Lower Limb Edema Research Articles

PS-BPR03-5: A CASE OF LIDDLE SYNDROME-LIKE REFRACTORY HYPERTENSION WITH TREATMENT-RESISTANT HYPOKALEMIA COMPLICATED BY NEPHROTIC SYNDROME DUE TO DIABETIC NEPHROPATHY

A 62-year-old woman had been treated for diabetic nephrotic syndrome, hypokalemia, and edema with perindopril, furosemide, potassium L-aspartate, valsartan, and spironolactone since January, X. On May 15, X, fatigue and nausea appeared, and on the morning of May 20, these symptoms increased. On the morning of May 20, she visited the hospital. She was urgently admitted to the hospital because of prominent edema in both lower limbs, elevated blood pressure (164/83 mmHg), marked hypokinemia (K 2.4 mEq/L), and metabolic alkalosis (pH 7.612, HCO3- 31.3 mmol/L) in the arterial blood gas. Post-hospitalization examination revealed hyporeninemia and hypoaldosteronemia. Since administration of spironolactone in addition to previous medications failed to improve the hypokaremia and hypertension, triamterene 100 mg was added. The treatment was resulted in rapid hypotension, accompanied by improvement of hypokalemia and metabolic alkalosis. The dose of triamterene was later reduced to 50 mg, and excess blood pressure lowering was improve. Genetic testing did not identify any mutations in the beta or gamma subunits of the ENaC gene. Discussion: In this patient, no hypokalemia was observed in previous examinations. The hypokalemia in this patient was spironolactone-resistant, and the fact that triamterene, a distal tubular epithelial Na channel (ENaC) inhibitor, was effective in this patient; furthermore, no genetic abnormality in ENaC, suggests the possibility of an acquired ENaC abnormality similar to the Liddle syndrome.

May-Thurner Syndrome: a case of unilateral left lower limb deep vein thrombosis

The May–Thurner Syndrome (MTS) is a rare anatomical condition in which the compression of the left common iliac vein by the right common iliac artery causes an outflow obstruction, presenting frequently as chronic venous insufficiency or deep venous thrombosis (DVT). This variant is rarely considered when investigating DVT, especially in patients with other risk factors. MTS requires careful workup and management to avoid complications such as chronic venous insufficiency, post-thrombotic syndrome, and primary lymphedema. The authors present a 63-year-old woman admitted to the emergency department with a 24-hour history of left lower limb pain and edema. Initial assessment, with computed tomography of the lower left limb and pelvis, showed compression of the left common iliac vein with an extensive thrombus of the left common iliac and external iliac veins, as well as femoral and popliteal left veins, consistent with MTS. Therapeutic enoxaparin initially implemented, was then switched to oral anticoagulation. At 6 months reevaluation, venous duplex ultrasound showed only partial recanalization of the femoral vein. Investigation for May-Thurner Syndrome in patients with left lower limb venous thrombotic events, regardless of risk factors, should always be present since the establishment of an effective therapeutic plan and eventually, endovascular treatment can minimize the long-term sequelae of deep vein thrombosis.

PS-R03-10: CASE REPORT: CUSHING SYNDROME IN A YOUNG MALE

A 27-year-old male without any significant past medical history was advised to visit a hospital for elevated blood pressure, elevated liver enzymes, and dyslipidemia in a workplace health checkup. His body weight had increased by more than 10 kg in the last two years. He presented to our department and underwent laboratory work-up. He had bilateral lower limb pitting edema, hypokalemia, and elevation of low-density lipoprotein. No sign of dysthyroidism, renin-angiotensin-aldosterone system disorder, or increased catecholamine secretion was found. Diet and exercise therapy and calcium channel blocker did not improve his hypertension, and he suffered from lumber vertebral fracture, refractory hypokalemia, and lower leg cellulitis. He was admitted to our department for detailed examination of worsening lower limb edema. On admission, he had striae on his abdomen and legs as well as edema of both lower extremities. The endocrinological data showed high levels of adrenocorticotropic hormone (ACTH) and cortisol. Overnight 1 mg dexamethasone suppression test resulted in a non-suppression response, and his circadian rhythm of cortisol was absent. Urine cortisol level was high. These findings confirmed the diagnosis of ACTH-dependent Cushing syndrome. A contrasted magnetic resonance imaging (MRI) scan demonstrated enlargement of the pituitary gland more than 1 cm in length. Taking into account drug-resistant hypokalemia and vulnerability to infection, he was administered with metyrapone 500 mg per day until he underwent transsphenoidal hypophysectomy. The pathological findings were consistent with that of a pituitary adenoma. Postoperative MRI scan showed remnant lesions which stretch to the bilateral cavernous sinuses and the right middle cranial fossa. Although a decrease in urine cortisol was observed, the absence of a circadian rhythm of cortisol, hypertension, and hypokalemia persisted. He is now treated with somatostatin analog and craniotomy followed by gamma knife surgery is planned. Cushing syndrome should be suspected in cases of early-onset hypertension with symptoms including weight gain, hypokalemia, and bone fracture.

