Fatal Complication Research Articles

Hemorrhagic intramedullary spinal cord metastasis from renal cell carcinoma: a rare case 15 years after cured renal cell carcinoma. Illustrative case.

Renal cell carcinoma (RCC), the most common kidney cancer, often metastasizes to bones, lungs, liver, and the central nervous system. Intramedullary spinal metastasis from RCC is rare but can cause significant neurological deficits, necessitating prompt diagnosis and treatment through surgical intervention, radiotherapy, and immunotherapy. An 86-year-old man presented with progressive right lower-limb weakness and reduced sensation over 3 weeks. His medical history included a right nephrectomy for RCC 15 years earlier and L4-S1 spondylosis. Imaging identified a bleeding lesion in the conus medullaris at T11-12 and an incidental left kidney mass. Urgent surgical exploration led to a T12 laminectomy and en bloc removal of the lesion, which was confirmed as RCC metastasis. Postoperatively, the patient received focused radiotherapy and immunotherapy, showing significant motor and sensory improvement before dying 3 months later. This case underscores the importance of comprehensive diagnostic imaging for the accurate identification and characterization of spinal lesions. An interdisciplinary approach involving neurosurgeons, oncologists, radiologists, and pathologists is crucial for optimal treatment planning. Urgent surgical intervention can effectively address acute neurological deficits caused by intramedullary lesions. Additionally, adhering to postoperative care instructions, such as deep venous thrombosis prophylaxis, is vital to prevent fatal complications. https://thejns.org/doi/10.3171/CASE24349.

Extracranial-intracranial bypass using a cephalic vein graft for iatrogenic internal carotid artery injury during functional endoscopic sinus surgery: illustrative case.

Injury to the internal carotid artery (ICA) during functional endoscopic sinus surgery is a rare but potentially fatal complication. Although treatment algorithms have been developed, guidelines for effectively managing iatrogenic ICA injury have not been established. A case of ICA perforation during functional endoscopic sinus surgery treated with cerebral bypass utilizing a cephalic vein graft is presented. A woman in her late 50s presented with a left cavernous ICA injury that had occurred during endoscopic nasal polypectomy at an outside hospital. Hemostasis was achieved with intranasal Foley catheter placement. Left common carotid artery angiography revealed a high-flow carotid-cavernous fistula. Cerebral revascularization was chosen as the optimal procedure. The initial intent was to use a radial artery graft, but the radial artery was found to be occluded intraoperatively. Postoperatively, the patient experienced decreased vision and left eye movement but was otherwise neurologically intact. Postoperative angiography showed complete resolution of the fistula. In cases involving ICA injury and carotid-cavernous fistula formation, microsurgical trapping with high-flow bypass is a favorable treatment option. The cephalic vein is a viable graft option when unexpected challenges arise with a radial artery graft. https://thejns.org/doi/10.3171/CASE24222.

Iatrogenic needle penetrating injury of cervical spinal cord: a case of fatal therapeutic complication.

A 52-year-old woman with of neck pain underwent percutaneous neck injection of local anesthetic and a corticosteroid without image guidance. She collapsed asystolic during the procedure was resuscitated and then died after 2 weeks in the intensive care unit with hypoxic encephalopathy. Complete postmortem examination included additional posterior neck dissection and cervical spinal cord removal with intact dura mater. The entire cervical spinal cord with the dura and leptomeninges was embedded in an oriented sequence of several paraffin blocks. Serial sections of each selected blocks were then studied to locate a putative puncture site. Serial sections from the third and fourth cervical levels (C3-C4) were stained with luxol fast blue-hematoxylin-eosin, iron stain, trichrome stain, and immunostained for b-amyloid precursor protein, and CD68. Histological examination revealed a linear needle track with a subacute healing reaction. The path included the dorsal spinal dura, arachnoid, and the left dorsal column. Clinicopathological correlation and the cause of death are discussed. Careful planning, dissection, sampling, and oriented serial sectioning with immunostaining were key points to document the injuries and understand this case.

ECPR-the evolving role in cardiac arrest.

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is ahighly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

A case report of fatal Rickettsia japonica bloodstream infection in Zhejiang, China.

Japanese spotted fever (JSF) is an emerging acute febrile natural infectious disease caused by the neglected zoonotic pathogen Rickettsia japonica. Here we reported a 64-year-old female patient who initially presented to the local hospital with an intermittent fever of unknown origin (FUO). A systemic, evident edema and eschar on the skin of the patient's upper limb was observed. The patient was diagnosed with critical Rickettsia japonica bloodstream infection by Q-mNGS and treated with doxycycline, as well as symptomatic treatments. Unfortunately, the patient passed away as a result of complications of septic shock and multiple organ and acute respiratory failure. Delayed treatment resulting from the nonspecific clinical symptoms in the early stages of infection can lead to fatal complications. Q-mNGS is an emerging pathogen detection method with the advantages of comprehensive detection, high accuracy and sensitivity and should be promoted and applied by clinicians.

