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Society of General Internal Medicine Society of General Internal Medicine 24th Annual Meeting San Diego, California May 2±5, 2001 ABSTRACTS SEVERE HYPERNATREMIA DUE TO A HIGH CALORIE MEAL SUPPLEMENT. D. 1 1 CLINICAL VIGNETTES Addamo ; Mount Sinai School of Medicine, New York, NY LEARNING OBJECTIVES: 1) Raise index of suspicion for severe metabolic derangement in elderly patients. 2) Recognize clinical signs of hypernatremia. 3) Recognize limitations of using concentrated supplements as meal replacement. CASE INFORMATION: A 79 year old woman with advanced Alzheimer's disease was brought SUCCESSFUL TREATMENT OF RECURRENT LEUKOCYTOCLASTIC VASCULITIS to the E.D. due to a 4-week progressive decline in her overall level of function. She had been WITH CELOCOXIB IN A CYSTIC FIBROSIS PATIENT. C. Vergara1,R.Knauft2; hospitalized 8 weeks prior for an aspiration pneumonia. Her daily fluid intake since that time 1University of Connecticut Health Center, Farmington, CT; 2Hartford Hospital, Hartford, consisted of six 8oz cans of a ``balanced nutrition shake'', along with some soup. 4 days prior she CT was given antibiotics by her primary physician. She showed no improvement and developed diarrhea. Physical exam revealed an obtunded woman. Her pulse was 120bpm and rectal LEARNING OBJECTIVES: Recognize the occurence of leucocytoclastic vasculitis in cystic temperature was 38.9 Celsius. She was normotensive. She had dry oral mucosa and skin tenting. fibrosis patients. Recognize arthalgias and tendonitis associated with such conditions. Treat Her neurological exam was nonfocal. Lab studies were significant for sodium of 185mEq/L, such conditions with Celocoxib - a COX 2 inhibitor nonsteroidal anti-inflammatory agent. chloride of 148mEq/L, BUN of 124mg/dL and a creatinine of 3.0mg/dL. Urine osmolality was CASE INFORMATION: Case: We present a 24 year old white female with cystic fibrosis 819mOsmol per kg with urine sodium of 22mMol/L. Her WBC was 13K. Labs from her prior with recurrent pulmonary infections and associated rashes on her extremities. The rashes are admission revealed sodium of 143mEq/L; chloride of 106mEq/L; BUN and creatinine were on her legs as well as her arms. They are always associated with and wax and wane with acute 7mg/dL and .7mg/dL respectively. Her free water deficit was calculated at 9 liters, and she was exacerbations of lung disease(infections). They are small circumscribed pruritic red lesions placed on D5W1/2NS at 150cc/hr. Her tachycardia and fever resolved. She began keeping her which became palpable within a week of appearance. This episode, in addition to the rash she eyes open and speaking some words. On the sixth hospital day serum sodium was 146 with had polyarthalgias and tendonitis of the distal left pronator tendons. Lab results: WBC normal BUN and creatinine. The patient was discharged on a diet of purees and thickened 15,000/L, Hemoglobin 13 gm/dL, Platelets 254000/L, serum chemistry within normal liquids. limits (WNL), coagulation parameters WNL, urinanalysis WNL, ESR 100 mm/hr, serum DISCUSSION: Patients with dementia are at a risk for hypernatremia due to their inability to ANA/RF negative, C-ANCA negative, sputum cultures grew pseudomonas aeruginosa, verbalize a need for water or to obtain it for themselves. Hypernatremic dehydration can lead to Complements C3 was low, Cryoglobulins negative. Biopsy Results: Skin biopsy results showed mental status changes that are easily missed in a severely demented patient. While canned high angiocentric segmental inflammation, endothelial cell swelling, fibrinoid necrosis of calorie shakes are an attractive supplement for patients with poor oral intake, they are highly postcapillary venules with cellular infiltrate around and within dermal blood vessel walls concentrated and contain little water. This renders them a poor substitute for total meal composed mostly of neutrophils having fragmentation of nuclei (leukocytoclasia). replacement. Immunofluorescence and ultrastructural studies documented immunoglobulins (IgG), complement components (C1q, C3) and fibrin deposits within postcapillary venule walls. Treatment: She had previously been treated with high dose oral corticosteroids, IVIG G as an immune modulator, ibuprofen (800 three times a day) all with poor tolerance and many side SPINAL METASTASIS AS THE INITIAL PRESENTATION OF A NON-SECRETORY effects. After treating her with Celocoxib 200mg a day, her arthalgias disappeared in 2 days GLUCAGONOMA. A. Aggarwal1, J. Brainard1, D. Brotman1; 1Cleveland Clinic Foundation, and her purpura by the third day. Further recurrences treated similarly were also decreased in Cleveland, OH extent, duration and severity. DISCUSSION: Leukocytoclastic vasculitis is a vasculitis of the post capillary venules resulting LEARNING OBJECTIVES: 1. Recognize that glucagonomas can present with spinal in palpable purpura and a hallmark histopathologic of angiocentric segmental inflammation, metastases. 