Warfarin-Induced Limb Contusion Section and Haematoma

Warfarin is a narrow therapeutic index drug with high potential to cause adverse effects. It is generally a preferred drug for the management of venous thrombosis. This case is an unusual presentation of left arm contusion and limb haematoma secondary to long-term warfarin use. A 32-year-old male patient was admitted with the complaints of left lower limb oedema and left upper arm oedema. He was on warfarin for dural sinus thrombosis for two years. The integrative analysis of patient clinical presentation, medication history, International Normalized Ratio (INR) level, Ultrasonography (USG) scan and Naranjo assessment showed the probable case of warfarin-induced left arm contusion and limb haematoma. The patient was successively managed with the administration of vitamin K, injection heparin, packed red blood cell and other supportive therapy after the withdrawal of the culprit drug. Thus, patients prescribed with warfarin should be looked at for this typical adverse event. Monitoring of anticoagulant therapy is vital for the positive clinical outcome and minimisation of adverse events. Clinical pharmacists have a key role to play in the patient safety and their inputs can fertilise the concept of pharmacist led anticoagulation clinic in India.

Cardioprotective effect of thiotriazoline in cancer patients

Aim. To evaluate the effectiveness of morpholinium-methyl-triazolyl-thioacetate (thiotriazoline) as a cardioprotector in patients with non-Hodgkin’s lymphomas who received chemotherapy with the inclusion of anthracyclines.Material and methods. Fifty patients with non-Hodgkin’s lymphomas were examined on the background of antitumor therapy. The patients were divided into 2 following groups: group 1 (n=27) — standard chemotherapy; group 2 (n=23) — thiotriazoline as a cardioprotector. The quality of life was assessed using the SF-36 questionnaire; the level of troponin I and the natriuretic peptide NT-proBNP was determined; an electrocardiography and echocardiography were performed.Results. In the course of the study, significant differences (p<0,05) were found in following parameters: the severity of dyspnea and lower limb edema, alanine aminotransferase, aspartate aminotransferase, creatine phosphokinase, troponin I level, NT-proBNP, corrected QT interval, end systolic volume, left ventricular ejection fraction, E/A ratio. The results obtained indicate the clinical and paraclinical advantage of thiotriazoline and reflect its cardioprotective effect. Conclusion. The use of thiotriazoline makes it possible to prevent and slow down the cardiovascular disease continuum, leading to the development of heart failure or decompensation that exists in this category of patients. Keywords: cardio-oncology, thiotriazoline, heart failure, anthracyclines, cardiotoxicity>˂0,05) were found in following parameters: the severity of dyspnea and lower limb edema, alanine aminotransferase, aspartate aminotransferase, creatine phosphokinase, troponin I level, NT-proBNP, corrected QT interval, end systolic volume, left ventricular ejection fraction, E/A ratio. The results obtained indicate the clinical and paraclinical advantage of thiotriazoline and reflect its cardioprotective effect.Conclusion. The use of thiotriazoline makes it possible to prevent and slow down the cardiovascular disease continuum, leading to the development of heart failure or decompensation that exists in this category of patients.