Covid-19-related pulmonary artery pseudoaneurysm managed with endovascular intervention

BackgroundPulmonary pseudoaneurysm (PAP) is a fatal complication of severe acute respiratory syndrome caused by coronavirus 2 infections in the lungs. Other causative agent such as fungal and tubercular also responsible for this entity. Early detection and treatment can save a patient’s life.Case presentationHere we describe a case of a left pulmonary artery pseudo aneurysm in a 54-year-old patient with COVID-19 pneumonia who presented with massive hemoptysis and which was treated with endovascular embolization.ConclusionIt is caused by vasculopathy due to immunosuppression /immune dysregulation in COVID-19. Minimally invasive endovascular embolization of pseudoaneurysm carries less mortality and morbidity.

Assessment of IV albumin and ringer lactate on the acute oral toxicity of acetylsalicylic acid in albino rats

BackgroundDespite the frequent inclusion of fluid therapy in the treatment of many conditions, there are limited studies available to provide an evidence-based specific recommendation for fluid therapy in acute drug toxicity. Salicylate toxicity is considered one of the common clinical problems. It is commonly associated with fatal complications and even can lead to death. The study was designed to investigate the effects of various IV fluid types as isotonic saline (NaCl 0.9%), Ringer lactate (RL), and albumin and their impact on acetyl salicylic acid (ASA) toxicity outcome in a rat model of acute salicylate toxicity.Sixty male Albino rats were divided into 10 groups of 6 rats each. The first four groups were the control, saline, RL, and albumin groups. The fifth group received two doses of ASA solution orally, and the next five groups were treated with IV fluids as follows: saline-ASA, RL-ASA, albumin-ASA, RL + albumin-ASA, and saline + albumin-ASA. Upon completion of the study, spirometry, arterial blood gas analysis (ABG), and serum liver and kidney function tests were done on all groups. Furthermore, quantitative real-time polymerase chain reaction (PCR) was used to assess interleukin-6 (IL6), nuclear factor kappa beta (NF-kβ), and beta-actin mRNA gene expression of histopathology and immunohistochemistry assessments were also performed on liver and kidney tissues.ResultsThe results revealed the ASA group showed marked deterioration across all the investigated parameters. The groups that received saline and RL showed improvements in the following: respiratory rates, ABG, liver and kidney function, and histopathological findings.The RL + albumin group did not show any improvements. The albumin group and the saline + albumin group showed variable responses, ranging from mild improvement to no improvement.ConclusionsThe saline and RL groups showed positive results; however, the RL + albumin group showed the worst outcomes. The inclusion of albumin did not appear to provide any extra benefits and produced varying results.

Sutureless FOCUS harmonic scalpel versus clamp-and-tie techniques for thyroidectomy: A meta-analysis of 43 randomized controlled trials

Background: One of the most important surgical steps during thyroidectomy is the safe ligation of vessels. In fact, it is crucial to avoid postoperative bleeding and nerves’ injury. The “clamp and tie” technique was first introduced in the 19th century. Since then, a lot of other techniques have been adopted to facilitate the safe ligation and sectioning of thyroidal vessels; however, one of the most relevant advances is the introduction of energy-based devices (EBDs), which occurred three decades ago. Purpose: The aim of this systematic review and meta-analysis is to evaluate the safety and effectiveness of sutureless FOCUS harmonic scalpel (second generation EBDs) versus conventional clamps-and-tie technique) in total thyroidectomy. Results: This systematic review and meta-analysis represent the largest comparison in literature between the thyroidectomy procedure with the second-generation Advanced Harmonic Scalpel Ultrasonic Focus (UAS FOCUS) versus the conventional Clamp-and-Tie (CT) technique: as a matter of fact, it includes 43 randomized controlled trials (RCTs) and a total of 10.361 patients. The incidence of transient recurrent laryngeal nerve was statistically lower in patients undergoing UAS (3.99%) rather than CT (5.23%) (RR 0.79, 95% CI 0.63 to 0.99). The incidence of transient hypocalcemia was 11.3% in patients who underwent thyroidectomy with UAS FOCUS and 15.4% in those who underwent thyroidectomy with CT. Conclusion: Sutureless EBD is associated with a lower risk of damage to the laryngeal nerves and parathyroid glands. The rate of hypocalcemia and nerve paresis is indeed lower due to less thermic damage. Sutureless EBD can also diminish the rate of postoperative bleeding and cervical hematoma, a rare but potentially fatal complication.

