Common Presenting Symptoms Research Articles

Clinical, Radiological Features and Treatment Outcomes of Tuberculosis in Patients Aged 75 Years and Older.

Tuberculosis (TB) is a significant contributor to morbidity and mortality. With a progressively aging population, TB is increasingly encountered in older adults. Understanding the clinical presentation and optimal treatment strategies for TB in this population is essential. Clinical, radiological features, treatment, and outcome of patients aged 75 and above who were diagnosed with tuberculosis at King Abdulaziz Medical City in Riyadh in the period between January 2015 to December 2021wereevaluated retrospectively. Among 92 elderly tuberculosis patients, most were male (76.1%) with a mean age of 82.5 years. Pulmonary TB was diagnosed in 52.2% of patients, Extra Pulmonary TB in 32.6%, and Disseminated TB in 15.2%. Comorbidities included Diabetes Mellitus (59.8%) and Congestive Heart Failure (41.3%). The most common presentation symptoms included cough (51.1%), fever (43.5%), dyspnea (39.1%), and weight loss (31.5%). Delay of TB diagnosis for up to 3 months was observed in 31.5% of patients. Weight loss and male gender were significant predictors of delayed diagnosis. Laboratory findings varied among TB types, with disseminated TB showing higher eosinophilia and thrombocytopenia. Completion of an initial RIPE treatment protocol was achieved in 67.6% of patients. Mortality during treatment occurred in 23.9% of patients. Pulmonary TB was associated with higher mortality compared to extrapulmonary TB (p = 0.007). Tuberculosis is associated with high mortality in patients above the age of 75. There is still a substantial delay in TB diagnosis in the elderly. RIPE regimen is frequently changed due to side effects. Alternative regimen choices were quite variable. More studies on tuberculosis in this patient's population are needed to define the most effective therapeutic approach.

Bartonella endocarditis: lessons learnt from an African cohort

Abstract Background Bartonella (B) quintana endocarditis is a preventable, vector-borne, and important cause of blood culture-negative endocarditis (BCNE). The ESC guideline for the management of endocarditis recommends blood serology (IgG titer ≥800) and polymerase chain reaction (PCR) testing on both blood and valvular tissue for diagnosis. Access to these molecular technologies is limited in Africa and there is a paucity of B. quintana endocarditis research on the continent. Purpose Record the clinical picture and explore the risk factors for disease and the diagnostic utility of immunofluorescence (IFA) in PCR-proven cases with B. quintana endocarditis. Methods Data were analysed from a prospective observational cohort study of patients with infective endocarditis managed at our institution. All BCNE cases from October 2019 to January 2024 were evaluated to identify patients with PCR-proven B. quintana on valvular tissue. A commercially available IFA was used for blood serology testing. 16S rRNA PCR testing with sequencing was performed on valvular tissue. Results Thirty five of the 58 cases (60.3%) with BCNE were diagnosed with Bartonella endocarditis. A diagnosis of PCR-proven B. quintana endocarditis was made in 21 cases. Of these, seven patients (33.3%) were either homeless or lived in informal housing. Thirteen patients (61.9%) had an alcohol-use disorder. Four patients (19%) were Human Immunodeficiency (HIV) virus- positive. Eighteen patients (85.7%) reported the onset of symptoms more than two weeks before presentation. Common presenting symptoms were dyspnea (n=21;100%), loss of weight (n=10;47.6%) and fever (n=7;33.3%). Common clinical features were digital clubbing (n=17;80.9%), pallor (n=13; 61.9%), microscopic haematuria (n=12; 57.1%) and severe regurgitant lesions (n=21; 100%). Blood serology was available in 17 patients with an IgG titer (1≥256) in all patients apart from one (1:64). Only one case (5.8%) had an IgG titre ≥800. The most common isolated valve lesion on echocardiography was severe aortic regurgitation (n=10;47.6%). Surgical replacement and repair were performed in 17(80.9%) and 4(19%) patients respectively. The one-, three- and six-month mortality was 14%, 14 % and 14% respectively. No cases of relapse were reported. Discussion B.quintana is the most prevalent cause of BCNE in our centre. The typical clinical and echocardiographic profile was consistent with the reported literature of a destructive endocarditis in a patient with a low socioeconomic background. Despite this, the surgical outcome is fair and comparable to European data. The IFA used in this study is different to the assay referenced in the ESC guideline and may explain the relatively low serology titres observed (despite PCR-proven disease). Further study with the commercial IFA is needed to determine a cut-off titre that will give a comparable sensitivity to the referenced in-house IFA.Destructive aortic valve endocarditisResultant severe aortic regurgitation

Nature and impact of symptoms at time of initial presentation for patients with glioblastoma.