397 HEART FAILURE WITH REDUCE VENTRICULAR EJECTION FRACTION FOLLOWING THERAPY WITH RITUXIMAB IN A PATIENT AFFECTED BY MPO ANCA RELATED MICROSCOPIC POLYANGITIIS

Abstract Introduction Rituximab is a chemotherapeutic drug widely used for the treatment of oncologic and rheumatologic diseases. Its cardiotoxic profile has not yet been defined in detail; only a few isolated case reports delineate cardiovascular adverse reactions following its use. In the cases described in literature, the drug was used to treat neoplastic diseases, often in combination with other chemotherapeutic drugs. We present a clinical case of heart failure with reduced ventricular ejection fraction (HFrEF), developed following therapy with Rituximab and a single administration of Cyclophosphamide, in a patient affected by MPO-ANCA-related Microscopic Polyangiitis. Case Report 54-year-old man arrived at the emergency department for weight loss, fever, asthenia, and lower limbs oedema; laboratory findings where diagnostic for acute kidney injury (AKI). His past history was unremarkable. He was admitted to the nephrology department where he was diagnosed with MPO-ANCA-related microscopic polyangiitis. Echocardiography on admission showed normal left systolic ventricular function. He underwent diuretic therapy, intermittent hemodialysis, plasmapheresis and immunosuppressive therapy with steroids, Rituximab (two administration of 375 mg/m2 i.v. one week apart) and Cyclophosphamide (one administration of 300 mg i.v.). Following the achievement of good clinical and hemodynamic compensation, the patient was discharged. However, 5 days later, the patient came back to the hospital, prior to the follow-up that was scheduled for the continuation of immunosuppressive therapy, with symptoms of worsening dyspnea related to acute pulmonary edema. A transthoracic echo showed severe left ventricular systolic dysfunction for global hypokinesia. Cardiac MRI showed hypokinetic dilated cardiomyopathy with severely depressed systolic function (EF 30%) in the absence of lesions compatible with edema and myocardial fibrosis/necrosis. No coronary artery disease was detected with CT coronary angiogram. Given the absence of signs of ischemic cardiopathy or inflammatory related cardiomyopathy, we considered this new onset of HFrEF likely due to cardiotoxicity from chemotherapy drugs, which, in agreement with nephrology colleagues, were discontinued. The patient was started on heart failure medication with Bisoprolol 2,5 mg once daily and Ramipril 2,5 b.i.d., mineralocorticoid receptor antagonist and glifozines were not administered due to the renal injury. Given the HFrEF and numerous features of non-sustained ventricular tachycardia found on EKG monitoring during hospitalization, the patient was discharged with a wearable ICD. He was discharged after 3 weeks in stable clinical conditions with a follow-up appointment in a month. Conclusion Our clinical case provides further evidence regarding the cardiotoxic effect of Rituximab. In contrast with the other cases in literature, Rituximab was used for the treatment of rheumatologic and non-neoplastic pathology, without being combined with several other chemotherapeutics but only with a low-dose administration of Cyclophosphamide. In light of the above, it is worth mentioning that when chemotherapeutics are used, not only in oncology but also in rheumatology, even when their cardiotoxicity profile has not been defined in detail, as in the case of Rituximab, it is essential to use the utmost caution in assessing cardiac function before and after drug administration, so that early detection of cardiotoxicity will be possible.

221 NONBACTERIAL THROMBOTIC ENDOCARDITIS WITH ATYPICAL PRESENTATION AS OVERT CONGESTIVE HEART FAILURE

Abstract Introduction Non-Bacterial Thrombotic Endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or, rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography. Case presentation An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep vein thrombosis. On physical examination, he was apyretic, mildly hypotensive and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed “thrombotic” thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed in the diagnostic workup and prescribed palliative care. Discussion Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo-density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about treatment of NBTE and the only role of anticoagulation to prevent systemic embolism. Conclusions We report a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging played a crucial role for the final diagnosis.

871 AN ADVANCED BREATHING DISORDER IN HEART FAILURE: IS THERE AN OVERLAP THROUGH EXERCISE OSCILLATORY VENTILATION AND CHEYNE-STOKES RESPIRATION? A CASE REPORT