Type 3c diabetes mellitus: what are we dealing with? Review

The authors presented updated data on the term «type 3 diabetes mellitus», its modern classification, pathophysiological mechanisms of development and features of treatment, its definitions, epidemiology and modern classification based on the recommendations of the American Diabetes Association. Definitions and epidemiological features of acute pancreatitis and its most frequent complications, including 3c type diabetes have been described. Statistical data were presented on the risk of developing complications of acute pancreatitis in the form of carbohydrate metabolism disorders. Historical prerequisites of fatal complications of acute pancreatitis in the form of hyperglycemic states were also described. The pathophysiological mechanisms of the development of type 3c diabetes, namely local and systemic inflammation, loss of islet tissue of the pancreas, dysregulation of the insulin­­incretin axis, autoimmune destruction of β­cells of the pancreas, etc. were highlighted in detail. The role of genetic factors in the development of diabetes against the background of acute pancreatitis is described. Currently there are no standardized unified criteria of type 3c diabetes, thus the main and additional diagnostic criteria according to the different authors have been analyzed in detail. The differential characteristics and features of the diagnosis of diabetes mellitus by type and peculiarities of the diagnosis of type 1, 2 and 3c diabetes mellitus have been presented. The discussion on the glycemic target goals for patients with type 3c diabetes and the need for screening and prevention of carbohydrate metabolism disorders in patients with acute pancreatitis has been outlined. The authors provided current recommendations for the treatment of type 3c diabetes and discussed the possibilities of the use of insulin in the basis/bolus mode to achieve compensation of carbohydrate metabolism. The necessity to compensate pancreas exocrine insufficiency to improve the assimilation of fats and fat‑soluble vitamins has been emphasized.

Determining the Association Between MSP1/2 Variant and Multiplicity of Infection on Incidence of Severe Malaria in Sudanese Children in Gezira State, Sudan

The Almanagil province located in Gezira scheme, Gezira state, Sudan, represents a suitable environment for the breeding of malaria-carrying mosquitoes. An estimated 5.9% of Sudanese people suffer from malaria, with 87.6% of cases caused by Plasmodium falciparum and 12.4% by Plasmodium vivax. Clinical manifestation of malaria cases range from mild uncomplicated to severe and fatal complications and the genetic variants and multiplicity of falciparum infection can worsen the manifestations of malaria. The objective of this work is to determine the degree of genetic variation in P. falciparum infection in a high-transmission region of central Sudan by analyzing merozoite surface protein-1 (msp1) and merozoite surface protein-2 (msp2) variations. During the rainy season of 2022, Eighty-nine children with confirmed severe falciparum malaria whom admitted to Almanagil Pediatric Hospital were included in this study. Dry blood spots were used to extract the DNA and amplification of three msp1 and two of msp2 allelic subfamilies, namely K1, RO33 and MAD20 and FC27 and IC/3D7, respectively. The data was analyzed by using SPSS computer program (v 23.0). The three genetic subfamilies of msp1 (K1, RO33 and MAD20) and the two alleles of msp2 (FC27 and IC/3D7) were identified. Msp1 variants represent K1 (64/89, 71.9%), RO33 (56/89, 62.9%) and MAD20 (72/89, 80.9%), while msp2 diversity represents ICI/3D7 (52/89, 58.4%), FC27 (62/89, 69.6%) and ICI/3D7/FC27(33/89, 37.1%). The MAD20 and FC27 showed high genetic diversity among both genes respectively. RO33 allele shows a strong association with severity of falciparum malaria (OR 2.572, P 0.045 ), while the K1 was the lowest risk factor for malaria severity. The allele subfamily K1 and MAD20 of msp1 were associated with hypoglycemia (OR 4.21 and 2.91) respectively. Our study revealed high genetic polymorphisms of msp1 and msp2. Among Central Sudanese children with high MOI of P. falciparum isolates, there was a significant frequency of msp1, a strong association between the K1 allele and hypoglycemia, and a substantial association between the RO33 and MAD20 alleles with the severity of the infection. These findings could help develop malaria control strategies.

