History Of Multiple Sclerosis Research Articles

New Onset Nystagmus in a Patient with Multiple Sclerosis.

Case PresentationA 50-year-old male with a history of multiple sclerosis with dizziness and nystagmus presented to the emergency department. On physical exam, nystagmus was noted. Computed tomography of the head without contrast was obtained showing a low density in the left frontal lobe. During admission, magnetic resonance imaging (MRI) findings were consistent with Balò’s concentric sclerosis.DiscussionBalò’s concentric sclerosis is a rare, inflammatory demyelinating disease, often considered to be an infrequent variant of multiple sclerosis with alternating rings of healthy myelin and demyelination leading to pathognomonic findings of concentric lamella on T2 or contrast-enhanced T1 MRI imaging.

A case series and literature review of multiple sclerosis and COVID-19: Clinical characteristics, outcomes and a brief review of immunotherapies.

Background:In view of the emerging coronavirus pandemic, the demand for knowledge about the impact of SARS-CoV-2 on people with Multiple Sclerosis (MS) continues to grow. Patients receiving disease modifying therapy (DMT) for MS have a higher background risk of infection-related health care utilization when compared to the general population. Therefore, there is a need of evidence-based recommendations to reduce the risk of infection and also managing MS patients with SARS-CoV-2.Case Description:We present three patients with history of Multiple Sclerosis (MS) on DMTs presenting with worsening MS symptoms likely pseudo exacerbation who were diagnosed with COVID-19.Discussion:An extensive review of 7 articles was performed, in addition to a brief review on DMTs use in MS patients with COVID-19. In our cases, all patients were on DMT and severe course of disease was noted in 2 cases. No fatality was observed.Conclusions:This review provides a base on the clinical characteristics, outcomes and the roles of DMTs in MS patients suffering from n-cov-2. Physicians need to be vigilant about considering COVID-19 infection related relapse in the MS patients, especially in this COVID-19 pandemic era and look for pseudo-exacerbation. As most cases are found to have mild course and full recovery on DMTs, further research is needed to formulate evidence-based guidelines. This review will particularly be helpful for the researchers and registries to collect future data on MS and COVID-19.

SAT-476 Alemtuzumab Induced Graves Disease

Introduction: Immune reconstitution therapy (IRT) with the monoclonal antibody alemtuzumab (anti-CD 52) has been shown to be superior to β-interferon in relapsing-remitting multiple sclerosis. It can cause early hyper-population of immature B cells which increases the risk of autoimmune disorders. The most common autoimmune adverse effect is autoimmune thyroid disorder (AITD) which has not been well recognized by internists, especially primary care physicians. We present a case of alemtuzumab-related hyperthyroidism. Most of these cases are mild and can be easily managed. Case presentation: A 44-year-old female with history of multiple sclerosis (MS) presented to the office with a two-month history of fatigue, palpitations, tremors, weight loss and pruritus after completing a course of Alemtuzumab. Her symptoms started 1 month after completing 2 years of a consecutive series with IRT. Her thyroid function panel was not checked before starting IRT. She had no previous history of thyroid disease. Family history is positive for goiter in her mother. She had no exposure to contrast dye, steroids, amiodarone, supplements or biotin use. On exam, she had tachycardia, dry skin, tremors on outstretched hands and a non-tender goiter with no palpable nodules. Her initial labs showed a suppressed TSH (<0.005 mIU/L), elevated FT4 (>7.77 ng/dL), elevated T3 (647 NG/dL) and TSI of 338% (<140%), consistent with Graves’ Disease. She was started on methimazole. Two months into treatment, she became clinical and biochemical euthyroid without medication side effects. Discussion: This patient might have Graves’ disease before IRT which can be easily treated if TFTs were routinely checked; or her Grave’s disease was induced by IRT later. Lack of TFTs checked before, during and after IRT put those patients at risk of unawareness of thyroid abnormalities. Based on this case, we strongly recommend doing routine TFTs (TSH, free T4) check before starting IRT to rule out existing thyroid function abnormalities and provide treatment accordingly. We also recommend checking TSI, TPO antibody for high-risk patients (positive family history, past history) and thyroid US for those who have nodules or goiters before starting IRT. For those found to have abnormal TFTs, TSI or TPO, routine follow up with an Endocrinologist should be recommended during, and even after therapy completion.

