Bilateral Pedal Edema Research Articles

Efficacy of Treatment in Ayurveda for the Management of Diabetic Nephropathy: A Case Study

Diabetic Nephropathy is one of the serious clinical condition that originated as a complication of the Diabetes Mellitus. It is the main culprit for end-stage renal diseases, which ultimately may lead to life-threatening conditions. A 58 years old male patient was having diabetes mellitus and hypertension for 15 years came to Mahatma Gandhi Ayurved College, Hospital and research centre, Wardha, Maharashtra (India) having bilateral pedal edema, vomiting, nausea, general weakness, frequent nocturnal micturition, hiccough from last two months. He was treated with Gokshuradi Guggulu, Chandraprabha Vati, Bhumyamalaki Churna, a freshly prepared decoction of Trunpanchmula [combination of Kush (Desmostachya bipinnata), Kash (Saccharum pontaneum), Darbha(Saccharum munja), Nal (Saccharum officinarum)and kandeshu] 50 ml daily twice a day after food. All other allopathic treatments for hypertension and Diabetes were continued as before, but the patient took only Ayurveda’s treatment for Nephropathy. After continuous treatment for two months, Blood Urea level was remarkably decreased from 51 mg/dl to 45 mg/dl & Serum Creatinine also reduced from 3.0 mg/dl to 1.5 mg/dl with a gross decrease in proteinuria. Both Blood sugar fasting & post- prandial were also reduced from 246mg/dl & 346 mg/dl to 190mg/dl & 225mg/dl respectively. The present Case report is discussed here to show the efficacy of Ayurveda in diabetic Nephropathy.

Invasive Rhino-Cerebral Mycormycosis

Mr. Rameshwaran, 51 years who admitted in a private hospital with left upper and lower limb weakness and slowing of speech. He is a known case of Diabetes Mellitus, Systemic Hypertension and CVA. He was an allergic to POSCONAZOLE. On the day of admission, he was conscious and oriented. His BP was 160/90mm of Hg. On examination, he was dehydrated, bilateral pedal edema and right side hemiparesis. Investigations reveals that increased serum urea and creatinine, GFR below 26ml/min, low serum sodium and potassium. MRI shows that large acute infarct. ENT opinion reveals that presence of fungal mass in orbit and secondary to vasculitis. He was treated by corticosteroids, diuretics and anti-platelet. He was advised for physiotherapy, speech therapy, restricted salt and fluids.

English

A 49-year-old female patient was admitted in the medicine department of Assam Medical College with complaints of paraparesis of 15 days duration and backache of 3 months’ duration. She had history of dizziness and low blood pressure. On general examination, she had tachycardia (heart rate of 126 beats / min), tachypnoea (respiratory rate 24 / min), severe pallor and bilateral non-pitting pedal oedema. The patient had low haemoglobin (6.6 gm / dl) with red blood cell (RBC) count of 2.5 million / mm3 . She was sent to the radio-diagnosis department for non-contrast computed tomography (CT) scan of thorax and contrast enhanced magnetic resonance (CEMR) of dorsolumbar region. On CT scan, soft tissue density lesions were noted in paraspinal region extending from lower thoracic, lumbar region without destruction of vertebral bodies. Additional findings include hepato-splenomegaly and left sided pleural effusion. On CEMR, there was T1 hypo and T2 / T2FSisointense soft tissue lesion in paraspinal region extending from lower thoracic, lumbar and sacral vertebrae. The lesions were showing diffusion restriction, diffusion weighted imaging (DWI) with low apparent diffusion coefficient (ADC) value and mild enhancement on post contrast scan. The soft tissue component was noted to extend into the epidural space in multiple vertebral levels in thoracic, lumbar and sacral regions causing spinal canal stenosis, maximum (7.0 mm) at L4 vertebral level. Based on the imaging findings, a diagnosis of extramedullary haematopoiesis in paraspinal region with extension of the soft tissue in the epidural space leading to compression of spinal cord at multiple levels was made.