7378 Glargine Induced Neuroglycopenia in Patients with End-Stage Renal Disease: Importance of Insulin Regimen Optimization in Haemodialysis Patients

Abstract Disclosure: M. Shrivastava: None. L. Kaur: None. B. Armendariz: None. R. Kaur: None. A. Shetty: None. In patients with end stage renal disease (ESRD), hypoglycemia accounts for up to 3.6% of all the admissions with mortality rates of up to 30%. A combination of impaired insulin clearance, changes in glucose metabolism and dialysis process makes the patients with end stage renal disease vulnerable to neuroglycopenia.Case description:53 year old female with past medical history of insulin dependent type 2 diabetes mellitus, ESRD secondary to diabetes, on hemodialysis(HD) thrice weekly since two years, presented to the emergency with altered mental status, respiratory distress, tachycardia. Lab work revealed blood glucose(BG) of 23 mg/dl, HbA1c of 8.4%, eGFR of 6, and arterial blood gas showed hypercapnic respiratory acidosis. Patient received dextrose, with no improvement of symptoms. Eventually she developed acute hypercapnic respiratory failure requiring endotracheal intubation with mechanical ventilation, and was transferred to the ICU. As per family, a night prior to presentation, last recorded BG after dinner was 253 mg/dl, she took her night time glargine, which was recently increased by her primary care for poorly controlled HbA1c levels. Brain MRI and long term EEG monitoring findings were consistent with underlying extensive brain injury secondary to prolonged hypoglycemia. Unfortunately, the patient's condition did not improve despite HD and BG correction, eventually she underwent compassionate extubation. Case Discussion:The insulin requirements in ESRD patients are reduced by approximately 50%, regardless of residual insulin secretion. Malnutrition and acidosis reduce hepatic glycogen stores and availability of gluconeogenic precursor, expected compensatory renal gluconeogenesis is compromised by decreased renal function causing hypoglycemia, which is further worsened by inappropriately high plasma insulin levels caused by reduced renal insulin breakdown. Diabetes mellitus patients with ESRD are frequently managed with basal-bolus insulin regimen, and HD up to thrice weekly, leaving them without HD for up to 3 days especially over the weekend. This can result in accumulation of insulin metabolites causing delayed insulin clearance as seen in our patient. In such cases even long acting insulin, such as glargine, can have compounding effects, which could possibly cause fatal complications such as neuroglycopenia. In such patients continuous glucose monitor use with tapering dose glargine regimen may help eliminate this compounding effect. Conclusion: Neuroglycopenia is a rare manifestation of diabetes mellitus with ESRD. Compromised renal gluconeogenesis and impaired insulin clearance can cause inappropriately high plasma levels of insulin. In such patients continuous glucose monitoring along with tapering dose of long acting insulin should be utilized for proper glycemic control to limit compounded effect of insulin metabolite accumulation. Presentation: 6/3/2024

7668 Rhabdomyolysis Associated with Severe Hypothyroidism

Abstract Disclosure: H. Soe: None. P. Mikkilineni: None. Background: Over 70% of the patients with newly diagnosed hypothyroidism can present with muscle complaints such as weakness, fatigability, cramps, myalgia. However, rhabdomyolysis, which is the rapid breakdown of skeletal muscle cells, is the rare presentation. Clinical Case: A 70-year old male patient with history of rheumatoid arthritis, hyperlipidemia, prior CVA (left hemispheric subcortical stroke) 6 months ago without residual deficit presented to the hospital with poor oral intake and generalized muscle weakness for 3 weeks. He was unable to get out of bed without assistance and also needed adult diapers. Found to have new-onset severe hypothyroidism with TSH 228 uIU/ml (Ref: 0.350-4.940) and FT4 <0.40 ng/dL (Ref: 0.70-1.50), positive TPO antibody 197 IU/ml (Ref: 0-34). No prior thyroid labs were available and no known history of thyroid disorder was recorded. He has never been on Amiodarone or Lithium before. On physical exam, he was alert and oriented. There was no goiter or palpable thyroid nodule. There was no focal neurological deficit and no peripheral edema. There were no other signs and symptoms pertinent to hypothyroidism except mild bradycardia (HR 56-60) and borderline low blood pressure. AM cortisol was 10.1 ug/dL (Ref: 3.7-19.4). EKG showed low-voltage sinus bradycardia. Echocardiogram was normal. Urinalysis was positive for large blood but only 3 RBCs were present which raised the suspicion of rhabdomyolysis. Creatinine kinase (CK) was 15,584 IU/L (Ref: 30-200). Other laboratory studies were significant for acute renal failure with mild hyperkalemia and mild hypocalcemia, also transaminitis; BUN 130 mg/dl (Ref: 8-26), Creatinine 9.51 mg/dl (Ref: 0.72-1.25), eGFR 5 ml/min/1.73 m2 (Ref: >59), AST 435 IU/L (Ref: 5-34), ALT 269 IU/L (Ref: <55), ALP 171 IU/L (Ref: 40-150). On medication review, he was started on Atorvastatin 80 mg daily during prior admission for CVA 6 months ago. He received IV fluids, s/p 1 dose of Hydrocortisone 100 mg IV, Levothyroxine IV 200 mcg, followed by Levothyroxine IV 50 mcg daily x 3 days and switched to Levothyroxine PO 100 mcg daily (weight-based dose). Atorvastatin was on hold. He became anuric during the hospital course and received 2-3 sessions of hemodialysis. 3-4 days later, CK was trending down to 3000 IU/L, FT4 improved to 0.54 ng/dl and there was also significant improvement in kidney and liver functions. The patient was diagnosed with acute renal failure secondary to rhabdomyolysis associated with severe hypothyroidism caused by Hashimoto's thyroiditis, in the setting of high dose statin use. Conclusion: Clinicians should raise the suspicion of rhabdomyolysis in a patient with severe hypothyroidism, especially in patients with recent high dose statin use as rhabdomyolysis can be a rare and fatal complication of severe hypothyroidism, in the presence of precipitating factors. Presentation: 6/2/2024

