A Al-khazraji

Morbidity and mortality of infective endocarditis in a hospital system in New York City serving a diverse urban population

Infective endocarditis (IE) is a severe illness associated with significant morbidity and mortality. The primary purpose of this study was to evaluate morbidity and mortality of IE in a hospital serving the most diverse area in New York City. An analysis of 209 patients admitted to the hospital from 2000 to 2012 who were found to have IE based on modified Duke criteria. Among the 209 patients with IE, 188 (88.8%) had native heart valves and 21 (11.2%) had prosthetic valves. Of the patients with native heart valves, 3.7% had coronary artery bypass graft, 4.3% were active drug users, 6.3% had permanent pacemakers, 12.2% had a history of IE, 25.7% were diabetic, 17% had end-stage renal disease (ESRD), 9% had congestive heart failure, 8% had abnormal heart valves, and 13.8% had an unknown etiology. Mortality rates of the patients with prosthetic heart valves were 27.7% compared to 8.11% in patients with native heart valves (OR 3, p<0.0001). Since we identified diabetes mellitus and ESRD to be significant risk factors in our population, we isolated and compared characteristics of patients with and without IE. IE among patients with diabetes mellitus was 23% compared with 13.8% in the control group (p=0.016). Cases of IE in patients with ESRD were 15.3%, compared with 4% in the control group (p<0.0001). We identified an overall mortality rate of 20.1% in patients with IE, a readmission rate within 30 days of discharge of 21.5%, and an average age of 59 years. Among 209 patients, 107 were males and 102 females. The most common organisms identified were Staphylococcus aureus (43.7%), viridans streptococci (17%) followed by Enterococcus (14.7%). Despite appropriate treatment, high rates of morbidity and mortality remained, with a higher impact in patients greater than 50 years of age. Such discoveries raise the importance of controlling and monitoring risk factors for IE.

Serum vitamin D levels correlate to coronary artery disease severity: a retrospective chart analysis

ABSTRACT Background: The pro-atherosclerotic nature of vitamin D deficiency has been shown to increase cardiovascular events. We further emphasized and evaluated the severity of coronary artery disease (CAD) with varying levels of vitamin D in relation to age, gender, ethnicity and baseline confounders. Methods: A retrospective, single-center study of 9,399 patients admitted between 2005 and 2014 for chest pain who underwent coronary angiography. Patients without a vitamin D level, measured as 25-dihydroxyvitamin D (25[OH]D) were excluded from our study. 25(OH)D deficiency and insufficiency were defined by having serum concentration levels of less than 20 ng/ml and 20 to 29.9 ng/ml, respectively, while normal levels were defined as greater than or equal to 30 ng/ml. We assessed levels of 25(OH)D and extent of coronary disease with coronary angiography as obstructive CAD (left main stenosis of ≥50% or any stenosis of ≥70%), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Results: Among 9,399 patients, 1,311 qualified, of which 308 patients (23%) had normal 25(OH)D levels, 552 patients (42%) had 25(OH)D deficiency and 451 patients (35%) had 25(OH)D insufficiency. In an analysis of the extent of coronary disease, we identified 20% of patients having normal coronaries, 55% having obstructive CAD and 25% having non-obstructive CAD. Baseline clinical risk factors and co-morbidities did not differ between the groups. Patients with normal 25(OH)D levels were found to have normal coronaries compared to patients with 25(OH)D deficiency or insufficiency (OR: 7, 95% CI: 5.2 – 9.5, p < 0.0001). Comparing patients with normal 25(OH)D levels, patients with 25(OH)D deficiency or insufficiency (<29 ng/ml), 62% were found to have obstructive CAD (n = 624, OR: 2.9, 95% CI: 2.3-3.7, p < 0.0001) and 25% had non-obstructive CAD (n = 249, OR: 1.5, 95% CI: 1.1-2, p = 0.02). Conclusion: Normal coronaries and CAD were shown to correlate with normal and low levels of 25(OH)D, respectively. There is an inverse relationship between the percentage of coronary artery occlusion and serum 25(OH)D concentrations. Vitamin D may provide benefits in risk stratification of patients with CAD and serve as a possible risk factor.