Sclerosing Mesenteritis Presenting with Small Bowel Obstruction in a Patient with Compensated Cirrhosis: A Case Report

Sclerosing Mesenteritis (SM) is a rare fibroinflammatory disease of unknown etiology in which intestinal obstruction results from encasement of variable lengths of bowel by a dense fibrocollagenous membrane that gives the appearance of a cocoon. To our knowledge no cases of SM have been reported in patients with compensated cirrhosis without ascites. We report a case with SM diagnosed at laparotomy due to rapidly worsening small bowel obstruction, in a patient with compensated alcoholic cirrhosis. A 50-yearsold Caucasian male was evaluated because of cramping abdominal pain and discomfort associated with diarrhea, occasional post-prandial vomiting, fatigue and a significant weight loss. Compensated alcoholic cirrhosis had been diagnosed, two months before current presentation. Physical examination revealed abdominal distention with highpitched metallic sounds and bilateral peripheral pedal edema. Computed tomography of the abdomen demonstrated severe dilated small bowel loops as well as fluid into the peritoneal cavity. Based on the imaging findings, a surgical procedure was carried out. During laparotomy, an extra fibrous layer fully surrounding the small intestine was divided and a side-to-side functional ileo-cecum anastomosis was performed. Histopathological examination revealed fibroconnective tissue proliferation and inflammatory infiltration. Combined with the characteristic surgical findings a diagnosis of SM was made in a patient with compensated alcoholic cirrhosis. The patient recovered uneventfully and at 6-month follow-up he had no symptoms or signs of SM recurrence. The insidious onset of bowel obstruction symptoms in patients with even compensated cirrhosis, should include SM in the differential diagnosis.

Hepatic vein thrombosis secondary to COVID-19

COVID-19 is known to cause both arterial and venous thromboembolism. Although a lot of attention is being given to those presenting with myocardial infarction and stroke, splanchnic vein thrombosis which includes portal, mesenteric, splenic, and hepatic vein thrombosis is often underreported. A 21-year-old female presented with progressive abdominal distension and obstipation for the past 2 weeks. The patient was diagnosed as a case of moderate COVID-19 illness 2 weeks before the onset of these symptoms and recovered on receiving treatment according to the COVID protocol. Physical examination revealed pallor and bilateral pitting pedal edema up to ankles. Systemic examination revealed uniformly distended abdomen with signs of free fluid and tenderness in the right hypochondrium. Hematological investigations showed moderate-grade microcytic hypochromic anemia. Biochemically, indirect hyperbilirubinemia and transaminitis with moderately elevated D-dimers and Lactate dehydrogenase (LDH) was noted. Radiological imaging of the abdomen (including USG with doppler and CT contrast Scans) revealed gross ascites, nutmeg appearance of liver with completely obscured hepatic veins indicating no flow of blood, multiple intrahepatic portosystemic collaterals and a partially thrombosed inferior vena cava with no evidence of portal hypertension. All other workup to rule out other causes of hepatic vein thrombosis was inconclusive. The patient was treated with low-molecular-weight heparin and then continued with oral warfarin at discharge. On a 4-week follow-up, the patient showed marked clinical improvement with partial resolution of presenting symptoms.

LEFT VENTRICULAR NONCOMPACTION: AN UNUSUAL CAUSE OF HEART FAILURE

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Left ventricular noncompaction (LVNC) is a cardiomyopathy characterized by prominent trabeculae and deep intertrabecular recesses in communication with the ventricular cavity. LVNC affects up to 1.3% of the population and is responsible for 3-4% of all heart failure syndromes. CASE PRESENTATION: A 76-year-old male presented to the emergency department due to increasing dyspnea. He endorsed lower extremity swelling and orthopnea. He was tachypneic and hypoxemic. Lung auscultation revealed bibasilar crackles. Bilateral pitting pedal edema was noted. BNP was elevated at 861 pg/mL and troponins were elevated at 0.6 ng/L. Electrocardiogram demonstrated normal sinus rhythm with T-wave inversions in the inferolateral leads. Chest radiograph showed cardiomegaly, vascular congestion and bilateral pleural effusions suggestive of congestive heart failure syndrome. Transthoracic echocardiogram revealed left ventricular ejection fraction of 25-30%. Prominent trabeculae and deep interventricular recesses were noted, concerning for LVNC. Coronary angiography showed moderate nonobstructive coronary artery disease without need for percutaneous coronary intervention. His clinical condition improved with diuretic therapy, blood pressure control, and initiation of guideline-directed medical therapy. During his hospitalization, telemetry captured 6 beats of non-sustained ventricular tachycardia. Lifevest was placed to evaluate need for ICD implantation after optimization of medical therapy. He was scheduled for follow up echocardiogram in 3 months and counseled on the need for family screening. DISCUSSION: LVNC is thought to be a congenital cardiomyopathy caused by failure of cardiac sinusoids to compact during embryogenesis. However, studies demonstrate development of LV trabeculations on serial echocardiograms suggesting LVNC may be an acquired cardiomyopathy. Predisposition to trabeculation development may be genetically determined, LVNC has a 30% rate of familial recurrence. Excessive preload and afterload are thought to contribute as the development of trabeculations is noted in chronic renal failure and valvular heart disease. Criteria for diagnosis of LVNC vary and are not universally agreed upon. Thus, a multi-modality imaging approach involving echocardiography and cardiac MRI is recommended. LVNC is associated with significant complications, 56% of patients will develop heart failure syndrome and up to 40% will require heart transplantation. Additionally, 11% of patients undergo ICD implantation for ventricular arrhythmias and 7.6% of patients die of sudden cardiac death. Risk of thromboembolism ranges from 21-38%, likely due to turbulent flow through intertrabecular recesses. Three-year mortality rate is estimated at 14%. CONCLUSIONS: LVNC is a relatively common cardiomyopathy with significant morbidity and mortality. We urge clinician awareness to facilitate prompt diagnosis and management. Reference #1: Bhatia, Nisha L., et al. “Isolated Noncompaction of the Left Ventricular Myocardium in Adults: A Systematic Overview.” Journal of Cardiac Failure, vol. 17, no. 9, 2011, pp. 771–778., doi:10.1016/j.cardfail.2011.05.002. Reference #2: Tian, Julia, et al. “Left Ventricular Noncompaction: A Rare Case of Nonischemic Cardiomyopathy.” Case Reports in Cardiology, vol. 2019, 2019, pp. 1–3., doi:10.1155/2019/5637638. Reference #3: Gati, Sabiha, et al. “Adult Left Ventricular Noncompaction.” JACC: Cardiovascular Imaging, vol. 7, no. 12, 2014, pp. 1266–1275., doi:10.1016/j.jcmg.2014.09.005. DISCLOSURES: No relevant relationships by Gopika Dasari, source=Web Response No relevant relationships by Anneka Hutton, source=Web Response No relevant relationships by Eli Levine, source=Web Response No relevant relationships by Shaheen Mizyed, source=Web Response

