University of Virginia Health System

January 23, 2009

» Monday was all about the endocrine system.  We started off with Sid presenting a case of a man with severe paroxysmal hypertension.  His blood pressure swung wildly from the 200s systolic down to 60s systolic with only small doses of antihypertensives.  He was transferred to UVA to evaluate for pheochromocytoma.  Urine metanephrines at the outside hospital were negative but were slightly positive here.  We discussed the differential for paroxysmal HTN, including:  Pheochromocytoma, Renovascular, Autonomic dysfunction (e.g. Spinal Cord Injury, Guillain Barre), Hypertensive Encephalopathy, CNS lesions (stroke, tumor, medulla compression, trauma), Hyperthyroidism, Anxiety, Seizure d/o, Carcinoid, Drugs (e.g. cocaine, amphetamine), Serotonin Syndrome, Baroreflex failure, Coronary ischemia, and Idiopathic. We also discussed how Bayes theorem applied to the common indications for pheochromocytoma testing (HTN w/ episodic palpitations/sweating and adrenal incidentaloma), in general, in low positive predictive values (check out the morning report slides on pheochromocytoma).  In the end, this case was thought to NOT be a pheochromocytoma, but it remains unclear why the blood pressure is so labile.

» Dave Lopez rounded out endocrine Monday with the case of a middle-aged woman who presented with malaise and was found to be hypercalcemic with a calcium level over 16.  Her EKG did not show the QT shortening typical for hypercalcemia but did show ST elevation, which is a rare bur reported manifestation of hypercalcemia.  Further history revealed that she was taking 20-30 TUMS/day for heartburn symptoms and thus a diagnosis of milk-alkali syndrome was made.  She responded rapidly to IVF and calcitonin and in fact briefly became hypocalcemic, which is not unusual in cases  of milk-alkali syndrome. 

» On Thursday, we started off with Zivony presenting a case of a woman with ESRD and a prosthetic valves who presented with a febrile illness and 4/4 staph bacteremia.  Of course, everyone was thinking of endocarditis, but the TEE was negative.  Despite a high sensitivity/specificity, there are still a few false negatives (would have to be small vegetations) with TEE, and this patient would still have to be treated presumptively for endocarditis.  However, she then developed a retroperitoneal/psoas hematoma on coumadin, discovered when a CT was done for sudden onset abdominal pain (emboli and mesenteric ischemia being the other worisome entities on the ddx at the time).  Because there was an active component of bleeding on the CT and her hematocrit was dropping, she was taken urgently for angiography, where lumbar artery aneurysms were found in a distribution that favored mycotic aneurysms.  Lumbar artery aneurysms are rare with only 8 reported cases in the literature.  Applying the ddx of mesenteric aneurysms, which we recently, discussed, we flushed out the ddx (see the Morning Report Slides) and discussed the management of these uncommon aneurysms (mainly angiography).

» Next, Dr. King presented a 28 year old graduate student from Spain who had a previous past medical history significant an asymptomatic second degree AV block that had been followed for the past five years. Over the christmas holiday, while in Spain, it was discovered on Holter moniter that he was having 9 second pauses. The cardiovascular team called the patient in for further management that resulted in the placement of a pacemaker. Five days after placement, the patient complained of increasing lethargy and chest pressure. He was found to be hypotensive and tachycardic. Telemetry demonstrated electrical alternans. Echocardiography demonstrated a pericardial effusion resulting in tampanod physiology. Urgent pericardiocentesis was performed. Patient then underwent cardiac CT to determine the cuplrit lead. Patient underwent a corrective procedure and was discharged home.

» Basil presented the patient he presented a couple of weeks ago with cholestatic jaundice secondary to Augmentin.  She was itchy and her pruritis was refractory to multiple standard agents.  Basil found a series of articles discussing the use of naltrexone as therapy for cholestatic pruritis, and although the studies were small, it seemed to be relatively effective.  

» Next up was Zivony, who discussed using CT vs. ultrasound to evaluate patients for peri-rectal fistulae or abscesses.  Ultrasound is more sensitive for the discovery of these abnormalities, and this confirmed Adam's initial suspicion.  

» Matt Graham evaluated an article comparing 1 vs. 4 weeks of DVT prohylaxis with enoxaparin in patients with abdominal malignancies who have undergone abdominal surgery.  The study showed a number needed to treat of 14 to prevent venous thromboembolism when comparing 4 weeks vs. 1 and only a minimally increased risk of bleeding.  

» Chetan presented a retrospective look at 41 elderly patients undergoing percutaneous ASD repair which showed good hemodynamic and symptomatic outcomes.  The study was uncontrolled and had a relatively short follow-up, but suggested the procedure was safe and effective in that population.  

» Finally, Uther (aka Luter) presented a large retrospective study evaluating the risk/benefit ratio of anticoagulating patients with A fib and a high fall risk.  Although a study of this type has many limitations, it showed that those who have a high risk of ischemic stroke (CHADS2 score 2 or greater) benefit from anticoagulation.  

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