Image of the Month: An Exophytic Gastrointestinal Stromal Tumor of the Stomach Complicated by Bacteremia and Liver Abscess.

An Exophytic Gastrointestinal Stromal Tumor of the Stomach Complicated by Bacteremia and Liver Abscess

ID: 31: VIRAL CYTOMEGALOVIRUS IN GRANULOMATOSIS WITH POLYANGIITIS

Introduction Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract commonly involves the esophagus, Stomach and colon. It frequently affects immune-compromised patients with Human immune deficiency (HIV), malignancy, organ transplant recipients, those on immunosuppressive medications or long standing steroid therapy. The most common symptoms include nausea, vomiting, dysphagia, odynophagia, abdominal pain, tenesmus and hematochezia. The endoscopic findings of CMV infection are variable from simple erosion, ulceration to pseudo-tumor formation. We present a rare case of CMV gastritis in an asymptomatic patient with history of Granulomatosis with Polyangiitis on immunosuppressant. Case presentation A 62-year-old Hispanic female with past medical history of Granulomatosis with Polyangiitis, hypertension and End Stage Renal Disease on hemodialysis, was evaluated for chronic anemia. Review of symptoms was negative for diarrhea, nausea, vomiting, abdominal pain, melena or hematochezia. Her medications included Furosemide, Amlodipine, Metoprolol, Prednisone and Cyclophosphamide. Physical exam was remarkable for pallor, normal oropharynx and negative for lymphadenopathy. Abdomen was soft, non-tender, non-distended, with normal bowel sounds. Rectal exam revealed external hemorrhoids, guaiac positive brown stools. Pertinent laboratory data included Hemoglobin/ Hematocrit (7.9 g/dL/23.5%), Mean Corpuscular Volume of 102fL, and Serum Albumin 3.1 gm/dL. Iron studies showed normal Iron-76 mcg/dL with low total iron binding capacity (TIBC)-195. Colonoscopy was significant only for diverticulosis. Esophagogastroduodenoscopy (EGD) revealed multiple erosions in the gastric antrum along with small non-bleeding clean based ulcer (Forrest class III). Biopsy of the gastric antrum showed intra-nuclear inclusions bodies (“owl eye”) with positive immune staining for CMV antigen pathognomonic for CMV gastritis. Patient received intravenous Ganciclovir treatment for one week followed by one week of oral ValGanciclovir. Discussion There have been reported cases of symptomatic CMV gastritis. However, CMV gastritis in our case patient was asymptomatic. CMV infection can involve any part of the gastrointestinal tract with symptoms usually include nausea, vomiting, dysphagia, odynophagia, abdominal pain, tenesmus and hematochezia (1). It frequently affects immune-compromised patients with Human Immunodeficiency Virus, malignancy, organ transplant recipients, those on immunosuppressive medications or long standing steroid therapy but can affect immunocompetent individuals as well. CMV infection of the gastrointestinal tract commonly involves the esophagus, stomach and colon. The endoscopic findings of CMV infection are variable from simple erosion, ulceration to pseudo-tumor formation. In patients with persistent immune deficiency such as granulomatosis with polyangiitis, endoscopic evaluation is a reasonable approach to prevent potential serious complications such as gastrointestinal hemorrhage, progressive intestinal disease and death.