MON-914 Ectopic ACTH Syndrome Caused by Adenocarcinoma of Lung - a Rare Association with Rare Complication

INTRODUCTION Ectopic ACTH constitutes 5-10% of ACTH dependent Cushing’s syndrome. Evolution of symptoms can be rapid. Cortisol & ACTH is usually higher as compared to Cushing’s disease. Imaging studies should be obtained for localization of the source of ACTH. Here, we present a case of Cushing’s syndrome caused by ectopic ACTH production caused by adenocarcinoma lung, which has very rarely been associated with this syndrome CASE A 52-year-old male presented with 3-month H/O bilateral pedal edema & puffiness of face. He noticed bruises over his trunk & darkening of face for 2 months. There was a recent worsening of his HTN (requiring 3 antihypertensives) & recently diagnosed with DM. On examination patient had cushingoid features, acne and ecchymosis. BP - 166/110 mm Hg. Proximal myopathy, Pedal edema, clubbing & cervical lymphadenopathy was present (largest node - 2.5cm). Fasting & postprandial blood sugars were 190 & 285 mg/dl respectively. Serum K+ was 3.0 meq/L (3-5-5.0meq/L), 11pm serum cortisol was 51.6 mcg/dl (cutoff < 7,5mcg/dl), 8 am cortisol after overnight 1mg dexamethasone was 60.7 mcg/dl (cutoff<1.8mcg/dl). Serum ACTH(8am) - 178 pg/ml.(>20 pg/ml-ACTH dependent Cushing’s) Biopsy of neck node revealed poorly differentiated adenocarcinoma. PET scan showed left lung upper & lower lobe masses. A diagnosis of ectopic ACTH syndrome was made, the source of which was adenocarcinoma of lung, which has been very rarely reported to be associated with it. Oral ketoconazole was started followed by Chemotherapy with paclitaxel & carboplatin. Within the next 7 days patient developed pleural effusion, neutropenia & worsened rapidly. BAL revealed Nocardia species, known to be associated with hypercortisolism. He was treated with appropriate antibiotics & supportive treatment but succumbed to septic shock. CONCLUSION If a patient presents with rapidly evolving symptoms of Cushing’s syndrome, ectopic ACTH syndrome should be considered. The presence of wasting and weight loss, hypokalemic alkalosis, pedal edema & marked hyperpigmentation should also alert towards the diagnosis. Histopathological confirmation of malignancy is important, as in our case with ectopic ACTH where the source was an adenocarcinoma of the lung, of which only 5 cases have been reported till now (Ectopic ACTH more commonly associated with SCLC). Finally, in cases of severe hypercortisolemia, there should be a high index of suspicion for opportunistic infections including invasive fungal infections, Nocardiosis etc, so that specific antibiotic therapy can be initiated. Typical features like fever, leukocytosis can be absent. Treatment of underlying hypercortisolism with surgical/medical management prior to initiation of chemotherapy has been shown to reduce the frequency of infections.

