig1; 1Tulane University, New bacteremia resulting from MRSA prostatitis. The patient's prostate biopsy showing prostatitis, Orleans, LA (Tracking ID #77065) along with the identical antimicrobial sensitivities of MRSA from both the prostatic tissue and peripheral blood, implicate MRSA prostatitis with hematogenous spread. This is a unique case LEARNING OBJECTIVES: 1. Develop a thorough diagnostic strategy for fever in patients of MRSA bacteremia, which appears to have resulted from MRSA prostatitis. Furthermore, who use intravenous drugs. 2. Diagnose splenic abcess. this case highlights the importance of eliciting a careful review of systems and performing a CASE INFORMATION: A 25 year-old woman presented with lethargy and fever. She thorough physical examination when evaluating the source of a fever. reported a history of intravenous drug use and a recent forearm cellulitis. She had a temperature of 38.28C, a systolic murmur, diffuse abdominal pain, and a purulent pustule on the left leg. The WBC was 19,000. An Abdominal CT scan demonstrated several hypodense THE STRESS OF A TEST. N. Shakir1, R. Flores1, H. Sweeney1; 1Mercy Hospital & Medical lesions in the spleen. Subsequent laparatomy confirmed splenic abscesses, and a splenectomy Center, Chicago, IL (Tracking ID #76661) was performed. Blood and splenic tissue cultures grew methicillin-resistant Staphylococcus aureus. Transesophageal echocardiogram did not show evidence of endocarditis. The patient LEARNING OBJECTIVES: To recognize Hypokalemic Thyrotoxic Periodic Paralysis and was diagnosed with impetigo and splenic abscesses with subsequent sepsis. its precipitating factors, especially since it is a rare disorder that is treatable if diagnosed. We IMPLICATIONS/DISCUSSION: Staphlococcal bacteremia is common in intravenous drug describe a case of HTPP likely precipitated by a test. users due to unsterile injection techniques. Not all patients with bacteremia, however, will CASE INFORMATION: The patient is a 59-year-old African-American female admitted for develop endocarditis. The evaluation of a fever in a patient who uses intravenous drugs should hypokalemia after a colonoscopy. The colonoscopy was for evaluation of her microcytic, extend past the heart if the patient does not meet the Duke criteria for endocarditis. The local hypochromic anemia and a recent history of a 30 lb. weight loss. The colonoscopy was skin infection in this patient led to bacteremia and subsequent splenic abscess formation and negative, and a CT scan of the chest, abdomen, and pelvis was done for further evaluation of sepsis. Spleenic abscesses with or without endocarditis are a frequent complication of patients possible malignancy which was also negative. Review of systems was notable for bilateral lower who use intravenous drugs. Almost all patients have fever and abdominal discomfort, but signs extremity weakness in addition to the weight loss. Two months prior, she had a persantine and symptoms of a splenic abscess may be vague and overshadowed by underlying endocarditis. thallium stress test for evaluation of chest pain which was positive and was followed by an The careful attention to the historical complaint and a methodical and thorough physical angiogram which showed only moderate coronary artery disease requiring no intervention. examination led to the appropriate diagostic test. Treatment requires splenectomy and Since the stress test, she had progressive lower extremity weakness associated with muscle antibiotics directed against the involved pathogens. Patients with IVDU and fever require cramps and had difficulty walking, standing at length, and had difficulty climbing stairs. careful evaluation not only for endocarditis, but also for bacterial seeding of other organs. Physical exam revealed tachycardia, thyromegaly, 3/5 motor strength of bilateral lower Abdominal signs should prompt the search for intraabdominal abscess formation. extremities, and areflexia. The remainder of the examination was unremarkable. Labs revealed a potassium level of 2.9 mg/dL, and oral and intravenous potassium replacement was given. ECG revealed a sinus tachycardia with left atrial enlargement. A thyroid workup revealed a POSTPARTUM CEREBRAL VASCULITIS. M. Schnell1, E. Warm1; 1University of Cincinnati, TSH of <0.01 and a free T4 of 8.33. We diagnosed hypokalemic thyrotoxic periodic paralysis Cincinnati, OH (Tracking ID #74060) likely precipitated by iodine in the dye. The patient was started on propylthiouracil 150 mg three times daily and metoprolol. The patient was referred for radioactive thyroid scan and LEARNING OBJECTIVES: 1) Diagnose postpartum cerebral vasculitis. possible radioablation therapy. At discharge, the patient's hypokalemia and symptoms had 2) Manage postpartum cerebral vasculitis. resolved. CASE INFORMATION: Postpartum cerebral vasculitis is rare and poorly understood. We IMPLICATIONS/DISCUSSION: HTPP is a rare, sporadic, acquired disorder usually seen in present an unusual case of a patient with progressive and evolving postpartum neurologic Asians. The incidence is <1% in Americans. The disease is associated with an underlying changes thought secondary to a pregnancy related vasculitic process. A healthy 30 year-old thyrotoxicosis (commonly Grave's disease or thyroiditis) and hypokalemia. The serum female (G1 P0) underwent a Cesarean section after unsuccessful induction of labor. The potassium level is low, but the total body potassium remains normal. Thyroid hormone pregnancy was uneventful without signs or symptoms of pre-eclampsia. Six hours postpartum mediates an increase in sodium-potassium ATPase activity and a transcellular potassium influx. she presented with right-sided hemiparesis and language difficulties. A head CT scan showed a This interferes with potassium's involvement in promoting muscle contraction Treatment of hypodensity in the left caudate and anterior internal capsule. The patient was anticoagulated HTPP includes antithyroid drugs, beta-blockers, and cautious use of potassium. Definitive and evaluated for thromboembolic source. By hospital day 4, the patient's symptoms had nearly treatment involves radioablation therapy. The current vignette helps one to recognize the signs resolved. On day 5 she developed recurrence of symptoms and was found to have new areas of and symptoms of HTPP, and describes a case that was precipitated by dye used in an infarction including the left cerebellum and posterior frontal lobe. She was started on high dose angiogram. steroids and cerebral angiogram was done which showed findings consistent with vasculitis. Subsequent imaging showed continuous evolving infarcts and intravenous cyclophosphamide was then added. A complete rheumatologic and hypercoagulable work up was performed and SHORTNESS OF BREATH IN A POSTMENOPAUSAL WOMAN WITH AN ENLARGED unremarkable except for an erythrocyte sedimentation rate (ESR) of 98 mm/hr on admission UTERUS. N. Shalan1,L.Lu1; 1Baylor College of Medicine, Houston, TX (Tracking that decreased to 52 mm/hr prior to initiation of steroids. The patient was continued on ID #74655) steroids and cyclophosphamide, as repeat imaging 6 months postpartum showed new evolving LEARNING OBJECTIVES: 1) Review the differential diagnosis of an enlarged uterus in a infarcts. 9 months postpartum, no new areas of infarction were noted and repeat angiogram non-pregnant woman. showed some resolution of changes. 18 months postpartum, the patient continues to improve 2) Recognize intravenous leiomyomatosis as a rare cause of intracardiac tumors. and is slowly being tapered off of immunosuppressive therapy. The patient has never had any CASE INFORMATION: A 56 year-old postmenopausal woman with a history of uterine other manifestations of vasculitis other than the cerebral findings as above. fibroids presented with two days of exertional shortness of breath and constant retrosternal IMPLICATIONS/DISCUSSION: The pathogenesis of postpartum cerebral vasculitis chest pressure, worse with exertion and lying flat. She denied orthopnea, paroxysmal nocturnal remains unclear. It is postulated that vasospasm of the vessels, as seen with migraine dyspnea or cough. Physical exam revealed normal vital signs, elevated JVD, clear lungs, regular headaches, may be triggered by hormonal changes unique to the postpartum period possibly rhythm with II/VI holosystolic murmur at the left lower sternal border, no extremity edema, producing an autoimmune reaction resulting in a vasculitis. Contributing factors may also and an enlarged uterus palpable 4 cm below the umbilicus. Basic labs, cardiac enzymes, and include altered hemodynamics, and the relative coagulopathy associated with pregnancy. EKG were normal. Chest x-ray showed cardiomegaly and vascular prominence. An Diagnosis of this rare but potentially neurologically devastating disease should be confirmed echocardiogram revealed normal left ventricular ejection fraction, dilated right atrium (RA) with angiogram as current therapy with high dose steroids and cyclophosphamide is not and right ventricle (RV), and tricuspid regurgitation. There were two linear mobile without risk. Recurrence of disease with subsequent births has been documented and women echodensities in the inferior vena cava (IVC) protruding into the right atrium and ventricle. diagnosed with postpartum cerebral vasculitis should be counseled on potential risks with Cardiac and abdominopelvic MRI showed multiple uterine leiomyomas, with a lobulated mass subsequent pregnancies. arising from the uterine fundus and extending up the right gonadal vein into the IVC, RA, and RV. The patient underwent total hysterectomy and total excision of the mass through the infrarenal IVC. Pathology of the mass showed intravenous leiomyomatosis. ELICITING A CAREFUL REVIEW OF SYSTEMS IS IMPORTANT IN DETERMINING THE IMPLICATIONS/DISCUSSION: The differential diagnosis of an enlarged non-pregnant UNUSUAL SOURCE OF A STAPHYLOCOCCAL BACTEREMIA. D. Schwartz1, uterus includes endometrial and myometrial processes. Advanced endometrial carcinoma is the T. Beckman1, R. DeJesus1, K. Schwartz1, S. Crane1; 1Mayo Clinic, Rochester, MN main endometrial cause. Myometrial causes are divided into benign and malignant. Benign (Tracking ID #73687) conditions include leiomyomas (i.e. fibroids), adenomyosis, and stromal adenomyosis. LEARNING OBJECTIVES: 1. Recognize the importance of eliciting a careful review of Malignant causes include leiomyosarcoma and endometrial stromal sarcoma. Uterine systems when evaluating patients with fever. 2. Consider prostatitis in the differential diagnosis conditions capable of extending into the IVC and heart are endometrial stromal sarcoma of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. and intravenous leiomyomatosis. CASE INFORMATION: A 53-year-old truck driver with diabetes presented with a three-day Intravenous leiomyomatosis is a rare benign condition in which nodules of benign smooth history of subjective fever and rigors. On review of systems the patient disclosed urinary urgency grow within the veins of the myometrium and may extend into the uterine and and dysuria. Physical examination was remarkable for a slightly enlarged, exquisitely tender hypogastric veins. Rarely, these tumors extend up the IVC into the heart. Only 43 cases of 88 Abstracts JGIM

intravenous leiomyomatosis with cardiac extension have been reported in the English therapy (HRT), presents with slowly progressive dyspnea on exertion, orthopnea, and literature. Symptoms of cardiac extension include venous obstruction, right-sided heart failure, paroxysmal nocturnal dyspnea for one year. Lower extremity duplex ultrasounds were negative and rarely, sudden death. Successful therapy entails total excision of the tumor, as residual for blood clot but did show inguinal adenopathy. Review of systems included loud snoring, tumor could result in recurrence. possible apneic episodes during sleep, nonrestful sleep, intermittent lower extremity swelling, nonproductive cough for 1 week, but no daytime somnolence, fevers, chills, or sweats. She had an 18 pound intentional weight loss over the past year. No history of alcohol, tobacco, or illicit BACK PAIN AND FEVER IN A MIDDLE-AGED WOMAN. N. Shalan1,L.Lu1; 1Baylor drug use. Physical exam: temperature 100.5 degrees F, blood pressure 146/57 mmHg, pulse 67 College of Medicine, Houston, TX (Tracking ID #74821) bpm, respiratory rate 20, pulse oximetry 95% on 2 liters supplemental oxygen. Patient was a mildly obese woman in no acute distress, with no palpable adenopathy, slightly elevated jugular LEARNING OBJECTIVES: 1) Review warning signs that suggest serious causes of back pain. venous pulse, normal air movement except for rare bibasilar crackles, a prominent P2 heart 2) Recognize the limitations of imaging studies in early spondylodiscitis. sound, and no peripheral edema, cyanosis, or clubbing. Arterial blood gas on room air: pH 3) Identify Salmonella as a rare infectious cause of spondylodiscitis. 7.44/PaCO2 35/PaO2 55/bicarb 23. Ventilation/perfusion (V/Q) scan was low probability for CASE INFORMATION: A 65-year-old woman presented with four days of low back pain and pulmonary embolism. Pulmonary function tests showed moderate combined obstructive and fever. The pain radiated down her left leg and was aggravated by movement. She denied trauma, restrictive physiology with severe gas transfer defect. Computed tomography (CT) of the chest weakness or numbness. She had a temperature of 104, blood pressure of 154/76, and heart rate showed enlarged right atrium, bulky mediastinal adenopathy, and diffuse patchy ground glass of 115. Physical exam showed lumbar paraspinal spasm with no focal tenderness. Neurological infiltrates without effusion or consolidation. Echocardiogram showed normal left ventricular exam was normal, including straight leg test. White cell count was 14000 with 90% neutrophils. (LV) size and function, moderate dilatation of the right ventricle (RV) and right atrium (RA) ESR was 64. Blood and urine cultures were negative. Lumbar x-rays were normal. An indium with flattened septum. A diagnostic procedure was performed. scan done as part of the workup for fever and leucocytosis showed increased uptake at L4-L5. IMPLICATIONS/DISCUSSION: Initial differential diagnosis included pulmonary embolus MRI of the spine revealed disc herniation at L4-L5, but no spondylodiscitis. Even though the (young woman on hormones), sleep apnea (given the pulmonary hypertension), and source of fever was uncertain, the patient was treated empirically with vancomycin with hypertensive cardiomyopathy with heart failure. However, the negative V/Q and CT, and resolution of fever. However, the pain persisted and she underwent discectomy. Pathological the bulky lymphadenopathy and patchy ground-glass infiltrates were suspicious for pulmonary exam showed acute discitis, but cultures were not done. Despite the surgery, her back pain sarcoid. Bronchoscopy with lavage and biopsy confirmed this diagnosis with negative cultures, worsened, and repeat imaging showed destruction of L4 and L5 vertebral end plates, with peri-mucosal granuloma and reactive histiocytes. The patient was diuresed, started on high prevertebral, epidural and paraspinal abscess. A CT-guided biopsy was done, and Salmonella dose steroids with slow taper, and is doing well. The diagnosis, pathophysiology and treatment javiana grew from the drained fluid. The patient had hemoglobin C trait but no of pulmonary sarcoid will be discussed. immunocompromising conditions. She was treated with fluoroquinolones and slowly improved. IMPLICATIONS/DISCUSSION: Most cases of back pain are due to simple benign etiologies. However, certain red flags prompt the search for more serious causes. These FEVER AND NORMOCYTIC ANEMIA IN A MIDDLE-AGED MAN. H. Singh1,L.Lu1; include advanced age, malignancy, signs of infection, and progressive neurological symptoms. 1Baylor College of Medicine, Houston, TX (Tracking ID #76003) Spondylodiscitis is the simultaneous infection of the vertebral body and disc space. MRI is the most sensitive and specific imaging modality, with a sensitivity of 91% during the first two LEARNING OBJECTIVES: 1) Review the differential diagnosis of normocytic anemia. weeks of symptoms. Radionuclide scanning is done when MRI cannot be performed. It is very 2) Recognize the cause of normocytic anemia by mixed processes of microcytic and macrocytic sensitive but not as specific. CT-guided biopsy should be pursued in cases of suspected anemia. spondylodiscitis, even with a normal MRI. 3) Appreciate the wide and unusual manifestations of . Most cases of spondylodiscitis are due to Staphylococcus aureus. Other organisms include CASE INFORMATION: A 56 year-old black male with history of hypertension presented to Streptococcus, E. coli and Salmonella, with the most frequent serotypes being Salmonella the outpatient clinic with six month history of intermittent low grade fever. On review of typhimurium and S. choleraesuis. Predisposing factors for salmonellosis include sickle cell systems, he denied cough, chest pain or shortness of breath, palpitations, gastrointestinal bleed, disease, HIV, immunosuppressive therapies and previous trauma. Spondylodiscitis due to S. urinary or bowel symptoms, arthritis, weight loss, numbness or weakness. Vital signs revealed javiana has not been previously reported. Hemoglobin C disorders have not been associated temp 100.5, pulse 116, blood pressure 158/96, respirations 18. Physical exam was significant with Salmonella osteomyelitis. for pale conjunctiva, guaiac negative stool, and slight decreased sensation to light touch, pinprick, and vibration in the lower extremities. Labs showed Hgb 6.7, MCV 87 with normal WBC and platelet with blood smear displaying THE YOUNG WOMAN WITH NUMB FEET. J.J. Silverman1; 1University of Pennsylvania, nucleated rbcs, anisocytosis, poikilocytosis, and isolated macrocytes. A work up including Philadelphia, PA (Tracking ID #75939) chemistries, cultures of blood and urine, ANA, ESR, and TSH was unremarkable. A vitamin B12 level was 108 pg/mL (normal 180±914 pg/mL) and hemoglobin electrophoresis showed LEARNING OBJECTIVES: 1) Recount the most common causes of a symmetric beta thallasemia. With Vitamin B12 supplementation, the patient's fever resolved. polyneuropathy; 2) Perform the initial evaluation of a polyneuropathy 3) Recognize an IMPLICATIONS/DISCUSSION: The differential diagnosis of normocytic anemia includes uncommon presentation of hypothyroidism. chronic diseases, inflammation, endocrinopathies and renal diseases. In some cases, the CASE INFORMATION: A 28 year-old female with no significant past medical history simultaneous processes of microcytic and macrocytic anemia should also be in the differential presents complaining of bilateral foot and hand numbness for the past six weeks. The sensation diagnosis of normocytic anemia. The abnormal blood smear with size variation of erythrocytes begins mid-foot, occurs intermittently throughout the day, and she specifically notes and neuropathy led to the work up and concomitant diagnosis of beta thallasemia and Vitamin worsening symptoms walking on the treadmill at the gym. She reports similar but milder B12 deficiency. symptoms in her hands, which are not related to activity. Review of systems is otherwise The clinical manifestations of Vitamin B12 deficiency include fatigue, glossitis, vomiting, notable for chronic constipation and longstanding irregular menses (since menarche at age 14). diarrhea, dementia, and neuropathies, but fever is not considered a typical feature. From the Family history is negative for polyneuropathies, cancer and thyroid disease. She smokes two literature, fever was found in approximately 40% of patients with megaloblastic anemia caused packs of cigarettes per week, does not drink alcohol or use drugs, and denies toxic exposures. by folate and Vitamin B12 deficiencies in two case studies. The mechanism of the fever is She has no history of blood transfusions, reports regular condom use with her two prior sexual uncertain, but one proposed theory is the increased activity and ineffective erythropoiesis in the partners, and is not presently sexually active. She takes fexofenadine as needed for seasonal bone marrow. Fever resolves rapidly with treatment and failure to do so should prompt a allergies. Physical exam revealed a well-appearing young woman, who was afebrile, with a search for other causes. In summary, normocytic anemia can be caused by dual processes of blood pressure of 130/80 and a heart rate of 74. Neurologic exam was notable for decreased microcytic and macrocytic anemia and fever should be recognized as an atypical feature of sensation to light touch and pinprick in the plantar aspect of her right foot, as well as decreased Vitamin B12 deficiency. vibratory sense in her right foot. The remainder of the physical exam was unremarkable. Labs were notable for a TSH of 109, FTI of 2.9, Thyroxine of 2.7 and T3U of 1.06. IMPLICATIONS/DISCUSSION: Polyneuropathy is not an uncommon problem in the ``DOCTOR, MY CHEST HURTS!'': GYNECOMASTIA IN THE ADULT MALE. primary care setting. The differential diagnosis is quite broad, but chronic systemic disorders, C.L. Spagnoletti1, M.A. McNeil1; 1University of Pittsburgh, Pittsburgh, PA (Tracking hereditary causes and inflammatory diseases account for the majority of cases. Chronic medical ID #74107) conditions commonly associated with polyneuropathies include diabetes mellitus, malignancy, LEARNING OBJECTIVES: 1) Differentiate between gynecomastia and breast cancer collagen vascular disease, organ failure, B12 deficiency, alcoholism, AIDS, toxic exposures and 2) Recognize the causes and treatment of gynecomastia. plasma cell dyscrasias. Though the history can direct the initial evaluation, for most cases it will CASE INFORMATION: The patient is a 67 year-old male with alcoholic cirrhosis who include a CBC, basic metabolic panel, liver panel, ANA, SED rate, B12, folate, lead level, RPR, presented with a painful lump in his right breast. Medications included spironolactone. Social HIV, hepatitis serologies and TSH. If this initial evaluation is inconclusive, an EMG and history was significant for one year of sobriety and current tri-weekly use of marijuana. On neurology consult are warranted. Finally, it is important to realize that hypothyroidism is physical exam, a 3 by 3 centimeter subareolar, tender, mobile, rubbery right breast mass was protean in its manifestations, and can present without its most commonly recognized signs and palpated. A smaller, similiar mass was palpated on the left. There was no nipple discharge or symptoms. retraction, overlying skin changes, or lymphadenopathy. His testosterone was normal. A diagnosis of bilateral gynecomastia was made, felt to be due to his cirrhosis, compounded by his use of spironolactone and marijuana. The patient stopped both drugs. Two months later, the SHORTNESS OF BREATH: A ``NEGATIVE'' LOWER EXTREMITY DOPPLER STUDY. patient had significant improvement in his pain and decrease in breast tissue. C.W. Simpkins1, C. Passaretti1, A. Zaas1, J. Cofrancesco1; 1Johns Hopkins University, IMPLICATIONS/DISCUSSION: Gynecomastia is common in adult males. The highest Baltimore, MD (Tracking ID #76910) prevalence is between 50 to 80 years, with an incidence of 24 to 65 percent. Patients present LEARNING OBJECTIVES: 1. Assess subacute progressive dyspnea in a young woman. with a unilateral or bilateral breast mass that may be painful. The most important 2. Recognize the presentation of pulmonary sarcoidosis. 3. Recognize the pathology and differentiation is between gynecomastia and breast carcinoma. Carcinoma is less common, pathophysiology of early pulmonary sarcoid. usually unilateral, and eccentric rather than symmetric to the nipple/areola. It is firm, fixed and CASE INFORMATION: A 48 year old African American female with hypertension, gastro- may be associated with skin dimpling, nipple retraction or discharge, and lymphadenopathy. esophageal reflux disease, bipolar disorder, a remote history of therapy and history of The conditions associated with gynecomastia are felt to represent an imbalance between total abdominal hysterectomy and bilateral salpingoophorectomy on hormone replacement estrogens and androgens. The most common causes in the adult male are as follows: idiopathic, JGIM Volume 18, April (supplement 1) 2003 89