ID: 33: ACUTE PANCREATITIS WITH NORMAL LIPASE AND AMYLASE ENZYMES

Case Report A 44 year-old Male with no significant past medical history presented to the Emergency Department complaining of nausea, vomiting, diarrhea, upper abdominal pain and fever. For the past one week prior to presentation, patient developed pressure-like epigastric pain, radiating to the back, worsened with lying down, and associated with non-bloody, non-bilious vomiting, followed by anorexia, nausea and fever to 102F. Patient had not eaten several days prior to arrival to the hospital; hence he was brought in by his family for evaluation. Notably, two months prior to presentation, patient was evaluated in an outside hospital for abdominal pain similar in quality, but not in intensity, and reportedly had normal blood tests and imaging. Physical examination: vital signs significant for hypertension of 150/90, tachycardia to 108 and fever of 101.5; abdomen notable for tenderness to palpation over epigastrium, with mild guarding, but no rebound or Murphys sign; the rest of the exam, including cardiovascular, pulmonary, integumentary and neurological exam, unremarkable. Initial laboratory findings are: WBC of 10.1, with 81% neutrophils, amylase of 47 (N 28–100 U/L), lipase level of 14 (N 11–82 U/L), and unremarkable basic metabolic panel. Liver function tests notable for normal AST and ALT, elevated GGT to 277 (N <50 U/L), LDH: 681 (N 90–225 U/L), Total bilirubin: 0.9(N 0–1.5 mg/dl). Lipid panel: Total Cholesterol 201 (N<200 mg/dL), Triglycerides 80 (N<150 mg/dL), LDL 68 (<100 mg/dL). Chest X-ray showed a small left-sided pleural effusion. Patient was admitted to medicine service for treatment of gastroenteritis, and was started on intravenous fluids and symptomatic management. On day three of hospitalization, patient developed worsening abdominal pain, associated with inability to tolerate per oral intake secondary to vomiting of food contents, and due to worsening abdominal pain, underwent further workup. CBC revealed leukocytosis with a left shift, WBC count of 15.3, with 81.5% neutrophils. Basic metabolic panel notable for sodium of 124, potassium of 3.2, calcium of 7.4, magnesium of 1.7, phosphate of 1.9. Repeat lipase was 67(N 11–82 U/L). An abdominal CT scan (figure 1) with IV and oral contrast was performed, and showed extensive pancreatic edema, especially involving the pancreatic head and uncinate process, and peripancreatic stranding; these changes deemed consistent with acute pancreatitis; no calcifications or pseudocysts were observed on the CT. Abdominal ultrasound showed multiple gallbladder stones, however, common bile duct was of normal diameter (2.5 mm), and no intrabiliary duct dilatation was noted. Based on clinical presentation and radiological findings, the diagnosis of acute pancreatitis was made. The patient started on aggressive intravenous fluid hydration, pain management and bowel rest, with good improvement in symptoms. On day 5, patient was able to tolerate a regular diet, and noted an almost complete resolution of pain, and therefore was discharged home. Abstract ID: 33 Figure 1

