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New Jersey Chapter American College of Physicians NEW JERSEY CHAPTER AMERICAN COLLEGE OF PHYSICIANS ASSOCIATES ABSTRACT COMPETITION 2015 SUBMISSIONS 2015 Resident/Fellow Abstracts 1 1. ID CATEGORY NAME ADDITIONAL PROGRAM ABSTRACT AUTHORS 2. 295 Clinical Abed, Kareem Viren Vankawala MD Atlanticare Intrapulmonary Arteriovenous Malformation causing Recurrent Cerebral Emboli Vignette FACC; Qi Sun MD Regional Medical Ischemic strokes are mainly due to cardioembolic occlusion of small vessels, as well as large vessel thromboemboli. We describe a Center case of intrapulmonary A-V shunt as the etiology of an acute ischemic event. A 63 year old male with a past history of (Dominik supraventricular tachycardia and recurrent deep vein thrombosis; who has been non-compliant on Rivaroxaban, presents with Zampino) pleuritic chest pain and was found to have a right lower lobe pulmonary embolus. The deep vein thrombosis and pulmonary embolus were not significant enough to warrant ultrasound-enhanced thrombolysis by Ekosonic EndoWave Infusion Catheter System, and the patient was subsequently restarted on Rivaroxaban and discharged. The patient presented five days later with left arm tightness and was found to have multiple areas of punctuate infarction of both cerebellar hemispheres, more confluent within the right frontal lobe. Of note he was compliant at this time with Rivaroxaban. The patient was started on unfractionated heparin drip and subsequently admitted. On admission, his vital signs showed a blood pressure of 138/93, heart rate 65 bpm, and respiratory rate 16. Cardiopulmonary examination revealed regular rate and rhythm, without murmurs, rubs or gallops and his lungs were clear to auscultation. Neurologic examination revealed intact cranial nerves, preserved strength in all extremities, mild dysmetria in the left upper extremity and an NIH score of 1. Electrocardiogram revealed normal sinus rhythm, non-specific ST changes and PVCs. Transthoracic Echocardiogram revealed normal left ventricular function with mild tricuspid regurgitation, and stage 1 diastolic dysfunction. Transesophageal echocardiogram was negative for intracardiac thrombus. Echocardiography with agitated saline contrast noted microbubbles entering the left atrium from the left lower pulmonary vein indicative of Intra-pulmonary A-V Shunt. CTA of the chest revealed a connecting pulmonary vein and artery in the left lower lobe. Unfractionated heparin was continued and the patient was transferred to a tertiary center for embolization of the shunt. There the patient developed recurrent strokes while anticoagulation was temporarily on hold. CT of the abdomen for persistent abdominal pain noted an omental mass and the patient subsequently underwent exploratory laporatomy and was found to have an omentum adenocarcinoma with nodular peritoneal implants, however the primary is unknown. The patient was placed on enoxaparin, scheduled for chemotherapy. Embolotherapy of the intrapulmonary shunt was deferred. This case illustrates the embolic effect of intrapulmonary AV shunt and the characteristic appearance in those with paradoxical emboli. The main complications are hypoxia, stroke and brain abscess, as the capillary bed within the pulmonary vasculature is bypassed. Classic symptoms of dyspnea, clubbing and cyanosis are only seen in a small population of patients. These may be due to hereditary or idiopathic phenomona. Appropriate embolization, follow-up for recannulization and antibiotic prophylaxis for dental procedures is warranted. 3. 322 Clinical Balkema, casey Ronald Yglesias MD, Atlanticare Unusual presentation of young female with SLE, Cardiomyopathy, and multi-vessel coronary aneurysms Vignette Vadzim Chyzhyk MD, Regional 2 2015 Resident/Fellow Abstracts Haitham Dib MD Medical Systemic Lupus Erythematosus is a chronic inflammatory autoimmune disease affecting multiple organ systems. Cardiac Center manifestations of SLE include pericarditis, myocarditis, nonbacterial endocarditis, coronary arteritis, and premature CAD. Coronary (Dominik artery aneurysms (CAA) are rare among all patients undergoing coronary angiography with an estimated incidence of 0.3-5%. CAAs Zampino) are an even more unusual finding in SLE patients. There have been only 17 cases reported, most with single vessel involvement in the right coronary artery. A 25-year-old African American female with a medical history significant for SLE for 10 years, CVA, and hypertension presented to the hospital with complaints of worsening orthopnea for 3 days associated with decreased appetite and generalized body aches. Physical exam was significant for bilateral basilar crackles and chronic left upper extremity weakness. BNP was elevated at 2455 and a chest x-ray was consistent with congestive heart failure. 