drugs, cirrhosis, malnutrition, primary hypogonadism, testicular tumors, secondary hypogo- surpassed those of the squamous cell type. The general locations of adenocarcinoma metastasis nadism, hyperthyroidism, and chronic renal insufficiency. Causal drugs include antiandrogens, are lymph nodes and liver, and occasionally lung and bone. We report a case of antibiotics, antiulcers, chemotherapeutics, cardiovascular drugs, and drugs of abuse. The adenocarcinoma of the esophagus with leptomeningeal carcinomatosis. A 56 year old thin history, physical, and certain diagnostic tests can identify the cause in the majority of patients. white male presented with dysphagia, and a 40 pound weight loss over six months. He also had Patients with a pain, acute onset, or without an obvious etiology should be evaluated with nausea, vomiting, abdominal pain, rectal bleeding, and diplopia during this period. On exam, serum hCG, luteinizing hormone, testosterone, and estradiol levels. An asymptomatic patient he was alert and oriented. He had sluggish reaction of his left pupil, diplopia on downward found to have gynecomastia incidentally, deemed to be idiopathic, does not require further gaze, guaiac positive stool, and a microcytic anemia (MCV 61). Esophagogastroduodenoscopy tests and should be reevaluated in six months. Otherwise, treatment should be directed at showed a mass that extended from the 28th cm of the esophagus to the 37th cm including the removing the underlying cause. Active treatment with androgens, antiestrogens, and aromatase GE junction. Whole body CT scan showed an isodense mass in the foramen of Monro, mid- inhibitors is indicated in persistent gynecomastia associated with severe pain, tenderness, or esophageal thickening, multiple hepatic lesions, and celiac lymphadenopathy. Brain MRI embarrassment. Surgical therapy, including liposuction or excision, is considered in patients showed leptomeningeal carcinomatosis surrounding the pons and multiple cranial nerves. The who do not respond to medical therapy. patient received urgent whole brain radiation. Upon completion of radiation an Ommaya reservoir was suggested for intrathecal methotrexate. However, his overall quality of life deteriorated rapidly and he chose to receive hospice care. CAN'T WE JUST LET HER LEAVE? T. Spector1, P.P. Balingit1, A.G. Gomez2; 1UCLA San IMPLICATIONS/DISCUSSION: Metastatic sites for esophageal cancer typically involve the Fernando Valley Program, Sylmar, CA; 2University of California, Los Angeles, Sepulveda, liver and lymph nodes and rarely lung and bone. Direct CNS involvement is an extremely rare CA (Tracking ID #76525) occurrence. On identification of the leptomeningeal carcinomatosis our patient was able to undergo whole brain radiation to prevent any immediate risk of herniation, but given the extent LEARNING OBJECTIVES: 1. To recognize and avoid counter-transference with difficult of his disease his prognosis was extremely poor. The reasons why this adenocarcinoma spread patients. 2. To maintain a professional attitude in difficult circumstances. 3. To discuss when a to involve the CNS are unclear, and further study needs to be undertaken. As esophageal patient has capacity to refuse treatment. adenocarcinoma becomes more common, this type of presentation may be seen more CASE INFORMATION: A 36 year old female with a history of polysubstance abuse presented frequently, and clinicians should be aware of this. with 2 weeks of fevers and painful forearm lesions after skin-popping heroin. The patient was an ill-appearing, disheveled woman. Temperature was 38.4C, BP 114/68, heart rate 112. Multiple abscesses were noted on her forearms. A II/VI holosystolic cardiac murmur over the tricuspid area, not heard on previous exams, was also present. EKG and CXR were normal. NO PAIN, NO GAIN - RHABDOMYOLYSIS ASSOCIATED WITH A PERFORMANCE 1 1 1 The patient was admitted with the diagnosis of probable infective endocarditis. Within ENHANCER HERBAL SUPPLEMENT. C. Stahl , M. Szerlip ; Eisenhower Army Medical minutes of arriving to the monitored unit, she demanded to be moved to a room with a TV and Center, Fort Gordon, GA (Tracking ID #76363) swore at the nurses when they refused to give meperidine for her pain. She also demanded that LEARNING OBJECTIVES: Unregulated herbal supplements may cause severe illness in the intern be paged until methadone was ordered for her heroin withdrawal. The intern arrived young, otherwise healthy adults. to the unit after the patient had ripped off her monitor leads, pulled out her IV line and was CASE INFORMATION: A healthy 21 y/o Army 2LT presented to the Emergency dressing to leave the hospital. A panicked intern told the resident that the patient was leaving Department after taking 2 minutes off his usual 2 mile run time during his Army Physical because she felt her needs were being ignored. A psychiatrist was urgently called to determine Fitness Test (APFT). The patient had no prior difficulty passing his APFT, however he was her capacity to refuse treatment, but she left before the psychiatrist arrived. The resident found never happy with his performance. He trained for the test by running 2±3 miles at least 3Â/ the patient outside the hospital. The patient was allowed to vent her frustrations with much week. The test took place at 6 AM with an ambient temperature of 75F. At the end of the test vehemence and profanity. Satisfied that her grievances were heard, she allowed the resident to the patient collapsed complaining of ``complete muscle failure''. He was found to be fully explain the benefits of treatment and the risks of refusing care, including death. The hypotensive and tachycardic. The patient's history was significant for the use of an herbal patient was alert, oriented, and able to repeat the risks clearly prior to leaving. supplement called Energel. He had been taking this consistently for the past month to try IMPLICATIONS/DISCUSSION: Most internists are enthusiastic about finding solutions to improve his performance time. Laboratory results initially revealed severe rhabdomyolysis with difficult medical problems. However, a patient's psychological or social problem may not be a creatinine kinase (ck) of 11,000. Acute renal failure secondary to pigment-induced ATN was greeted with the same enthusiasm. It is not uncommon for a patient's personality trait or demonstrated by a serum creatinine (cr) of 2.4 mg/dl and urine positivity for myoglobin. The attitude to invoke anger, disdain or frustration in health workers. Caring for such patients with patient's ck peaked at 240,000 during his hospital course. After 8 days his ck was 45,000 and his compassion becomes a challenge. It is important to understand one's own response to difficult cr returned to normal. patients in order to recognize and prevent counter-transference from interfering with sound IMPLICATIONS/DISCUSSION: Energel is a herbal supplement that contains Ma Huang. and appropriate medical decisions. One must also recognize that the patient's decision to leave Ma Huang is the Chinese version of Ephedra which grows in many parts of the world and is without treatment, although a poor one by medical standards, was certainly within her rights. It used predominantly as a stimulant. Ephedra alkaloids are structurally similar to ephedrine and was important to appease the patient's anger to assure that she made an informed decision to pseudoephedrine. They stimulate both alpha and beta-adrenergic receptors as well as release leave against medical advice rather than out of rash frustration and anger. By clearly repeating norepinephrine from storage sites. Each tablet of Energel contains 330 mg of Ma Huang the risks and consequences, she demonstrated legal capacity to leave and was empowered with extract, which is 6% (19.8 mg) of Ephedra. The dose is 2 gelcaps a day. Our patient took this the knowledge to return or seek care elsewhere. Definitive guidelines exist that dictate when a dose. The FDA has banned the sale of Ephedra in large amounts (over 24 mg a day and does physician can treat a patient against his will. not recommend taking this product in small amounts for more than 7 consecutive days. Our patient was taking 40 mg a day for 30 days. Ephedra has caused 17 deaths and hundreds of serious side effects including stroke, myocardial infarction and seizures in previously healthy 1 1 1 AN UNCOMMON CAUSE OF HYPOGLYCEMIA. S. Agresta , B. Springgate ; Tulane, young adults. To this date there have been no reported cases of rhabdomyolysis associated with New Orleans, LA (Tracking ID #75148) Ma Huang. This is an extremely important health concern since Ephedra, in its many forms, is LEARNING OBJECTIVES: 1. Recognize ethanol ingestion as an important cause of readily available in unscrutinized and easily obtainable health supplements. sustained hypoglycemia. 2. Provide appropriate treatment for ethanol-induce hypoglycemia. CASE INFORMATION: A 37 year-old man presented after a syncopal episode. Seven months earlier he was diagnosed with alcoholic liver disease. On presentation, he was tremulous and IATROGENIC STROKE AND UNDIAGNOSED DELIRIUM: OPPORTUNITIES TO diaphoretic. The remainder of the physical exam was normal. An initial blood glucose was 30 IMPROVE CARE FOR HOSPITALIZED ELDERS. R. Sudore1, C. Landefeld1; 1University mg/dL. He received one ampule of intravenously D50. Twenty minutes later the symptoms of California, San Francisco, San Francisco, CA (Tracking ID #73989) returned. His glucose was 28. Despite additional intravenous dextrose, his glucose continued to LEARNING OBJECTIVES: To describe the risk of stroke after cardiac catheterization and to drop to between 30 and 40 mg/dl. His AST was 175 U/L, ALT 73 U/L, Hgb A1C 4.6%, and recognize iatrogenic impediments to stroke rehabilitation in elderly patients. C peptide 15.5 ng/mL (nl). Drug and ethanol screens were negative. After two days of CASE INFORMATION: An independent 73 yr-old man with a history of NIDDM and HTN continuous dextrose-containing intravenous fluids, his blood glucose level returned to normal. was transferred for cardiac catheterization (cath) after a recent non-Q-wave MI. An uneventful IMPLICATIONS/DISCUSSION: Alcohol-induced hypoglycemia is an important but cath revealed 5 vessel disease and an ejection fraction of 30%. 90 minutes post cath he infrequently diagnosed sequella of ethanol ingestion. Symptoms are precipitated by a period developed right hemiparesis and receptive and expressive aphasia. Head CT was negative and of fasting followed by ingestion of alcohol. Ethanol inhibits the normal hepatic gluconeogen- TPA was administered within 2 hours of symptom onset, but without clinical improvement. esis response to starvation-induced hepatic glycogen depletion. As this inhibition may be Two weeks later, neurologic function had not improved; agitation developed and hand gradual, hypoglycemic symptoms may develop slowly. Patients may not demonstrate acute restraints and diazepam were started. On consultation, we confirmed the sequelae of stroke, alcohol toxicity at the time of presentation. 1 Continuous intravenous glucose is required to identified ischemic lesions in three toes, and diagnosed delirium. Serum sodium was 128, but prevent recurrent hypoglycemia and to replete hepatic glycogen stores. Chronic alcoholics may other lab studies were normal. After discontinuing diazepam and restricting free water, his also have inhibition of pituitary ACTH, creating a hypo-cortisolemic state, exacerbating the agitation resolved, and his dysphagia and receptive aphasia improved. Physical therapy was hypoglycemia. started. Once his restraints were discontinued his strength improved, though other than feeding, he remained dependent in all activities of daily living. IMPLICATIONS/DISCUSSION: This case highlights the importance of iatrogenic stroke ADENOCARCINOMA OF THE ESOPHAGUS PRESENTING AS LEPTOMENINGEAL and of undiagnosed delirium. Stroke occurs unpredictably in 0.1% of persons undergoing cath. CARCINOMATOSIS. R. Srikantiah1, E. Warm1; 1University of Cincinnati, Cincinnati, OH Stroke is most often due to emboli, as evidenced by this man's cerebral and toe ischemia. His (Tracking ID #74062) risk factors for stroke from cath included advanced age, extent of coronary artery disease, and LEARNING OBJECTIVES: 1) Recognize the changing epidemiology of esophageal depressed ejection fraction. In-hospital delirium incidence on medical wards varies from 11± carcinoma. 2) Assess the usual manifestations of metastatic adenocarcinoma of the esophagus. 33%; the diagnosis is often missed in elderly patients. Delirium increases the risk of death 8- 3) Diagnose leptomeningeal carcinomatosis, a rare complication of adenocarcinoma of the fold and the frequency of nursing home placement 5-fold. Diazepam likely led to this man's esophagus. delirium and slowed his rehabilitation. Also, restraints have been shown to exacerbate delirium, CASE INFORMATION: Adenocarcinoma and squamous cell carcinoma of the esophagus adding to deconditioning and slow recovery. In addition, the incidence of delirium is decreased comprise 95 % of all esophageal cancers. Recently, the numbers of adenocarcinoma cases have from 15% to 10% by a multicomponent inter-vention including avoidance of 90 Abstracts JGIM