In patients diagnosed with glioblastoma (GBM), minimal data exist on the pathway to presentation and the impact of symptoms on survival outcomes. This study aims to detail the symptoms that occur at time of initial presentation, the response to subsequent intervention, and the factors that predict survival in patients managed for GBM. A retrospective audit was performed from established prospective databases in patients managed consecutively with radiation therapy (RT) for GBM between 2016 and 2019. The major endpoint was median overall survival (mOS). Analysis was performed to determine associations with clinical factors including presenting symptom, performance status, tumour site and extent of resection. The level of carer support and objective perception of carer mastery was also assessed. Overall, 182 patients with GBM were eligible for analysis. The majority of patients presented directly to Emergency (52%), with the most common initial presenting symptom being personality change in 23% of patients. The primary symptoms resolved pre-operatively in 47% of patients, with 9% having worse symptoms postoperatively. The mOS was 16.5 months (95% CI: 14.5-18.5). ECOG Scores 0-1 were associated with improved mOS at both initial ECOG (P < 0.001) and ECOG at 6 months (P = 0.006). Recognised Carer Mastery (P = 0.007) but not presence of carer (P = 0.35) was associated with improved mOS. In patients with GBM initial presenting symptoms, level of performance status and role of carer influence clinical outcomes and survival. These findings can assist to guide clinicians and supportive care services to optimise future patient care.

9183 Pituitary Metastasis Of Lung Adenocarcinoma Presenting As Anterior Pituitary Dysfunction

Abstract Disclosure: O. faour: None. M. Kinaan: None. S.K. Suryanarayanan: None. Introduction: The pituitary should not be overlooked as a site for metastasis and can be the first presentation of neoplastic disease in some patients. Most common presenting symptoms: headache, ophthalmoplegia, visual field defect and Arginine Vasopressin Deficiency (AVP-D). We present a case of pituitary metastasis of lung adenocarcinoma presenting as anterior Pituitary dysfunction that also showed partial AVP-D unmasked after starting steroids. Case Description: A 63-year-old male with history of tobacco use, COPD, and hypertension presented with syncope. He reported a 30lbs weight loss within prior 2 months, low energy, increased thirst, and polyuria. Physical exam was significant for cachexia, normal visual field on confrontation, and vital signs of BP 100/61, HR 83, and Weighing 180 lbs. Since he had syncope, Cortisol checked was undetectable and Free T4 was low, He was started on hydrocortisone and levothyroxine. CTA chest revealed a right hilar mass measuring 2.7 x 3 cm. Endobronchial biopsy was consistent with lung adenocarcinoma. MRI of pituitary gland revealed solid hypointense lesion with glandular thickening and diffuse heterogeneity involving most of the pituitary gland measuring up to 16 mm. No cavernous sinus invasion. Pituitary infundibulum showed diffuse thickening and enhancement of the pituitary stalk throughout with Intact posterior pituitary bright spot. Labs showed low LH, cortisol, ACTH, GH, TSH, and ADH. Initially, the patient was able to maintain a euvolemic status through increased water intake; however, he was later found to have partial central AVP-D when steroids were introduced. He responded to the use of Desmopressin, developed hyponatremia after 3 doses. He was started on a combination of carboplatin/pemetrexed/pembrolizumab but had no response and was transferred to palliative care/hospice and passed away within 7months after diagnosis.Discussion:Pituitary metastasis is rare and most commonly occurs in lung and breast cancers. Unfortunately, they are associated with poor prognosis. MRI findings of loss of posterior pituitary bright spot, thickening of the stalk, and dumbbell shape can be helpful in distinguishing between primary pituitary tumors and metastases. PET-FDG scan has limited value. Pituitary metastasis commonly presents with posterior pituitary dysfunction due to direct blood supply. Unmasking or worsening of AVP-D can happen with steroid replacement in patients requiring initiation or intensification of Desmopressin therapy. Treatment involves combination of surgery, radiation therapy, and systemic treatment for the primary cancer which can improve symptoms only but does not improve mortality. Presentation: 6/1/2024

