Robert Dobbin Chow

Inappropriate Use of D-Dimer Assay and Pulmonary CT Angiography in the Evaluation of Suspected Acute Pulmonary Embolism

The authors question whether the d-dimer assay and pulmonary computed tomography angiography (CTA) are being used appropriately to evaluate suspected acute pulmonary embolism (PE) at their hospital. To answer this question, a retrospective review was performed on all emergency department (ED) patients who underwent d-dimer assay and/or CTA from August 15, 2008, to August 14, 2009. The authors’ algorithm for diagnosing PE requires that patients with low or intermediate probability of acute PE undergo a d-dimer assay, followed by CTA if the d-dimer is positive. Patients with high probability of PE should have CTA performed without a d-dimer assay. This result suggests that d-dimer assay and CTA are used inappropriately to evaluate patients with suspected acute PE in our ED. The low threshold for initiating an evaluation for PE decreases the prevalence of PE in this population.

Synthetic cannabinoids: the multi-organ failure and metabolic derangements associated with getting high

Synthetic cannabinoids (SC), though not detected with routine urine toxicology screening, can cause severe metabolic derangements and widespread deleterious effects in multiple organ systems. The diversity of effects is related to the wide distribution of cannabinoid receptors in multiple organ systems. Both cannabinoid-receptor-mediated and non-receptor-mediated effects can result in severe cardiovascular, renal, and neurologic manifestations. We report the case of a 45-year-old African American male with ST-elevation myocardial infarction, subarachnoid hemorrhage, reversible cardiomyopathy, acute rhabdomyolysis, and severe metabolic derangement associated with the use of K2, an SC. Though each of these complications has been independently associated with SCs, the combination of these effects in a single patient has not been heretofore reported. This case demonstrates the range and severity of complications associated with the recreational use of SCs. Though now banned in the United States, use of systemic cannabinoids is still prevalent, especially among adolescents. Clinicians should be aware of their continued use and the potential for harm. To prevent delay in diagnosis, tests to screen for these substances should be made more readily available.

Sarcoidosis mimicking metastatic thyroid cancer following radioactive iodine therapy

Introduction Sarcoidosis is an inflammatory disease characterized by non-caseating granulomas that can be present in diverse organ systems. Sarcoidosis can be associated with malignancy, presenting either preceding, during, or after chemotherapy. We herewith report a case of sarcoidosis mimicking cancer recurrence that developed after radioactive iodine therapy for papillary thyroid cancer. Background A 68-year-old Caucasian woman was found to have an incidental mediastinal lymph node. She underwent biopsy, which revealed sarcoidosis. There was no further treatment or evidence of recurrence over the ensuing 9 years. She was then diagnosed with low-grade papillary thyroid cancer in the right posterior lobe and treated with total thyroidectomy followed by radioactive iodine therapy. Six months later, she was found to have elevated serum thyroglobulin. Post–remnant ablation scan showed increased tracer uptake in the bed of the thyroid. Though two thyroid ultrasound scans were negative, she was treated with I-131 for possible recurrence. She then developed right hip pain, prompting further investigation. Though a skeletal survey was negative, an 18-fluorodeoxyglucose positron emission tomography (PET) scan study revealed multiple hypermetabolic skeletal lesions in both humeri and the proximal left femur. In addition, hypermetabolic hilar and mediastinal nodes were noted. As widespread cancer metastasis was suspected, bone biopsy was performed, which showed non-caseating granulomas, consistent with recurrence of sarcoidosis. Conclusion Sarcoid lesions may mimic metastatic disease or recurrence in oncologic patients. Biopsy and histopathology examination should be performed to confirm the diagnosis. Recurrence or reactivation of sarcoidosis has been proposed to result from altered immunologic milieu because of the presence of either active cancer or its therapy. Teodorovic and colleagues postulated that the radioactive I-131 therapy leads to reduced secretion of Th2 cytokines such as interleukin (IL)-4, IL-5, and IL-13. Few case reports of sarcoidosis associated with papillary carcinoma have been published; this is the first report of systemic recurrence of sarcoidosis associated with papillary thyroid carcinoma after treatment with radioactive iodine therapy.