and restraints, but this intervention is not implemented in most hospitals, including ours. As acute airway collapse, and the element of reversibility noted in our patient may point to a role more elders undergo cath, iatrogenic stroke may occur more often. Simple clinical strategies for adjuvant anti-inflammatory medications. are indicated to prevent delirium, which is often missed and may slow or prevent rehabilitation from stroke. LINDANE TOXICITY PRESENTING AS ACUTE MENTAL STATUS CHANGES IN A YOUNG WOMAN. G. Szabo1, E. Warm1; 1University of Cincinnati, Cincinnati, OH (Tracking DON'T FORGET THE TRIGLYCERIDES: A 17 YEAR OLD FEMALE WITH ACUTE ID #74064) NECROTIZING PANCREATITIS. A. Sura1, R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73858) LEARNING OBJECTIVES: 1) Recognize the potential for lindane toxicity in adults. 2) Diagnose the signs and symptoms of lindane toxicity in adults. LEARNING OBJECTIVES: 1. To recognize the impact of severely elevated triglycerides CASE INFORMATION: The toxicity of lindane is well known for the pediatric population, 2. To recognize the common causes of acute pancreatitis 3. To evaluate and manage the patient but is generally under appreciated among adults. Inappropriate application of lindane by adults presenting with acute pancreatitis can lead to significant neurologic changes and even death. A 22-year-old thin female without CASE INFORMATION: KD is a 17 year old female with a history of hypertriglyceridemia significant medical history was brought to the emergency room by her mother after one day of who presented to the emergency department with severe abdominal pain, nausea, and agitation, visual and tactile , paranoia and a five-day history of rash. The rash vomiting. She also complained of dizziness and lightheadedness. She denied alcohol use, consisted of pruritic erythematous macules on her abdomen and body. The patient was seen at medication use, family history of pancreatitis, history of or trauma. Although her an outlying emergency room, diagnosed with scabies and given lindane cream. Her rash symptoms were similar in character to her previous episodes of pancreatitis, they were much persisted and she went to another emergency room for evaluation; again she was diagnosed more severe. At the time of presentation, she was febrile to 103 degrees Fahrenheit and with the scabies and prescribed lindane. 2 days later she presented with the above symptoms. orthostatic. Her examination revealed significant abdominal distention, absent bowel sounds, Her exam showed numerous crusted, mildly erythematous erosions and excoriations and exquisite diffuse tenderness to palpation. There was no rebound tenderness. Her lab work throughout her body. No vesicles or burrows were noted. She was agitated with paranoia revealed a hemoglobin of 6.8 (normal for her was 15), WBC 15.8, albumin 2.3, calcium 6.5 and and visual hallucinations. An extensive workup was essentially negative and included a normal triglyceride level of 11,000. Lab work also showed Na 133, K 3.3, Cl 100, CO2 22, BUN <2, lumbar puncture, negative blood cultures and herpes simplex PCR, an unremarkable head CT, Cr 0.4, glucose 217, lipase 1221, amylase 117, triglycerides >11,000, total cholesterol 245, no vasculitic change on skin biopsy, and negative serologic studies for RMSF, varicella zoster, HDL 14, Ca 7.4, albumin 2.3, Tbili 1.6, AST 25, ALT 22, GGT 83 and alkaline phosphatase syphilis, cryptococcus and HIV. After her sensorium cleared she acknowledged that she left the 96. CT scan of the abdomen revealed severe necrotizing pancreatitis with necrosis of the lindane cream on for 12 to 16 hours, applied it all over her body and did not wash her sheets. pancreatic duct, large amount of ascites, and a large retroperitoneal phlegmon. She was started She was discharged in stable condition without any neurologic deficits. on imipenem, given blood transfusions, and maintained NPO. She was admitted to the ICU IMPLICATIONS/DISCUSSION: Although lindane deposits in all lipid tissues, it has a high for severe necrotizing pancreatitis. propensity for the white matter of the brain. Generally, children are at higher risk for toxicity IMPLICATIONS/DISCUSSION: Acute pancreatitis is an acute inflammatory process of the because of their smaller size and lipid deposits. However, thin adults like the one described pancreas. It is associated with severe acute upper abdominal pain and elevated serum levels of above, are also susceptible. Lindane absorption is enhanced by its contact with irritated skin, pancreatic enzymes. Most cases are associated with gallstones or alcohol, but the precise another risk factor also present in our case. Lindane toxicity is a clinical diagnosis and as such pathogenetic mechanisms are not understood completely. Other causes of acute pancreatitis must be kept in mind especially in patients presenting with a history of ascabies-like rash and include biliary sludge, post-procedure, hypertriglyceridemia, hypercalcemia, drugs, trauma, mental status changes. HIV, and hereditary causes (pancreas divisum or a genetic mutation). The diagnosis is made via clinical exam, laboratory findings, and, if needed, imaging studies. CT scan is the most helpful imaging test for the diagnosis and its intrabdominal complications. Serum triglyceride WHY YOU SHOULD RUN TO SEE EVERY CROSS-COVER PATIENT WHEN ON-CALL. concentrations above 1000 mg/dl can precipitate attacks of acute pancreatitis and may account S. Tadic1, J. Hefner1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76487) for 1.3±3.8% of cases. The clinical manifestations of hypertriglyceridemia associated pancreatitis are similar to those seen with other causes with the exception that, for poorly LEARNING OBJECTIVES: 1.) Recognize an unusual presentation of a hypertensive understood reasons, the serum amylase may not be elevated substantially. Clinical assessment emergency in a young person; 2.) Diagnose an atypical presentation of a pheochromocytoma; of severe pancreatitis is as accurate as most scoring systems. Treatment of acute pancreatitis is 3.) Evaluate and treat a catecholamine-producing tumor. aimed at correcting predisposing factors and at the pancreatic inflammation itself. General CASE INFORMATION: A previously healthy 27-year-old Vietnamese male was brought to management consists of supportive care with intravenous hydration, pain management, the emergency room with an acute onset of an expressive aphasia and left hemiparesis. He was antibiotics, parenteral or enteral (jejunal) feeding, and in severe cases, necrosectomy. unresponsive upon arrival and required intubation. A head CT revealed a large subcortical intracranial hemorrhage (ICH) involving the right basal ganglia. The patient underwent an emergent right craniotomy with evacuation of the intracerebral hemorrhage and placement of ACUTE-ONSET ADULT TRACHEOBRONCHOMALACIA. A.C. Sura1, M. Ghajarnia1, an extraventricular drain. Postoperatively, he was admitted to the Neuro Intensive Care Unit R. Granieri1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #73859) (NICU) for monitoring. Over the next 72 hours the patient was observed by nursing staff to have periods of intermittent hypertension, treated with prn IV medications and hypotension, LEARNING OBJECTIVES: 1) To recognize the clinical presentation and diagnostic workup treated with fluid boluses (SBP range 88±210). After 4 days in the NICU, the patient was of tracheobronchomalacia in adults. 2) To manage the patient with severe hypoxemia observed to have facial and chest . A pheochromocytoma was suspected. Abdominal secondary to tracheobronchomalacia. MRI revealed bilateral large adrenal masses with increased T2-weighted signal. Results of a 24- CASE INFORMATION: A 74 year-old male with hypertension and degenerative joint disease hour urine collection for metanephrines and catecholamines included: metanephrines 6,320 presented for preoperative evaluation prior to hip replacement. He endorsed progressively (26±230 mcg/24 hr); normetanephrines 24,760 (44±540 mcg/24 hr); VMA 16.5 (6 or less mg/ worsening dyspnea with exertion in the past three weeks, orthopnea and lower extremity 24 hr); and total metanephrines 31,080 (90±690 mcg/24 hr). Urine dopamine 2,136 (80±440 edema. His oxygen saturation was found to be 69% on room air. He denied fever, chills, chest mcg/24 hr); epinephrine 423 (0±25) and norepinephrine 3,071 (0±100). Calcitonin level was 5 pain, or chronic cough but endorsed occasional wheezing and cough productive of white (0-8) and genetic testing for von Hippel-Lindau(vHL) syndrome was negative. The patient sputum in the past two months. He had a distant history of 20 pack-years tobacco use as well as developed a right femoral DVT and tested positive for the Lupus Anticoagulant. He a 50 year history of work in a coal mine. On physical, blood pressure was 147/84, pulse of 69, underwent a bilateral adrenalectomy and was discharged to home 2 months later on Coumadin and respiratory rate of 25; oxygen saturation improved to 91% on non-rebreather facemask. and Hydrocortisone. Pathology revealed malignant pheochromocytoma and a metastatic ABG revealed respiratory acidosis with metabolic compensation. The patient developed workup was negative. His post-surgical evaluation revealed normal levels of urine ventilatory failure with a drop in O2 saturation to 45% and PCO2 of 140. He was intubated, metanephrines and catecholamines. and chest CT revealed left lower lobe collapse. Bronchoscopy showed complete collapse of the IMPLICATIONS/DISCUSSION: Although pheochromocytoma is a rare disease, this case left mainstem bronchus. The patient's subsequent hospital course consisted of intermittent represents the value of bedside evaluation by a physician. Paroxysmal symptoms (i.e. respiratory failures requiring repeat intubations. Once extubated, he was maintained on intermittent) can often be treated with prn interventions leading to misdiagnosis or delay in supplemental oxygen and BiPAP. Repeat bronchoscopy found similar findings of flaccid diagnosis. A rare presentation of pheochromocytoma is one of cyclic fluctuations of HTN and airways. The patient was deemed ineligible for stent placement and high risk for distal collapse hypotension that occurs via an uncertain mechanism. While most are given extensive airway involvement. The patient was discharged on oxygen and BiPAP but sporadic, bilateral tumors are often associated with 2 primary familial disorders: MEN-2 and subsequently weaned off of supplemental oxygen completely. VHL. Measurement of plasma or urine catecholamines and metabolites are diagnostic in 95% IMPLICATIONS/DISCUSSION: Hypoxemia and hypercarbia refractory to standard of patients with symptoms. MRI scans are sensitive (98±100%) but are only 70% specific. On treatments for obstructive pulmonary disease may result from airway collapse without any T2-weighted images, however, pheochromocytomas appear hyperintense while other adrenal immediately identifiable causes. Well recognized in infants, tracheobronchomalacia (TBM) tumors appear isointense. While there is no universally accepted method of preparation for may also be present in 4.5±15% of all adult patients with respiratory complaints and can mimic surgery, alpha-adrenergic blockade followed by beta-blockers with surgery 2 weeks later, is chronic bronchitis. It is a disease of middle to late age, more common in males, and in those common practice. Recurrence rates are 14% at 10 years. with a history of chronic respiratory irritation or inflammation but without a clear association to obstructive lung disease. Identified pathology has been limited to a decrease in the longitudinal elastic fibers of the trachea. Bronchoscopy under local anesthesia is the diagnostic THE ETHICS OF HOUSING AND OPIATE CONTRACTS IN CASE MANAGEMENT. gold standard, demonstrating airway narrowing greater than 50% during expiration. Also E. Tan1, M. Merlin2, W. Mains1, L. Zenki2, E. Miller2; 1UCSF, SF, CA; 2San Francisco General supportive are pulmonary function tests showing a low FEV1/EIV1 ratio and characteristic Hospital, SF, CA (Tracking ID #76455) notching in the forced expiratory spirogram. Bronchodilators, antibiotics, and mucolytics may be beneficial in patients with concomitant obstructive airway disease or asthma; however, LEARNING OBJECTIVES: This clinical vignette discusses the ethical implications of using definitive treatment in TBM involves reversing the airway collapse. Avoidance of airway medication and housing contracts in voluntary case management programs. The Medical High irritants and cough suppression are first line measures. Surgical stenting has been used with User Case Management Program provides intensive case management, assisting patients with success in many cases, but in patients too frail to undergo such procedures or in those with medical adherence, entitlements and housing. When appropriate, case managers will draft extensive airway involvement, positive airway pressure appears to be the best means of housing and medication contracts for opiate pain medications Contracts are done in medically managing patients with TBM. Moreover, airway inflammation may play a role in consultation with primary care providers and the program internist psychiatrist and nurse. JGIM Volume 18, April (supplement 1) 2003 91

As part of these contracts, the program will assist with the refilling of opiates and provide test to distinguish SIADH from psychogenic water drinking, as the concentrating effects of temporary housing. Patients must agree to make scheduled medical and substance abuse ADH should increase the urine osmolarity. Hyponatremia may cause neurologic impairment, appointments. but this impairment is usually in the form of seizures as opposed to psychosis. Treatment of CASE INFORMATION: The patient is a 47-year-old woman with a history of admissions for psychosis-induced SIADH is with neuroleptics designed to control the psychosis. Medical CHF secondary to cocaine dependence. Her care has been complicated by a history of consultation for hyponatremia in the psychiatric ward is a common occurrence . Physicians borderline personality disorder, chronic back pain, a history of upper GI bleeds, major should be aware of this underdiagnosed cause of hyponatremia, and of its successful resolution depression and homelessness. The patient's stated goals on enrollment include housing and with anti-psychotic therapy. sobriety. The patient signed a contract that included opiate pain medications, temporary housing, substance abuse treatment and money management. Over the course of the next few months the patient would repeatedly binge on cocaine after receiving her general assistance 30-YEAR-OLD FEMALE WITH SHORTNESS OF BREATH AND TACHYCARDIA. check at the beginning of each month. The case management program terminated the housing K. Thavarajah1; 1Boston University, Boston, MA (Tracking ID #74339) and medication contract and asked the patient to see her primary care physician for all opiate refills. While the patient continued to binge on cocaine, the case manager continued to assist LEARNING OBJECTIVES: Management of postpartum cardiomyopathy. the patient with non-opiate medication refills, appointments with her primary care physician CASE INFORMATION: 30-yr-old Black female (G2P2, uneventful pregnancies, 3 months and applications for both housing and a money management. The patient eventually enrolled postpartum) presented with 5 days of cough, shortness of breath, palpitations, diaphoresis, herself in a residential drug treatment program. She was restarted on her pain medication fatigue, PND and orthopnea without chest discomfort, leg edema/pain, fevers/chills, urinary contract after seeing her primary care provider and is awaiting housing. symptoms or recent illness. Meds: oral contraceptive. Family history: no cardiac disease. Exam: IMPLICATIONS/DISCUSSION: While we believe that contracts for housing and pain BF in no acute distress, 145/89, 138, RR 20, 96% on room air, JVP 8 cm with HJR, laterally medication refills may be useful in providing external control for seriously medically ill displaced PMI, no RV heave, S1S2 summation gallop, bibasilar crackles, trace lower extremity patients, these contracts poses important ethical questions. These contracts may challenge the edema. WBC 8.2, Hct 37.3, Na 136, K 4.7, BUN 12, creatinine 0.5; TSH 2.01; U/A negative principle of patient autonomy in patients who retain the legal ability to make medical decisions. for protein. EKG: sinus tachycardia @ 130, borderline LVH with strain pattern. Transthoracic These contracts also use housing and pain medications as incentives, items that many feel echocardiogram: EF 15%, LV dilated, global HK, severely depressed RV systolic function, should be viewed as rights. Therefore these contracts should never deny patients access to the biatrial enlargement, 2+ MR, 1+ TR (valves structurally normal), no pericardial effusion. The usual standard of care. Instead they should be voluntary and provide additional services that are patient was given gentle diuresis, afterload reduction (initially ace inhibitors (ACE), then contingent on the patient's adherence to a care plan. It is also important that contracts be done angiotensin receptor blockers (ARBs) after development of cough), digoxin, anticoagulation as part of an ongoing patient provider relationship to insure patient safety. Finally these (lovenox and coumadin), beta-blockers (Toprol XL after symptoms of heart failure resolved), contracts have the potential to reduce morbidity and mortality, which remains an important and sodium/water restriction; oral contraception was discontinued. She continues to do well as ethical imperative. an outpatient (NYHA Class I heart failure) on this regimen. IMPLICATIONS/DISCUSSION: Postpartum cardiomyopathy (PPCM), a dilated CM, defined as LV dilatation and systolic dysfunction occurring between the 9th month of A GENTLEMAN WITH INTRACTABLE HYPERTENSION. C. Tang1; 1Wayne State pregnancy and 5 months postpartum in the absence of other cardiac or metabolic conditions, University, Detroit, MI (Tracking ID #74797) affects 1000±1300 women/year in the US. Up to 50% recover sytolic function within 6 months of diagnosis (85% 5-yr mortality in those who do not recover systolic function.) Risk factors are LEARNING OBJECTIVES: 1. Recognize secondary causes of hypertension. poorly defined. The etiology may involve myocarditis, maladaptive immune or hemodynamic 2. Recognize Cushing's reflex. response to pregnancy, cytokines, prolonged tocolysis and/or a familial syndrome. Complica- CASE INFORMATION: A 48 year old male presented with crushing chest pain of several tions of dilated CM include arrhythmia, thromboembolism or sudden death. Diagnosis is based hours duration and a worsening of his chronic headaches (which had started 8 months ago after primarily on history, physical and echocardiography. Treatment consists of diuresis with lasix a closed ). In the previous 30 hours, he had taken 14 tablets of clonidine to try to (and spironolactone in class IV CHF), afterload reduction (ACE, ARBs, hydralazine/nitrates), relieve the headache which he thought was due to his hypertension. On review of systems, he beta blockade (after decompensated heart failure symptoms are controlled), anticoagulation noted a 35 pound weight loss over the past 8 months and admitted to sexual activity with and digoxin. Given the hemodynamic stress of future pregnancy (increased intravascular several prostitutes. The only other medication he takes is ibuprofen. volume, heart rate, basal metabolic rate and anemia) and the uncertainty of recurrence of His vitals revealed he was afebrile with a pulse of 42 and a blood pressure of 205/133. His exam PPCM, most physicians advise against future pregnancy. showed some temporal wasting and grade III hypertensive retinopathy without papilledema. He had an S4 present, but the remainder of his initial cardiac, respiratory, abdominal, neurologic and musculoskeletal exam was unremarkable. 1 2 1 Serial ECGs showed sinus bradycardia, left ventricular hypertrophy, and T-wave inversions in USING OCCAM'S RAZOR TO GUIDE DIAGNOSIS. A. Toprani , J. Wiese ; Tulane 2 the lateral and inferior leads. Initial electrolytes, CBC and serial cardiac biomarkers were also University HSC (SL-12), New Orleans, LA; Tulane University, New Orleans, LA (Tracking unremarkable. A head CT without contrast showed grey-white matter changes consistent with ID #76972) hypertension. LEARNING OBJECTIVES: 1. Use Occam's razor as a cost-effective guide to investigate The patient was admitted to the cardiac care unit. A CT scan with IV contrast of the abdomen multiple complaints and thorax showed no evidence of an arotic dissection. His blood pressure was controlled with 2. Recognize the importance of evaluating infectious metastasis from endocarditis. IV nitroglycerine initially, but then required fenoldopam and nicardipine drips, parenteral CASE INFORMATION: A 45 year-old man presented with one week of fever and back pain. hydralazine, procardia, clonidine, and labetolol. He developed a third cranial nerve palsy on the He had no history of trauma, leg pain, weakness or paresthesias. Two weeks prior he had been right and his serum sodium dropped from 137 mmol/liter on admission to 121 mmol/liter seen for the same symptoms. A urinalysis at that time showed 20 WBC's and 90 RBC's; he was three days later. CT scans of the head were repeated twice with and without contrast with no empirically treated for a urinary tract infection and lower back muscle strain. After no relief, he change from the initial CT scan. re-presented with persistent back pain and fevers. His exam was notable for a 3/6 systolic A lumbar puncture was performed and cryptococcal meningitis was diagnosed. A subsequent murmur at the apex obscuring S2, and point tenderness over the lumbar spine. His blood HIV test was positive. His CD4 count was 12. Amphotericin B was started. Elevated cultures grew Streptococcus viridans. An MRI of the lumbar spine showed edematous changes intracranial pressure was controlled by serial lumbar punctures. The patient's cranial nerve at T12-L1 with loss of disc space, consistent with discitis. An echocardiogram confirmed palsy showed minimal improvement, but his hypertension improved. endocarditis. Further questioning revealed he had had a tooth extraction six months prior to IMPLICATIONS/DISCUSSION: The presence of intractable hypertension, bradycardia, and presentation. headache suggests increased intracranial pressure as a cause for his hypertension. It is a well- IMPLICATIONS/DISCUSSION: DISCUSSION: Together the diagnoses of urinary tract known cause of hypertension but rarely considered. In this case, his bradycardia was initially infection and lower back strain adequately explained his symptoms, though each was unable to thought to be secondary to clonidine. He also lacked any focal neurologic deficits or do so on its own. Integrating the two symptoms, per Occam's razor, pointed to endocarditis as papilledema on initial presentation to suggest an intracranial pathology. A retrospective case- a common diagnosis. The fever, bacteremia, and back pain generated sufficient pre-test control study published in 1992 showed an increased incidence of diastolic hypertension in probability for discitis to warrant an MRI for evaluation. Unlike the more common acute AIDS patients with cryptocccal meningitis. bacterial endocarditis from intravenous drug use, sub-acute endocarditis may exist with sub- clinical symptoms for months. Any bone or joint pain in the setting of suspected endocarditis should prompt evaluation for a metastatic infection. Using Occam's razor as a guide, an MRI SIADH. CAUSING OR CAUSED BY PSYCHOSIS? A. Tendler1, J. Wiese1; 1Tulane was obtained. The appearance of the verterbral lesions suggested the diagnostic: while cancer is University, New Orleans, LA (Tracking ID #77076) dependent upon vascularity and therefore respects the avascular verterbral disc space, infections extend through the disc space. The patient was treated with six weeks of antibiotics LEARNING OBJECTIVES: 1. Recognize organic psychosis as a correctable cause of SIADH with resolution of his symptoms. 2. Distinguish SIADH from from psychogenic polydypsia. 3. Know other causes of SIADH in the psychiatric patient. CASE INFORMATION: A 56 year-old woman with a history of schizophrenia was admitted T' IS VAIN TO DO WITH MORE, WHEN ONE EXPLAINS IT ALL: OCCAM'S RAZOR. to the inpatient psychiatry service with paranoid delusions of her brother trying to kill herself A. Toprani1, J. Wiese2; 1Society of General Internal Medicine, New Orleans, LA; 2Tulane and all religious ministers. Her physical examination was normal, including normal neurologic University Dept of Internal Medicine, New Orleans, LA (Tracking ID #76650) and pulmonary examinations. Her serum sodium was 124 mmol/L and her measured osmolality was 261 mosm/kg. The urine osmolality was 522 mosm/kg. She was treated with LEARNING OBJECTIVES: To illustrate the concept of Occam's Razor through a case that risperidone and free water was restricted. She was allowed a liberal salt-containing diet. Her was initially misdiagnosed as two separate disease processes and later found to have a single psychosis improved over the next week, with normalization of her serum sodium. cause. IMPLICATIONS/DISCUSSION: Hyponatremia in the schizophrenic patient should not be CASE INFORMATION: A 45 year-old Caucasian man presented with fever, chills, night reflexively attributed to psychogenic polydyspia. Because ADH is liberated from the sweats and back pain. Nine days prior, he had experienced fever and back pain. He had no hypothalamus through the posterior pituitary, anti-psychotic medications acting at surround- history of trauma, leg pain, weakness or paresthesias. A urinalysis showed 16 WBC's, 92 ing structures may cause SIADH, as may primary psychosis. The urine osmolarity is the best RBC's; he was empirically treated for a urinary tract infection and lower back strain. He 92 Abstracts JGIM

