Yub Raj Sedhai

Contrast-Induced Nephropathy After Cardiac Catheterization: Culprits, Consequences and Predictors

Background: Contrast‐induced nephropathy (CIN) is a common complication after radiocontrast exposure. Methods: A retrospective medical record review of 513 hospitalized patients who underwent cardiac catheterization from June‐December 2014 was done, of which 38 patients with end‐stage renal disease and 57 patients without preprocedural creatinine were excluded. Serum creatinine concentration before the procedure and each day for 3 days after the procedure was recorded. CIN was defined as an increase in serum creatinine concentration by ≥25% or ≥0.5 mg/dL from the preprocedural value within 72 hours of contrast exposure. Results: A total of 418 patients (mean age: 69.1 ± 13.8 years, 55% males) were included in the study. Mean incidence of CIN was 3.7% (n = 16). CIN accounted for longer duration of hospitalization, lengthier intensive care unit admission, requirement of hemodialysis and higher mortality. Incidence of CIN was higher in the presence of preexisting atrial fibrillation (AF), congestive heart failure (CHF) and chronic kidney disease (CKD). When tested by univariate analysis, incidence of CIN was 13.8% in the AF group (P < 0.001), 8.6% in CHF group (P < 0.01) and 8.9% in CKD group (P < 0.002), compared with 2.3%, 1.9% and 2.4% in the absence of preexisting AF, CHF and CKD, respectively. On further testing using multivariate logistic regression model using AF, CHF and CKD as independent variables, development of CIN was strongly associated with preexisting AF with an odds ratio of 4.11, 95% CI: 1.40‐12.07, P = 0.01. Conclusion: Identifying patients at risk is an important step in preventing CIN. Preexisting AF, independent of traditional risk factors, may increase the risk for CIN.

May-Thurner Syndrome: Patient Centered Focused Review

ABSTRACT This single‐center, retrospective review identified 6 patients (n = 6, 100% female) treated by endovascular therapy for May‐Thurner syndrome from June 2013 to September 2015. Patients consisted of 3 African American, 2 Caucasian and 1 Asian; mean age was 53.50 ± 8.31 years, range: 39‐63 years. Clinical presentations consisted of left lower extremity deep vein thrombosis in 4, left lower extremity deep vein thrombosis with pulmonary embolism in 1 and pulmonary embolism with left common iliac vein thrombosis in 1 patient. All 6 patients were treated with catheter‐directed thrombolysis and venous stenting to correct the underlying anatomical defect. Hypercoagulability work up revealed antiphospholipid antibody syndrome in 1 patient. No major periprocedural complications were observed. Median follow‐up period was 22 ± 5.5 months (range: 13‐30 months). One patient with pre‐exiting antiphospholipid antibody syndrome developed stent thrombosis with secondary loss of patency. Endovascular therapy for May‐Thurner syndrome in our adult cohort seemed safe and effective. One patient with pre‐existing thrombophilia developed secondary loss of stent patency, suggesting need for further investigation in this subgroup.

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.

Unusual case of pheochromocytoma presenting with diabetic ketoacidosis

Pheochromocytoma is a rare catecholamine-secreting tumour that arises from chromaffin cells in the adrenal medulla or extra-adrenal sympathetic ganglia. It classically presents with paroxysmal headaches, hypertension, palpitations and sweating related to catecholamine excess. Diabetes is reported to be present in approximately one-third of patients with pheochromocytoma; however, diabetic ketoacidosis is an extremely rare complication. We present a case of an African-American male aged 30 years who initially presented with diabetic ketoacidosis and hypertensive urgency whose blood pressure and glycaemic control improved remarkably following tumour excision. We will discuss this unusual presentation of pheochromocytoma along with a management approach for such adrenal incidentalomas.

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.