Abstract Case summary A 60-year-old man, normal-weighted, former smoker with a known non obstructive hypertrophic cardiomyopathy (HCM), severe mitral and tricuspid regurgitation and permanent atrial fibrillation was hospitalized for decompensated heart failure (recent worsening of exertional dyspnoea and appearance of lower limbs oedema). At the admission the ECG documented a permanent AF with normal average heart rate (66 rpm). Blood tests showed only a mildly elevation of BNP (497 pg/ml). Before the valvular repair surgery patient completed the diagnostic work-up with spirometry and cardiopulmonary exercise testing (CPET). The spirometry showed a mixed disorder predominantly obstructive (FEV1 1.8 L/min, 51% of predicted value), consistent with COPD. Also DLCO was moderately reduced. CPET documented a severe reduction in functional capacity (VO2 peak/Kg 9.2 ml/Kg/min, 32% of predicted value, Watt at peak 61), clear signs of cardiac and pulmonary vascular limitation (VO2 Work Slope 7.1, VE/VCO2 Slope 45). Interestingly, during the entire duration of the effort there were an exercise oscillatory ventilation (EOV). Instead, cardiopulmonary registration at rest showed an advanced oscillatory breathing disorder with regular long phases of apnea (average duration of 40 sec). Apnea phases were diurnal and were associated with desaturation at pulsossimetry (SpO2 93-92%). This rest breathing disorder consisted with the definition of Cheyne-Stokes respiration. Of note, the patient had no previous history of OSAS or central sleeping disorder. Discussion Cheyne-Stokes respiration (CSR) is historically considered as a central sleeping disorder, particularly common in patients with heart failure with reduced ejection fraction (HFrEF) with a wide prevalence range between 16% up to 50%. It is also well known its negative prognostic value as it highly impairs quality of life and increases cardiac mortality. Recently, in HFrEF patients emerged that CSR could be also diurnal and sometimes associated to EOV. The peculiarity of this clinical case lies firstly in the fact that we clearly documented a possible overlap through EOV and CSR, respectively seen as exerctional and rest advanced breathing disorders. Secondly, CSR was previously reported predominantly in case of LVEF < 40%, but this patient had a non obstructive HCM without systolic disfunction (LVEF was 63%). This suggest that CSR and EOV could have the same pathophysiology pathway, with a continuum through each other, regardless the model of HF (reduced vs preserved ejection fraction). Keywords: Cardiopulmonary Exercise Testing, Exercise Oscillatory Ventilation, Cheyne-Stokes Breathing, Heart Failure, Hypertrophic Cardiomyopathy.

Prediction Of Postoperative Improvement in Lower Limb Oedema After Endovenous Laser Ablation Using a Noninvasive Venous Pressure Measurement Device

Prediction Of Postoperative Improvement in Lower Limb Oedema After Endovenous Laser Ablation Using a Noninvasive Venous Pressure Measurement Device

Huge Aortic Aneurysm? Massive Fistula!

A 73 year old man presented to the emergency room with lumbar pain, dyspnoea, and oliguria. An abdominal tender pulsatile mass with a thrill and bilateral lower limb oedema were noted. Abdominal X ray revealed a giant calcified spherical mass (A; arrows). Computed tomography angiography showed a 14 cm infrarenal abdominal aortic aneurysm associated with inferior vena cava contrast filling during the arterial phase (B; arrow). Blood work revealed a serum creatinine of 5.2 mg/dL (basal 0.6 mg/dL) and N terminal pro B type natriuretic peptide of 25 000 pg/dL.

Coronary Embolism After Infection with Covid-19 in Non-Diabetic Non-Hypertensive Patient. A Case Report

A 72-year-old female patient presented to the emergency department with one week history of dry cough, sore throat, and dyspnea grade 3, and 9 hours history of retrosternal chest pain. The patient had normal pulse, temperature and blood pressure. She had bilateral decreased air entry, S1 and S2 heard normally and had no lower limb edema. The patient had free past medical and surgical history. Laboratory investigations and ECG were done. Laboratory investigations showed that the patient was infected with SARS-CoV-2, and also showed positive cardiac enzymes, low hemoglobin (10.4 g/dl), high WBCs (14.9) 10^3/ul and high platelets (614) 10^3/ul. ECG showed normal sinus rhythm (NSR) at 75 BPM and ST segment elevation in II, III and aVF leads. The patient received one vial intravenous streptokinase in 50 cc glucose 5% and was transferred to the ICU for further management. Discussion: We report a patient who developed ST elevation myocardial infarction (STEMI) as a result of intra-coronary embolism following infection with SARS-CoV-2. Cardiac involvement was reported in COVID-19 patients. Some studies reported coronary embolism after COVID-19 infection. This may be attributed to thrombus formation, hyper-coagulation, plaque rupture, inflammation or immune complications. Chest pain, dyspnea, ST segment elevation and positive cardiac enzymes are the most clinical presentations in myocardial infarction patients after COVID-19 infection. This requires urgent management with thrombolytic agents and may need further surgical intervention. Conclusion: Myocardial infarction as a result of intra- coronary embolism may follow infection with COVID-19. Many mechanisms were reported explaining this possible association. More research is required to know how COVID-19 can cause coronary embolism.