received no relief, however, and he re-presented with persistent back pain and fevers. Further THE USUAL SUSPECT IN AN UNUSUAL SPOT. J.T. Tseng1, P.P. Balingit1; 1UCLA San questioning revealed he had a past history of mitral regurgitation and had had a tooth Fernando Valley Program, Sylmar, CA (Tracking ID #76488) extraction six months prior. He had a 3/6 systolic murmur at the apex and point tenderness LEARNING OBJECTIVES: 1. Recognize the clinical presentation of . over the lumbar spine. His blood cultures grew Streptococcus viridans. An MRI of the lumbar 2. Consider mycobacterial and other atypical organisms as etiologies of liver abscess in the spine showed edematous changes at T12-L1 with loss of disc space, consistent with discitis. An immunocompromised host. echocardiogram confirmed endocarditis. CASE INFORMATION: A 41 year old Mexican male with no significant past medical history IMPLICATIONS/DISCUSSION: Although the diagnosis of urinary tract infection and lower presented to an urgent care clinic with 1 month of gradually worsening right upper quadrant back strain adequately explained his symptoms, each of the two diagnoses was insufficient in abdominal pain associated with fevers and night sweats. He described the pain as a dull, explaining all of the symptoms. William of Occam suggested that, ``one should not increase, constant discomfort without radiation, exacerbated with movement and without change with beyond what is necessary, the number of entities required to explain anything.'' Known as food intake. Several episodes of nausea and vomiting occurred in the last two days. Intermittent Occam's Razor, this principle guides physicians to search for one diagnosis to explain all watery diarrhea was present over the past two weeks. He sought medical attention for his symptoms, instead of invoking multiple diagnoses. The fever, bacteremia, discitis and immune- abdominal pain one week ago and was prescribed levofloxacin and metronidazole without relief mediated glomerulonephritis in a patient with valvular abnormality and poor dentition can all of symptoms. The patient reported frequently visiting Mexico, his last trip being 2 months be attributed to infective endocarditis. prior. He denied HIV risk factors including homosexual or promiscuous sexual behaviors, IV drug use, or transfusions. Exam was significant for temperature of 38.8 C and heart rate of 106. Tenderness was elicited upon palpation of the right upper abdominal quadrant. No AN OIL PIPE CLEANER OUT OF BREATH. D. Tran1, J. Wallace1; 1UCLA±San Fernando hepatomegaly was apparent, and a Murphy's sign was not present. CBC was remarkable for Valley Program, Sylmar, CA (Tracking ID #75804) lymphopenia. Liver transaminases were within normal limits. No organisms were identified from blood cultures, stool cultures, and studies for ova and parasites. HIV antibody test was LEARNING OBJECTIVES: 1. Recognize as a cause of pulmonary fibrosis. 2. Discuss positive. Abdominal CT scan revealed a 2 Â 2 cm low-density irregular lesion consistent an the differential diagnosis of silicosis with abscess within the right hepatic lobe. Tissue obtained from percutaneous drainage of the CASE INFORMATION: 25 y/o Hispanic male presented to ER for increasing dyspnea on liver lesion revealed necrosis and granulomatoid inflammation. AFB stain was positive, and TB exertion. His symptoms began insidiously about a year prior to admission, and have gradually was identified in culture. TB was also isolated from the patient's sputum, despite the absence of worsened to the point where he can walk less than 1 block. His clinical course, thus far, has cough, dyspnea, or other pulmonary symptoms. Four-drug antitubercular therapy was initiated been punctuated by periods of exacerbation for which he was treated with antibiotics and with resolution of the patient's presenting symptoms. prednisone with moderate success. He denies fever, chills, weight loss. There is no history of IMPLICATIONS/DISCUSSION: Liver abscesses of varying etiologies tend to have similar wheezing, asthma, chest pain, orthopnea, PND, or edema. The patient emigrated from Mexico clinical presentations. Patients typically present with fever, night sweats, and right upper three years ago. He denies any current or past of tobacco, drug abuse, or alcohol. On further quadrant abdominal pain. Identification of the causative agent becomes critical when patients questioning, the patient states that he spent three years in Mexico working as an oil pipe fail to respond to empiric therapy against pyogenic or amebic abscesses. Serologies are often ``cleaner''±which involved sandblasting. Physical exam and labs are only significant for a not helpful in identifying an organism as assays often lack sufficient sensitivity or specificity and respiratory rate of 32 and paO2 of 70 mmHg at rest. CXR showed diffused bilateral infiltrates. blood cultures may not reveal the offending agent. While CT, MRI, or ultrasonography may High Resolution CT showed extensive, bilateral, coalescing pulmonary nodules with an upper help differentiate liver abscesses from neoplastic processes, they are unable to identify a specific lobe predominance and non-calcified hilar adenopathy. Patient is PPD and HIV negative. ACE organism. Drainage of the abscess remains the mainstay of diagnosis. For immunocompro- level was 73 (9±67). He underwent video assisted thoroscopic lung biopsy. The pathology mised patients, laboratory analysis of drainage fluid should include evaluation for atypical showed non-casseating granulomas with bifringent spicules consistent with sicilosis. Fungal organisms as well as Gram stain, culture, and ova and parasites. In these patients, mycobacterial and AFB cultures were negative. and fungal organisms may form abscesses in addition to typical granulomatous lesions when IMPLICATIONS/DISCUSSION: Silicosis is a type of caused by the they invade the liver. inhalation of silica dust leading to pulmonary fibrosis. Individuals who work in metal mining or cutting, polishing, or carving stone are at risk. Symptoms usually develop after 3 to 20 years, depending on exposure level. Silicosis can either be simple: asymptomatic and non-progressive, HEADACHE : MORE THAN IT LOOKS. S. Vadgama1, O. Melamed2, M. Bhandari2; 1VA identified by small, round opacities on chest x-ray; or complicated: symptomatic with West Los Angeles Healthcare, Los Angeles, CA; 2Olive View±UCLA Medical Center, progression despite discontinuance of the insults. Differential diagnosis includes sarcoidosis, Sylmar, CA (Tracking ID #76053) coal worker's pneumonconiosis, neoplasia, TB, and fungal pneumonia. The diagnosis of silicosis is based on careful occupational history, radiographical evidences and pathology. LEARNING OBJECTIVES: 1. Acromegaly can present in younger patients 2. The role of Radiographically, silicosis is characterized by small, round opacities with an upper lobe insulin-like growth factor 1 in diagnosis and therapy 3. The importance of early diagnosis predominance that can form extensive coalescing masses in advanced cases. The presence of CASE INFORMATION: 22 y/o latino male presented to our urgent care clinic with a history eggshell calcifications on hilar lymph nodes may help distinguish silicosis from other of headache for over 2 years. The headache was intermittent in nature, mostly frontal and pneumoconiosis. ACE level is elevated in sarcoidosis but can also be elevated in miliary TB, without exacerbating, relieving factors or associated symptoms and with minimal relief from , , and silicosis. When the diagnosis is in doubt, biopsy can help establish analgesics. On systems review he admitted to an increase in the size of his hands and feet. His the diagnosis and exclude other causes. On pathology, hyalinized silicotic nodules can be seen. family also reported a gradual change in his appearance. On examination, the patient was They are formed by macrophages engulfing the particles, releasing cytotoxic enzymes causing normotensive. He had prominent supraorbital ridges and a large lower jaw with poor occlusion fibrosis. There is a high incidence of TB co-infection in individuals with silicosis. Co-infection of teeth and lower teeth overbite. His facial wrinkles were exaggerated and lips full. The nose can be confused with a progression of the silicosis and should be excluded first. There is no tongue and were enlarged, the hands were large, doughy spade like and the skin over them effective treatment aside from preventing further exposure. thickened. Neurological exam showed grossly intact bitemporal visual fields. His appearance was consistant with the diagnosis of acromegaly. A work up consisting of growth hormone (GH), insulin-like growth factor 1 (IGF-1), TSH and random glucose was initiated with MRI imaging of the brain. The patient was also referred to ophthomology for visual field testing. A 92 YEAR-OLD WOMAN WHO TOOK A TURN FOR THE WORSE. V. Tsai1, IMPLICATIONS/DISCUSSION: Acromegaly is a disease caused by secretion of excessive R. Ziegelstein1; 1Johns Hopkins University, Baltimore, MD (Tracking ID #75756) amounts of growth hormone, almost always occurring as a result of a benign adenoma of the anterior pituitary gland. The disease occurs most frequently in middle age with an incidence of LEARNING OBJECTIVES: To call attention to the possibility that moving a patient soon 3±4 per million. Somatotroph adenomas of the pituitary may be large enough to cause visual after a cardiac procedure can result in malposition and malfunction of a permanent pacemaker. impairment or headaches as in our patient. Acromegaly leads to decreased life expectancy with CASE INFORMATION: A 92-year-old woman was found unresponsive in her nursing home a 2±3 fold increase in mortality from cardiovascular causes, cancer and all causes. The bed. She was in complete heart block with a ventricular rate in the 20s±30s. Soon after arrival diagnosis is made clinically and confirmed by finding a high levels of GH and IGF-1. Growth to the hospital, she sustained an asystolic arrest and required emergency temporary pacemaker hormone binds to receptors resulting in the stimulation of production of IGF-1 which therapy. The patient did not regain consciousness after electrical pacing at 60 beats per minute. mediates most of the actions of GH. Growth hormone release is pulsitile with concentrations The patient's health care agent consented to the implantation of a permanent pacemaker. After varying throughout the day. Random GH is therefore not a reliable diagnostic marker and is the procedure, a chest radiograph showed an appropriately placed dual chamber permanent only useful when correlated with the glucose tolerance test. IGF-I is present at more steady pacemaker. The patient did not regain consciousness nor spontaneous movement. Nursing concentrations and is a reliable marker of disease and its control. Most patients are treated with staff turned the patient every two hours to avoid pressure sores. Several days later, a chest transphenoidal surgery which usually results in clinical improvement with decreased GH and radiograph showed that the pacemaker generator was rotated and in the opposite configuration serum IGF-I concentrations. Other options include radiation therapy, medical therapy with from that noted on the original film. There was no evidence of electrode dislodgment or dopamine agonists or somatostatin analogues. Pegvisomant is a newly developed GH receptor pacemaker malfunction. antagonist that leads to decreased IGF-I levels and clinical improvement. Reducing growth IMPLICATIONS/DISCUSSION: Pacemaker-twiddler's syndrome is an unusual complica- hormone levels improves symptoms and complications of the disease and increases life tion of permanent pacemaker implantation, first described by Bayliss, et al. in 1968. It is usually expectancy. characterized by partial or total loss of pacemaker function secondary to rotation of the pulse generator in its subcutaneous pocket and subsequent electrode dislodgment. The rotation is related to manipulation of the generator by the patient, either consciously or unconsciously. JUST ANOTHER CASE OF UNSTABLE ANGINA? G.J. Van Londen1, J. Hefner1; The present report differs from previous cases, since the pacemaker generator rotation could 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76750) not have been induced by the patient, but was likely the result of routine turning of the patient by the nursing staff in an effort to prevent pressure ulcers. The possibility that turning LEARNING OBJECTIVES: 1.) Distinguish between Type A and B aortic dissections; immobile patients soon after device implantation will result in malposition and malfunction of 2.) Recognize an uncommon clinical presentation of an aortic dissection; 3.) Manage and treat pacemaker or cardioverter-defibrillator generators is important to recognize, since these a dissecting aorta. devices are being used in an increasing number of elderly patients. Caution should be exercised CASE INFORMATION: A 56-year-old male with a history of a 3-vessel coronary artery while moving elderly bedbound patients in the first few days after their cardiac procedure, in bypass graft in 1991, HTN and hyperlipidemia presented to the Emergency Room (ER) with order to prevent a potentially life-threatening condition. bilateral jaw and retrosternal chest pain accompanied by an occipital headache and dyspnea on JGIM Volume 18, April (supplement 1) 2003 93

