Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112 copy. Acute metabolic encephalopathy (AME) is an acute condition of global cerebral dysfunction, in the absence of primary structural brain disease. It is an often-overlooked medical emergency that can arise during preparation for colonoscopy. Female, 70 years old, caucasian, with hypertension, treated with bisoprolol and no history of psychiatric or neurological disease, presented to our emergency department with neurological symptoms including confusion, disorientation, lethargy, generalized weakness, tremor and multifocal myoclonus. Those manifestations appeared one day after colonoscopy preparation with Fleet Phospho-Soda. She was also tachycardic (100/minute) and had hypertension (180/90 mmHg). The laboratory investigation revealed severe hypoosmolar hiponatremia (238mOsm/Kg, 118 mmol/L), hypocalcemia (7,6 mg/dL) and hypocaliemia (2,9 mmol/L). Computed tomography of the head was normal. No electrolyte abnormalities previous to the colonoscopy preparation existed. She fully recovered and was discharged after correction of the electrolyte disturbances. We present a case of AME following preparation for colonoscopy with an aqueous sodium phosphate containing regime as Fleet Phospho-Soda. Those types of regimens appear to be better tolerated and are safe in most healthy individuals. However, a growing number of reports have demonstrated serious electrolyte and renal complications in patients with certain risk factors, including age.
Fig 1. Varicose veins of the thoracicabdominal wall
Fig 2. IVC Agenesis ( Angio MRI).
Methods: Bibliographic review. Results: The results of this literature review reaffirm the rarity of the subject. Conclusion: Anatomical changes of IVC are an important risk factor for DVT and need to be emphasized during the screening of these patients. Finally, we would like to remind all physicians to be aware of these anatomical changes in order to diagnose and manage them.
SCHNITZLER’S SYNDROME: ANOTHER CASE OF SUCCESSFUL TREATMENT WITH ANAKINRA
DILATED CARDIOMYOPATHY AS A COMPLICATION OF CYTOMEGALOVIRUS CHRONIC MYOCARDITIS
Beatriz Amaral, Ana Margarida Carvalho, Ana Paula Vilas. Internal Medicine Department, Saint Mary’s Hospital, Lisbon, Portugal
Marta Amorim, Eduardo Oliveira, Rui Veiga, José Artur Paiva. Department of Intensive Care Medicine, Hospital de São João, Porto, Portugal
Background: Schnitzler’s syndrome is a rare disorder characterized by chronic urticaria in association with a monoclonal gammopathy and at least two of the following: fever, joint and/or bone pain, lymphadenopathy, hepato- or splenomegaly, increased ESR, leukocytosis and bone abnormalities. Case report: A 68-year-old man presented with a 8-year history of a chronic pruritic urticarial rash, a 4-year history of chills and bone pain and a 6-month history of recurrent fever. Investigation disclosed leukocytosis, an elevated ESR and CRP, a monoclonal IgMN gammopathy and positive ANA and antiSSA. The skin biopsy showed findings of neutrophilic urticaria. The body CT scan had no significant changes. Bone scintigraphy showed increased concentration of the radioactive tracer in the costocondral and metatarsal joints. Until 2008, he was on and off steroid therapy. Then he began continuous oral deflazacort (minimum dose 30mg/day), but this caused only partial remission of symptoms. In 2011, Schnitzler's syndrome was diagnosed. Anakinra, an interleukin-1 receptor antagonist, was then commenced at a daily dose of 100mg subcutaneously. A rapid complete remission followed. The patient remains symptom free even after steroid cessation. Discussion: Unusual features of the reported case include the rash being pruritic from the onset of disease and the positive ANA and anti-SSA. A complete remission following Anakinra occurred, as described in many other cases. Conclusion: Published data (and the presented case) support monotherapy with Anakinra as the most promising treatment for Schnitzler’s syndrome.
Background: Myocarditis is an inflammatory heart disease classified by clinical, immune, and histopathological criteria, commonly caused by infectious agents. In Western countries, viral infections are the most common cause. Usually a benign and self-limited disease, viral myocarditis may evolve towards a chronic inflammatory process leading ultimately to a dilated cardiomyopathy that at end-stage is a major cause for cardiac transplantation. Methods and Results: We present a 27-year-old female patient, with a history of a child delivery 18 months before, and a recent hospital admission for acute cytomegalovirus (CMV) hepatitis. Shortly after discharge (<1 month) she developed acute respiratory distress, hemodynamic instability and altered mental status, with admission to an Intensive Care Unit. A cardiogenic shock secondary to a dilated cardiomyopathy unresponsive to vasopressors with associated multiorganic dysfunction was diagnosed. Given the patient’s serious clinical condition extracorporeal membrane oxygenation was used as a bridge for cardiac transplantation, successfully performed one week after hospital admission. CMV serology was positive (only IgG) and CMV genome was detected in patient’s blood (> 500 copies/mL). The anatomopathological exam of the patient’s heart revealed a dilated cardiomyopathy secondary to a chronic pancarditis; immunohistochemical assay for CMV was negative. Conclusion: It’s our belief that in spite of lack of adequate microbiological findings to determine the myocarditis’ etiology (viral serology is insufficient for an accurate diagnosis) this clinical condition was caused by CMV infection. This case illustrates the difficulties in establishing a proper etiology for viral myocarditis given the several limitations of the diagnostic methods currently available.
INFERIOR VENA CAVA AGENESIS – ATTENTION TO THIS DIAGNOSIS Antonio Amorim, Gabriela Correia, Carina Carvalho, Leonor Monjardino. Hospital Of Santo Espírito Background: Inferior Vena Cava (IVC) agenesis is a malformation caused by a disturbance of embryological development occurring between the sixth and the tenth weeks of gestation and requires specific attention and management. We report the case of a 39-year-old male who attended the Emergency Department to treat sores of the lower limbs. He had 3 episodes of deep venous thrombosis (DVT) of both lower limbs between the ages of 20 and 23. He has been under anticoagulation therapy since then. The physical examination showed serious venous insufficiency of the lower limbs with active ulcers (class 6- CEAP classification) and Varicose veins in the thoracic-abdominal wall (Fig.1). D. Dimers were at the normal range. We followed up with assessment of both pro coagulation states (which results were negatives) and venous abnormalities by imaging studies (Fig.2) that diagnosed “IVC agenesis and left kidney agenesis associated”. This rare condition has recently been confirmed as a major risk for development of deep venous thrombosis, especially in young patients.
ADMISSION CHARACTERISTICS OF PATIENTS PRESENTED WITH ACUTE ABDORMINAL PAIN Apostolos Pappas1, Hara Toutouni1, Emmanuel Lagoudianakis2, Vasiliki Drantaki1, George Andrianopoulos1, Athanasios Panoutsopoulos1, Konstantinos Toutouzas2, George Zografos2. 1Internal Medicine Department, General Hospital of Argos, Greece; 2First Department of Propaedeutic Surgery, Hippokrateion General Hospital, Athens Medical School, University of Athens, Greece Background: Abdominal pain is one of the most common presenting complaints of emergency department (ED) patients. In order to achieve maximum efficiency in managing these patients it would be of benefit to identify clinical and laboratory parameters that would indicate a serious underlying disease process, and therefore warrant more expedited evaluation and treatment. The purpose of this study is to investigate the factors that influence hospital admission for abdominal pain.