ID: 50: PERFORATED DIVERTICULOSIS COMPLICATED WITH ACTINOMYCOSIS INFECTION AND PRESENTED AS PELVIC MALIGNANCY

Case Presentation A 48-year-old female with no significant past medical history who presented with fatigue, and lower abdominal pain, unintentionally weight lost and yellowish vaginal discharge. Physical examination was remarkable for a palpable mass extending from supra-pubic to supra-umbilical area and vaginal examination remarkable for foul-smelling vaginal discharge. Initial laboratory studies indicated Hemoglobin 5.8 mg/dl and white blood counts 15,000/µL. Computerized tomography of Abdomen/Pelvis CT with contrast which demonstrating an infiltrative process or mass like structure involving the pelvis measuring 10×12×6 cm. The initial impression was Gynecological cancer which could be uterine/cervix/ovarian cancer. However, Pap-smear was negative. Biopsy was obtained which showed acute inflammatory exudates fragments of benign appearing smooth muscle proliferation and fibro-adipose tissue infiltrated with histiocytes. The decision for exploratory laparotomy was made which revealed a large pelvic abscess. The surgery resulted in modified radical hysterectomy, resection of left and right tubo-ovarian abscess complexes, recto-sigmoid resection with end-sigmoid colostomy and Hartmanns pouch, and ileo-colic resection with a primary anastomosis. Pathology examination revealed a segment of colon with perforated diverticulosis and a tubo-ovarian complex with acute and chronic inflammations, granulation tissue formation and bacterial colonies morphologically suggestive of Actinomyces. Patient started on Intra-venous Penicillin-G. After 4 weeks, CT abdomen/Pelvic repeated which showed post-surgical changes and decreased in size of abscess/fluid collections. Discussion Actinomycosis is a rare and insidious disease. The most common etiologic organism is the anaerobic, Gram-positive bacterium, Actinomyces israelii. Actinomycetes are prominent among the normal flora of the oral cavity but less prominent in the lower gastrointestinal and female genital tract. Because these microorganisms are not virulent, they require a break in the integrity of the mucous membranes and the presence of devitalized tissue to invade deeper body structures and to cause human illness. Cervicofacial actinomycosis is the most common type of the infections followed by Thoracic actinomycosis and less common in abdomen and pelvis. The most common cause of abdominal/pelvic actinomycosis is acute perforated appendicitis. Also, most of Abdomen/Pelvis cases have a history of recent or remote bowel surgery (e.g.perforated appendicitis, perforate colonic diverticulitis). Pelvic actinomycosis has become more common in females who use an Intra-Uterine Devices, which may increase the risk of infection through injury to the normal uterine mucosa. Diagnosis of Abdomen/Pelvic actinomycosis is usually established postoperatively, following exploratory laparotomy for a suspected malignancy. Involvement of any abdominal organ, including the abdominal wall, can occur by direct spread, with eventual formation of draining sinuses. Abstract ID: 50 Figure 1

ID: 68: CORONARY ARTERY DISEASE AND ACUTE CORONARY SYNDROME IN PATIENTS ≤40 YEAR OLD

Background Coronary artery disease (CAD) in the younger adult population has been commonly under-represented in clinical practice and research studies given its early latent asymptomatic course, in addition to the underestimation of this populations CHD lifetime risk by commonly used CHD risk predictors such as Framinghams score. Objective To assess the risk factor profile for premature coronary artery disease CAD and ACS presentation in younger adults. Methods Retrospective chart analysis of 393 patients ≤40 years old admitted from 2005 to 2014 for chest pain and underwent coronary angiography. The implication of modifiable risk factors and non-modifiable risk factors were evaluated in those with obstructive CAD (LM stenosis of ≥50% or stenosis of ≥70% in a major epicardial vessel), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Additionally we evaluated the impact of the same risk factors on ACS presentation (NSTEMI vs STEMI) and the extent of CAD (single-vessel/multi vessel). Results Of 9012 patients who underwent cardiac catheterization, 393 (4.3%) patients were ≤40 years old. Out of 393, 212 (54%) had CAD (153 obstructive versus 59 non-obstructive) while 185 (46%) had normal coronaries. Fifty two (25%) patients presented with STEMI while 140 (66%) patients presented with NSTEMI. Of 153 patients with obstructive CAD, 87 (57%) patients had single vessel disease vs 66 (43%) multiple vessel disease. When compared to patients with normal coronaries patients with CAD were more likely to be smokers (p<0.0001), dyslipidemia (p<0.0001), Diabetic (p<0.0001) cocaine users (p 0.4) have a family history of premature CHD (<0.0001) and be males (p<0.0001) (figure=1). Smokers were more likely to present with acute coronary syndrome; 5 times more likely to present with STEMI (p<0.0001) and 1.7 with NSTEMI (p 0.0003) compared to the control group. When compared head to head, smokers were 2.2 times more likely to present with STEMI compared to NSTEMI (p<0.001). Smoking also, alone and with another risk factor increased the risk of obstructive versus no obstructive CAD (p=0.04 and 0.015, respectively). No significant difference was noted in the single vessel vs multi vessel CAD subgroups. Coronary artery disease was highest in South Asian population (38.4%), followed by Hispanic (13.7%), African-American (10%) and Caucasian (9%). The main in risk factors in African–American was Hyperlipidemia +/− Diabetes (47.8%) while the main risk factors in Hispanic and white were smoking alone (24.14% and 47.4% respectively). In East Asia population, Smoking with hyperlipidemia was the main risk factors (44%). Conclusion In our population of young adults, smoking as a single risk factor was the most prevalent for earlier CAD. It was also associated with more STEMIs and obstructive CAD. Healthcare intervention in the general population through screening, counseling and education regarding smoking cessation is warranted to reduce premature coronary artery disease. Abstract ID: 68 Figure 1