Five-year girl with advanced lupus nephritis and insulin dependent diabetes mellitus

Systemic Lupus Erythematosus (SLE) and Insulin Dependent Diabetes Mellitus (IDDM) are two common auto immune disorder occurring in children which can involve the renal system. The condition when occurs simultaneously in a child and its effects and follow up on the kidneys and its management have been mentioned here. A five-year-old girl was presented with low grade fever, dryness of mouth and bilateral pain over knee joints over four months. She had facial puffiness, mild bilateral pedal edema, and ascites on admission. She was treated immunosuppressive medications following a renal biopsy and insulin for IDDM

P884 Rare case of primary cardiac lymphoma in immunocompetent patient

Abstract Primary cardiac lymphoma is a rare tumour especially in immunocompetent person. It is invariably fatal unless diagnosed and treated early. Our patient was a 76 year old Chinese gentlemen, known case diabetes mellitus and hypertension, who presented with 3 months history of failure symptoms. He also had loss of appetite. His vital signs were stable. There was bibasal crepitation, raised JVP with normal heart sounds and bilateral pedal edema. Chest X-ray showed bilateral pleural effusion.He was admitted for stabilization of heart failure and started on diuretics. Echocardiography showed the LV ejection fraction was 50% with grade 1 diastolic dysfunction. There was a global pericardial effusion with effusion size 2.52cm maximum at posterior to LV. There was partial RA collapse .Patient was otherwise hemodynamically stable. Patient was observed closely and diuretics continued. Echocardiography on the third day of admission showed a suspicious looking mass in the right atrial (RA) and right ventricular (RV) wall near the AV groove. It become apparent after pericardial effusion became less. Patient was counselled and agreed for pericardial tapping but procedure had to be abandoned as effusion has reduced compared to before (&amp;lt;20mm). MRI cardiac showed an infiltrating mass around the right atrio-ventricular groove extending to the right ventricular free wall and around the pericardial lining around the ascending aorta and pulmonary trunks. There is inhomogenous signal in STIR with iso-intensity on T1 weighted images. First pass metabolism revealed some vascularity. There was a patchy myocardial enhancement on late gadolinium enhancement. pericardium was thickened with global pericardial effusion- 16mm. Large right pleural effusion seen and minimal left pleural effusion. Mediastinal lymphadenopathy was seen. The finding were suggestive of cardiac lymphoma with differential sarcoma. Subsequent day, patient develop acute ischemic stroke which was complicated by aspiration pneumonia and septic shock. Fortunately he recovered after 1 week of antibiotics and non-invasive ventilatory support. FDG PET- CT scan showed FDG-avid primary cardiac lymphoma with pericardial involvement and conglomerate of multiple group of mediastinal and supra clavicular lymph nodes . Bilateral hypermetabolic adrenal nodule were seen but unable to determine its relevance to the primary pathology(lymphoma). No marrow or other organ involvement. Stage is likely IIE. We were unable to harvest the lymph node because they were too deep. Patient"s family was counselled for cardiac biopsy but family did not want to take the risk as patient was bedridden and fragile. They were also not keen for any chemotherapy or invasive procedure. Once patient was out of infection, they requested to bring back patient to home. He was sent to nursing home for full time care but succumbed to another bout of aspiration pneumonia one week after discharge. Abstract P884 Figure. Echo, MRI, Pet CT scan

Nephrotic Syndrome: A Rare Sequelae of Varicella Zoster Infection

Nephrotic syndrome without haematuria following the sequelae of the infection is uncommon. The present case report describes nephrotic syndrome following varicella infection, without haematuria and hypertension in a 21-year-old young adult. The patient presented with four weeks history of fever, swelling of both feet and facial puffiness. General physical examination revealed vesicular lesions with skin crusts present on the face, trunk and extremities, Blood Pressure (BP)-110/70 mmHg, bilateral pedal oedema. Systemic examination was unremarkable. Laboratory data showed nephrotic range proteinuria, hypoalbuminaemia. Varicella Zoster Virus (VZV) was detected in blood through Polymerase Chain Reaction (PCR). Renal biopsy confirmed the diagnosis. Thus, viral glomerulopathies should be considered in patients following infection.

Leiomyosarcoma of inferior vena cava

A 57-year-old female presented with intermittent abdominal pain and bilateral pedal oedema. She was diagnosed as leiomyosarcoma from inferior vena cava (IVC). Imaging suggested encasement and occlusion of infra-renal IVC. She had received palliative chemotherapy from elsewhere, with no regression. We excised the tumour. At 14 months after the surgery, she is disease-free. Surgery is the mainstay in the treatment of retroperitoneal sarcomas. Even locally advanced retroperitoneal sarcomas may be successfully managed with complete surgical resection. Reconstruction of resected IVC segment may be avoided in selected cases.