Multiple painful vesicles in a patient with erythroderma

A 50-year-old male with a history of alcoholism was evaluated for a 4-week history of painful vesicles and hemorrhagic erosions on the face without any previous treatment (Figs 1 and 2). He had a 15-year history of eczematous plaques on flexural surfaces with periods of remission and relapse. Over the last year, the patient developed widespread erythema with diffuse scaling and lower-limb edema. Laboratory tests revealed mild normochromic normocytic anemia (Hb 11.8 g/dL, MCV 94.3 fL, MCH 33.5 pg) with eosinophilia (13%), and abnormal liver function tests (ALT 15.1 U/L, AST 67 U/L, AST/ALT ratio 4.4).

The role of tolvaptan in pulmonary hypertension: A retrospective study.

Pulmonary hypertension (PH) is a severe form of pulmonary vascular disease that can lead to right heart failure (RHF). Nearly 2-thirds of patients with PH die within 5 years. Studies suggest that a new diuretic medication, called tolvaptan (TLV), can be used to treat PH. However, there is still insufficient evidence to confirm its effectiveness. Therefore, we investigated the role of TLV in patients with PH. This retrospective study included 73 patients with PH hospitalized in Shanghai Pulmonary Hospital between November 2019 and March 2022. All patients received 7.5 to 15.0 mg of TLV for 3 to 21 days starting at admission, in addition to targeted drugs and traditional diuretic therapy. The outcomes included the blood pressure, urine and water intake volumes, electrolyte concentrations, and renal, liver, and cardiac function indexes before and after TLV treatment. In addition, we assessed the clinical symptoms and adverse reactions during the treatment. After TLV treatment, the water intake and urine volumes significantly increased, and body weight, diastolic blood pressure (DBP) and mean arterial pressure significantly decreased. Total bilirubin, direct bilirubin, N-terminal pro-brain natriuretic peptide, and serum uric acid (UA) levels after TLV treatment were significantly lower than before treatment. After TLV treatment, dyspnea significantly improved in 71 of 73 patients, and lower limb edema disappeared in 42 of 53 patients. No obvious adverse reactions occurred during the TLV treatment period. These results suggest that adding TLV to targeted drug and traditional diuretic therapies is effective for patients with PH. However, more data are required to support these findings.

Woman With Leg Edema

A 71-year-old woman with chronic kidney disease presented with bilateral lower limb edema for 1 week. Physical examination revealed normal blood pressure and overt leg pitting edema. The chest radiograph revealed mild perihilar infiltrates, and blood chemistry tests showed anemia and severe azotemia. The point-of-care ultrasonography revealed an enlarged left renal vein between the aorta and superior mesenteric artery in both transverse and sagittal views (Figure 1A, asterisk and arrows, and Video E1, available at http://www.annemergmed.com).

Abstract 13819: Case Report of a Mitral Stenosis in a Young Growing Teenager After Rheumatic Mitral Regurgitation Valve Repair