9332 Breathless Struggle: Unraveling The Interplay Between DKA And Acute Respiratory Distress Syndrome

Abstract Disclosure: S. Zahra: None. R. Subramani: None. M. Abbas: None. K.Y. Hasan: None. F. Manas: None. C. Bajracharya: None. Introduction: Diabetic Ketoacidosis (DKA) is a life threatening emergency with mortality rate of 0.15%-0.30%. Acute Respiratory Distress Syndrome (ARDS) is a rare complication of DKA which presents as a sudden onset of dyspnea and progressive hypoxia. It is an inflammatory process that damages the alveolar-capillary membrane leading to the fluid leakage into the alveolar space. The incidence of ARDS in DKA remains unknown. It is more commonly seen in adolescents and young adults. The exact pathogenesis of ARDS in DKA is currently unknown. Some proposed mechanisms are that a severe metabolic acidosis in DKA along with increased cytokines production due to long standing hyperglycemia leads to increased capillary membrane permeability allowing fluid to accumulate in the alveolar space. TNF-a and IL-6 along with other pro-inflammatory cytokines are known to cause endothelial damage and increase pulmonary permeability leading to pulmonary edema. However most DKA patients with severe metabolic acidosis do not develop ARDS. Case Presentation:Case 1: A 19 year old male with uncontrolled type I diabetes mellitus presented with altered mental status. On examination, he was tachycardic and tachypneic with dry mucous membranes. Lab workup revealed leukocytosis, severe hyperglycemia, and severe anion gap metabolic acidosis with beta hydroxybutyrate level of 14.20 mmol/L (normal: 0.02-0.27 mmol/L). He was diagnosed with DKA and started on intravenous fluids, and insulin as per institutional DKA protocol. Approximately 12 hours post-admission, the patient experienced sudden-onset dyspnea with deteriorating hypoxia, necessitating emergent intubation and mechanical ventilation. Chest radiography displayed bilateral patchy ground-glass opacifications consistent with acute respiratory distress syndrome (ARDS). Despite the administration of 8 liters of intravenous fluids, the patient exhibited a negative net fluid balance of 2.3 liters, implicating fluid shift. Further investigations, including bronchoscopy and bronchoalveolar lavage, revealed an unobstructed airway, minimal secretions, and no evidence of hemorrhage or infection. Comprehensive infectious work-ups yielded negative results as well, reinforcing the diagnosis of DKA as the underlying cause of ARDS. Conclusion: Acute Respiratory Distress Syndrome is a rare but potentially fatal complication of Diabetic Ketoacidosis. Early recognition of this serious pulmonary complication of DKA and its prompt management is essential to prevent respiratory failure and mortality. Presentation: 6/1/2024