exertion. The chest pain was waxing and waning in intensity, non-radiating with a maximum Prednisone therapy. The patient reported no further polyuria, headaches, stiff neck, and blurry pain score of 5/10. There was diaphoresis but no nausea or vomiting. The night prior, he noted vision but still had residual DOE and fatigue. Repeat MRI showed no dural enhancement. some parathesias in his fingers and blurred vision that resolved within two hours. On exam, the Prednisone was tapered off and the resultant decrease in weight and edema lead to resolution of patient's pulse was 110 with a BP of 130/80 on the left and 124/70 on the right. Room air pulse her low back and knee pain. ox was 96%. No pulsus paradoxus, JVD or bruit was appreciated. Lung exam revealed IMPLICATIONS/DISCUSSION: Discussion: Sarcoidosis can have numerous extrapulmon- decreased breath sounds in the left lower lobe. Cardiac exam was regular rhythm with a 2/6 ary involvement. CNS and cardiac involvement portend worse prognosis than hepatic, diastolic murmur. Exam of the upper and lower extremities revealed equal and symmetric pulmonary or arthritic involvement. SOB and DOE is most likely due to pulmonary pulses. EKG showed sinus tachycardia with no ischemic changes. His first set of cardiac involvement (i.e., due to endstage parenchymal fibrosis with or without acute inflammation) enzymes was negative. Portable chest x-ray revealed a left pleural effusion and a widening of the but concomitant restrictive cardiomyopathy due to sarcoidosis may exist synchronously. mediastinum with the patient rotated to the right. The patient was diagnosed in the ER with Echocardiography is essential in ruling out this possibility. Hepatic sarcoidosis involvement unstable angina and admitted. Based on the diastolic murmur and left pleural effusion on chest can progress from mild elevations in LFTs to frank cirrhosis, which fortunately was not x-ray, an aortic dissection was suspected and a stat MRI was performed. This revealed a Type A present in this patient. The LFTs elevation may, however, be simply due to fatty liver of dissection. Emergent surgery with replacement of the ascending aorta, valve and evacuation of obesity. Uveitis due to sarcoidosis must be a consideration in patients with vision complaints, a left hemothorax was performed. Cardiac arrests and a CVA complicated the perioperative but retinitis, episcleritis, glaucoma and premature cataracts, as well as the sicca syndrome course. The patient expired nine days after admission. due to involvement of the lacrimal and salivary glands, can occur. Symptomatic CNS IMPLICATIONS/DISCUSSION: A dissecting aorta must be recognized quickly as an acute sarcoidosis classically manifests as diabetes insipidus due to posterior pituitary infiltration. Type A dissection (involves the ascending aorta) is a surgical emergency, whereas an Other CNS syndromes include aseptic meningitis and diffuse white matter disease. Diabetes uncomplicated Type B dissection (all others) can be treated with pharmacotherapy. Acute insipidus is a distinct possibility in this patient. Although comparison of urine and serum management consists of blood pressure control while confirming the diagnosis and type. Aortic osmolality and water deprivation test were not done to confirm diabetes insipidus, the dissection is relatively common with over 2000 cases reported each year. A recent study showed patient's polyuria readily responded to glucocorticoids therapy. The MRI and CSF findings that 100% of dissections were diagnosed when all of the following clinical features were clearly support an aseptic meningitis picture and her headache symptoms responded to present: 1.) Acute onset of tearing or ripping-like chest or back pain; 2.) Mediastinal widening glucocorticoids therapy. on chest x-ray and 3.) Variation in pulse and/or pressure in the upper extremities. A diastolic murmur, EKG without ischemic changes and a left-sided pleural effusion (hemothorax) are uncommon presentations of a dissection. Transesophageal echocardiogram (TEE) is recommended for unstable patients with acute chest pain. MRI is preferred in stable patients AN UNUSUAL CASE OF BRADYCARDIA, HYPOTENSION AND RESPIRATORY 1 1 1 with chronic chest pain. CT scan or aortography should be reserved for situations in which FAILURE IN A PATIENT ON HEMODIALYSIS. S. Verma , R. Granieri ; University of both TEE and MRI are unavailable. Pittsburgh, Pittsburgh, PA (Tracking ID #74358) LEARNING OBJECTIVES: To recognize a hypersensitivity reaction to dialyzers in a patient on hemodialysis HOW FAR WEST OF THE NILE DO YOU HAVE TO BE? A. Venditto1, J. Wiese1, CASE INFORMATION: A 67 year old female with end stage renal disease secondary to M. Landry1; 1Tulane University, New Orleans, LA (Tracking ID #77081) chronic uncontrolled hypertension was admitted to the hospital with fevers and chills. On admission, the potential etiologies of her fever were line sepsis or lower extremity cellulitis. LEARNING OBJECTIVES: 1) Utilize effective diagnostic methods in cases of encephalitis. She was begun on appropriate antibiotic therapy. Within 5 minutes on her routine 2) Recognize the importance of early diagnosis of West Nile virus to control disease outbreaks. hemodialysis, she suddenly became bradycardic, hypotensive and unresponsive. On examina- CASE INFORMATION: A 58-year-old man presented with two days of fever, headache, tion before dialysis, vitals were HR-80/min, BP-215/110 mm Hg, and RR-16/min. Lungs unsteady gait, and a macular rash. Although initially lucid, he deteriorated into a state of were clear to auscultation. Cardiovascular exam revealed a normal S1 and S2 and a 3/6 delerium within the first day of hospitalization. His vital signs were normal. He had holosystolic murmur at the apex. After 5 minutes on dialysis, her vitals were HR-48/min, BP- meningismus with passive and active neck flexion; he had an ataxia gait and a macular rash over 64 mm Hg systolic; respirations became agonal, followed by apnea. The patient became his extremities. There were 6 white blood cells /mm3 in the CSF and a normal protein and obtunded and unresponsive, with twitching of her lips. She sustained cardio-respiratory arrest glucose. Owing to the degree of impairment, a serum immunofluorescent assay for flavivirus and required CPR with endotracheal intubation and mechanical ventilation and oxygenation. IgM was ordered. The titer was 1:32, increasing to 1:64 over the next five days. An assay for Dialysis was aborted during this episode. Her EKG revealed pulseless electrical activity West Nile virus was sent to the CDC for public health monitoring. followed by junctional rhythm. Once dialysis was stopped, it converted to normal sinus rhythm IMPLICATIONS/DISCUSSION: Most non-herpetic viral encephalitities are due to with normalization of hemodynamic parameters. Her WBC was 8000, H/H 8.2/ 25.1, arboviruses that cycle with the lifecyle of the tick or mosquito that is the primary vector. electrolytes were normal, BUN 72 and Cr 14.6, BNP-1300, CPK 20, Troponin I-0.21. Chest While all are endemic to warm climates, viruses such as the Eastern Equine Virus, West Nile X-ray showed mild congestion and her subclavian catheter tip was in right atrium. and St. Louis encephalitis can become epidemic when the mosquito vector greatly exceeds its Echocardiogram revealed concentric left verntricular hypertrophy with normal LV function. primary host. For all three viruses, there is little more than supportive care to be offered. 72 hours later, at her next routine hemodialysis, a similar episode occurred. Heparin was Contrary to most medical interventions, however, testing for a definitive diagnosis has merit in discontinued from her dialysis regimen due to possibility of heparin sensitivity as she was providing community outbreaks. The best test for distinguishing St. Louis from West Nile is thrombocytopenic with presence of heparin associated antibodies. However, a third episode an enzyme-linked immunosorbent assay (ELISA). A positive serum ELISA indicates probable occurred on the next dialysis. At this time, the patient's dialyzer was changed from B3-1.3 to infection with West Nile virus, whereas a positive cerebrospinal fluid ELISA confirms the F-8. Thereafter, no further episodes occurred and she tolerated subsequent hemodialysis diagnosis. Early identification of West Nile virus is important for mosquito population control without complication. and public education to prevent further disease spread. IMPLICATIONS/DISCUSSION: Dialyzer-induced acute hypersensitivity reaction is a rare entity (5/100,000 dialysis cases), but is a potentially life threatening condition. Presentation varies from mild urticarial reaction to cardiorespiratory failure. The onset of symptoms due to CLINICAL CONSIDERATIONS IN A PATIENT WITH SARCOIDOSIS. C.M. Vergara, MD, dialyzer-induced hypersensitivity reaction is usually 5±30 minutes after initiation of 1 1 FACP ; Hartford Hospital, Rock Hill, CT (Tracking ID #74715) hemodialysis. Possible causes are bio-incompatible membrane (i.e. cellulose), ethylene oxide LEARNING OBJECTIVES: To Illustrate potential clinical presentations that must be use for sterilization, use of ANP69 membrane in patients on ACE inhibitors, bacterial considered in a patient with sarcoidosis contamination of dialysate in high flux dialyzer, heparin allergy, acetate bath (acetate is a CASE INFORMATION: History: 49 year old African American female with history of vasodilator and myocardial depressant), and inappropriate cytokine and complement obesity, asthma and possible fibromyalgia presented with worsening fatigue, SOB, DOE over 2 activation. Differential includes severe hypotension, acute MI, arrhythmias, air or pulmonary months. She has been tobacco-free for the past 4 years and compliant with her asthma regimen. embolism, or severe pulmonary edema. A high index of suspicion is necessary to recognize this Over the ensuing 6 months she continued to have worsening symptoms which required entity. Treatment is standard care for any anaphylactic reaction and includes intravenous episodic reinstitution of systemic steroids for presumptive asthma exacerbation. Further review steroids, antihistamines and supportive care. Removal and avoidance of the culprit inciting revealed a past medical history of a 2 cm right upper lobe nodule with bilateral hilar agent is of paramount importance. adenopathy and interstitial lung disease 2 years ago. CT guided-biopsy of the nodule yielded non-caseating granuloma. Serum labs, such as CBC, Chem 10 (including calcium), TSH, ESR and ACE levels, were normal. LFTs were mildly elevated. Subsequent viral hepatitis serologies RED IN THE FACE: A LEPROMATOUS REACTION. A.R. Vidyarthi1, E. Vasilevskis1; were negative. PFTS were consistent with combined obstructive and restrictive lung disease 1University of California, San Francisco, San Francisco, CA (Tracking ID #75320) with mildly reduced DLco. The patient returned for an urgent care visit complaining of worsening DOE, bilateral lower extremity edema, polyuria, nocturia, blurry vision and severe LEARNING OBJECTIVES: 1. Identify and diagnose the type II reaction associated with M. persistent daily headache and stiff neck for the past 2 months. Prednisone 60 mg was started Leprae infection. 2. Review the treatments for Erythema Nodosum Leprosum (ENL). empirically for pulmonary sarcoidosis exacerbation and possible sarcoidosis involvement of the CASE INFORMATION: A 67 year-old Filipino male presented to the ED with right facial eyes, CNS, liver and heart. Repeat of the above serum labs were normal. Fasting glucose level erythema, edema, and subjective fever. The lesion progressed from a 2 days prior. His was not diagnostic for diabetes mellitus or glucose intolerance. Urinalysis and urine C&S were past medical history was significant for Lepromatous Leprosy diagnosed in 1998. He had been normal. Urine osmolality was ordered but not performed. A water deprivation test was deferred treated with rifampin and ofloxacin since then. In the ED, he was treated with amoxicillin- until other test results were known. PT (INR) and albumin did not suggest cirrhosis. PFTs clavulanate for presumed cellulitis. Nevertheless, his facial lesion worsened, and he developed were unchanged from the prior study. PPD test was <5 cm. Gallium scan showed no uptake in diffuse lymphadenopathy and a reddish rash on his upper extremities. Upon admission, the the lung, salivary and lacrimal glands (e.g. ``panda bear'' sign) or any other part of the body. patient was afebrile with normal vital signs. His exam demonstrated left facial erythema, ECG and echocardiography were also normal. MRI of CNS showed dural enhancement but no edema, and induration with central ulcertation extending from the maxillary area to the left ear pituitary or other parenchymal lesions. CSF fluid analysis revealed only a lymphocytic and mandible and exhibited normal sensation. He had diffuse lymphadenopathy of the head pleocytosis and negative cytology for malignancy. Ophthalmology referral showed no uveitis, and neck, and erythematous plaques on both upper extremities. His chronic findings of a left cataracts or retinal abnormalities. The patient's symptoms improved but she complained of hand claw deformity and decreased sensation in the lower extremities were unchanged. Lab increasing weight, generalized edema, low back pain and bilateral knee pain after 6 months of studies were notable for a WBC of 13 and blood and wound cultures were negative. Antibiotics 94 Abstracts JGIM

were changed to vancomycin and imipenem without improvement. Subsequent skin biopsy and sitting. The patient continued to improve as an outpatient and was playing golf within 2 revealed numerous acid-fast rods within macrophages and a dense neutrophilic infiltrate. His weeks after discharge. clinical presentation and biopsy findings were consistent with a Type II lepromatous reaction, IMPLICATIONS/DISCUSSION: Our patient exhibited the platypnea-orthodeoxia syn- or Erythema Nodosum Leprosum (ENL). He was treated with prednisone and thalidomide drome. This is defined as dyspnea and arterial desaturation in the upright position and with ultimate resolution of his symptoms within days of treatment. improved by recumbency. This syndrome occurs with an intracardiac or intrapulmonary shunt. IMPLICATIONS/DISCUSSION: ENL is characterized by fever with multiple erythematous Our patient had the most common etiology, a patent foramen ovale, with a right-to-left shunt. tender nodules, sometimes accompanied by neuritis, edema, arthralgias, leukocytosis, Shunting in the face of normal right sided pressures, as in this case, is unusual but described in iridocyclitis, pretibial periostitis, orchitis, and/or nephritis. It is associated with Borderline the literature. Diagnosis is made by visualization of the PFO with shunting on transesophageal and Lepromatous forms of Leprosy and occurs in up to 25% of patients. ENL is most common echocardiogram with agitated saline (``bubble study''). Percutaneous closure of the PFO is safe during treatment, but can also occur before or after therapy. It is thought to be an immune- and effective. Cardiac shunts should be suspected in all patients with persistent hypoxia, complex disorder with tumor necrosis factor alpha playing a role in its pathogenesis. Acute especially in those who exhibit worsening symptoms and hypoxia in an upright position. treatment consists of steroids and/or thalidomide; the latter is highly effective, generally controlling the reaction within 48 hours. Clofazimine may be effective for chronic reactions. Prompt detection and treatment of ENL has decreased the number of patients with resultant RIGHT VENTRICULAR INFARCTION PRECIPITATING A BIDIRECTIONAL SHUNT IN A chronic disabilities. Our patient had a clinical picture consistent with ENL which was initially PATIENT WITH INCIDENTAL ASD. N.I. Visweshwar1, R. Sudheendra1, A. Devarajan1, difficult to distinguish from cellulitis. He responded to treatment with prednisone and A. Ameen1, T. Vallur1; 1Jersey City Medical Center, Jersey City, NJ (Tracking ID #74202) thalidomide. As international travel and immigration continue to increase, it is important to recognize the reactions associated with Mycobacterium Leprae. LEARNING OBJECTIVES: 1. RV infarction resulting in raised RA pressure can precipitate a bi-directional shunt in an ASD. 2. Reversal is not a contraindication for surgical correction. CASE INFORMATION: A 59 yr old White male presented with a h/o two hours of crushing AN UNUSUAL CASE OF POST-OPERATIVE HYPOXEMIA. A.B. Levin1, A.R. Vidyarthi1; retrosternal chest-pain. The pain was 9/10 in intensity; occurred while at rest, non-radiating 1University of California San Francisco, San Francisco, CA (Tracking ID #75439) and was associated with dyspnea and diaphoresis. Pt. has a 90-pack year h/o smoking and a LEARNING OBJECTIVES: 1. Recognize the clinical manifestations of transfusion-related family h/o CAD. He denied HTN, DM, hypercholesterolemia, ETOH abuse or illicit drug acute lung injury. 2. Increase the awareness of life-threatening transfusion reactions. use. Four weeks prior to this admission, he was worked up at another hospital for exertional CASE INFORMATION: A 71 year-old man was admitted for elective T12-L2 posterior chest pain. He had a reportedly negative stress test, normal 2-D ECHO and EGD. 0/E, vitals spinal fusion. His past medical history included CAD, s/p CABG, and idiopathic scoliosis with were BP 120/80, HR 85/m, RR 14/m, T-998 F, SaO2-90%. Pt had raised JVD, normal prior spinal surgeries. Six hours post-operatively, the patient developed hypotension, fever and carotids, PMI not felt, S1 normal intensity, S2 widely split and fixed, 2/6 ESM heard on Left hy-poxemic respiratory failure. Intra-operatively, he received multiple blood products sternal border. RS-normal. Extremities-no edema, 2+ pulses and equal on both sides. EKG- including 6 units of whole blood, 5 units of PRBC, 12 units of FFP, and 3 6-packs of NSR,ST elevation in inferior leads and in V4R. CXR-Hilar prominence with pulmonary platelets. On exam in the ICU post-operatively, he had a temperature of 398C and a BP of 70/ plethora. CK-1515/172, Troponin 299. WBC 7.7 Hct 40 Plt 211. ECHO-mild LV systolic 40. He had a normal cardiac exam including a normal JVP, lungs had coarse breath sounds, and dysfunction; RV dilated; ASD & mild pulmonary HTN. Patient received thrombolytic his extremities were warm without a rash. Chest x-ray revealed diffuse bilateral infiltrates and a therapy; heparin I.V, ASA, B-blocker and ACE-I. Pt. improved clinically. He had a cardiac- chest CT was negative for PE. Echo showed no focal wall motion abnormalities. Labs were cath, which showed 90% diffuse RCA stenosis with mild LV systolic dysfunction; A 3 cm ASD notable for a new low WBC count (0.4). Successive blood and sputum cultures were negative. with bi-directional shunt. Oxymetry data: IVC 65%, SVC 58%, RA 75%, RV 75%, PA 74%, The blood bank was notified to investigate a possible transfusion reaction. There was no LA 84%, LV 84%, Left pulmonary vein 96 %. Hemodynamics: RA 19/14, RV 60/18, PA 60/ evidence of hemolysis and a direct Coombs' test was negative. The patient was treated with 37, LV 126/22, AO 126/89, LA 17/15, PCWP 20/15. Shunt estimation: Qp/Qs = 1:1.6, vasopressors, including epinephrine, and broad-spectrum antibiotics. On post-operative day 7, R-L = 2.0L/min, L-R = 4.5L/min C.O. = 7.0 L/min. the patient suffered a cardiac arrest and expired despite full resuscitative efforts. Post-mortem IMPLICATIONS/DISCUSSION: Discussion: Normally, reversal of shunt in an ASD pt. analysis revealed that 1 of the 32 total blood product donors was a multiparous female who indicates inoperability. Four weeks prior to this admission, there was no significant detectable donated a platelet pheresis. She carried an HLA-I antibody against one of the patient's shunt. Eisenmenger's is unlikely as the pt. has been asymptomatic with no cyanosis prior to this neutrophil antigens (Bw4 public antigen). This confirmed the cause of death as transfusion- admission. The RV infarction caused an acute increase in the RA pressure with resultant bi- related acute lung injury (TRALI). directional shunt, as is evidenced by the `step-up' between SVC (58%) & RA (75%) and a `step IMPLICATIONS/DISCUSSION: TRALI is a clinical syndrome characterized by fever, down'; between Left pulmonary vein (96%) & LA (84%). A difference of >5% in Oxymetry severe hypoxemia, non-cardiogenic pulmonary edema, and hypotension occurring one to six values is considered as significant. hours post transfusion. Case reports have identified transient leukopenia as another In summary, this pt. had an Infr. wall MI, RV infarction, diastolic equalization of pressures, manifestation. 80% of patients recover within 48-96 hours with little permanent sequelae. 90% diffuse RCA stenosis, secundum ASD with a bi-directional shunt and moderate Despite being the third most common cause of death from transfusions in the developed world pulmonary. HTN. The patient underwent arterial by-pass graft of RCA and closure of a 3 cm (estimated incidence of 1/5000 transfusions, with a mortality rate of 5±14%), it is probably ASD defect. Post op recovery was uneventful significantly under diagnosed. The majority of cases are associated with transfused complement-activating antibodies, either HLA (class I or II) or granulocyte specific. All blood components containing plasma have been associated with the injury. Risk factors include RESPONSE TO STEROID THERAPY OF FACTOR VIII SPECIFIC INHIBITOR IN multiparous donors, underlying recipient conditions such as recent surgery, cytokine HEPATITIS-C VIRUS INFECTION. N. Visweshwar1, R. Sudheendra1, A. Devarajan1, treatments, massive blood transfusions, active infection, and prolonged storage of transfused T. Vallur1; 1Jersey City Medical Center, Jersey City, NJ (Tracking ID #74204) products. Current treatment is limited to respiratory and hemodynamic supportive measures. LEARNING OBJECTIVES: In Hepatitis C patients, with acquired Factor VIII inhibitor, Diuretics and steroids have been used with variable efficacy and have not been tested in clinical there is an excellent response to steroids.inspite of Hepatitis C infection. trials. Our patient had an unusual course for TRALI in that his symptoms developed relatively CASE INFORMATION: A 48 yr old Indian male was admitted with a h/o hematemesis and late post-operatively and he did not recover despite maximal support. TRALI should be considered in all patients with hypoxemia following transfusions. frank rectal bleed. He had h/o acquired Hepatitis-C and intravenous drug abuse. He had had prior admissions for ascites and ankle edema from decompensated liver disease. His blood count 2 wks prior to this admission showed Hb 8.9 gm/dl, WBC 4600/cmm and platelet count 119,000/dl. Coagulation screen showed PT 12.5 secs (12±14 secs), PTT 28.5 secs (25±40 secs), LIE DOWN AND CATCH YOUR BREATH: HYPOXIA IN AN ELDERLY MAN. and his bio-chemical screen was within normal limits. The LFT's were within normal limits. A.R. Vidyarthi1, D. White1; 1University of California, San Francisco, San Francisco, CA (Tracking ID #76981) During the present admission, the patient was found to have pallor, edema of ankles and abdominal distension. Ascites and splenomegaly were noted. There was no evidence of jaundice LEARNING OBJECTIVES: 1. Recognize the platypnea-orthodeoxia syndrome. 2. Under- or flapping tremor of the out-stretched hands. He received 2 units of compatible blood for a Hb stand the diagnosis and treatment of a patent foramen ovale (PFO). of 6.5 gm. Within the next 24 hrs, he developed deep jaundice with total biliribin 9.5 mg/dl CASE INFORMATION: An 80 year-old man presented with persistent hypoxia for 3 months. (direct 3.5 mg/dl and indirect 6 mg/dl). Direct Coombs test was positive. Repeat antibody Previously, the patient was playing golf 3 times a week without difficulty. His hypoxia began screening showed anti-Kell antibody. Coagulation screen showed PT 12.5 secs, PTT 85 secs post surgery to relieve a small bowel obstruction. He was treated with antibiotics for and fibrinogen 220 mg/dl. Factor VIII level was 3%. Mixing studies of the patients' plasma and pneumonia and ruled out for PE with 2 low probability V/Q scans. The patient was discharged normal plasma showed (50:50) immediate correction of PTT to 30 secs, but PTT done after home on oxygen, but his symptoms worsened. He had increasing malaise with shortness of incubation of one hour was 66 secs confirming a delayed inhibitor. At this time he had a positive breath upon minimal exertion, such as sitting up in bed. Eventually, he was bed bound. He hemoccult and bloody gastric aspirate. The tests for ANA and dsDNA were negative. He was denied cough, fever, wheezing, chest pain, or leg swelling. Upon admission the patient was prescribed oral Prednisone 60 mg /day and Prevacid 30 mg/day and inj. Procrit 40,000 units SC/ afebrile, BP 130/70, RR 18 and supine O2 saturation of 93% on 10 liters of oxygen. Upon week. Over the next few days he improved with no fresh bleeding and was discharged. Three sitting, the patient was dyspneic with RR 40 and O2 saturation 70% on 10 liters of oxygen. His weeks later, the patient was reviewed in the clinic, when his Hb was found to be 9.7gm% and his exam was normal including a normal cardiac exam including JVP, slightly decreased breath PTT 30 secs. The dose of Prednisone was decreased to 30 mg/day. On follow up patient sounds at the right base, and his extremities were warm without edema. Laboratory exam continues to be free of inhibitor inspite of withdrawing the steroids. revealed a normal EKG, CXR with unchanged right opacity, chest CT negative for PEor A-V IMPLICATIONS/DISCUSSION: Factor VIII±specific antibody occurs in elderly patients fistula, electrolytes, CBC, and cardiac enzymes were also normal. PA02 on 4 liters of oxygen with no obvious secondary cause. However, secondary causes including auto-immune diseases was 54 mm Hg and on 100% oxygen 84 mm Hg. Transthoracic echo showed normal left and lympho-proliferative disorders should be excluded. The patient with an acquired inhibitor ventricular size and function with an inter-atrial septum hypermobility and a large patent presents with extensive sub-cutaneous bleed with or without mucosal bleeding. The clue to the foramen ovale with normal right sided pressures. Injection of agitated saline revealed a large diagnosis is isolated prolongation of PTT with mixing studies confirming a delayed inhibitor. amount of immediate right to left shunting. Transesophageal echo confirmed the PFO with Various treatment options include Immunosuppressive therapy (Prednisone with or without right to left shunting. The patient underwent transcateter closure of his defect. One day post Cyclophosphamide), plasmapheresis, high dose porcine-factor VIII and recombinant factor procedure, the patient was markedly improved with O2 saturation on room air of 95% supine VIIa. In patients with idiopathic Factor-VIII specific antibody one may need to give a JGIM Volume 18, April (supplement 1) 2003 95