Background: Mitral stenosis (MS) is a well- defined slowly progressive complication after mitral valve repair for non-rheumatic mitral regurgitation (MR) in adults. The pubertal growth spurt has potential hemodynamic implications for a mitral valve prosthesis matched prior to surgery for a projected indexed effective orifice area (EOA) using the lower pre-surgical body surface area (BSA) that preceded the growth spurt. The peak height velocity usually occurs at Tanner stage 3 in females and 4 in males. To our knowledge, there are no reports highlighting a rapid increase in Trans-Mitral pressure gradient (TMPG) and decline in mitral valve area (MVA) after rheumatic MR valve repair in an early pubescent child. Case presentation: A 14-year-old female presented with orthopnea, abdominal distension and bilateral lower limb edema. She was cachectic with a BMI (Body Mass Index) in the first percentile, a high-pitched holosystolic murmur most prominent at the cardiac apex, bilateral basal crackles, tender hepatomegaly, pitting pedal edema and jugular venous distension. Her Tanner’s stage was 2. Anti-streptolysin O (ASO) titer was elevated. The transthoracic echocardiography (TTE) revealed loss of the mitral valve central coaptation with leaflet restriction and MR. There was an annular dilatation of the Tricuspid valve and Tricuspid regurgitation (TR). She had AHA/ACC stage D mitral and tricuspid regurgitation. Tricuspid annuloplasty and mitral valve repair for rheumatic MR were respectively performed utilizing Carpentier Edward numbers 30 and 34, appropriate for her pre-surgical BSA. Following the surgery, the murmur of MR resolved and her MVA was 4cm 2 . In the first year after surgery, she attained Tanner’s stage 3, a peak growth velocity of 8.4 cm during that year and her BMI rapidly increased to the 10th percentile. However, towards the end of the year she developed progressive increase in TMPG and a decline in the mitral valve area to 1.2 cm 2 . Conclusion: Growth spurts during puberty can potentially affect MR repair as the Mitral valve prosthesis based on a preoperative BSA is outgrown. There is a need for research for planning, prognostication and development of an optimal, individualized and adaptable approach to MR intervention in early pubescence.

Risk factors associated with venous thromboembolism in tuberculosis: A case control study.

Tuberculosis (TB) patients who develop venous thromboembolism (VTE) have poor clinical outcomes. This study aimed to explore the risk factors and the prognosis of TB patients with VTE. A total of 11 267 with TB patients from the Zhejiang University-affiliated Chest Hospital, China, were enrolled between January 2016 and January 2020. A total of 107 TB patients with VTE were selected as the VTE group. Patients in the control group were randomly screened in a 1:1 ratio between the VTE and control groups. Univariate and multivariate logistic regression analysis was used to evaluate the factors associated with VTE in TB patients. Of the 214 patients, 145 (60.17%) were male, 69 (32.2%) were female, with an average age of 62.21 ± 19.35. The incidence of VTE in TB patients was 0.95%. Using a univariate analysis, it was found that age, fever, dyspnea, lower limb edema, respiratory failure, malignant tumor, prothrombin time, activated partial thromboplastin time, D-dimer, and hemoglobin levels were different between the two groups (P < 0.05). Multivariate logistic regression analysis showed that higher D-dimer value, higher incidence of lower limb edema, and TB were risk factors for VTE; OR (95%CI) = 8.840 (2.383-32.794); OR (95%CI) = 4.957 (1.219-20.161); OR (95%CI) = 16.216 (4.779-55.025). However, the use of Rifamycin was found to be a protective factor against VTE [OR (95%CI) = 0.170(0.073-0.395)]. Receiver operating characteristic curve (ROC) curve of D-dimer (area under curve [AUC] = 0.831 ± 0.028 [95%CI: 0.776-0.886, P < 0.05]) and the cut-off value of 1855 μg/L was obtained according to the Youden index, with a sensitivity and a specificity rate of 82.2% and 74.3%, respectively. The risks of VTE seem higher in TB patients with fever, dyspnea, lower limb edema, and D-dimer levels of more than 1855 μg/L; therefore, it should be actively screened, and prophylactic anticoagulation given if necessary. Effective directly observed treatment plus short-course chemotherapy (DOTS) protocol anti-TB therapy helps reduce the probability of VTE in TB patients.

A case series of constrictive pericarditis and suggested echocardiographic diagnostic criteria.

The diagnosis of constrictive pericarditis (CP) is challenging as there are currently no standard echocardiographic diagnostic criteria. In this retrospective case series, we analyzed and summarized the features of 25 patients with CP and proposed echocardiographic diagnostic criteria. It is hoped that the suggested criteria help professionals make decisions in their daily practice so that patients receive timely diagnosis and effective treatment. Twenty-five patients with CP were selected for this retrospective study. The clinical and echocardiographic imaging data were analyzed and summarized, and echocardiographic diagnostic criteria for CP were proposed. The main clinical manifestations were fatigue, breathlessness, exertional dyspnea (88%), lower-limb edema (84%), hepatomegaly, and jugular vein filling (84%). Echocardiographic features comprised pericardial thickening (88%) and calcification (60%), pulmonary hypertension (52%), inferior vena cava dilation (80%), left and/or right atrial enlargement (100%), diastolic flattening of the left ventricular (LV) posterior wall (72%), septal shudder and bounce (64%), restrictive LV and right ventricular diastolic filling pattern (100%), early filling changes of mitral and tricuspid flow (80% and 60%, respectively), and mitral annulus reversus (73%). Echocardiography is a simple and valuable examination for CP. The echocardiographic diagnostic criteria are valid and worth promoting.