ID: 3: MORBIDITY AND MORTALITY OF CONGESTIVE HEART FAILURE IN TRAUMA PATIENTS: A RETROSPECTIVE CHART ANALTSIS

Background Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay are considered. With increasing life expectancy, HF prevalence continues to increase. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggests that HF is the most common cause for hospital admission in patients older than 65 years. Objective In this study, we sought out to compare the morbidity, mortality, 30-day readmission rate and length of stay in trauma patients who have a pre-existing history of HF to those who do not have a history of HF. Additionally, we emphasize the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] vs. HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic vs. nonischemic). Methods A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005–2013 secondary to trauma with an Injury Severity Score<30. Data was extracted using ICD-9 codes. Neurotrauma patients were excluded. Results Of 8,137 trauma patients, 334 had pre-existing HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology vs. 44 nonischemic. Of 334 patients, 81 patients (24%) were readmitted within 30 days vs. 1,068 (14%) of the non-HF patients (95% CI 1.52–2.25, RR: 1.85, p<0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus. HFrEF groups (figure 1 and table 1). Mortality, 30-day readmission and length of stay were all significantly higher in the ischemic vs. non-ischemic HFrEF group (figure 1 and table 2). Conclusions In our trauma population, HF patients had a significantly higher morbidity, mortality and 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF vs. HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and length of stay were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with pre-existing HF. Abstract ID: 3 Figure 1

Avoiding transthoracic echocardiography and transesophageal echocardiography for patients with variable body mass indexes in infective endocarditis

Background Echocardiography has been a popular modality used to aid in the diagnosis of infective endocarditis (IE) with the modified Duke criteria. We evaluated the necessity between the uses of either a transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) in patients with a body mass index (BMI) greater than or equal to 25 kg/m2 and less than 25 kg/m2. Methods A single-centered, retrospective study of 198 patients between 2005 and 2012 diagnosed with IE based on modified Duke criteria. Patients, required to be above age 18, had undergone an echocardiogram study and had blood cultures to be included in the study. Results Among 198 patients, two echocardiographic groups were evaluated as 158 patients obtained a TTE, 143 obtained a TEE, and 103 overlapped with TEE and TTE. Out of these patients, 167 patients were included in the study as 109 (65%) were discovered to have native valve vegetations on TEE and 58 (35%) with TTE. TTE findings were compared with TEE results for true negatives and positives to isolate valvular vegetations. Overall sensitivity of TTE was calculated to be 67% with a specificity of 93%. Patients were further divided into two groups with the first group having a BMI ≥25 kg/m2 and the subsequent group with a BMI <25 kg/m2. Patients with a BMI ≥25 kg/m2 who underwent a TTE study had a sensitivity and specificity of 54 and 92%, respectively. On the contrary, patients with a BMI < 25 kg/m2 had a TTE sensitivity and specificity of 78 and 95%, respectively. Conclusions Patients with a BMI <25 kg/m2 and a negative TTE should refrain from further diagnostic studies, with TEE strong clinical judgment is warranted. Patients with a BMI ≥ 25 kg/m2 may proceed directly to TEE as the initial study, possibly avoiding an additional study with a TTE.