prolonged course of immunosuppression as the antibody has been noted to be present for a WAS IT REALLY HYPOTENSION? G. Wali1, M. Panda1, N. Desbiens1; 1University of long time. Although the acquisition of Factor VIII inhibitor in Hep C infection is known, this Tennessee±Chattanooga Unit, Chattanooga, TN (Tracking ID #77000) case is being presented for the excellent response to steroids, in spite of continued Hep C LEARNING OBJECTIVES: 1. Recognize the limitations of accurate blood pressure (BP) infection, is less well known. measurement and that arm blood pressure readings may not reflect central perfusion pressure. 2. Recognize the cardinal clinical signs of shock. CASE INFORMATION: A 68-year old white female with a history of hypertension, CVA and ACUTE MYOPERICARDITIS PRESENTING AS MI. N. Visweshwar1, R. Sudheendra1, bilateral carotid endarterectomy was brought to the ED because of falling, right-sided A. Devarajan1, T. Vallur1; 1Jersey City Medical Center, Jersey City, NJ (Tracking ID #74205) weakness and decreased responsiveness. Vital signs revealed BP: 76/35 mmHg, pulse: 94/min, resp: 24/min, temp: 98.8F. She was minimally responsive and did not follow commands. There LEARNING OBJECTIVES: 1. A bedside Echo would delineate acute pericarditis from an were no signs of trauma or active bleeding. Pupils were 3 mm and reactive. She had a regular acute MI in case of suspision which also averts the disastorous complications of thrombolytic rate and rhythm with no jugular venous distension. Lung exam revealed decreased breath therapy sounds bilaterally with no wheezing or rales. Upper and lower extremities were cold without 2. Failure of St segment to revert back to isoelectric line following thrombolytic therapy should edema. Femoral pulses are 1+ and the dorsalis pedis pulses were not felt. She had a right sided alert the physician to consider a bedside echocardiography to differentiate acute myocarditis facial droop and hypotonia. She remained hypotensive despite aggressive IV fluids and large from acute myocardial infarction. doses of dopamine (40 ug/kg/min). EKG, CXR, CT of head & abdomen, echocardiogram, CASE INFORMATION: A 40-year-old caucasian male presented with history of crushing urine drug screen, ABG and complete lab evaluation failed to identify a cause of hypotension. central chest pain 9/10 in intensity at the retrosternal region radiating to the neck. This was Urgent cardiac catheterization was performed which showed 70% stenosis of the proximal associated with profuse sweating for about three hours prior to his arrival in ER. Patient had RCA, significant atherosclerotic disease in both subclavian arteries, central aortic systolic taken aspirin at home. In ER, patient was given two tablets of nitroglycerin with no response. A pressure of 149/52 mmHg, compared to simultaneous cuff pressure in either arm (98/51 12 lead EKG showed ST segment elevation in the anterior wall leads and PR segment mmHg). Only the left thigh pressure correlated well with central pressure measurements and depression. The cardiac injury profile showed CPK 1635, CKMB 171 and troponin 192. As the was used to monitor BP throughout remainder of the hospitalization. Repeat CT revealed a history and investigations were consistent with acute myocardial infarction, patient was started new left tempo-parietal infarct. The patient's alertness improved but had a receptive and on thrombolytic therapy with TNK 40 mg IV and heparin infusion. Repeat EKG done at 10 expressive aphasia. She was transferred to a nursing home with instructions to measure BP on minute and 20 minute interval showed no change and patient continued to have the same the left thigh with an appropriately sized cuff. intensity of chest pain. Patient needed two doses of morphine sulphate 4 mg IV to relieve his IMPLICATIONS/DISCUSSION: The presentation of shock is challenging and requires pain. As the patient did not respond to thrombolytic therapy, he had an echocardiogram that prompt assessment and management. The cardinal clinical signs of shock include hypotension, showed no evidence of segmental hypokinesia. The left ventricular ejection fraction was 45%. altered mental status, cool extremities and later decreased urine output. Our patient presented A diagnosis of acute myopericarditis was made, anticoagulant therapy was discontinued and with 3 of these 4 signs. However in our patient the arm BP readings did not reflect the patient was treated conservatively in intensive care unit. Cardiac catheterization was done on perfusion pressure to her major organs. Her urine output remained normal and her poor the second day of admission. During catheterization the coronary vasculature was found to be responsiveness was most likely related to her CVA. Her upper and lower extremities remained normal. Patient recovered with ST segment elevation reverting back to isoelectric line within cool secondary to her severe PVD. Accurate BP measurement both in the acute and the the next three days. ambulatory setting is an essential part of optimal patient care. Severe peripheral vascular IMPLICATIONS/DISCUSSION: Acute myocarditis usually presents with preceding viral disease can interfere with accurate blood pressure measurement and thus its management. prodrome followed by pleuropericardial pain and anginal type of Chest pain is uncommon. Measurement of lower extremity BP would be helpful and possibly prevent invasive diagnostic Patients may have tachycardia, gallop rhythm and other evidence of heart failure or conduction studies in patients with hypotension that does not respond to fluid and pressors, though even defect. EKG may show nonspecific ST-T changes and conduction disturbances. Chest x-ray is this approach might not work in patients who have severe atherosclerosis in all extremities. nonspecific but cardiomegaly may be seen. The confirmation is by endomyocardial biopsy that may reveal round cell infiltration with patchy areas of necrosis. Treatment with immunosup- pressive therapy with corticosteroids, NSAIDs and cyclophosphamide has been advised but PATIENT INDECISION: WHEN PROVIDING INFORMATION IS NOT ENOUGH. none has been shown to be of beneficial value. Most of these cases resolve spontaneously and S. Webster1, P.K. Han1; 1University of Pittsburgh, Pittsburgh, PA (Tracking ID #76812) some may progress to dilated cardiomyopathy; but the exact proportion of patients with viral myocarditis progressing to dilated cardiomyopathy is not known. In a series of 9 patients from a LEARNING OBJECTIVES: 1) To recognize ethical problems posed by patient indecision. single center with myocarditis presenting as MI, there has been no recorded case of death from 2) To understand the physician's role in cases of patient indecision. inadvertent treatment with thrombolytic therapy, In case of suspicion, especially when there is CASE INFORMATION: A 47 year-old man with a long history of type 2 diabetes mellitus, no change in EKG following thrombolytic therapy bedside echocardiography has been advised severe peripheral vascular disease, and medical noncompliance was admitted for further as a way of differentiating myocarditis from acute myocardial infarction. management of progressive bilateral lower extremity infections. He recently underwent bilateral BKA and developed soft tissue infections at the amputation sites. He consented to initial surgery, and was found to have extensive necrosis in his legs, hip and pelvis. He underwent a left AKA and aggressive debridement, with a plan to return to the operating 1 HOMOCYSTEINEMIA AND CLASSICAL HOMOCYSTINURIA. D. Waggoner , D. Babovic- room for more radical surgery including a possible hemicorpectomy. This plan became 2 1 2 Vuksanovic ; Mayo Clinic Jacksonville, Jacksonville, FL; Mayo Clinic Rochester, thwarted by the patient's indecision about further surgery. Multiple medical and surgical Rochester, MN (Tracking ID #74963) consultation teams held discussions with the patient. He was informed of the nature of the LEARNING OBJECTIVES: Diagnose classical homocystinuria by history, physical exam and operation, its consequent disabilities, and of the high likelihood of death without surgery. Yet laboratory analysis. the patient persisted in postponing a decision. He expressed clear comprehension of the Treatment modalities for individuals affected by classical homocystinuria. treatment alternatives and expected outcomes, but remained unable to choose between life CASE INFORMATION: A 22-year-old male, previously diagnosed with , with severe disability or death. In the meantime, his clinical status slowly deteriorated. After presented with complaints of a cold left foot. An abdominal CT revealed a massive thrombus two weeks, the involved physicians decided to present a firm recommendation against involving the abdominal vessels and the major arteries of the lower extremity. The patient was surgery. They informed the patient that they interpreted his indecision as a decision to taken to surgery and underwent an aorto-iliac thromboembolectomy, a segmental jejunal forego surgery, and that his condition had declined to the point where surgery was of high resection, and a left tibial thromboembolectomy. Coagulation studies were unrevealing. risk. His care was redirected towards palliation and he was discharged to home. The patient Genetic studies demonstrated heterozygosity for the MTHR common variant. The accepted this recommendation. homocysteine level was 277 umol/L. The patient was started on pyridoxine 1 mg/day and IMPLICATIONS/DISCUSSION: The modern model of medical decision-making is cyanocobalamin 1,000 mcg/day. grounded in the ethical principles of informed consent and respect for patient autonomy. In On physical exam, the patient was noted to be minimally dysmorphic with mild mid-facial this model, the physician's role is to provide sufficient information and support to allow the hypoplasia, a narrow palate with crowded teeth, myopia, and skin with areas of striae patient to make an autonomous decision±one that is free from coercive influence and made atrophicae about the upper extremities. Further diagnostic studies included quantitative plasma with the capacity to understand and intend a certain outcome. Sometimes, however, the amino acids and a formal eye exam. Folic acid was increased to 5 mg/day and pyridoxine was physician's role in decision-making may need to be expanded; simply providing information increased to 100 mg/twice a day. Homocysteine levels normalized, and no further thrombotic and support may not be enough. In our case, the patient was capable but unwilling to make a events have occurred. decision, so his physicians were compelled to decide on his behalf. They interpreted the IMPLICATIONS/DISCUSSION: Homocysteinemia is seen in a variety of conditions patient's indecision as a refusal of surgery, based upon his past ambivalence regarding medical including homocystinuria, an inherited disorder involving the metabolism of the amino acid attention, his aversion to future disabilities, and his passive allowance of his further decline. methionine. It is an autosomal recessive disorder commonly due to beta-synthetase deficiency The patient then fully assented to the physicians' decision. This case illustrates how respecting that affects approximately 1:200,000 people. Affected individuals may present with myopia, the autonomy of an indecisive patient might require physicians to assume an active role in dislocation of the lens of the eye, and a tendency to develop venous and arterial clots. decision-making, undertaking a cautious assessment of their patients' values, experiences and Newborns appear normal. Symptoms, if present, tend to be mild. Mental retardation is usually decisional capacity, and fully informing and allowing the patient to disagree with the decision. present, but some affected people have normal IQs. Untreated, the mental retardation is progressive and irreversible. Homocystinuria has several features in common with Marfan's syndrome: dislocation of the lens, a tall and thin build with long limbs, arachnodactyly, and a A CASE OF ACE-INDUCED JAUNDICE. B.M. Weinberg1, R.A. Cader2, E.F. Yee3, pectus deformity. High arches of the feet, genu valgum, and scoliosis may be present. The most G. Michelini2; 1UCLA±San Ferndando Valley Progam, Sylmar, CA; 2Sepulveda VA worrisome manifestation of homocystinuria is thromboembolic events. Diagnosis is aided by Ambulatory Care Center, North Hills, CA; 3University of New Mexico/Albuquerque VA, physical exam, blood and urine homocysteine levels, fiboblast culture, and enzyme assay for Albuquerque, NM (Tracking ID #73707) beta-cystathionine synthase. In addition to high dose pyridoxine, larger doses of folic acid than used for other forms of homocysteinemia are required. Unfortunately, only about 50% of LEARNING OBJECTIVES: 1. To recognize that captopril can cause severe cholestatic patients will respond to treatment. Those that fail treatment generally require a low jaundice methionine diet. 2. To discuss the management of captopril induced cholestasis 96 Abstracts JGIM

CASE INFORMATION: 48 yo Filipino female presented complaining of 2 weeks of HYPERKALEMIC PERIODIC PARALYSIS (AN UNUSUAL CAUSE OF WEAKNESS). worsening yellow skin, nausea, vomiting, weight loss and total body pruritus. Her PMH was H. Whelan1, G. Applebaum1; 1Olive View±UCLA Medical Center, Sylmar, CA (Tracking significant for HTN diagnosed three week prior to admission for which she was started on ID #75573) captopril. The patient denied abdominal pain, diarrhea, constipation, clay colored stool, LEARNING OBJECTIVES: 1. Hyperkalemic periodic paralysis(HYPP) as a rare cause of bright red blood per rectum, melena, fever, cough, or the use of other medications, alcohol weakness or drugs. Vital signs were stable and physical exam was significant for severe jaundice and 2. Review clinico-pathologic presentation of HYPP dry mucous membranes. Laboratory results were notable for: AST 230, ALT 455, Alk phos 3. Highlight iatrogenic precipitants of HYPP 252, Tbili 7.1, Dbili 6.3. Lipase, Amylase, electrolytes, CBC, albumin, PT/PTT, panel for CASE INFORMATION: A 64 year old Hispanic man with a history of CHF, atrial fibrillation, hepatitis a, b, and c, ANA, anti-mitochondrial antibody, ferritin, and blood cultures were all pacemaker and chronic renal insufficiency presented complaining of 2 weeks of progressive normal. The patient underwent abdominal U/S, CT scan, and two ERCPs, which were weakness of his extremities. He reported that his lower extremity weakness gave him the notable for the presence of cholelithiasis without biliary duct dilation. Her captopril was inability to walk and upper extremity weakness made it difficult to lift a glass to drink. The stopped and it was concluded that her cholestasis was an adverse effect of this medication. A patient denied headache, diplopia, dysphagia, dysarthria, paresthesia, or ataxia. Furthermore, he liver biopsy was contemplated but not performed because the Gastroenterology team felt reported no history of a febrile illness or upper respiratory symptoms. The patient did, however, that it would not change management. They would consider liver biopsy if liver tests report having loose stools over 2 weeks and that he had increased his potassium supplementation remained elevated for greater than one year. After her intitial discharge the patient required during this time period. Physical exam was remarkable for 4/5 strength in bilateral upper and several admissions for IV hydration because of severe nausea and vomiting. Two weeks after lower extremities and 3/5 in left hip flexion. The patient was unable to rise from a chair. His her initial discharge, her total bilirubin had increased to 27 mg/dl with a direct bilirubin of deep tendon reflexes were present and symmetric. Lab data was remarkable for potassium 7.6 24 mg/dl. These values normalized after six months. Seven months after her initial and creatinine 1.9. The initial EKG showed a paced rhythm with widening of the QRS and presentation, she had recovered fully except that her alk phos and ALT remained mildly peaking of the T waves. Initial management consisted of calcium gluconate, glucose and insulin. elevated The patient was further treated with kayexalate and furosemide and his serum potassium IMPLICATIONS/DISCUSSION: This case demonstrates a rare adverse effect of captopril. decreased to 4.9. In 24 hours, the patient demonstrated resolution of his weakness. To date there have been several dozen reported cases of captopril induced cholestatic jaundice. IMPLICATIONS/DISCUSSION: While hypokalemia is more commonly recognized to Case reports demonstrate an equal incidence in gender and a latent period to development of cause periodic paralysis, hyperkalemic periodic paralysis (HYPP) is a rare cause of weakness. symptoms of 1 to 20 months. Management is largely supportive following cessation of HYPP is caused by a defect in the muscle which is linked to an autosomal captopril with improvement of jaundice within 1 week to 6 months. Total bilirubin, alk phos dominant gene mutation. Clinically, HYPP is characterized by episodic bouts of weakness and AST are almost always elevated. The exact mechanism for this drug-induced cholestatic lasting hours to days, during which time the serum potassium is elevated although it can jaundice is unknown but appears to be a hypersensitivity reaction. As such, features of a drug occasionally be normal. Attacks can be precipitated by exercise, cold, and during pregnancy. hypersensitivity reaction (i.e. fever, chills, and eosinophilia) often accompany the jaundice and Common iatrogenic causes include potassium supplementation, glucocorticoids and potassium associated pruritus. The diagnosis is one typically of exclusion. Liver biopsy can be helpful in sparing diuretics. Treatment of HYPP includes acute management of hyperkalemia with EKG distinguishing cholestatic jaundice from other forms of parenchymal liver damage induced changes, and then lowering of serum potassium by usual means. The diagnosis is suggested jaundice. when muscular weakness resolves with potassium normalization. Based on the common use of captopril, it is important that practitioners are aware that cholestasis is a potential and serious complication of this medication.