Patients’ preferences for selection of endpoints in cardiovascular clinical trials

Background To reduce the duration and overall costs of cardiovascular trials, use of the combined endpoints in trial design has become commonplace. Though this methodology may serve the needs of investigators and trial sponsors, the preferences of patients or potential trial subjects in the trial design process has not been studied. Objective To determine the preferences of patients in the design of cardiovascular trials. Design Participants were surveyed in a pilot study regarding preferences among various single endpoints commonly used in cardiovascular trials, preference for single vs. composite endpoints, and the likelihood of compliance with a heart medication if patients similar to them participated in the trial design process. Participants One hundred adult English-speaking patients, 38% male, from a primary care ambulatory practice located in an urban setting. Key results Among single endpoints, participants rated heart attack as significantly more important than death from other causes (4.53 vs. 3.69, p=0.004) on a scale of 1–6. Death from heart disease was rated as significantly more important than chest pain (4.73 vs. 2.47, p<0.001), angioplasty/PCI/CABG (4.73 vs. 2.43, p<0.001), and stroke (4.73 vs. 2.43, p<0.001). Participants also expressed a slight preference for combined endpoints over single endpoint (43% vs. 57%), incorporation of the opinions of the study patient population into the design of trials (48% vs. 41% for researchers), and a greater likelihood of medication compliance if patient preferences were considered during trial design (67% indicated a significant to major effect). Conclusions Patients are able to make judgments and express preferences regarding trial design. They prefer that the opinions of the study population rather than the general population be incorporated into the design of the study. This novel approach to study design would not only incorporate patient preferences into medical decision making, but it also has the potential to improve compliance with cardiovascular medications.

Successful Management of Refractory Type 1 Renal Tubular Acidosis with Amiloride

A 28-year-old female with history of hypothyroidism, Sjögrens Syndrome, and Systemic Lupus Erythematosus (SLE) presented with complaints of severe generalized weakness, muscle pain, nausea, vomiting, and anorexia. Physical examination was unremarkable. Laboratory test showed hypokalemia at 1.6 mmol/l, nonanion metabolic acidosis with HCO3 of 11 mmol/l, random urine pH of 7.0, and urine anion gap of 8 mmol/l. CT scan of the abdomen revealed bilateral nephrocalcinosis. A diagnosis of type 1 RTA likely secondary to Sjögrens Syndrome was made. She was started on citric acid potassium citrate with escalating dosages to a maximum dose of 60 mEq daily and potassium chloride over 5 years without significant improvement in serum K+ and HCO3 levels. She had multiple emergency room visits for persistent muscle pain, generalized weakness, and cardiac arrhythmias. Citric acid potassium citrate was then replaced with sodium bicarbonate at 15.5 mEq every 6 hours which was continued for 2 years without significant improvement in her symptoms and electrolytes. Amiloride 5 mg daily was added to her regimen as a potassium sparing treatment with dramatic improvement in her symptoms and electrolyte levels (as shown in the figures). Amiloride was increased to 10 mg daily and potassium supplementation was discontinued without affecting her electrolytes. Her sodium bicarbonate was weaned to 7.7 mEq daily.

Ossifying parosteal lipoma of the thoracic spine: a case report and review of literature