Cutaneous manifestations of hepatocellular cancer (HCC)

Hepatocellular liver cancer (HCC) is the fifth most common cancer in the world and ranks as the third cancer-related leading cause of death after lung and stomach cancers. Although dermatological manifestations of HCC are rare, some are life threatening. Many patients present with skin lesions; however, understanding which lesion manifests as a sign of underlying HCC is challenging. This summary will potentially aid clinicians in recognizing its dermatological manifestation of HCC to promptly diagnose and treat the underlying cancer. HCC is an aggressive tumor that is progressively increasing worldwide and it is the fastest rising tumor in the United States since the emergence of hepatitis C virus (HCV). HCC most commonly arises from underlying chronic liver diseases such as hepatitis B and C viruses (HBV and HCV, respectively) [1,2]. Extraneous signs and symptoms of HCC may hint to its diagnosis. Association between cutaneous lesions and malignancies of other internal organs exists at an incidence rate of approximately 10–11%. Cutaneous manifestation of primary liver cancer (HCC) is lower, with an incidence rate ranging from 0.5% to 3% [3,5]. Dermatologic manifestation of HCC may present in diverse patterns. A prospective study conducted in Africa by George et al. identified that these skin lesions presented more in males. In addition, they found that cutaneous manifestations are also more common in cirrhotic patients in areas of low core temperatures. It is unclear if these skin lesions are a result of an underlying active liver infection as most patients with HCC concurrently have HBV, HCV, or cirrhosis. However, most reported cases of cutaneous skin lesions have isolated HCC. Cutaneous manifestations of HCC are divided into two categories: malignant and nonmalignant. Malignant HCC skin manifestations may present as metastatic HCC skin lesion or be part of an HCC paraneoplastic disorder. HCC metastatic skin lesions are extremely rare; however, localized skin lesion should make clinicians explore and be mindful of this diagnosis. These lesions may occur as an early primary HCC cutaneous manifestation or as a marker of cancer relapse following therapeutic resection and/or liver transplantation [6]. Most reported cases are sporadic lesions resembling pyogenic granulomas or localized dermal skin deposits of cancer cells. Areas commonly involved are proximal lower extremities, scalp, and back [7–9]. HCC cutaneous paraneoplastic syndrome (HCC CPS) includes diverse dermatological presentation. Dermatomyositis (DM) presents as Gottron’s papules and/or a heliotrope skin rash, which are typical skin manifestations of DM. It is an idiopathic inflammatory myopathy seen in HCC with an underlying HCV or HBV. Although DM is mainly association with solid organ malignancies such as breast cancer, it may also present with HCC [10,11]. Acanthosis nigricans described as thickening or hyperpigmentation of the dermis and epidermis is mainly associated with insulin resistance and obesity. It also can be a sign of internal organ malignancy such as HCC [12]. Another HCC CPS is Leser–Trélat sign, presenting as multiple seborrheic keratosis and an ominous sign of internal organ malignancy such as invasive HCC. It is mostly apparent on the face, back, trunk, chest, and extremities. Leser– Trélat sign is commonly seen in gastric cancer, lymphoproliferative disorders, breast, lung, ovarian cancers, and rarely in HCC [13]. Lastly, Tripe palm also referred to as acanthosis palmaris (AP) is a thickening of palms with rugose appearance similar to stomach ruminant. AP can also be a sign of internal organ malignancy, including HCC [12]. HCC nonmalignant skin disorders also present with variations. Pityriasis rotunda (PR), a rounded-well demarcated skin lesion, can present as a single or multiple oval lesions ranging from 1 to more than 30 cm in size. They are commonly found on the trunk, flanks, and lower extremities. Earliest cases were described in Africa and Japan in 1986. Histopathology demonstrates hyperkeratosis with atrophy of the dermal and epidermal layers. PR can be divided into two types (type I and II). Type I is commonly associated with chronic infections such as tuberculosis; however, it is mainly identified in patients with malignancies. Type II occurs in younger individuals and is not associated with malignancies. There is no specific treatment for PR, lesions resolve after treating the underlying condition [14,15]. Pemphigus foliaceus (PF) is a superficial blistering lesion with bullae formation. PF is a type II autoimmune skin disease similar to pemphigus vulgaris (PV) which involves IgG and complement deposition at the dermoepidermal junction. Unlike PV, PF does not involve mucus membranes. PF is associated with lypmphoproliferative cancers, however may present in HCC. PF can coincide with other paraneoplastic skin disorders and few clinicians consider PF as part of HCC