A Case Series of Ten Patients of Epidemic Dropsy June 2018 in a Tertiary Care Centre: Epidemic dropsy

Epidemic dropsy (ED) occurs because of intoxication with alkaloid sanguinarine of Argemone Mexicana, the Prickly Poppy. Here we report a case series of ten patients, belonging to the same family, residents of a northern district in Uttar Pradesh, India. All of these admitted in June 2018 with pallor and erythematous bilateral pedal edema. Our aim to report all these cases is to create awareness among people and to tell the importance of this malady, although it is illegal to sell mustard oil un-bottled in our country India. &nbsp

3200 A Rare Case of Hepatitis B Association With Sarcoidosis and Treatment Challenge With Immunosuppressive as Resulting in Colonic Histoplasmosis

INTRODUCTION: There have been documented cases reflecting association between Hepatitis C virus (HCV) and sarcoidosis but it is very interesting as in this case that we discussed about association of Hepatitis B virus (HBV) and sarcoidosis, presenting with vague symptoms and confirmed with liver biopsy and immunologic markers. Further challenging is treatment with immunosuppressive medication leading to colonic histoplasmosis. CASE DESCRIPTION/METHODS: 58 year old Indian female with past medical history of cirrhosis secondary to HBV diagnosed six months ago, hypertension and diabetes mellitus 2 presented with bilateral pedal edema, anorexia and mild epigastric discomfort. She has been started on Entecavir since diagnosis six months ago. Patient denied any significant surgical, social and family history. Ultrasonography Liver revealed hepatosplenomegaly and mesenteric lymphadenopathy. 21.3kPa liver stiffness on elastography and HBV level 83. Liver biopsy showed multiple non caseating granulomas consist of Langerhans cell in parenchyma and portal tract, associated with moderate inflammation. Chest CT scan showed upper and middle lobe fibrosis of lung, diagnosis further confirmed with elevated Angiotensin converting enzyme. She was started on prednisone; within 3 months she experienced weight loss, diarrhea and fever. Colonoscopy was done after CT abdomen showed mural thickening of ascending colon and terminal ileum, which on biopsy confirmed Histoplasmosis as described in Figure 1. Prednisone stopped and patient treated with Hydroxychloroquine, amphotericin followed by itraconazole. Patient improved symptomatically and repeated colonoscopy was normal. DISCUSSION: As in this report, studies are scarce to prove association. However; reasonably assumed that the alterations in the pool of cytokines and immune cells caused by HBV infection may have a vicious influence on the immune regulation and can be a trigger for granuloma. Further studies can impact future era for better understanding in pathophysiology of sarcoidosis and HBV correlation and treatment options.

2602 Strongyloidiasis Presenting as Gastric Outlet Obstruction

INTRODUCTION: Strongyloides Stercoralis is an intestinal parasite mostly seen in tropical areas. Commonly patients are asymptomatic with non-specific gastrointestinal manifestations. We present a case of strongyloidiasis presenting as gastric outlet obstruction. CASE DESCRIPTION/METHODS: Our patient is a 67-year- old woman, originally from Jamaica, recently diagnosed with Diabetes Mellitus who presented with 50 pounds weight loss, anorexia postprandial epigastric pain and recurrent episodes of vomiting. Her symptoms have been progressively getting worse and let her to doctor visits over the past several months. On physical exam she was afebrile but appeared cachectic. She did have minimal tenderness to palpation of the epigastric area and had minimal bilateral pedal edema. Laboratory testing revealed normocytic normochromic anemia, thrombocytosis, Hyponatremia and hypoalbuminemia. An Abdominal CT scan revealed dilatation of the second portion of duodenum and tapering of third portion of duodenum plus mild intrahepatic and extrahepatic bile ducts dilatation as well as dilation of the proximal pancreatic duct (Figures 1 and 2). The patient was admitted to the hospital for hydration and subsequently had an upper endoscopy. The procedure revealed marked retention of bilious fluid as well as evidence of severe duodenitis. Narrowing of the lumen of the duodenum was also seen (Figure 3). Biopsies from the duodenum were obtained and confirmed the presence of Strongyloides Stercoralis. Pt was given two days of Ivermectin with dramatic improvement of her symptoms and subsequent discharge. DISCUSSION: 1. Stercoralis is a nematode with a complex life cycle. The parasite infects humans and replicates within its host for years or even decades (autoinfection). Patients would have positive serologies for S. Stercoralis but usually are asymptomatic. Immunosuppressive medications, HIV, HTLV1, Chronic diseases and in our case the new onset diabetes cause the parasite to replicate and leads to life-threatening dissemination of larvae to multiple internal organs called hyperinfection.