6572 Acute Adrenal Crisis Secondary To Undiagnosed Addison's Disease

Abstract Disclosure: J.M. Deirmenjian: None. H. Nickowitz: None. T. Kavafyan: None. Addison’s disease, also known as primary adrenal insufficiency, is when the adrenal gland has a defect in making cortisol. Signs and symptoms of Addison’s disease include nausea, vomiting, diarrhea, fatigue, dizziness, hyperpigmentation, and mood changes. Acute Adrenal Crisis can occur as a result of Addison’s disease when patients experience acute physiologic stress such as acute illness. Patient is a 35- year-old woman with a PMHx of iron deficiency anemia presenting with intractable nausea and vomiting for 10 days and a single witnessed syncopal episode two days prior to presentation. She was also had intermittent dizziness. Patient initially presented to urgent care where she was found to be hyponatremic and then was sent to the ED. She had no seizure like activity or rashes prior to admission. On initial physical exam, her skin was warm and dry with skin discoloration and hyperpigmentation. She was awake, alert, and oriented to person, place, time, and situation. Patient had no neurological deficits and no lateral or vertical nystagmus on initial assessment. On admission, patient was hyponatremic to 114 mEq/L, potassium was 5.0 mEq/L, and glucose level was 79 mg/dL. Despite receiving a 500 cc NS bolus, 1L NS bolus, 25 grams of albumin, and D5-0.45 NS at 50 cc/hr, the hyponatremia was difficult to correct. Her sodium initially corrected to 120 mEq/L but the sodium later decreased to 117 mEq/L. The morning after admission, patient became hypotensive and hypoglycemic. Random cortisol was measured and found to be 2.2 mcg/dL, raising concern for acute adrenal crisis as a result of undiagnosed Addison’s Disease. ACTH level was 17 pg/mL. Endocrinology was consulted and she was treated with IV 100 mg Hydrocortisone in addition to IV hydrocortisone 50 mg IV q6h. Patient was able to be transitioned to PO hydrocortisone 15 mg qAM and 5 mg qPM and was started on PO fludrocortisone 0.1 mg daily. On day of discharge, sodium improved to 127 mEq/L. CT Abdomen with contrast was completed to evaluate the adrenal glands and it showed a normal appearance of the adrenal glands. The etiology of the patient’s acute adrenal crisis was secondary to undiagnosed Addison’s Disease. It is interesting to note that patient was not hypoglycemic on admission but later became hypoglycemic during her hospital course. Adrenal crisis is a possible fatal complication of undiagnosed Addison’s disease. Therefore, a possible Addison’s Disease diagnosis is important to consider when patients are presenting with symptoms such as nausea, vomiting, dizziness, and electrolyte derangements including hyponatremia. If patient’s present with hyponatremia, ruling out possible adrenal insufficiency by checking a cortisol level may change the course of patient’s care. After discharge, she was able to establish care with Endocrinology and remain stable on treatment with PO hydrocortisone and PO fludrocortisone. Presentation: 6/3/2024

7531 Spontaneous Coronary Artery Dissection Induced Diabetic Ketoacidosis In A Young Female: A Rare Complication Of Ketosis In A Priorly Non-Insulin Dependent Diabetic

Abstract Disclosure: F. farhat: None. P. Gonzalez: None. A.B. Ravin: None. H. Akhlaq: None. M. hossain: None. K. chalasani: None. S.W. Holland: None. R. Ong: None. J. Cheng: None. Introduction: Spontaneous Coronary Artery Dissection (SCAD) is a poorly understood and underdiagnosed condition that puts healthy young women at risk of Myocardial infarction (MI) and potential death. It occurs when a tear develops in a coronary artery. SCAD can have an atypical presentation especially in diabetic and young females; Diabetic ketoacidosis (DKA) is an uncommon, yet potentially fatal complication and can be the primary presentation in SCAD. We present a case of SCAD complicated by DKA in a non insulin dependent diabetic (NIDD).Case presentation: A 19 year old female with a past medical history of NIDDM presented to the Emergency Department with chest pain. She had troponemia and ECG revealed ST elevations. Patient was found in DKA initially. Insulin drip was started with DKA resolution in 24 hours. Hemoglobin A1c was 12.4% with negative antibody workup. Her course was complicated by SCAD found upon cardiac catheterization with unsuccessful recanalization; she was not a surgical candidate given late presentation and therefore, an intra aortic balloon pump was placed. Subsequently, she developed pericarditis and left ventricular thrombus. Discussion: SCAD is a rare condition, often presenting with acute MI and cardiogenic shock. MI may be complicated with DKA. One proposed mechanism for that is the activation of ketogenic pathways caused by excess catecholamines and cortisol; this increases physiologic stress on the body resulting in increased ketogenesis, lipolysis and free radicals causing further myocardial injury. DKA precipitated by MI increases the mortality rate to nearly 85% since the myocardium is denied glucose uptake. Signs and symptoms of SCAD are similar to MI symptoms including: chest tightness, shortness of breath and sweating. MI and SCAD can be differentiated by cardiac catheterization or by specialized contrasted CT scans. 20% of SCAD patients will experience a second episode within 5 years. Avoiding emotional stress, exercising regularly, following a healthy diet and controlling chronic conditions can help lower the risk for SCAD. Medical management is often preferred. Invasive treatments like coronary stenting or cardiac bypass may be needed if there is a complete blockage in the vessel, clinical instability or ongoing chest pain. Conclusion: SCAD is an important cause of MI in young females and can present initially as DKA in diabetics. For clinicians facing such rare cases, it is worth maintaining a broad approach to the diagnosis and treatment of these patients. The causes of SCAD remain fully unclear and genetic relations are still under investigation. Since DM type I and SCAD occur in young people, it is extremely important for clinicians to consider SCAD in the differential while managing DKA. Presentation: 6/3/2024