Introduction Lipomas are derived from the mesodermal germ layer and are frequently encountered in adults, and account for almost 50% of all soft tissue tumors. Lipomas are classified based on their component tissues and location. A rare subtype, ossifying parosteal lipoma, accounts for 0.3% of all lipomas and occurs with intimate association with the underlying periosteum of the adjacent bone. Though lipomas are considered to be benign tumors, ossifying parosteal lipomas can manifest symptoms due to their location and relationship to nearby skeletal tissues. We herewith report the first known case of ossifying parosteal lipoma presenting in the region of the thoracic spine. Case presentation An otherwise healthy adolescent boy presented with a 3-year history of a slowly enlarging painless thoracic mass. A general physical examination was normal, aside from a painless 10 cm mobile, hard mass along the posterior spine in the region of T4 through T6. Musculoskeletal and neurovascular examinations were normal. An ultrasound suggested a solid, cylindrically shaped mass with diffuse ossification. The mass was resected, and the pathology revealed ossifying parosteal lipoma without evidence of malignancy. Conclusion Ossifying parosteal lipomas are rare, benign soft tissue tumors that should be added to the differential diagnosis of thoracic masses.

Risperidone induced angioedema with concurrent EPS symptoms: a case report and review of literature

ABSTRACT Angioedema has recently been reported as a side effect associated with the antipsychotic risperidone. We report a case of dystonia with concurrent angioedema due to risperidone. A 40-year-old male with a history of schizophrenia was started on 3 mg of risperidone BID and developed perioral and periorbital edema along with increased muscle rigidity and hand tremor within 24 h of initial administration. His symptoms abated after cessation of risperidone and intravenous administration of corticosteroids and antihistamine. This case study adds to the current literature, which has already established angioedema as a dose-dependent side effect of risperidone. Moreover, this case study aims to increase awareness about the potential for the simultaneous occurrence of angioedema and extrapyramidal symptoms, and promotes vigilance among prescribers so that the life-threatening consequences of such effects can be avoided.

Nontraumatic urinary bladder rupture presenting as renal pseudo-failure and ascites

A 24-year-old man, with past medical history significant only for nocturnal enuresis until the age of 12 years, presented to the emergency department with acute abdominal pain after an episode of difficulty with micturition in the middle of the night. On presentation, physical examination was suggestive of ascites and laboratories revealed an elevated serum creatinine of 1.88 mg/dL. He was subsequently found to have a ruptured bladder, without any inciting trauma, which required surgical repair. His only surgical history is an unknown, apparently urologic, surgery when he was 11-12 years old. The patients unique presentation prompts discussion of bladder rupture and its manifestations, the role of clinical information in informing imaging protocol, and the importance of sagittal images in identifying pathology.

An atypical subacute presentation of posterior reversible encephalopathy syndrome

ABSTRACT Posterior reversible encephalopathy syndrome (PRES) characteristically presents with rapid onset of headache, seizure, encephalopathy, and visual changes, along with evidence of parieto-occipital vasogenic edema on magnetic resonance imaging. We describe the case of a 41-year-old female with a protracted presentation of two of the four classic PRES symptoms, which were not immediately recognized as PRES due to the presence of multiple other comorbidities and reasons for encephalopathy. This case highlights the possibility of atypical presentations of PRES and the diagnostic challenges in making this clinical diagnosis when competing diagnoses are present.

A Case of Post-partum Spontaneous Coronary Artery Dissection with Pulmonary Embolism: Survival with Thrombectomy and Stent Implant.

Spontaneous Coronary Artery Dissection (SCAD) is a rare life-threatening cause of acute coronary syndrome. It can affect young patients without atherosclerotic risk factors, particularly women in the antepartum or early post-partum period, as well as geriatric patients at high risk for atherosclerotic disease. The pathogenesis linking SCAD with pregnancy has not been fully elucidated. The few reported cases of SCAD in the setting of concomitant Pulmonary Embolism (PE) may highlight a potential mechanism in the pregnant or postpartum woman. Heretofore, cases of SCAD with the setting of pulmonary embolism have all been treated conservatively with medical therapy. We herein report a case of SCAD in the left anterior descending artery resulting in Non-ST elevation myocardial infarction and low ejection fraction associated with an acute pulmonary embolism in a young post-partum patient who was treated successfully with thrombectomy followed by stent placement. Her cardiac function returned to normal within six months with no recurrence of symptoms. To our knowledge, this is the first case of SC.