3027 Lipase Stands Out: Is It Sufficient to Diagnose Acute Pancreatitis?

INTRODUCTION: Acute pancreatitis is defined when two out of the three diagnostic criteria are present such as abdominal pain often radiating to the back, characteristic imaging findings, and amylase and/or lipase levels that are three times or more the upper limit of normal (ULN). We present the case of an elderly male with abdominal pain and isolated raised lipase concentrations treated as acute pancreatitis. CASE DESCRIPTION/METHODS: A 96-year-old male with a history of dementia, coronary artery disease, hyperlipidemia, presented with sudden onset right-sided abdominal pain and six episodes of vomiting that started a few hours prior. He denied constipation, diarrhea, and fever. The patient does not drink alcohol or smoke. On arrival, he had a pulse of 77 beats/minute, blood pressure of 165/88 mm Hg, respiratory rate of 16 breaths/minute and oxygen saturation of 93% on room air. Physical exam revealed bilateral pedal edema along with significant tenderness in the right lower quadrant with mild tenderness in the right upper quadrant with negative Murphy's sign. Laboratory investigations revealed white blood cell count of 13 K/ul, sodium of 131 mmol/l, chloride of 95 mmol/l, calcium of 9.4 mg/dl, triglyceride levels of 60 mg/dl, aspartate aminotransferase of 65 U/l, alanine transaminase of 36 U/l, and alkaline phosphatase of 123 U/l, and lipase of 4450 U/l. Ultrasound of the gall bladder and computed tomography of the abdomen revealed diffuse gallbladder wall thickening with pericholecystic fluid without any significant pancreatic abnormality. A provisional diagnosis of acalculous cholecystitis was made and he was started on intravenous (IV) ceftriaxone one gm, once a day and IV metronidazole 500 mg, thrice a day with IV pantoprazole 40 mg, once a day. Magnetic resonance cholangiopancreatography done after two days revealed the absence of gall bladder wall thickening. Cholecystitis was thus ruled out and the patient was diagnosed with acute pancreatitis owing to the raised levels of lipase. A resolution of abdominal symptoms and a decreasing trend was seen in serum lipase levels on day four of hospitalization but the levels still remained above the ULN (Figure 1). The patient was discharged with surgical follow-up on an outpatient basis. DISCUSSION: The cut-off set for lipase levels in acute pancreatitis has a specificity of &gt;99%. Clinicians should have a high suspicion of pancreatitis in patients with abdominal pain and isolated hyperlipasemia but be wary of alternative diagnosis too.

Lipid Inclusions in Cardiac Myocytes - A Rare Case of Cardiolipotoxicity

Introduction The heart oxidizes fatty acids for its energy production. However, excessive accumulation of lipids due to various processes such as obesity, diabetes, heart failure (HF), myocardial ischemia, or infarction can result in damage to the heart tissue, also known as cardiolipotoxicity. Case A 69-year-old gentleman with a history of non-ischemic cardiomyopathy, right ventricle failure, permanent atrial fibrillation, ventricular tachycardia and cardiac cirrhosis presented to the hospital with exertional dyspnea, orthopnea, and decreased functional capacity. Physical exam was pertinent for elevated jugular venous distension, bibasilar rales, and bilateral pitting pedal edema. Laboratory findings were significant for brain type natriuretic peptide 1641 pg/ml, hemoglobin A1c 6.1%, total cholesterol 79 mg/dl, triglyceride 84 mg/dl, low density lipoprotein (LDL) 53 mg/dl, and high density lipoprotein (HDL) 9 mg/dl. Chest x-ray demonstrated mild pulmonary vascular congestion. Electrocardiogram showed atrial fibrillation and right bundle branch block. Transthoracic echocardiogram showed normal left ventricular systolic function with ejection fraction of 55%, severely dilated right ventricle with severely reduced systolic function and markedly dilated right and left atrium. Right heart catheterization showed findings consistent with mild pulmonary hypertension from diastolic HF and severe tricuspid regurgitation. Endomyocardial biopsy showed intracellular accumulation of significant amorphous material in most cardiac myocytes. Electron microscopy revealed fat lobules and inclusion bodies within the myocytes, consistent with cardiolipotoxicity (figure 1). Guideline directed medical management of HF was initiated and patient was subsequently discharged home. Discussion Due to various stressors such as HF, myocardial ischemia, infarction or atrophy, there is increased expression of genes involved in glucose metabolism rather than fatty acid oxidation. This leads to increased accumulation of lipids in the failing myocardium, thereby leading to cardiolipotoxicity. Increased lipid accumulation causes cardiac steatosis thereby leading to ER dysfunction, contractile dysfunction, and cell death. Our case describes a distinct metabolic phenotype of myocardial dysfunction for which no definite cause or treatment has been identified. Further research is required to advance our knowledge on cardiac metabolism in normal myocardium as well as in patients with HF, which could result in development of novel therapeutic interventions and strategies in these patients.