12238 A Case Of Drug-induced Vasculitis

Abstract Disclosure: C. Javier: None. M.H. Horani: None. Title: A Case of Drug-Induced VasculitisChristian Javier, DOMohamad Horani, MD Introduction: Graves’ disease is commonly managed with thionamides. These have rare but serious complications of drug-induced lupus-like syndrome and vasculitis. In patients who present with rheumatologic and inflammatory findings, it is important to consider the possibility of these complications . Case Presentation: We present a 30-year-old female with Graves disease, asthma, and hypertension with concerns for cough, body aches, fatigue, bilateral flank pain, erythema, itching and burning of the hands, in the setting of recent spontaneous miscarriage. She was diagnosed with Graves’ nearly 2 years ago and was started on methimazole, but discontinued due to adverse effects of the medication. She was then started on PTU. The patient had a seizure, and head CT revealed a left-sided 4 cm brain mass in the left frontal lobe. The patient was admitted to the ICU, intubated, and started on IV Decadron. Further imaging showed multiple enlarged lymph nodes in the axilla, mediastinum, and hilum. Her brain mass was biopsied showing acute inflammation with early acute necrosis and multifocal fibrinous vascular necrosis, which has been reported in ANCA vasculitis. She had undetectable TSH (0.35-5.0) and free T4 of 1.54 (4.87-11.72). She was also found to have proteinuria and AKI. At this point, PTU-induced vasculitis and drug-induced lupus were suspected and PTU was discontinued. She was found to have low complement levels (C3 40, C4 6.1), elevated p-ANCA (&amp;gt;1:1280), ANA (1:640), anti-histone IgG (2.3) dsDNA (1:160), SSB La antibodies (70), anti-Smith antibodies (319), anti-RNP antibodies (146). Renal biopsy is pending. After discontinuation of PTU and administration of IV steroids, her symptoms largely resolved and she was extubated and stable for discharge. Conclusion: In patients being treated for Graves’ disease with PTU, there are rare but life-threatening complications associated with this medication including lupus-like state or vasculitis with elevated ANCA antibodies. Common presenting symptoms of drug-induced vasculitis include fever, joint pains, myalgias, skin lesions, glomerulonephritis, cerebral angiitis, and pulmonary hemorrhage. The onset of vasculitis can occur at any time after starting medication, with one study showing an average onset of 36 months after initiation of therapy. Other case reports have demonstrated positive serologies for ANA and anti DS-DNA antibodies in those with PTU-induced lupus. Drug induced lupus can also occur in patients taking PTU, with kidney and CNS involvement being more uncommon. In those with p-ANCA associated vasculitis secondary to PTU, anti-GBM, antiphospholipid, and antinuclear antibodies can also be present. Presentation: 6/1/2024

SPIN-03 PROFILE OF MALIGNANT SPINAL CORD COMPRESSION AMONG CHILDREN AT A SINGLE CENTRE IN JOHANNESBURG, SOUTH AFRICA

Abstract OBJECTIVE Malignant spinal cord compression (MSCC) in children can lead to permanent neurological deficits and therefore warrants urgent referral, prompt diagnosis and treatment. There is limited data on paediatric MSCC in Sub-Saharan Africa. The objective was to assess the characteristics, aetiology, clinical presentation, treatment and long-term outcomes of MSCC. METHODS Records of 23 patients with MSCC were retrospectively assessed over a 15-year period (2008-2023) at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa. RESULTS The median age of MSCC diagnosis was four years (range: 5 months to 15 years). The median interval between symptom onset and confirmed diagnosis was three months (1 week to 20 months). MSCC’s leading causes were central nervous system tumours (30%), lymphomas (22%), sarcomas (17%), germ cell tumours (9%), teratoid tumours (9%), neuroblastomas (9%) and leukaemias (4%). Commonest presenting symptoms were motor deficits (96%), pain (35%) and sphincter dysfunction (22%). Magnetic resonance imaging (MRI) of the spine was diagnostic in all cases. The primary tumour was managed using a multimodality approach: 70% underwent neurosurgical intervention and 39% received radiotherapy. The median follow-up duration was two years (1 month to 15 years). There were six deaths (two cases of ependymoma and a case each of glioblastoma multiforme, alveolar rhabdomyosarcoma, acute lymphoblastic leukaemia and Burkitt lymphoma) at a median interval of 4.5 months from diagnosis (1 month to 2 years). The commonest long-term sequelae were motor deficits (52%) and sphincter dysfunction (26%) and 22% of patients were asymptomatic. CONCLUSION We documented longer diagnostic delays than published in the literature and recommend increased awareness and rapid referral to decrease permanent sequelae. Patients presenting with new-onset neurological deficits suggestive of MSCC should have urgent radiological imaging; preferably MRI, followed by prompt referral to a specialised centre with an experienced multidisciplinary team.

Evaluating Pericardiectomy Outcomes and Determinants; an 8-Year Retrospective Study at Tertiary Teaching Hospitals in Ethiopia