PSAT018 Management of Pheochromocytoma in the Setting of a Patient with Multiple Vasculopathies

Abstract A 66-year-old male with history of Type 2 diabetes and adrenal incidentaloma presented to the hospital with significant left lower limb edema and was found to have severe peripheral vascular disease. CT surgery was consulted and performed an angiogram as well as an angioplasty; however, the patient had severe stenosis and stenting was not possible. Femoral popliteal bypass was planned. Due to the patient's acute kidney injury from renovacular hypertension, preoperative evaluation included a MRI abdomen w/wo contrast which showed a 1.4 cm right adrenal nodule with early contrast enhancement which appeared fairly avid and uniform. This nodule had been previously noted by CT scan three years prior. Previous outpatient labs showed elevated metanephrines of 543 pg/mL, which determined the adrenal nodule to be consistent with a pheochromocytoma. Subsequently, femoral popliteal bypass was postponed and the patient was started on an alpha blocker, doxazosin. Urology was consulted and right laproscopic adrenalectomy was planned. Preoperatively, patient developed chest pain due to ventricular tachycardia and NSTEMI was diagnosed by EKG. Patient then underwent a LHC which revealed severe left main 3 vessel coronary artery disease, postponing planned adrenalectomy. CABG was performed with pericardiectomy. After initial recovery, patient was discharged to in-patient rehabilitation, indefinitely delaying definitive pheochromocytoma therapy. Reference Jacques W. M. Lenders, Quan-Yang Duh, Graeme Eisenhofer, Anne-Paule Gimenez-Roqueplo, Stefan K. G. Grebe, Mohammad Hassan Murad, Mitsuhide Naruse, Karel Pacak, William F. Young, Jr, Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology &amp; Metabolism, Volume 99, Issue 6, 1 June 2014, Pages 1915–1942, https://doi.org/10.1210/jc.2014-1498 Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Bacterial infection possibly causing autoimmunity: Tropheryma whipplei and membranous nephropathy

A 45-year-old man presented to our department with a 5-month history of foamy urine and swollen legs. Previously, the patient had epilepsy, seronegative rheumatoid arthritis, and thyroid carcinoma. He was being prescribed the following medications: carbamazepine, levothyroxine, ezetimibe combined with simvastatin, calcitriol, ramipril, furosemide, and mesoglycan. On examination, the patient had moderate oedema of both lower limbs with no other atypical findings; his blood pressure was 140/85 mm Hg and heart rate was 76 beats per min.

Surgery, Limb Edema and Health-related Quality of Life: A Prospective Follow-up Study on Patients With Cutaneous Malignant Melanoma.

The latest developments in oncological therapies for malignant melanoma, and the discovery that complete lymph node dissection offers no survival benefit, are changing the landscape of melanoma surgery. There is a need for more information on health-related quality of life (HRQoL) consequences of melanoma surgery. This longitudinal cohort study was carried out from 2004 to 2009 in the Helsinki and Uusimaa Hospital District and patients were followed-up at 6, 12 and 24 months. The patients were asked to fill in the generic 15D questionnaire and the cancer-specific European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30). In addition, they were asked selected questions from the EORTC Item Library regarding upper and lower limb edema. A total of 169 (64.5%) patients with local or locally advanced melanoma referred for surgical treatment responded, of whom 161 were included in the final analysis. For the whole patient group, distress, depression and emotional function improved over time. Worse HRQoL in some of the dimensions were associated with female sex, skin transplant versus direct wound closure and complications 30 days or more after surgery, but none was associated with worse overall HRQoL. Postoperative complications, type of wound closure or lymph node surgery had no effect on overall HRQoL. Patient-reported limb edema was associated with worse overall HRQoL at baseline and during follow-up by both instruments. Patients reporting limb edema reported worse mobility and more pain throughout the study. Patient-reported limb edema, regardless of the cause, seems to be an important predictor of worse HRQoL among patients with melanoma.