2-D echocardiogram showed severe global left ventricular hypokinesia, estimated ejection fraction of 20-25%, and estimated pulmonary pressure of 47mmHg. A previous echocardiogram 3.5 years ago showed normal left ventricle systolic function and normal pulmonary artery pressure. The patient responded well to aggressive diuresis. Further workup included cardiac catheterization which revealed multiple large coronary aneurysms in the left circumflex and right coronary arteries, and mildly ectatic left anterior descending artery. A thrombus was also suspected in the right coronary artery. After consultation with rheumatology, large doses of pulsed steroids were started in addition to anticoagulation and antiplatelet therapy, as well as medical treatment for cardiomyopathy including beta blockers and ACE inhibitors. Further planned investigation will include cardiac MRI and possible endomyocardial biopsy. The patient will also need a prophylactic AICD implantation if there is no significant improvement in myocardial function after three months of optimal medical therapy. The most common cause of coronary aneurysms in adults is atherosclerotic disease. Other etiologies include Kawasaki disease, Marfan syndrome, Subacute bacterial endocarditis, Takayasus arteritis, Rheumatic fever, Mycosis, Syphilis, cocaine abuse, previous balloon angioplasty, and use of stents. This was a case of an unusual presentation of SLE, severe cardiomyopathy, and severe aneurysmal multi vessel coronary disease. Further workup and investigation may clarify the true etiology of this combination of cardiac manifestations and its relationship to SLE. Coronary artery bypass surgery and heart transplantation may be considered and/or needed for this patient in the future. 4. 76 Clinical Chyzhyk, Vadzim Laurence Ognibene, Atlanticare Muscle gain comes with…jaundice Vignette Garo Garabedian, Regional Liudmila Vasilets, Syed Medical INTRODUCTION: Drug induced cholestatic liver disease is a subtype of liver injury that is characterized by predominant elevations of Jaleel Center alkaline phosphatase and bilirubin secondary to the administration of a hepatotoxic agent. It can manifest itself as a cholestatic (Dominik hepatitis or as bland cholestasis, depending upon the causative agent and the mechanism of injury. Drugs that typically cause Zampino) cholestasis with hepatitis include psychotropic agents, antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). Pure cholestasis without hepatitis is observed most frequently with contraceptive and androgenic steroids. We describe a case of cholestatic liver injury in a young individual following ingestion of over-the-counter muscle building supplement. Description: A 29 year-old male with no past medical history was hospitalized with rapid onset of generalized jaundice and severe pruritus. His work up showed markedly elevated total bilirubin to 11.6 mg/dl, direct 9.3 mg/dl, ALAT 121 U/L, ASAT 78 U/L, Alkaline phosphatase 552 U/L, albumin 3.5 g/dl, INR of 1.2, normal CBC and BMP parameters. His hepatitis serologies were negative. Tests for autoimmune hepatitis, primary biliary cirrhosis, sclerosing cholangitis, hemochromatosis and Wilson’s disease were negative. Ultrasound of the abdomen, MRI of the abdomen as well as MRCP were unremarkable. Upon questioning he stated that following an advice of his instructor at the local gym he used EPG “Tri-methyl platinum” dietary supplement for 2 month prior to the admission. It was suspected that patient developed drug-induced liver injury. His total bilirubin continued to rise, reaching the peak of 26.1 mg/dl, however INR remained in 1.2 range. Liver biopsy was performed and showed canalicular cholestasis with acute inflammation. He 2015 Resident/Fellow Abstracts 3 was given symptomatic treatment including diphenhydramine, ursodesoxycholic acid and taper dose of prednisolone. His bilirubin, ALT, AST gradually decreased to normal values over 3 months. Puritis and jaundice successfully resolved as well. Discussion: While using dietary supplements among people involved in bodybuilding is extremely common, general public is usually not aware of the potential side effects as well as actual content of so-called “supplements”. Anabolic steroids are prohibited for non-prescriptional use, but some manufacturers are trying to market “pro-steroids or pro-hormones” which do not fall under strict regulatory scrutiny as regular steroids. However, the actual substance of these “supplements” is not very different from 17α-alkylated androgenic steroids, commonly known to use cholestatic liver injury. Supplement, which was used by our patient, contained 2 methylated derivatives of androgens. Use of such agents can lead to prolonged hepatic dysfunction with cholestatic syndrome that resembles primary biliary cirrhosis.
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