MON-365 Novel Use of Abaloparatide to Augment Spinal Fusion in Patient Undergoing Cervicothoracic Revision Surgery

Objective To present a case of using Abaloparatide (PTHrP 1–34 analogue) to promote spinal fusion in a patient with history of cervical instability s/p multiple cervical operations with non-union. Case Presentation 66 year-old female with a history of multiple sclerosis, obesity and hypothyroidism underwent neurosurgical evaluation of neck pain. She was found to have cervical spinal stenosis causing neck pain, radiculopathy, motor deficits and ataxia. Initially underwent anterior cervical discectomy and fusion which temporarily alleviated symptoms before suffering nonunion. Subsequently underwent two additional surgeries which also eventually failed. She presented to our facility for revision corpectomy and spinal fusion. Given her history of nonunion, endocrinology was consulted for evaluation of metabolic bone disease. No known personal or family history of metabolic bones disease. No history of chronic steroid use. Initial endocrine evaluation excluded common pathologies. A decision was made to pursue anabolic osteoporosis therapy to attempt to augment the spinal fusion process. Patient started on Abaloparatide 80mcg daily 2 weeks post procedure with planned 12-week therapy course. Cervical CT at 3 and 6 months showed post-surgical cervicothoracic fusion with no signs of non-union. Discussion Abaloparatide is a 34 amino acid synthetic analogue of parathyroid hormone related peptide (PTHrP) which works by selectively activating PTH1 receptor found on osteoblasts. Currently anabolic therapies are only FDA approved for treatment of osteoporosis but there is reported off label use in cases of spinal fusions, arthroplasty and fracture healing. Studies have shown that presence of PTH and PTHrP are necessary for fracture healing. Animal studies have also shown that intermittent PTH promotes spinal fusion. This case represents a novel use for Abaloparatide to augment spinal fusion in a human clinical model. Conclusion Further studies are warranted to better understand mechanism of action, drug timing and duration for optimal treatment of anabolic therapies in bone fractures and healing. The use of anabolic therapies like Abaloparatide can be considered in patients undergoing spinal fusion surgery at high risk for non-union or undergoing revision for failed fusion.ReferencesO’Loughlin PF, Cunningham ME, Bukata SV et al. Parathyroid Hormone Augments spinal fusion, fusion mass, and fusion mass quality in a rabbit spinal fusion model. Spine 2009 January; 34: 121–130

Effect of phenytoin on retinal ganglion cells in acute isolated optic neuritis.

Phenytoin has been shown to reduce the peripapillary retinal nerve fiber layer (pRNFL) loss in optic neuritis (ON). We evaluated the effects of phenytoin on retinal ganglion layers and visual outcomes of newly diagnosed acute ON. A randomized, placebo-controlled trial was conducted in a tertiary referral eye hospital and patients with the first episode of typical demyelinating ON, without any history of multiple sclerosis were randomly assigned to phenytoin or placebo. The thickness of ganglion cell-inner plexiform layer (GCIPL) measured by optical coherence tomography (OCT) was considered as the primary outcome. One patient in the phenytoin group developed severe cutaneous rashes that progressed to Stevens-Johnson syndrome (SJS)/toxic epidermal necrosis (TEN), and further allocation of patients to the phenytoin group was stopped, and finally fifteen participants were included in the phenytoin group. Fifty-one patients were enrolled to the placebo group, from which four were excluded. Both visual acuity and field were not significantly different between the control and phenytoin groups after 1 and 6months. Mean 3- and 6-mm macular GCIPL thicknesses decreased after 6months to 73.6 ± 14.1 and 57.9 ± 7.5μm, respectively, in the phenytoin group and to 71.6 ± 15.7 and 55.6 ± 6.6μm, respectively, in the placebo group with no significant differences between the two groups (P = 0.77 and P = 0.26, respectively, linear multilevel model). Phenytoin is not probably safe and effective as neuroprotection after acute ON. Further investigation with other sodium channel inhibitors could be considered.

EVALUATING ASYMPTOMATIC 2:1 CONDUCTION IN A 47-YEAR-OLD

A 2:1 atrial to ventricular conduction block can be either Mobitz type I or II second degree AV block. Differentiation between those two conditions is important as type II second degree AV block poses a greater risk of unstable rhythm A 47-year-old male with history of multiple sclerosis presented