2. Appreciate that the absence of cutaneous, endocrinologic and gastrointestinal endothelial cell swelling, fibrinoid necrosis of post capillary venules. The cellular infiltrate manifestations does not rule out the presence of a glucagonoma. 3. Know that tissue staining for around and within dermal blood vessel walls is composed largely of neutrophils showing neuroendocrine peptides can confirm that a tumor is of pancreatic origin, even when there is no fragmentation of nuclei (karyorrhexis or leukocytoclasia). Leucocytoclastic vasculitis is radiographically identifiable pancreatic mass. manifested clinically by a spectrum of cutaneous lesions, although ``palpable purpura'' is its CASE INFORMATION: A 38 year-old African-American woman presented to the emergency clinical hallmark. Although removal of the cause is the definitive treatment, it can be department with low back pain of three months duration. The pain involved both flanks and symtomatically treated with a variety of immunomodulating agents and/or anti-inflammatory radiated to the buttocks and posterior thighs bilaterally, as well as to the right groin and medial drugs. We found the use of celocoxib- a cox 2 inhibitory nonsteroidal antiinflammatory agent right thigh. By exam, she was thin and appeared uncomfortable. Shotty nodes were palpable in without any significant gastrointestinal or antiplatelet actions to be very useful in the multiple regions, but none were fixed or enlarged. There was percussion tenderness of the management of such a case. lumbar spine, but motor function and reflexes were normal in the lower extremities. Serum chemistries were notable for an elevated alkaline phosphatase but otherwise normal liver enzymes. Serum calcium and glucose were normal. CT of the abdomen and pelvis showed peri- pancreatic lymphadenopathy and numerous hepatic lesions suggesting metastases. MRI of the UNILATERAL RETROPERITONEAL FIBROSIS AS ABDOMINAL MASS. M. Aboyoussef1; spine demonstrated a destructive lesion in the second lumbar vertebra with soft-tissue 1University of Pittsburgh, Pittsburgh, PA extension compressing the spinal cord (figure). Whole body bone scan showed diffuse osseous LEARNING OBJECTIVES: Recognizing Unilateral Retroperitoneal Fibrosis as a cause for metastases to the upper and lower extremities as well as the axial skeleton. Ultrasound-guided hyronephrosis, and funtional constipation. biopsy of the peri-pancreatic adenopathy revealed a low-grade neuroendocrine tumor that CASE INFORMATION: A 47-year-old black male previously in good health presented with stained positive for glucagon, but stained negative for serotonin, pancreatic polypeptide and three weeks of left flank pain associated with constipation. His past medical history is significant gastrin. The serum glucagon level was normal. Due to widespread metastases, the patient was for type 2 diabetes mellitus on metformin. Preliminary work up revealed increase in creatinine deemed a poor surgical candidate, however she did undergo radiation therapy to the spine and to 1.6. CAT scan left hydroureter and hydronephrosis, with soft tissue fullness, 4 cm in the to painful lesions in the right humerus and left femur. Subsequently she was treated with largest diameter. A laparotomy was performed, with excision of fullness around the ureter. Final systemic chemotherapy consisting of adriamycin and streptozocin with no initial reduction in pathology of an abdominal lymph node and tissue from the mass revealed retroperitoneal. tumor mass. Twelve months later he remained asymptomatic and follow-up CT scan showed no evidence of DISCUSSION: Glucagonomas have previously been reported to metastasize to bone, but to our recurrence. knowledge there is only one other reported case of bony metastases as the initial manifestation 23 24 Abstracts JGIM of the tumor. This may be because most glucagonomas come to early clinical attention via the ARTHRALGIAS, RASH, AND FEVER. S. Agresta1, J. Wiese1; 1Tulane University, New effects of high serum levels of glucagon. It has previously been reported that systemic and Orleans, LA endocrine manifestations of glucagonomas are more common in advanced disease and are LEARNING OBJECTIVES: To recognize the value of likelihood ratios in making difficult directly related to tumor size. This is clearly not the case in our patient. Notably absent were the diagnoses. typical skin rash (necrolytic migratory erythema), diarrhea, hyperglycemia, stomatitis and CASE INFORMATION: A 31 year-old woman presented with four weeks of fever, arthralgias, chelosis associated with the classic glucagonoma syndrome. Another important clinical
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