&amp;lt;i&amp;gt;Background&amp;lt;/i&amp;gt;: Constrictive pericarditis has a variety of etiologies which leads to severe symptoms and heart failure which affects the quality of life. So far the main modality of treatment is pericardiectomy. &amp;lt;i&amp;gt;Objective&amp;lt;/i&amp;gt;: The aim of this research was to know pericardiectomy outcomes and determinants among constrictive pericarditis patients who were operated at Tikur Anbessa Specialized Hospital from 2014 - 2022. &amp;lt;i&amp;gt;Methods&amp;lt;/i&amp;gt;: A retrospective study was done among 65 patients. Data was presented using frequencies with percentages, mean (±standard deviation) and/ or median (interquartile range) as required. Perioperative mortality and complications were summarized using incidence density with 95% confidence interval (CI). &amp;lt;i&amp;gt;Result&amp;lt;/i&amp;gt;: Most patients were in their 20s (53.8%) and where male are (84.6%). The commonest presenting symptom was shortness of breath (100%), fatiguability (96.9%), and coughs (66.2%). The median time of presentation was 12.3 months (IQR, 7.0-25.5). There were also cases with clinical symptoms of tuberculosis (13.8%). The etiology of constrictive pericarditis was infectious in 83.1% of cases. The mean length of surgery was 3.3 ± 0.6 hours. The median duration of hospital stay is 9.0 days (IQR, 7.0-12.0). The incidence rate (IR) of perioperative death was 7.9 per 1000 person-days (PD) of observation (94% CI = 3.3 – 19.2) and the incidence rate of complication was 4.8 per 1000 PD (95% CI = 1.5 -14.9). &amp;lt;i&amp;gt;Conclusion&amp;lt;/i&amp;gt;: Pericardiectomy is the best treatment for patients with constrictive pericarditis. The majority of patients had a good outcome, with an improvement in symptoms and functional status. The mortality rate was low, and the complication rate was acceptable. However, this study is based on relatively small sample size, and it is a retrospective study from a single center. Hence, further prospective studies are needed to confirm the findings of this study.

Orbital Myeloma and Plasmacytoma: An Australian Study.

The purpose of this study was to provide Australian data on the clinical and radiological features and outcomes in patients with orbital plasmacytomas. Multicentre retrospective review of orbital plasmacytoma and orbital involvement in multiple myeloma (MM) from 2005 to 2022 in Australia. Twenty-one participants were identified. The median age was 62 years (range 34-88 years), and 11 (52%) were females. Eighteen (84%) had a known diagnosis of MM prior to their orbital presentation, with all patients eventually being diagnosed with systemic MM. Thirteen (72%) were receiving active treatment for systemic myeloma on presentation, while 3 (17%) were in remission. All but 1 had unilateral orbital involvement (n = 20, 95%). Common presenting symptoms and signs were decreased visual acuity (n = 13, 62%), proptosis (n = 11, 52%), limited motility (n = 15, 71%), and optic neuropathy (n = 5, 24%). Radiologically, 15 (71%) involved the superotemporal orbit, 7 (33%) inferotemporal orbit, and 16 (76%) involved ≥1 extraocular muscle. Sixteen (76%) were biopsied and confirmed orbital plasmacytoma on histopathology. Treatment modalities included intravenous and oral steroids (n = 7, 33%), chemotherapy (n = 9, 43%), radiotherapy (n = 13, 62%), stem cell transplant (n = 3, 14%), and surgical debulking and decompression (n = 3, 14%). Mortality was high, with 15 (71%) having MM-related mortality. This is the largest cohort of Australian data on orbital plasmacytomas. Most patients have a diagnosis of systemic MM at presentation. It is crucial to recognize and treat these patients early due to a poor systemic prognosis.

The Clinical Manifestations, Risk Factors, Etiologies, and Outcomes of Adult Patients with Infectious Meningitis and Encephalitis: Single Center Experience.

(1) Background: Central nervous system (CNS) infections, including meningitis and encephalitis, are serious conditions which are associated with high morbidity and mortality. This study aims to identify the clinical manifestations, etiologies, and outcomes of meningitis and encephalitis in adult patients in Saudi Arabia, addressing the current gap in understanding these conditions within this population. (2) Methods: This is a single-center retrospective study which included all adult patients diagnosed with meningitis and encephalitis from March 2016 to May 2022. (3) Results: This study found that most cases of meningitis and encephalitis occurred due to unknown pathogens. Pretreatment with antibiotics prior to lumbar puncture (LP) was found in 71.2% of patients with meningitis. Altered mental status and seizures were common presenting symptoms among patients with encephalitis while altered mental status and fever were common among patients with meningitis. (4) Conclusions: Adherence to guidelines in treating meningitis and encephalitis and performing LPs in a timely manner are important. Establishing national biobanks with biological samples from patients suspected of having meningitis or encephalitis will significantly enhance our understanding of these conditions in Saudi Arabia.