Heart in the \u2018jaws\u2019 of a constrictor, unusual cause of subacute right heart failure

BackgroundConstrictive Pericarditis(CP) can be viewed as a constellation of syndromes resulting from compression of the heart, etiologies, course and types are well discussed in other reports. However, localized CP as a cause of right heart failure is rare, and presentation with interposed fluid under-pressure is extremely odd.Case reportA case of C.X. Z, male aged 39 years old, who presented to our department with sudden onset of symptoms of subacute right heart failure due localized CP. In January, 2018 C.X.Z presented to the county hospital with complaints of 10-day history of transient mild bilateral pedal edema. He was managed on diuretic therapy and symptoms resolved completely. 10 months later, he suddenly presented to the local facility with symptoms of subacute right heart failure. 7 days after on-set of symptoms, his condition shifted from NYHA I to III-IV. Although wake-up chest radiography appeared normal, standard medical therapy yielded no positives results. He was referred to our hospital, upon which after echocardiography and computed tomography investigations, aforementioned diagnosis was made. We performed off-pump partial pericardiectomy with no complications. After operation, he received analgesics and diuretics for pain and edema(ascites) respectively. He was discharged 7-days after operation on analgesics only, with no symptoms of right heart failure.ConclusionLocalized constrictive pericarditis as a cause of subacute right heart failure (RHF) has never been reported elsewhere, and presentation with interposed fluid is extremely odd. Progressive symptoms of Acute RHF in the absence of typical radiologic clue ‘egg-shell’ should heighten suspicion index of CP.

SAT-483 A Rare Case of Pituitary Adenoma: The Mysterious Crooke's Cell Adenoma

Cushing's disease is caused by an excess of cortisol. In a cushingoid state, excess cortisol leads to a cytoplasmic accumulation of cytokeratin filaments. This accumulation of cytokeratin filaments and hyalinization characterizes a Crooke cell tumor which is an interesting variant of corticotroph adenoma (1) This transformation is known as Crooke’s cell transformation. Crooke’s cell tumors are very rare (largest case series of 36) reported by George et al. (2), aggressive, and prone to recurrence after resection which makes identification and distinction from adenomas important for treatment and patient management. A 42-year-old Caucasian male, with a PMH of obesity, HTN, DM2, and refractory hypokalemia presented to the hospital, with symptoms of headache, eye pressure, bilateral pedal edema, and weight gain x 4 weeks. admitted for evaluation with suspicion for Cushing's syndrome. The patient appeared cushingoid with positive parinaud sign (limited upward eye deviation) suggestive of a pituitary mass. CT head revealed a 1.2cm right pituitary macroadenoma with remodeling of sella turcica. Random cortisol 39.6 and ACTH 140. Dexamethasone suppression testing, low and high dose, failed to suppress cortisol production which suggested hypercortisolism from an ectopic source. Inferior petrosal sinus sampling confirmed pituitary Cushing's with lateralization to the right pituitary, as the source of hypercortisolemia. The patient underwent endoscopic endonasal transsphenoidal (EET) resection of pituitary macroadenoma, Postoperatively cortisol levels initially decreased, plateaued and then began rising again with suspicion for a residual tumor in the sella. The patient underwent repeat EET mass resection. Cortisol levels dropped and reached a nadir of 3.0 with ACTH 13 upon discharge. Pathology results revealed Crooke cell adenoma. Discussion: Crooke’s cell tumors are a rare variant of pituitary adenoma and are important to distinguish from other types of adenomas due to their unique cellular behavior. There isn’t a good explanation as to why these tumors cause hyalinization and despite this hyalinization and microfilament deposition, which would be expected to suppress functionality, result in increased production of ACTH. There have been cases reported multiple recurrences in patients requiring repeat surgical removal. Prompt and complete resection may limit the risk for recurrence, and the increase in morbidity and mortality that are inherent to tumor regrowth and continued invasive resection. Additionally, nonsuppressable serum cotrisol with high dexamethasone dose in the presence of pituitary tumor , should raise possibility of Crook cell tumor in addition to paraneoplastic syndromes . conclusion: this case highlights the importance of suspecting Crooke’s tumor in patients with evidence of pituitary adenoma and Cushing’s syndrome.