HYDROCHLOROTHIAZIDE-INDUCED HEMOLYTIC ANEMIA? K.C. Wilson1; 1University of Illinois at Peoria, Peoria, IL (Tracking ID #76998) 1 1 EHRLICHIAL MENINGITIS. M. Wellons ; University of Alabama at Birmingham, LEARNING OBJECTIVES: 1. Recognize the clinical and laboratory features of drug- Birmingham, AL (Tracking ID #76671) induced autoimmune hemolytic anemia (DIAHA). 2. Recognize treatment and need for LEARNING OBJECTIVES: Consider tick-borne illness early when managing a patient with referral in DIAHA. meningitis. CASE INFORMATION: A 55-year-old Caucasion female presented with nausea, myalgias, CASE INFORMATION: A 68 year old white male presented with fever, altered mental status, and jaundice 2 weeks status post rectal surgery. At that time she had received cefotetan and respiratory distress. He is an avid outdoorsman and lives alone. He was found unresponsive perioperatively, as well as hydrochlorothizide (HCTZ) prior to discharge. Review of systems at home after coworkers reported him missing for two days. He was febrile, orthostatic, with revealed pronounced fatigue, myalgias, dark colored urine, nausea, and jaundice. Medical diffuse rhonchi and a fine macular truncal rash. Laboratory studies revealed mild anemia, history was significant for hypertension, tobacco use, and remote history of blood transfusion. hepatitis (AST = 306), renal failure (creatinine = 7.2) and thrombocytopenia (platelets = 28,000). She was allergic to sulfa, which caused a rash. She denied alcohol or intravenous drug use. She White cell count was 5600 with 33% bands. Lumbar puncture chemistries suggested bacterial denied any abdominal pain, hematochezia, melena, or recent viral illness but reported some meningitis. Cerebrospinal fluid gram stain revealed intracellular clusters of gram negative dyspnea on exertion. Medications included atenolol,estrogen, sertraline, and the newly bacteria in cytoplasmic vacuoles of mononuclear cells. Doxycycline, begun early for coverage prescribed . Her vitals were stable except for a pulse of 120. On physical exam, the skin of tick-borne illnesses, was continued upon receipt of the gram stain. Four days after was jaundiced with rare ecchymosis but without rashes. The conjunctivae and mucous admission, ehrlichia indirect fluorescent IgG antibody test returned at 1:64. Twelve days later, membranes were pale and scleral icterus was evident. The remainder of the exam was normal IgG antibody was 1:4096. including abdominal exam. Hemoglobin was 3.5 g/dl, WBC 34,000, total bilirubin 4.1, LDH IMPLICATIONS/DISCUSSION: Two forms of human ehrlichiosis are found in North 1070, haptoglobin was low,and direct Coombs was positive. HIV and viral hepatitis studies American, human monocytic ehrlichiosis (HME) and human granulocytic ehrlichiosis (HGE). were negative. CT of the chest was negative for lymphoma. Methylprednisolone and gamma HME is predominant in the south, is caused by Ehrlichia chaffeensis, and is transmitted by the globulin were begun for presumed DIAHA, and patient was tranfused blood products. A lone star tick, Amblyomma americanum. Symptoms of ehrlichiosis are generally nondescript. hematologist suspected HCTZ as the culprit, given her sulfa allergy. Other possibilities Common signs are hepatitis (85±90%), thrombocytopenia (50±75%), and rash (36%). included cefotetan. Patient markedly improved and was discharged 5 days later on oral Although neurologic symptoms are not common, abnormal CSF chemistries are common predisone. (55%) when lumbar puncture is performed. When CSF is abnormal, mortality is high (19%). IMPLICATIONS/DISCUSSION: With advancements in pharmacologic medicine have come CDC case definition includes antigen, antibody, PCR, and/or culture data. Our patient met an increasing incidence of drug-related reactions, including DIAHA. Common drugs case definition by his Y fourfold rise in IgG antibody. implicated in DIAHA include high-dose penicillin, sulfa-based drugs, cephalosporins (e.g. cefotetan and ceftriaxone), methyldopa, procainamide, , isoniazide, and primaquine. HCTZ has the potential to cause allergic reactions and hemolytic anemia due to its sulfa- component. Other causes of hemolytic anemia to be ruled out include viral infections LEGIONNAIRES' DISEASE, RASH AND RENAL FAILURE. C. Wells1, D. Balkovetz1; (HIV, etc.), autoimmune diseases,lymphoma, hypersplenism, and microangiopathy (DIC, 1University of Alabama at Birmingham, Birmingham, AL (Tracking ID #76633) HUS, TTP). DIAHA typically presents with jaundice, anemia, low haptoglobin, elevated LDH, positive direct Coombs test, and elevated indirect bilirubin. Treatment requires removal LEARNING OBJECTIVES: Review a case of Legionnaires' Disease (LD) associated with of the offending drug, corticosteroids, and hematology referral for gamma globulin therapy. acute renal failue (ARF) and rash. CASE INFORMATION: A 50 year-old male presented with a 5-day history of fever to 1048F, abdominal pain, non-bloody diarrhea, malaise, and an erythematous, non-pruritic rash. FIBROSIS, NOT SO BENIGN. M. Woodske1, R. Granieri1; 1University of Pittsburgh, Physical examination was significant for fever, tachycardia, hypotension, cardiac murmur, Pittsburgh, PA (Tracking ID #74956) crackles in the left lung field, and a diffuse erythematous maculopapular rash. Hospital evaluation revealed pneumonia and ARF with creatinine of 7.1. The patient was treated for LEARNING OBJECTIVES: 1. To recognize the differential diagnosis of extrinsic lung community-acquired pneumonia (CAP) with vancomycin and ceftriaxone. Renal function masses. 2. To recognize the causes, associated syndromes, and treatment of fibrosing deteriorated further with peak creatinine of 13.6, a renal biopsy was consistent with acute mediastinitis. interstitial nephritis (AIN), and the patient required hemodialysis. Legionella urine antigen CASE INFORMATION: A 49 year old male, a smoker with 75 pack-years, with additional sent on hospital day #3 was positive, and the patient's renal and pulmonary function began to medical history of occupational exposures to petrochemicals from auto body repair and improve with the initiation of doxycycline. multiple recurrent pneumonias over the last 3 years, presented to an outside hospital IMPLICATIONS/DISCUSSION: Legionella pneumophila, the causative organism in LD, is approximately 2 months prior to admission with hemoptysis and progressive dyspnea. The responsible for 2±9% of cases of CAP. Classic associations include abdominal pain and ROS was unremarkable and the patient denied weight loss. The patient's hemoptysis and diarrhea. ARF and rash are less common. ARF was described in 14 of the original 123 patients dyspnea initially resolved with a course of antibiotics. However, a chest x-ray and subsequent from the outbreak in 1976, three of which required hemodialysis. At least 45 more patients CT scans revealed a soft tissue density between the left mainstem bronchus and esophagus, with LD and ARF have been described with various pathology including ATN, AIN, and compressing the left mainstem bronchus. Split function ventilation perfusion scans showed RPGN. Only three cases of rash associated with LD are documented in English journals. In minimal function in the left lung. A malignancy work up including EGD, colonoscopy, CT of each case the rash developed after antibiotics. In this patient the rash was observed on the abdomen and pelvis, and multiple labs test was unrevealing. Several attempts at presentation and resolved with doxycycline. bronchoscopy only revealed dense fibrosis. The patient then had an open thoracotomy to JGIM Volume 18, April (supplement 1) 2003 97

obtain tissue diagnosis, which was unsuccessful. Another bronchoscopy and rigid mediastino- Given the otherwise unremarkable history and physical exam, the patient's symptoms were scopy were performed. These showed an extrinsic compression of the left mainstem bronchus consistent with primary EM. She was instructed to avoid extreme heat, and avoid ice water without endobronchial lesions and enlarged subcarinal level IV and level VII lymph nodes. immersion given the risk of skin necrosis. An empiric trial of propanolol was initiated. Because Biopsies were again taken of the nodes and of the compressive mass. All showed reactive EM can sometimes preceed myeloproliferative disorders, the patient was encouraged to follow- changes without evidence of malignancy. Gram stains, AFB, and cultures showed no up for hematologic monitoring. pathological organisms. Lab data were unrevealing including renal function and CBC with IMPLICATIONS/DISCUSSION: This case adds to the handful of case reports describing RP differential. The patient was then treated for his symptoms with a bronchial stent. This was and EM occurring in the same patient. Previously, it has been assumed that EM is the opposite replaced about 2 months later as it had migrated from its original location. of RP, but new studies suggest that they may have similar underlying mechanisms. IMPLICATIONS/DISCUSSION: The differential for a mediastinal mass is usually RP is a common disease affecting between 5±20% of women and 4±14% of men. Patients compartmentalized into abnormalities in the anterior, middle and posterior mediastinal describe episodes of cool extremities, accompanied by typical color changes. Although most segments. This differential includes: 1) anteriorly: thymoma, thymic carcinoma, thymolipoma, cases represent a relatively benign primary disease, up to one fifth of cases seen by internists thymic cysts, teratomas, seminoma, germ cell tumor, thyroid goiter, lymphangioma, and accompany serious underlying disorders. Treatment consists of environmental measures, and parathyroid adenoma; 2) middle and posterior: lymphoma foregut cysts, pericardial cysts, evidence favors calcium-channel blockers as first-line drug therapy. neurofibomatoma, , ganglioma, ganglioneuroblastomas, neuroblastoma, and In contrast, EM is a rare condition resulting in episodes of red, warm, and painful extremities. lateral thoracic meningocele. Fibrosing mediastinitis, often considered ``benign,'' causes a The primary form of disease constitutes 60% of cases. Among patients with underlying variety of clinical syndromes secondary to compression and/or erosion into the surrounding disorders, myeloproliferative diseases are most common. Approaches to diagnosis and mediastinal structures. It often presents with superior vena cava syndrome, pulmonary vein or treatment remain poorly studied, but most experts agree that ruling out myeloproliferative artery compression, extrinsic compression of the tracheo-bronchial tree, and rarely with diseases is an essential part of care. constrictive pericarditis. It is a rare disease and has a reported association with Histoplasma and Mycobacterium tuberculosis. The mass is comprised of dense fibrotic tissue in the mediastinal area which often causes symptoms secondary to compression of adjacent structures. The THE MAN WITH CHUNKY URINE. G. Michelini1, E.F. Yee2, M. Davis1; 1GLAVAHCS/ disease is histologically and pathologically similar to sclerosing cervicitis and retroperitoneal UCLA±San Fernando Valley Program, Sepulveda, CA; 2Albuquerque VA/U New Mexico, fibrosis, and thus, is often viewed as a ``variable manifestation of a single disease.'' No definitive Albuquerque, NM (Tracking ID #75953) treatment is known at this time, although symptomatic treatment is warranted. Case reports have shown tamoxifen, also used in retroperitoneal fibrosis, to be an effective treatment, but LEARNING OBJECTIVES: 1. Recognize colo-vesicular fistula as a cause of recurrent urinary this does not have widespread acceptance. tract infections 2. Discuss work up and management of colo-vesicular fistula CASE INFORMATION: A 53 y.o. male presented to clinic with one week of dysuria, penile discharge, and bilateral flank pain, three months of low grade intermittent fever, and seven FATAL HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN AN ELDERLY MAN. E. Wu1, months of intermittent left groin/lower abdominal cramping associated with a 35 pound weight M. Maher1, L. Mermel1, L. Glasser1; 1Rhode Island Hospital, Providence, RI (Tracking loss. A similar episode of dysuria one month prior resolved on its own after 2 days. He was ID #75023) homeless, last sexual contact was 6 months ago, and he had no history of STDs. On exam he LEARNING OBJECTIVES: To recognize the hallmark signs and symptoms potentially was afebrile, had bilateral flank tenderness, non-tender penis and testes, and no discharge. indicating a diagnosis of hemophagocytic lymphohistiocytosis (HLH), which may present UA:202 RBC, 730 WBC, -nitrite, +LET; Na 130, Cr 1.9. The patient was treated with po simply with recurrent fevers. To recognize the tenuous course of HLH and manage it levofloxacin and oral hydration for pyelonephritis. Three days later he reported improvement accordingly. of dysuria and flank pain. Labs showed Na 134, Cr 1.0, and urine culture ``highly indicative of CASE INFORMATION: An 88-year-old male with a PMH of Sjogren's syndrome and contamination.'' He then presented twice more over the following two months with recurrent rheumatoid arthritis presented to an outside hospital with 2 weeks of fevers, weight loss, night symptoms, noting ``gunk/chunks'' in his urine. Urine was positive for RBC, WBC and LET, sweats, and fatigue. He had splenomegaly, elevated LFTs, and pancytopenia. Bone marrow but cultures negative (including one off antibiotics for two weeks). He was treated with po biopsy, pan-cultures, and a hepatitis panel were unrevealing. He received empiric antibiotics levofloxacin and po bactrim. Abdominal CT found bowel loop inflammation and thickening, and was discharged. possible mass. Urine eosinophils 7%. HIV, and urine fungus, AFB, chlamydia, and gonorrhea Recurrence of fever prompted admission to our hospital. Physical examination revealed a were all negative. Prostate exam unremarkable. Post void residual 43 cc. Repeat CT revealed temperature of 38.58C and splenomegaly. Hg was 10.7 g/dl, platelets 62,000/ul, and WBC diverticuli, and thickened bladder wall with air suggestive of colovesicular fistula. He was given 2,000/ul with 70% PMNs, 3% bands, 12% lymphs, 15% monos. AST was 140 U/l, ALT 133 po levofloxacin and flagyl and a surgical appointment scheduled. Four months after initial U/l, alk phos 307 U/l, albumin 2.2 g/dl, and total bili 4.3 mg/dl. ESR was 56 mm/hr. presentation, colovesicular fistula repair, and sigmoid resection with primary were Abdominal CT revealed mild splenomegaly, a 2-cm low density splenic mass, bilateral pleural performed. effusions, para-aortic lymphadenopathy, and ascites. Bacterial, viral, fungal, and parasitic IMPLICATIONS/DISCUSSION: It is important to recognize clinical clues such as fecaluria, cultures were negative. Epstein-Barr virus (EBV) IgG Ab titer to viral capsid antigen was dysuria, pneumaturia, irritative symptoms, abdominal pain, diarrhea, hematuria, and rectal 1:10240; IgM titers was negative; Ab titers to EBV early antigen and nuclear antigen were 1:20 urine passage in order not to miss the diagnosis of colovesicular fistula and delay treatment or and 1:40, respectively. incur unneccessary work up of other diagnoses. Aseptic pyuria from fungus, TB, or chlamydia, The patient received empiric antibiotics for febrile neutropenia and was hydrated with aseptic prostatitis, bladder mass/malignancy, eosinophilic cystitis, interstitial nephritis, intravenous fluids. Total bilirubin peaked at 12.2 mg/dl. Bone marrow aspirate revealed nephrolithiasis, and fistula were all considered in this patient's differential. He was treated hemophagocytosis, with PCR positive for EBV in the bone marrow specimen. After several for multiple UTI's (common) due to a colovesicular fistula (rare) from diverticulitis, the most days, the fever and neutropenia resolved and he was discharged. However, he was readmitted common cause of this type of fistula. CT, BE, colonscopy, cystoscopy, and intravenous with recurrent febrile neutropenia, and became encephalopathic and expired shortly thereafter urogram are all diagnostic modalities. Surgical intervention is recommended for symptom with liver failure and persistent fevers. relief. Diverting colostomy will decrease the risk of ascending UTI. Patients may also be IMPLICATIONS/DISCUSSION: Hemophagocytic lymphohistiocytosis (HLH) is an unu- managed conservatively with prophylactic antibiotics and observation if there is no urinary sual syndrome characterized by fever, splenomegaly, jaundice, and the pathologic finding of tract obstruction. hemophagocytosis on bone marrow examination. It is associated with familial and infectious etiologies. Familial cases have been observed in children. EBV-associated HLH is the most common form and can occur at any age. Our patient's serology suggested recent EBV infection A YOUNG MAN WITH HIV AND STROKE. C.L. Young1, A. Sofair1, S. Aronin1; 1Yale or more likely, reactivation. Overall prognosis in HLH remains poor. Familial HLH is an University, New Haven, CT (Tracking ID #76038) important variant to diagnose, as patients have done well with bone marrow transplantation. Patients with other forms of HLH may respond to etoposide with or without cyclosporine A. LEARNING OBJECTIVES: 1) To recognize the clinical manifestations of meningovascular syphilis. Treatment of underlying bacterial, fungal, or parasitic infection is imperative; however, antiviral treatment of patients with EBV-associated disease has not been found to be helpful. 2) To recognize that meningovascular syphilis should be considered in the differential diagnosis of HIV patients who present with focal neurological findings. 3) To recognize that meningovascular syphilis is a treatable cause of stroke. CASE INFORMATION: A 37 year-old male with HIV, CD4 390 cells/mm3 and a HOT HANDS, COLD HANDS: APPROACHING VASCULAR DYSFUNCTION OF THE nondetectable viral load, presented with right arm weakness, right hand paresthesias, a history EXTREMITIES. J. Yazdany1; 1University of California, San Francisco, San Francisco, CA (Tracking ID #76054) of two aphasic episodes, and episodic frontal headaches. His neurological exam was significant for horizontal nystagmus, right arm distal weakness, and mild right hand sensory loss. LEARNING OBJECTIVES: To recognize the clinical diagnoses most commonly associated Cerebrospinal fluid (CSF) studies revealed elevation of his protein and a positive VDRL at 1:2. with dysfunctional vascular response of the extremities: Raynaud's phenomenon [RP] and Serum VDRL was positive at 1:256. Trans-esophageal echocardiography was unremarkable [EM]. To develop an evidence-based approach to the evaluation and treatment and a hypercoagulable work-up was negative. An MRI/MRA of the brain revealed a diffuse of these disorders. vasculitis that correlated with his stroke symptoms. After treatment with ten days of high dose CASE INFORMATION: A 40 year-old woman with long-standing RP reported a six month intravenous penicillin, his symptoms resolved, his CSF VDRL was negative, and his MRI/ history of intermittent ``hot hands and feet'' associated with redness and pain. Symptoms were MRA normalized. exacerbated by heat, exercise and alcohol, and relieved by immersion in ice water. Past medical IMPLICATIONS/DISCUSSION: Meningovascular syphilis is a clinical entity marked by history revealed only mitral valve prolapse. The patient denied tobacco, alcohol or drug use. stroke symptoms secondary to a vasculitis. Clinical manifestations are characterized by an acute Her mother had also complained for many years of ``hot, painful hands''. onset of hemiparesis. Other possible symptoms include aphasia, seizures, and a prodrome of Physical examination revealed a blood pressure of 116/89 and heart rate of 97. The patient was headaches, dizziness, mood changes, or impaired memory. Population based studies in the a well-appearing white female. No abnormality was noted except marked erythema and warmth literature have demonstrated higher rates of neurosyphilis among HIV co-infected individuals. of both hands. Normal capillary beds were visualized at the periungual folds. Pulses were This vignette demonstrates that HIV patients who present with focal neurological findings symmetric and strong. Labs revealed normal CBC, lytes, renal function, and TSH. ANA was deserve a work-up that includes testing for meningovascular syphilis. In addition, treatment of 1:40 in a speckled pattern, and ESR was 4. this entity can lead to resolution of the stroke symptoms and vasculitis. 98 Abstracts JGIM