280. MANOMETRIC FINDINGS IN PATIENTS WITH GIANT HIATAL HERNIA: OESOPHAGEAL PHYSIOLOGY APPEARS TO IMPROVE WITH SURGERY

Abstract Background High resolution manometry (HRM) is a gold standard test of oesophageal physiology. The use of HRM in patients with giant hiatus hernia (GHH) is limited by historical technical challenges as well as unclear clinical implications of the findings. The aim of this study is to demonstrate feasibility of HRM in patients with GHH and study effect of surgery on oesophageal physiology of patients undergoing GHH repair. Methods Data was extracted from a prospectively populated database of patients with giant (&amp;gt;30% stomach above diaphragm) hiatus hernias. All patients that underwent HRM before and after surgery were included. Manometric findings before and after surgery were analysed and compared. Patient symptoms were correlated with manometric findings. Results Inclusion criteria were met by 30 patients: 83% female, average age 74 (range 51-86), 93% had type III hernia containing on average 55% of stomach. All operations but one were performed laparoscopically. Pre-operatively average LOS length was 1.89cm which improved significantly to 2.19cm after surgery (p&amp;lt;0.05). Nine patients had ineffective oesophageal motility on index study which normalised post operatively in 4 patients. Lower oesophageal sphincter integrated relaxation pressure (IRP) increased post-operatively from 9.07mmHg to 11.52mmHg (p&amp;lt;0.05). Distal contractility improved post-operatively, however this was not significant. Most common presenting symptoms were dyspnoea, anaemia, retrosternal pain, and dysphagia. There was no association between dysphagia and manometric findings before or after surgery. Conclusion This study provides an insight into HRM findings in patients with GHH before and after surgery. Majority of the physiological parameters improved with surgery. There was no correlation of symptom of dysphagia with manometric findings.

Characteristics and Outcomes of Operatively Treated Discoid Lateral Meniscus in Pediatric and Young Adult Patients: A Multicenter Study.

Discoid lateral meniscus (DLM) is the most common congenital abnormality of the meniscus. Tears are common; treatment is frequently not definitive, often requiring reoperation. To report the clinical manifestations, physical characteristics, operative treatments and findings, complications, and reoperations of DLM in pediatric patients from multiple centers across North America. Case series; Level of evidence, 4. Consecutive patients who underwent treatment for symptomatic DLM at 9 institutions between 2000 and 2020 were included. Patient data, presenting symptoms and signs, surgical findings, treatments rendered, and postoperative complications, including reoperation rates, were collected. Means with ranges and counts with proportions are reported for continuous and categorical variables, respectively, and comparisons were made using either the chi-square or Fisher exact test. In total, 784 patients (867 knees) were included with a mean age at diagnosis of 12 years (range, 1-22 years) and a mean follow-up of 22.6 months (range, 0-154 months). Common preoperative symptoms were locking (33%) and snapping (30%). At surgery, tears in the DLM were present in 647 knees (594 patients [76%]); 95 knees (11%) had multiple tears; and in 140 knees, tears extended into >1 zone. Tears, when present, were more common within the posterior horn (41%) or body (34%) than the anterior horn (25%). Peripheral rim instability was reported in 241 knees (28%). Significantly more knees had instability posteriorly (15%; P = .0004) and anteriorly (9%; P = .0013) than along the body (3%). Tear type was most commonly complex (38%) or horizontal (34%). A total of 358 knees in 333 patients with tears (42% of all patients) underwent repair (55% of knees with tears). A total of 175 complications were reported, occurring in 139 knees in 134 patients (17%); 116 of these knees with complications (83%) had a single complication, while 23 (17%) had >1. Of the 784 patients, 105 (13%) underwent reoperation, undergoing 135 additional procedures related to their DLM. Of those, 60 (44%) were repeat arthroscopy and meniscal trim; 40 (30%), arthroscopy and meniscal repair; and 17 (13%), an articular cartilage procedure. Locking and snapping were common presenting symptoms. Over three-quarters of patients had meniscal tears, which were most often complex and located posteriorly. Seventeen percent of patients experienced complications, and a sixth of patients with complications had >1. Reoperation was typically for persistent symptoms or meniscal retear.

Exploring the Link Between Somatic and Psychiatric Symptoms in Patients With Medically Unexplained Physical Symptoms: A Cross-Sectional Survey From North India.

The association between somatic symptoms and psychiatric co-morbidities remains unexplored among patients with medically unexplained physical symptoms (MUPS) in Asian populations. This study aims to bridge this gap by investigating psychiatric morbidities and their determinants among patients presenting with MUPS in an Indian setup. This cross-sectional study, conducted in the outpatient department (OPD) of a tertiary care hospital in India, assessed 200 patients diagnosed with MUPS. Assessment tools, such as the Somatic Symptom Scale (SSS-8), Presumptive Stressful Life Event Scale (PSLES), and Depression, Anxiety, and Stress Scale (DASS), were administered to collect data. The study examined patients (mean age 36.51±9.82 years), predominantly comprising females (67.5%), presenting with MUPS. Common presenting symptoms were general (96.3%), musculoskeletal pain (91.7%), and gastrointestinal symptoms reported by 81.7%. Medium somatic symptom severity (57%) was more prevalent in females. Prevalent psychiatric co-morbid conditions included depression (mild: 22.0%, moderate: 26.5%), moderate anxiety (41.5%), and moderate stress (26%). Strong associations were observed between the SSS-8score and depression (χ²(6, N = 200) = 49.26, p < 0.001), anxiety (χ²(8, N = 200) = 37.90, p < 0.001), stress (χ²(6, N = 200) = 44.45, p < 0.001), and the experience of stressful life events (χ²(3, N = 200) = 6.5, p < 0.05). The study indicates an intertwined association between MUPS and psychiatric disorders. Individuals with MUPS commonly experience heightened anxiety and depression, emphasizing the complex interplay between somatic symptoms and emotional well-being. Consideration of environmental and social factors may be crucial for a comprehensive understanding.