Role of Transforming Growth Factor-β in Pathogenesis of Pulmonary Fibrosis in COVID-19, Post-COVID Syndrome, Oncological and Chronic Inflammatory Lung Diseases

INTRODUCTION: Persistent post-COVID syndrome is the persistent physical, medical and cognitive sequelae of coronavirus disease 2019 (COVID-19), including persistent immunosuppression, pulmonary, cardiac and vascular fibrosis which lead to increased mortality and impair the quality of life of patients. АIM: To analyze the completed foreign and domestic studies on the pathophysiology of transforming growth factor-β (TGF-β) in conditions of COVID-19, post-COVID syndrome, oncological and chronic inflammatory lung diseases. Mast cells are among the main producers of inflammatory cytokines in COVID-19, their stimulation leads to the release of many proinflammatory cytokines, such as interleukin 1β, tumor necrosis factor α, interleukin 6, and also TGF-β. The basis of the pathogenesis of post-COVID syndrome is the overexpression of TGF-β leading to a prolonged state of immunosuppression and fibrosis. TGF-β acts as a tumor suppressor inhibiting proliferation and inducing apoptosis in the early stages of oncogenesis; plays an important role in most cellular biological processes leading to remodeling of the airway structures; is involved in epithelial changes, in subepithelial fibrosis, remodeling of smooth muscle of airways and in microvascular changes; induces resistance to glucocorticosteroids; stimulates the production of blood coagulation factor XII, thereby leading to development of potentially fatal complications, such as pulmonary embolism and ischemic stroke. CONCLUSION: In this literature review, a structured analysis of a multicomponent role of TGF-β in the pathogenesis of post-COVID syndrome, pulmonary fibrosis in COVID-19, tumors of respiratory system, chronic obstructive pulmonary disease, bronchial asthma, is given. A possible use of TGF-β as a biomarker of severe and moderate degree of COVID-19 is substantiated.

A Prospective Study on the Spectrum of Liver Abscess With Special Reference to Ruptured Abscess in a Tertiary Care Hospital.

Introduction Liver abscesses are one of the most concerning healthcare issues in Western countries, with a prevalence rate of three per 100,000. Although with the improvement in the socio-economic status and the health care system, its incidence has decreased in developed nations, pyogenic and amoebic liver abscesses are still high in resource-poor countries. Low socioeconomic conditions, improper hygiene, lack of awareness, and often a delay in diagnosis can lead to fatal complications and high mortality. Methods This prospective study was conducted in the Department of General Surgery, Calcutta National Medical College (CNMC) from 1st January 2019 to 31st August 2020 after obtaining approval from the Institute Ethical Committee (IRB no: EC-CNMC/2019/238/1). Patients over 10 years old with clinical and radiological features of liver abscesses were included in the study. Demographic, clinical, and treatment parameters were analyzed. Clinical and biochemical data were also compared statistically between ruptured and unruptured cases. Results Sixty patients with liver abscesses were included in the study. A pyogenic liver abscess (PLA) and amoebic liver abscess (ALA) were 28 and 32 cases, respectively. Most patients were between 21 and 40 years of age (53.3%, n=60), with male predominance (76.7%, n=60).The most common symptom was fever in both PLA (89.2%, n=28) and ALA (65.6%, n=32). Most abscesses were 5-10 cm in size (56.6%, n=60). Clinical parameters like pedal edema, ascites, respiratory distress, intercostal tenderness, and peritonitis were associated with ruptured abscesses. Biochemical parameters like low albumin raised total leucocyte count (TLC), increased prothrombin time, and large size of the abscess were predictors of ruptured abscess (p<0.001). Image-guided aspiration was performed in 14 patients (23.3%, n=60), and CT-guided percutaneous catheter drainage was done in 30 cases (50%, n=60). The most common organism isolated was E. coli. The ruptured abscess was diagnosed in six patients (10%, n=60). All ruptured abscesses required laparotomy and open surgical drainage. After three months of follow-up, a complete resolution of abscess cavities were seen in 38 patients (63.3%, n=60). Mortality in our study was 5 (8.3%, n=60). Conclusion Although modern diagnostic tools can efficiently diagnose liver abscesses, the identification of clinical features still has its place. Percutaneous catheter drainage is most commonly performed as a minimally invasive procedure without significant morbidity.Clinical suspicion of a ruptured liver abscess should be dealt without a delay. Improved hygiene and awareness can reduce its incidence, but early identification of clinical features, prompt diagnosis, and treatment can reduce mortality and morbidity.

