Aasim Mohammed

Metastatic Cutaneous Melanoma of the Gallbladder

Metastatic melanoma is an aggressive disease that can spread to many organs of the body. In rare cases, it can spread to the gallbladder causing secondary lesions, yet presenting with little to no symptoms. Therefore, most cases of metastatic melanoma lesions to the gallbladder go undiagnosed. Here, we present the case of a 41-year-old male with a four-month history of melanoma of the face, with a postresection status, who presented with right upper quadrant abdominal pain. Doppler ultrasound and computed tomography confirmed the presence of a mass on the gallbladder. Laparoscopic excision along with liver wedge resection was performed. Pathology staining revealed the presence of a malignant metastatic melanoma lesion of the gallbladder.

908: CRITICALLY ILL PATIENTS WITH TOBACCO DEPENDENCE REQUIRE LONGER INFUSION OF DEXMEDETOMIDINE

Learning Objectives: Smoking is one of the most common addictions in the world. It has proven to increase mortality and cause withdrawal when immediately stopped. We have previously shown that patients with alcohol dependence show improved outcomes on dexmedetomidine (DEX) in terms of intensive care unit (ICU) length of stay (LOS) and mortality. We hypothesize that smokers who required DEX, also have better outcomes, when compared to non-smokers in the ICU. Methods: A retrospective observational study was conducted from January 2014 to September 2015 in adult ICUs at two academic community hospitals in a large urban setting. All patients were on a DEX infusion (196) during their hospitalization (15 excluded based on exclusion criteria). Baseline patient demographics, comorbidities, and clinical characteristics were collected. Patients were split into two groups, smokers versus non-smokers. Clinical outcomes were compared using Chi-Squared and unpaired T-test. Results: 181 patients were included in final data analysis; mean age was 58.3, in a primarily male and African American population. Average APACHE II scores were 25.1 for smokers, and 26.4 for non-smokers. In our study, smokers had significant longer hours of infusion on DEX versus non-smokers, 48 hours versus 37 hours (p-value < 0.04, 95% CI 0.40 to 22). Interestingly, smokers on DEX did not have a longer hospital or ICU LOS. Smokers with a nicotine patch were compared with smokers without a patch, and there was no significant reduction in hours of infusion (p-value = 0.66), or ICU LOS (p-value = 0.82). Conclusions: Based on our study, the smoking population required longer duration of infusion when compared to the non-smoking population. We also concluded that smokers with a nicotine patch had no reduction in hours of duration, ICU or hospital LOS when compared with smokers without a patch. We conclude DEX has a role in suppressing nicotine withdrawal, by acting as an alpha-2 agonist to decrease sympathetic activity. Therefore, there is no added benefit of a nicotine patch on patients on a DEX infusion.

1240: ACUTE PERICARDITIS, A RARE PRESENTATION OF AUTOIMMUNE POLYGLANDULAR SYNDROME TYPE II (APS II)

Case Report: Autoimmune polyglandular syndrome type II (APS II) is described as autoimmune damage of adrenal, thyroid &/or type 1 diabetes. Here we report a rare presentation of APS II with acute pericarditis. A 47 yr old male presented to emergency department after he was found unresponsive. He was in a state of shock with blood pressure 70/40, heart rate 120, had 9 cm jugular venous distension, muffled heart sounds & diffuse crackles. EKG showed low voltage in precordial leads. Contrast computed tomography of the chest done to rule out pulmonary embolism revealed hyperemia & thickening of pericardium with pericardial effusion. Acute pericarditis with cardiac tamponade was diagnosed and treated with emergent pericardiocentesis. Serum inflammatory markers were normal. Rheumatologic and viral serology were negative. He had low free T4, elevated TSH, low serum cortisol & normal ACTH. Adrenal response to cosyntropin was poor. Other hormone levels were normal except mildly elevated prolactin. Brain MRI showed partially empty sella (PES) with no pituitary tumor. Petrified ear pinna were noted in brain MRI. He was treated colchicine & supplemented with hydrocortisone & levothyroxine. Striking features in our patient are acute pericarditis, adrenal insufficiency (AI), hypothyroidism, petrified ear pinna & PES. PES was considered primary. Autoimmunity is regarded as the most common cause of AI in the developed world & AI is considered the most frequent systemic disease associated with calcification of the ear pinna. We tried to speculate a common etiology that would trigger pericarditis, thyroid & adrenal damage. APS II explains the clinical picture. 88.4% APS II have two gland disease, thyroid & adrenal is the most frequent combination accounting 56.1%. 11.6% cases may have triglandular involvement described as Carpenter’s syndrome. Pericarditis can be a rare presenting feature of APS II & endocrine work up should be pursued in unexplained pericarditis. To the best of our knowledge, this is the first reported association of APS II with petrified ear pinna and empty sella.