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: patient outcomes and lessons learned over a 3-decade single-center experience.

The role of stereotactic radiosurgery (SRS) in the management of intracranial dural arteriovenous fistula (dAVF) is unclear given the rarity of this lesion and the variability in treatment paradigms. This study describes a 3-decade experience with the SRS technique and its outcomes for patients with dAVF. The authors conducted a retrospective analysis of patients with dAVF who had undergone single-fraction SRS in the period from 1990 to 2021. The imaging modality initially used for targeting was angiography alone, then angiography plus MRI, and most recently MRI alone. Two hundred twenty-two patients underwent SRS alone (n = 56, 25%) or SRS plus embolization (n = 166, 75%), depending on the severity of symptoms or the presence of cortical venous drainage (CVD). Most patients were women (64%), and the median patient age was 60 years. Common presenting symptoms were pulsatile bruit (55%), visual change or chemosis (21%), headache (10%), and intracerebral hemorrhage (5%). The most frequent dAVF location was the transverse or sigmoid sinus (44%), followed by the cavernous sinus (24%), jugular bulb (9%), and torcula (5%). CVD was noted in 28% of cases, and venous ectasia in 5%. Borden dAVF types among the patients were I (72%), II (20%), and III (8%). Cognard dAVF types among the patients were I (44%), IIa (27%), IIb (5%), IIa+b (15%), III (4%), and IV (5%). The median SRS treatment volume was 7.6 cm3; the median margin and maximum doses were 18 and 36 Gy, respectively. Follow-up after SRS was available for 209 patients (median follow-up 31 months). Obliteration was noted in 75% of the patients (110/147) with follow-up vascular imaging; the median time to obliteration was 37 months. Multivariate analysis revealed that a cavernous sinus dAVF location was predictive of radiological obliteration (HR 1.86, 95% CI 1.08-3.18, p = 0.024). The absence of CVD was predictive of obliteration in subgroup analysis of non-cavernous sinus dAVF (HR 0.53, 95% CI 0.29-0.98, p = 0.04). Symptoms resolved in 86% of patients (160/185) with clinical follow-up. Twelve patients (5.4%) had complications related to angiography for SRS planning (n = 2, 0.9%), embolization (n = 3, 1.4%), post-SRS hemorrhage (n = 1, 0.5%), delayed sinus thrombosis (n = 1, 0.5%), radiation-induced tumors (n = 2, 0.9%), and chronic encapsulated expanding hematoma (n = 3, 1.4%). SRS alone or in conjunction with embolization provided obliteration and symptom relief for the majority of patients with dAVF, with a low rate of procedure-related morbidity. Patients are at risk for late radiation-related complications, which can require treatment many years after SRS.

Clinical, Biochemical, and Histological Manifestations and Long-Term Outcomes of Renal Sarcoidosis - A Single Center Study

Background Renal involvement in sarcoidosis is rare. We evaluated the pattern of renal involvement in sarcoidosis, its clinical course, renal histology, and response to treatment. Materials and Methods We retrospectively analyzed the data of all cases with sarcoidosis exhibiting renal involvement referred to our department between January 2010 and December 2021. Results A total of 33 patients (age: 50.6 ± 12.6 years, males: 57.6%) were analyzed. Common presenting symptoms were weight loss (81.8%; n = 27), fever (75.8%; n = 25), and vomiting (63.6%; n = 21). A total of 14 (42.4%) patients had granulomatous interstitial nephritis (GIN), 13 (39.4%) had isolated hypercalcemia, and six (18.2%) had GIN along with hypercalcemia. Renal biopsy was performed in 20 (60.6%) patients, and all showed GIN, with concomitant glomerular disease in four (12.1%) patients. Mean serum creatinine and 24-h urine protein at presentation were 4.3 ± 2.1 mg/dL and 2.5 ± 0.9 g/day, respectively. All patients received oral prednisolone 1 mg/kg/day with subsequent tapering, concomitantly with azathioprine. Mycophenolate mofetil was used in three (9.1%) patients who developed azathioprine-induced hepatoxicity. After a median follow-up of 24 months (8–120 months), mean serum creatinine and 24-h urine protein improved to 1.9 ± 1.5 mg/dL and 1.1 ± 0.6 g/day, respectively, (P = 0.005). On follow-up, two patients (6.1%) became dialysis-dependent, and three (9.1%) succumbed: one due to a cardiovascular event and two to sepsis and septic shock. Conclusion Granulomatous interstitial nephritis was the most common diagnosis in sarcoidosis patients with kidney failure. Early steroid treatment improves kidney function.