SUN-375 A Diagnostic and Therapeutic Challenging Case of Ectopic Cushing Syndrome

Introduction: Ectopic ACTH secretion is a rare cause of ACTH dependent Cushing syndrome and accounts for approximately 10% of the cases. Identification of ectopic source involves a complex evaluation. We present a case of ectopic Cushing syndrome from small cell cancer posing diagnostic and therapeutic challenges. Clinical case: A 50-year-old woman with HTN, newly diagnosed DM, 45 pack year smoking admitted to hospital for pneumonia, uncontrolled HTN, and hypokalemia. The patient’s CT chest and abdomen showed a new 2cm cavitary lesion in the right lung and incidental left adrenal nodule. Biopsy of the cavitary lesion was negative for malignancy. Endocrinology was consulted for left adrenal incidentaloma. The patient reported 40lb weight gain in 6 months, hirsutism, proximal muscle weakness, and easy bruising. On physical exam, facial plethora, thinning scalp hair, supraclavicular fullness, diffuse bruising, truncal obesity, and bilateral pedal edema were noted. Bilateral lower extremities strength was markedly decreased. No abdominal purple striae were present. Work up for Cushing's showed, serum cortisol after 1mg overnight Dexamethasone suppression test- 49.3mcg/dl (N<1.8), 24 hour urine free cortisol-5767mcg/dl (N<45), midnight salivary cortisol 3.47mcg/dl (N<0.01-0.09) and ACTH-183pg/ml (6-58). 8mg Dexamethasone suppression test did not suppress cortisol more than 50%. Work up for Pheochromocytoma and Aldosteronism were negative. Labs confirmed ACTH dependent Cushing's. The pituitary MRI was unremarkable. Octreotide scan was negative. Ga- DOTATATE scan was unavailable. Meanwhile, the patient deteriorated within a few days, developed right lung empyema, shingles, and could not ambulate without support. The patient was started on Ketoconazole and later switched to Metyrapone because of insurance. The patient had bronchoscopy for her unresolved empyema, which revealed small cell lung cancer in the brushings. Post-discharge, the patient responded fairly well to chemo and radiation. But her cortisol was not fully controlled with ketoconazole, then Metyrapone. And she required high doses of potassium. The complications of her ectopic Cushing's became more life threating necessitating referral for bilateral adrenalectomy for definitive management of her ectopic Cushing's. Conclusion: Localization of ectopic source of ACTH secretion poses a diagnostic challenge. In our case, the initial biopsy of cavitary lung lesion was negative, and later ectopic source was identified on bronchial washings. Early diagnosis of the ectopic source is crucial to avoid complications from Cushing's. Even if initial localization fails, it is prudent to start medical management as early as possible for hypercortisolemia as in our case and to refer for bilateral adrenalectomy if uncontrolled, to decrease the morbidity and mortality from Cushing's.

Ayuvedic approach in Primary Biliary Cholangitis (PBC): A case study

Despite of countless facilities and highly developed technologies for the treatment of diseases in modern medical science, there are many diseases which has no medical cure other than prophylactic treatment while the disease is progressing and needs organ transplant in last stage, one such disease is Primary Biliary Cholangitis (PBC). A 65 year old female patient presenting with pain in upper abdomen (Udarshool), decrease appetite (Agnimandhyata), weakness (Daurbalyata), distension of abdomen (Kuchheradmanam), bilateral mild pedal edema (Ubhaypaad-shoth), itching (Kandu), muscular and bony pain (Mansasthishool) diagnosed as Yakritpleehodar Roga, a subtype of Udar roga was brought to Hospital National Institute of Ayurveda, Jorawarsingh Gate, Jaipur, Rajasthan. The patient was treated on the basis of Ayurvedic principles of treatment of Udar roga. According to Ayurveda, the principle of treatment of Udar roga includes Nitya Virechan (purgation), Agnideepan (increasing appetite), Yakituttejan (stimulation of Liver), Mutra Virechan (diuresis) and Ksheer Prayoga (use of milk as diet) for Balprapti (increasing strength of patient). Appreciable result were observed in the form of decreased abdominal pain, decreased abdominal girth, decreased pedal edema, decreased weakness, decreased muscular and bone pain, increased appetite, decrease in fibrotic changes of Liver, resolution of Ascites, decrease in size of Spleen along with significant improvement in other laboratory investigations.&#x0D; Keywords- Ksheer Prayoga, Jalodar, Primary Biliary Cholangitis, Udar roga, Yakritpleehodar Roga.