Factors related to cardiac rupture after acute myocardial infarction.

Cardiac rupture (CR) after acute myocardial infarction (AMI) is a fatal mechanical complication. The early identification of factors related to CR in high-risk cases may reduce mortality. The purpose of our study was to discover relevant risk factors for CR after AMI and in-hospital mortality from CR. In this study, we enrolled 1,699 AMI cases from October 2013 to May 2020. A total of 51 cases were diagnosed with CR. Clinical diagnostic information was recorded and analyzed retrospectively. We randomly matched these cases with AMI patients without CR in a 1:4 ratio. Univariate and multivariate logistic regression and stratifying analysis were used to identify risk factors for CR. Univariate and multivariate Cox regression hazard analysis and stratifying analysis were used to assess predictors of in-hospital mortality from CR. The incidence of CR after AMI was 3.0% and in-hospital mortality was approximately 57%. Multivariate logistic regression analysis identified that white blood cell count, neutrophil percentage, anterior myocardial infarction, a Killip class of >II, and albumin level were independently associated with CR (p < 0.05). Stratifying analysis showed that age, systolic blood pressure, and bicarbonate were independent risk factors for female CR (p < 0.05) but not male CR. Triglyceride and cardiac troponin I were independent risk factors for male CR (p < 0.05) but not female CR. Anterior myocardial infarction, a Killip class of >II, and neutrophil percentage were independent risk factors for male and female CR (p < 0.05). Multivariate Cox regression analysis showed that the time from symptom to CR and the site of CR were independent predictors for in-hospital mortality from CR (p < 0.05). Stratification analysis indicated that risk factors did not differ based on gender, but platelet counts were predictors for in-hospital mortality in female and male CR. Low albumin, a high white blood cell count, neutrophil percentage, anterior myocardial infarction, and a Killip class of >II were independent and significant predictors for CR. However, risk factors are different in male and female CR. The time from symptom to CR, the site of CR, and platelet counts were independent predictors for in-hospital mortality from CR. These may be helpful in the early and accurate identification of high-risk patients with CR and the assessment of prognosis. In addition, gender differences should be considered.

Coronary artery compression by dilated pulmonary artery in an early infantile case of tetralogy of Fallot with absent pulmonary valve: ventricular fibrillation as the initial symptom of myocardial ischaemia.

Coronary artery compression by a dilated pulmonary artery is a rare complication in patients with tetralogy of Fallot with absent pulmonary valve. We present a case in which this condition manifested at two months of age, with ventricular fibrillation as the initial symptom of myocardial ischaemia. It is important to recognise that this potentially fatal complication can occur in early infancy.

Characteristics and Treatment Outcome of Pediatric Diabetic Ketoacidosis in Mekong Delta, Vietnam: A 5-Year Retrospective Study

Background Diabetic ketoacidosis (DKA), a critical and potentially fatal complication resulting from a lack of insulin, presents with elevated blood sugar, acid-base imbalance, and increased ketone bodies. Objectives Our research was designed to assess the clinical manifestations, laboratory findings, and outcomes of treatment in children diagnosed with DKA over a span of five years in the Mekong Delta region of Vietnam. Methods This study retrospectively analyzed pediatric cases of diabetic ketoacidosis treated at a major pediatric center in the Mekong Delta between 2017 and 2021. Results Diabetic ketoacidosis was more common in older children aged 11 – 16 years (66.7%), and females (70%). The majority of cases had not been diagnosed with previous diabetes (60%) and no history of diabetic ketoacidosis (90%). In univariate analysis, female gender (OR, 13.0; 95% CI, 1.4 – 124.3; p=0.026), previous diabetes diagnosis (OR, 7.8; 95% CI, 1.5 – 41.2; p=0.016), precipitating factors (OR, 10.1; 95% CI, 1.1 – 97.0; p=0.045), tachypnea (OR, 5.5; 95% CI, 1.1 – 26.4; p=0.033), Kussmaul breathing (OR, 5.4; 95% CI, 1.1 – 26.0; p=0.036), serum potassium level (OR, 3.5; 95% CI, 1.2 – 10.4; p=0.027), and anion gap (OR, 1.6; 95% CI, 1.8 – 2.3; p=0.003) were associated factors with severe DKA. All cases in our study had a 100% survival rate. Anion gap was an independent factor associated with severe diabetic ketoacidosis after adjustment multivariate analysis. Conclusion: Female, younger age, precipitating factors, tachypnea, Kussmaul’s breathing, and relevant laboratory findings, including increased anion gap, should be considered to ensure successful management in pediatric diabetic ketoacidosis. Bangladesh Journal of Medical Science Vol. 23 No. 04 October’24 Page : 1112-1119