Robot-assisted laser interstitial thermal therapy for drug-resistant epilepsy in hypothalamic hamartoma.

Hypothalamic hamartomas are congenital lesions of the hypothalamus, with a range of symptoms defined by lesion location. Common presenting symptoms include gelastic seizures and precocious puberty. When hamartoma-related seizures become resistant to medications, laser interstitial thermal therapy (LITT) has been shown to be an effective treatment. The authors present a case of robot-assisted LITT for a patient with an 11-year history of epilepsy due to hypothalamic hamartoma. In addition, they demonstrate the use of a stereotactic biopsy needle implemented during the procedure for possible biopsy of deep cranial lesions. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2415.

Intravascular large B-cell lymphoma (IVLBCL): subtle presentation and challenging diagnosis; a case report

Intravascular large B-cell lymphoma (IVLBCL) is a rare, clinically aggressive lymphoma defined by the proliferation of atypical lymphoma cells in the lumen of all sized blood vessels, particularly capillaries. The reasons for this unusual neoplastic cell proliferation are still only partially understood. IVLBCL is considered stage IV lymphoma and manifests with a variety of nonspecific signs and symptoms. Patients with IVLBCL usually do not present with lymphadenopathy. The tumor cells invade the blood vessels of multiple organs such as the central nervous system, skin, lungs, kidneys, and bone marrow. Common presenting symptoms are based on the organ affected and include mental status changes and fever of unknown origin. Although immunochemotherapy has significantly improved the often-poor prognosis of this kind of lymphoma, a large percentage of patients’ relapse. We present a 63-year-old man who had been diagnosed with large B cell lymphoma in the bone marrow in March 2021 and was in remission state after completing six cycles of chemotherapy. There was no abnormal FDG uptake on a post-chemotherapy PET/CT scan. Patient presented to the emergency room (ER) two months later with fever and dyspnea. The entire workup was completed and showed pancytopenia and elevated ESR. While chest CT scan did not show lymphadenopathy or lesions, PET/CT scans revealed a widespread increase in FDG uptake in both the lungs and spleen. Lung biopsy revealed large, atypical cells within alveolar septae and vessels. Immunohistochemical stains demonstrated that these cells were positive for CD20 and PAX-5 and had high proliferation rate based on Ki67. IVLBCL has a low incidence rate with non-specific clinical presentation. The diagnosis can be easily missed in both clinical, radiological and the corresponding histopathological findings. Radiological finding and CT scan are not sensitive enough and may miss the lesion. Even though the PET/CT scan is more sensitive, the definitive diagnosis of IVLBCL relies mainly on histopathology and immunohistochemistry, at which point awareness of this entity by the pathologist is most necessary.

MDB-14. TREATMENT AND OUTCOMES OF MEDULLOBLASTOMA: FIRST REPORT FROM ARMENIA

Abstract BACKGROUND Medulloblastoma accounts for approximately 20% of all primary CNS tumors. Although advanced diagnostic tools and risk-adjusted treatment regimens produce a more than 70% five-year overall survival in HICs the data from LMICs is scarce. This study analyzed the outcome of children with medulloblastoma treated in Armenia. METHODS Demographic and treatment data was collected from medical records of pediatric and young adult patients (≤ 25 years) treated in four major centers in Armenia from 1995-2023. Event-free survival and overall survival were estimated using Kaplan-Meier method. RESULTS During the study period 41 patients with medulloblastoma were registered (20.7% of primary CNS tumors), male-to-female ratio 1.73:1. The median age at diagnosis was 8 years (range: 0.83-25 years). Most common presenting symptoms were nausea and vomiting (82.5%), headache (75%) and ataxia (50%). Metastatic status was evaluated (spinal MRI and CSF cytology) in 48.8% of patients (25% M+ disease). Risk assessment was available for 30 patients (12 standard-risk and 18 high-risk). All patients underwent surgery, gross-total or near-total resection was achieved in 53.7% of cases. Radiation therapy and chemotherapy given to 63.4% and 58.5% of cases, respectively. Of 8 infants included in this study 4 were treated with chemotherapy only, 3 died without further treatment. Median time from surgery to RT/chemotherapy was 6 weeks. Five-year EFS and OS were estimated 58.3% (95% CI 37.5-71%) and 62.5% (95% CI 43.75-77.1%), respectively. Patients with GTR/NTR had a higher OS than patients with STR (83.3% vs 33.3%, p=0.005). No statistically significant difference in EFS/OS was detected based on risk group, metastatic status, or completion of the protocol. CONCLUSIONS OS was lower than expected in this study. Accurate risk assessment and risk-stratified treatment were often lacking during the study period. Compliance to the standardized treatment protocols and multidisciplinary care are needed for improving outcomes of medulloblastoma.