SMOKING CHINESE BROCCOLI? J.L. Yuh1,E.Yee2, A.G. Gomez3; 1Olive View±UCLA mass( with a small air pocket) adjacent to the hepatic flexure with mesenteric stranding and SFVP, Sylmar, CA; 2VA Albuquerque±University of New Mexico, Albuquerque, NM; sigmoid . Bowel rest and ampicillin -sulbactam were implemented. By the third 3University of California, Los Angeles, Sepulveda, CA (Tracking ID #75461) day, her exam markedly improved. She was discharged on amoxicillin-clavulanate with follow up colectomy planned. LEARNING OBJECTIVES: 1. Recognize acute nicotine in toxication 2. Discuss the IMPLICATIONS/DISCUSSION: The frequency of diverticulosis in younger patients is management and treatment of acute nicotine intoxication thought to be increasing. Most people will be asymptomatic. Overall, 15% will be right CASE INFORMATION: A 56 year old Thai nun, non-smoker, with no known medical sided in western countries. Symptoms include bloating and abnormal bowel habits. About history was brought in for an acute onset of confusion, lethargy, and diffuse body weakness. 20% develop clinical diverticulitis and of those, 10 to 20% will require surgery. Following breakfast, the patient was found to be minimally responsive next to a bowl of soup. Complications of diverticula include simple inflammation, abscess, bleeding, and fistula By report, this soup contained many leaves of Chinese broccoli self-grown at the temple. In the formation. Abscess may cause abdominal pain for several days duration, nausea, constipation ED, the patient's presenting GCS was 9, T 37.1F, pulse 49, BP 91/39, respirations 16, and and fever. WBC can be normal in up to 45% of patients. Treatment of complicated room air O2 sat 94%. She was minimally responsive and diffusely flaccid on motor exam. IV diverticulitis often requires combined medical and surgical approach. Evidence suggests fluids, NG charcoal lavage, and sorbitol were administered. CBC, CHEM 10, LFTs, and UA more virulent disease in young people. Often these patients are treated with early colectomy. were all normal; serum/urine toxicology screen, acetaminophen and alcohol levels were They have a higher incidence of right sided disease that can be mistaken for appendicitis. negative. CXR was clear, and head CT did not show any shifts, masses, or bleeds. EKG showed Longer lifespans lead to increased potential for morbidity. With CT guided drainage, the only sinus bradycardia at 50 bpm. On repeat exam, pt was slightly more responsive since two part surgeries (with colostomy and then take down) decreased dramatically. Contained presentation, with pupils dilated and sluggish, but not following commands in English or Thai. perforation is managed with antibiotics followed by partial colectomy. Offering colectomy She was admitted to the ICU for monitoring. Several leaves of the Chinese broccoli used in the after the second attack of uncomplicated diverticulitis has recently been challenged. soup were brought in later. Upon calling poison control and researching botanical atlases, it Conservative treatment after the second attack is now considered a reasonable option in was determined to be a tobacco plant. Her serum nicotine level was low, while her serum older patients. However, for younger individuals, with no medical comorbidities, early cotinine level was high, indicating the metabolism of nicotine to cotinine, and confirming an surgery may be the preferred option. ingestion of 15+ tobacco leaves. The patient regained her strength and alertness gradually and was discharged in normal health on day 3. The temple members subsequently removed all remaining `Chinese broccoli' plants! IMPLICATIONS/DISCUSSION: Nicotine overdose can result from overuse of cigarettes, FACTOR V LEIDEN AND PREGNANCY. D. Zalenski1, M.A. McNeil1; 1University of nicotine gum or patches, and plant ingestion. It is seen most commonly in patients smoking Pittsburgh, Pittsburgh, PA (Tracking ID #75621) while on a patch. Patients can exhibit weakness, convulsions, coma, respiratory distress/apnea, pupillary dilatation, abdominal cramps, vomiting, initial tachycardia/hypertension, followed by LEARNING OBJECTIVES: 1. Recognize indications for anticoagulation in pregnancy bradycardia/hypotension. Diagnosis is by careful history and physical exam as there are no set 2. Recognize the complications of pregnancy that result from factor V Leiden. serum toxicity levels. The half-life of nicotine is 0.5±2 hours while that of cotinine (a better CASE INFORMATION: The patient is a 33 year old female, gravida two para one, at eight marker due to its slower clearance) is 12±30 hours. Management includes airway protection, weeks gestation who presents to the office. Her first pregnancy was complicated by a deep charcoal lavage, sorbitol, hydration, and circulatory support. Symptoms can last several hours, venous thrombosis at fifteen weeks gestation. At that time hypercoaguability work up was and survival after 4 hours of intoxication usually prognosticates complete recovery. Lethargy performed due to a positive family history. The patient had elevated protein C resistance and may remain for several days. Caution needs to be emphasized for patients ingesting unknown she was placed on full dose heparin through the duration of her pregnancy. Her third trimester plants and to remind patients of the dangers of using nicotine replacements while continuing to she developed hypertension. She delivered at thirty-five weeks and remained on antic- smoke. oagulation six weeks following delivery. Factor V leiden mutation was confirmed by gene testing following delivery. She had a seizure disorder as a child and took dilantin and multivitamin prior to pregnancy. Her father had a pulmonary embolus and has antithrombin III deficiency. She is a pharmacist and does not smoke or drink alcohol. Comprehensive 1 PREECLAMPSIA AND PSEUDO POSTPARTUM CARDIOMYOPATHY. H. Zakariya , physical exam is normal. The patient was placed on continuous subcutaneous infusion of 1 1 R.D. Hobbs ; Oakwood Healthcare System, Dearborn, MI (Tracking ID #76568) heparin because she declined lovenox therapy. LEARNING OBJECTIVES: To recognize that volume overload in the preeclamptic patient IMPLICATIONS/DISCUSSION: Factor V Leiden is the leading cause of thomboembolism can lead to pulmonary edema and the misdiagnosis of postpartum cardiomyopathy. in pregnancy (44%). Pulmonary embolus contributes greatly to maternal mortality rates. CASE INFORMATION: A 29 year-old, G5P3AB2 woman presented with severe dyspnea, Venous thromboembolism occurs in one in 1500 pregnancies. The most prothrombotic time is orthopnea and peripheral edema five days after delivering a baby. Her pregnancy had been immediately post partum. In addition factor V Leiden has been associated with HELLP, complicated by preeclampsia but managed without difficulty. Vital signs were: BP 157/96, P intrauterine growth retardation, miscarriage, and pregnancy induced hypertension. The 110, R 22, T afebrile. Oxygen saturation was 94% on 100% O2. Bilateral rales, jugular venous activated protein C resistance test may be falsely positive because of changes that take place in distention, an S3 and S4 with 3+ pitting edema and a mitral regurgitation murmur were noted the coagulation system during pregnancy. Diagnosis must be confirmed with gene testing. If on physical examination. Cardiac enzymes were normal. Hgb was 9.7 g/dl. An EKG showed factor V positive, patients have a three to five times greater risk of stillbirth. Factor V Leiden is sinus tachycardia. Spiral CT was negative for pulmonary embolus. She was admitted with a present in 20±40% of abruptions. There have been no randomized control trials to diagnosis of postpartum cardiomyopathy. An echocardiogram showed severe mitral regurgita- demonstrate that full dose anticoagulation will reduce the risk of any of these complications. tion, trivial tricuspid regurgitation, a small pericardial effusion and an ejection fraction of 50- Treatment is based on extrapolation of data from nonpregnant patients. There is controversy 55%. She was treated with furosemide and rapidly improved. Repeat echocardiography, done over treatment of pregnant patients with factor V and a prior DVT. At present, patients are two weeks later when she was asymptomatic and off medications, showed that the mitral offered prophylactic dose heparin or full dose heparin or lovenox based on individual risk regurgitation had cleared, there was no pericardial effusion and her ejection fraction was stratification (i.e homozygous vs. heterozygous). For individuals with factor V but no prior unchanged. Further history revealed that in the last months of pregnancy and immediately event, a variety of options exist: prophylactic subcutaneous heparin throughout the pregnancy postpartum she had been advised to ``drink a lot of fluids.'' with full dose anticoagulation postpartum for six weeks versus postpartum treatment only IMPLICATIONS/DISCUSSION: In preeclampsia the expected fall in colloid oncotic versus clinical surveillance alone. Lovenox will likely replace heparin because of its favorable pressure is greater than that seen in normal pregnancies. Cardiac output increases 40% side effect profile. Risks include a 2% major bleeding risk, heparin induced thrombocytopenia, during normal pregnancy and extravascular volume is expanded. Following delivery, significant and osteoporosis. amounts of extravascular fluid move into the intravascular space and are cleared. In our patient, increased fluid intake led to over expansion of the extravascular volume with pulmonary edema occurring as the fluid was mobilized. Notably, this is not a case of postpartum cardiomyopathy. CYTOMEGALOVIRUS PANCOLITIS IN AN IMMUNOCOMPETENT TEENAGER. Her ejection fraction was normal on both initial and repeat echocardiograms and does not I. Zarraga1,L.Lu1; 1Baylor College of Medicine, Houston, TX (Tracking ID #75944) show primary muscular dysfunction. The mitral regurgitation cleared with diuretics and is not suggestive of a structural lesion. Small pericardial effusions may occur as a normal variant LEARNING OBJECTIVES: (1) To describe an unusual case of cytomegalovirus (CMV) during pregnancy. Instead, her condition is explained by extreme fluid shifts in a preeclamptic colitis in a young, immunocompetent host. woman. Diagnostic confusion occurs if the physician interprets the findings in terms of the (2) To review the presentation, treatment, and prognosis of CMV colitis among immuno- non-pregnant state. competent adults. CASE INFORMATION: A 17-year-old female was admitted to the hospital for a complaint of bloody diarrhea. She had been in good health until 4 months earlier when she noted intermittent passage of bright red blood and reddish tissue with her stool. Ten days before DIVERTICULAR DISEASE IN THE YOUNG: DILEMMAS IN DIAGNOSIS AND admission, she developed cramping periumbilical pain, soon followed by fever and watery MANAGEMENT. D. Zalenski1, M.A. McNeil1; 1University of Pittsburgh, Pittsburgh, PA diarrhea with hematochezia. Pertinent findings on examination included a temperature of (Tracking ID #73964) 100.4 F, slightly pale conjunctivae, a soft abdomen with normoactive bowel sounds and LEARNING OBJECTIVES: 1. Recognize the differing manifestations of diverticular disease minimal tenderness periumbilically, and bright red blood on digital rectal exam. Her white cell in a younger population 2. Manage diverticulitis and its complications count was 8,200/mm3 with 37% neutrophils and 55% lymphocytes. Atypical lymphocytes were CASE INFORMATION: A 46 year old female with no PMH except appendectomy, admitted present. Stool samples were negative for ova, parasites, C. difficile toxin, and other bacterial with a five days of abdominal pain. It began as ``'' in the epigastrum for several days enteropathogens. An abdominal CT scan showed thickening of the wall of the entire large but progressed to a sharp, constant, right-sided abdominal pain. Associated symptoms included bowel. On colonoscopy, there were diffuse inflammation in the colon, mucosal nodularities, anorexia, three days of constipation, with no bowel movement but some flaitus. She had no and diminished haustral markings. Colonic biopsies demonstrated active colitis with CMV dysuria, normal menses, and no bloody bowel movements. She had one episode of ``sweats'' infection, but no architectural distortion to suggest an underlying chronic inflammatory bowel and chills two days prior. On exam, she was afebrile and in moderate distress. Her vital signs disease (IBD). A CMV antigenemia test came back positive, and anti-CMV IgM and IgG titers were normal and abomen was soft with hypoactive bowel sounds and voluntary guarding in the were both elevated. HIV serology, however, was negative and CD4 count was 354. Markers for right mid abdomen. Rectal exam was guiac negative. The remainder of the exam was normal. IBD, including p-ANCA and ASCA, were likewise negative. The patient was treated with UA, CBC, LFTS, amylase, and lipase were normal. CT of the abdomen revealed a 5.3 cm valganciclovir for 21 days. JGIM Volume 18, April (supplement 1) 2003 99

IMPLICATIONS/DISCUSSION: Most primary CMV infections in immunocompetent adults are subclinical or associated with a mild mononucleosis-like syndrome, and all such infections resolve and enter a latent state. Reactivation of latent virus accounts for most CMV disease and almost always occurs in a setting of cell-mediated immunodeficiency. Gastro- intestinal CMV disease, in particular, is a well recognized problem among AIDS patients with CD4 counts <100, transplant patients, patients on steroid therapy, and patients with cancer or on cancer chemotherapy. Gastrointestinal CMV disease, especially severe colitis from a primary CMV infection, is very rare in the immunocompetent host. After excluding cases of individuals above 70 years of age, on immunosuppressive therapy, and with associated diseases such as AIDS, cancer, chronic renal failure, inflammatory bowel disease, or co-infection with another enteropathogen, a literature search from the mid-1960's to 2002 identified less than 15 cases of CMV colitis in truly immunocompetent adults. The youngest of these patients was 22 years old, and the most common presenting manifestations were diarrhea (100%), fever (82%), hematochezia (64%), and abdominal pain (27%). The outcomes ranged from death to development of a chronic illness indistinguishable from IBD, to complete resolution of the colitis. Because of the paucity of cases, the efficacy of antiviral therapy under these circumstances has not been established.

SUDDEN CARDIAC DEATH IN YOUNG HEALTHY PERSON. S. Zheng1; 1The Penn State Milton Hershey Medical Center, Hershey, PA (Tracking ID #76968)

LEARNING OBJECTIVES: To identified common causes of sudden cardiac death. To identified uncommon causes of sudden cardiac death. To learn diagnostic approaches to sudden cardiac death. CASE INFORMATION: A previous healthy 27 year-old young man collapsed suddenly while playing ice hockey. AED identified him in VF and shocked him four times. Patient was subsequently resuscitated. Patient has two similar episodes within the past month, every time occurs while patient was in rigorous exercise. Patient has no PMH and was not taking any medication at that time. Patient has no family history of sudden death. Echocardiogram was normal and drug screen was negative. Exercise echocardiogram was also normal with no ischemia. EP study was performed with IV epinephrine and procainamide challenge, no QT prolongation nor Brugadar syndrome were identified. Finally, MRI of the heart shown fatty infiltrate of the right ventrical free wall. Arrythmogenic right ventricular dysplasia (ARVD) was diagnosed and patient was discharged home with an AICD placement. IMPLICATIONS/DISCUSSION: Discussion: Sudden cardiac death (SCD) in young healthy men or women is a catastrophic event. In this country, majority of the cases are due to hypertrophic cardiac myopathy (HCM). Coronary artery disease (CAD) is by far the most common cause of SCD in people who are above the age of 35. It is crucial to rule out HCM and CAD by using echocardiogram. The next common cause of SCD is acquired or congenital QT prolongation induced VF/VT. Therefore, a detailed family history and medication are very important in identify this disease. If there is no obvious finding, EP study can be performed to bring out QT prolongation or . Finally, MRI of the heart is a great tool in diagnoses ARVD. ARVD is one of the indications for AICD placement.