OTHR-04. HEALTH SYSTEM DELAYS IN DIAGNOSIS AND TREATMENT OF CHILDREN WITH CENTRAL NERVOUS SYSTEM (CNS) TUMOURS IN SRI LANKA

Abstract BACKGROUND Children with central nervous system(CNS) tumours have to navigate multiple layers of care to reach the only centre providing oncology care (chemotherapy and radiotherapy) in Sri Lanka. This can lead to significant delays and affect outcomes. METHODS This is a retrospective study of patients less than 19 years registered at the National Cancer Institute Sri Lanka(NCISL) from 1st January 2022 to 31st December 2023. Data was extracted from clinic records and interviewing caregivers. RESULTS From a total of 828 new children with cancer 135 had CNS tunours and data was available for 130 for analysis. Commonest cancers seen were low grade gliomas and medulloblastoma. Fifty-one percent were males and the median age was 6 years (Range 1-18). Most common presenting symptoms were headache and vomiting. Median time from onset of symptoms to first medical contact was 4 days (InterQuartile Range(IQR) 1-9.5) and to first imaging it was 44 days (IQR 3-151) for all symptoms. In the presence of neurological symptoms, the time to imaging was 26 days (IQR 2-141). Ninety-six(74%) had upfront surgery at a median time 14 days from first imaging (IQR 7-34.5) with a median time of additional 25 days to reach an oncology centre (Range 7-94). Patients who did not have upfront surgery took 13.5 days (IQR 2-36.5) for the same. After arriving at the oncology centre, radiotherapy (80/130, 62%) was initiated in 24 days. When calculated from date of surgery radiotherapy initiation time was 61 days. (Range 5-88) CONCLUSION Although there seem to be no significant delay in presentation of children with CNS tumours to the health system, there were significant delays in imaging and initiating adjuvant radiotherapy. Further studies are warranted to determine the attributing factors and corrective steps to be taken to expedite referral of affected children.

A study of risk factors and clinico-pathological profile of patients with cervical cancer at BPKIHS: A descriptive cross-sectional study.

e17515 Background: Cervical cancer is the cancer with highest incidence and mortality among females in Nepal according to GLOBOCAN data 2020. The aims of this study was to evaluate the risk factors and clinico-pathological profile of patients with cervical cancer attending Department of Gynaecology, BPKIHS, Dharan, Nepal. Methods: It was a descriptive cross-sectional study conducted from April, 2019 to February, 2022 among seventy-nine patients with histological diagnosis of cervical cancer after ethical approval. Results: The mean age of these patients was 54.99±12.81 years. The commonest presenting symptom was postmenopausal bleeding (65.8%) and the commonest histological type was squamous cell carcinoma (87.3%). The commonly associated risk factors among them were illiteracy (88.6%), poor local hygiene (78.5%), postmenopausal status (72.2%) and poor socio-economic status (41.8%). The mean age at marriage and first pregnancy were 18.45 (SD=2.32) years and 19.47 (SD=2.51) years respectively. More than one-fourth (29.1%) of the patients had more than or equal to 5 children. Only three (3.8%) patients had undergone cervical cancer screening once in their lifetime.Most of them (n=66; 83.5%) had locally advanced disease at diagnosis. Altogether, sixty-seven (84.8%) patients were referred outside for radiation treatment. Among the surgically treated patients, twelve (63.2%) patients subsequently required dual treatment. Conclusions: Illiteracy, poor hygiene, low socio-economic status, patient’s delays, poor screening programmes, multiparity, early age at marriage and first child birth etc. are the factors requiring major focus to reduce the burden of cervical cancer in developing countries like Nepal.

An Audit of Laparoscopic Cholecystectomy.

Objective: Gallstones is a common problem, particularly among women .In modern medicine, uncomplicatedgall stones are usually treated with Laparoscopic Cholecystectomy “Key-hole Surgery” .It carries significantlylower morbidity and mortality as compared to open surgery . At Muhammad Medical College Hospital (MMCH)we have started the procedure in recent years. .Aims: To look into various demographic and clinic aspects of Laparoscopic Cholecystectomy done at MMCH.Methods: Retrospective audit of record of last consecutive 99 patients undergoing Laparoscopic Cholecystectomy at MMCH. Research Ethics Committee approval was obtained (No.250811/REC/003).Results: 33 Men and 66 women underwent this procedure. Average age was 45 year (range 16 to 75). Commonest presenting symptoms were Nausea/vomiting (n=36) and abdominal discomfort /pain (n=36). All patientshad pre-procedure ultrasound scan showing gall stones .At surgery, 99/99 were confirmed to have gallstones .Although 9 also had adhesions, 6 were acutely inflamed and 3 had empyema gall bladder. There were 2conversions Average duration of stay in hospital after procedure was 9 days (range 3 to 20). 2 patients hadwound infection and 3 atelectasis. No mortality was seen.Conclusions: Laparoscopic Cholecystectomy is a safe procedure for gall stones disease.Keywords: Laparoscopic cholecystectomy, conversion rate morbidity.