1553 A Phantom of the Large Bowel!

INTRODUCTION: Giant colonic diverticulum (GCD), referred to as giant colon cyst or “phantom tumor,” is a diverticulum that commonly arises from sigmoid colon and is larger than 4 cm in diameter. This occurs mostly in individuals older than 60 years and its pathogenesis is not well understood. Two theories have been proposed that could co-exist: A one-way valve mechanism at the transition point between the bowel lumen and diverticulum permitting air entry and progressive increase in intraluminal pressure with subsequent enlargement of the diverticulum. Alternatively, gas forming bacteria encased within a cyst of the colon contributing to chronic inflammation and consequent gradual distention of a diverticulum. Patients are mostly asymptomatic, otherwise common clinical manifestations range from a soft palpable abdominal mass to lower abdominal pain, constipation or rectal bleeding. However, it is uncommon for GCD to present as acute diverticulitis, and to our knowledge, this is a rare case to be reported in the literature. Herein we report a case of an elderly male who presented with sepsis due to acute diverticulitis as an initial presentation of a GCD. CASE DESCRIPTION/METHODS: A 63-year-old bed-bound male with a history of multiple sclerosis and major depression presented to our hospital with generalized abdominal pain of one-day duration. The patient was febrile at 101 F, and physical exam was remarkable for lower abdominal tenderness without guarding. He was septic with evidence of leukocytosis of 23,400/mm3, neutrophilia and lactate of 3 mmol/L (normal range: 0.5–2.2 mmol/L). A CT of the abdomen with contrast demonstrated an isolated 4.5 cm diverticulum at the sigmoid colon with evidence of acute diverticulitis. There was no evidence of a focal drainable abscess, free air or diverticulosis in other colon segments. He was considered high risk for surgery due to his sedentary status and was conservatively managed with parenteral antibiotics. His symptoms resolved and discharged three days later, without any further complications. DISCUSSION: GCD is a rare manifestation of diverticular disease and can present with a myriad of symptoms. Acute diverticulitis should be considered in those with evidence of sepsis and at risk of developing GCD. The gold standard treatment of en-bloc resection of the GCD with primary anastomosis is not always ideal for the management of this entity and a more conservative approach can be taken in high-risk surgical candidates as in our patient and may lead to a favorable outcome.

2212 Hemophagocytic Lymphohistiocytosis Disguised as Acute Liver Injury

INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder with unregulated immune activation and inflammation. Primary HLH occurs in infants or young children with or without family history whereas secondary HLH manifests in older children or adults without a family history or gene mutation. Concurrent infection, malignancy or rheumatological disorder usually trigger an uncontrolled immune response in the older age group. Our aim is to raise is awareness among physicians to recognize the early signs and symptoms of this life-threatening condition. CASE DESCRIPTION/METHODS: A 33-year-old female with a history of multiple sclerosis and rheumatoid arthritis presents with elevated LFTs, cholestatic jaundice and intermittent high-grade fever. Imaging studies showed no significant abnormality in the hepatobiliary system. Viral and autoimmune serologies were negative. Lab works revealed low fibrinogen and elevated ferritin and IL-2 receptor levels. Bone marrow biopsy was unremarkable; however, liver biopsy showed features suggestive of HLH. Steroid and etoposide therapy was started but treatment was complicated by pancytopenia and hemodynamic instability despite multiple transfusions and filgrastim administration. With worsening clinical pictures, emapalumab (Interferon gamma blocker) was started. However, the patient developed multiorgan failure with overwhelming sepsis and died within days of emapalumab administration. DISCUSSION: HLH has a wide spectrum of clinical manifestation often masquerading as sepsis or SIRS. Some studies have found that cholestasis and high AST levels are associated with poor outcomes in adult HLH patients. The goal of therapy is to suppress hyper inflammation with agents such as corticosteroids, calcineurin inhibitors, and immunoglobulins. When a patient presents with prolonged fever and liver dysfunction of unknown etiology, HLH should be considered in the differential diagnosis as early recognition and treatment can prevent mortality, which can be high up to 75 % in the adult age group.

Automatic detection of involuntary spasticity of major muscles with acoustic and electromyography

Spasticity is a severely debilitating condition where involuntary muscle contraction impedes normal movement, speech and gait. It usually results from motor root damage in patients with history of multiple sclerosis, traumatic brain injury, or stroke. This damage causes misfiring of neurons leading to erratic muscle contraction. Current treatments inhibit muscle activation, however, treatment is given upon onset of the spastic episode, delaying symptom alleviation. Here we developed a sensing device combining surface acoustic myography (sAMG) and surface electromyography (sEMG) for the automatic detection of spasticity. sAMG use acoustic-based sensors to detect pressure waves produced by muscle contraction whereas sEMG detect electrical signals from neuromuscular activity. Merging sEMG and sAMG sensors provided a robust set of spectral data to describe muscle contraction patterns in terms of electromechanical activities. Said patterns were used for calibration using machine-learning algorithms. With established normal patterns, the device can distinguish between voluntary and involuntary muscle movement. In sum, the symbiotic employment of both types of sensors shows potential in early detection of a spastic episode. Being able to detect the onset or to predict a spastic event can provide insight into the underlying physiological conditions and, ultimately, help develop technologies to mitigate its occurrence.

JC virus antibodies in Portuguese multiple sclerosis patients: JUSTIFY study results

ObjectiveTo confirm anti–JC virus (JCV) antibody seroprevalence in Portuguese patients with relapsing-remitting multiple sclerosis (RRMS) and to determine their anti-JCV antibody index. MethodsJUSTIFY was a retrospective, multicentre study that included 655 RRMS patients tested at least once with the anti-JCV antibody assay STRATIFY JCV DxSelect. Demographic data, multiple sclerosis history and results of the anti-JCV antibody test were collected, along with physicians' reasons for requesting the test and the impact of the results. ResultsOverall anti-JCV antibody seroprevalence was 60.8% (95% confidence interval, 56.9–64.5). Seroprevalence was associated with higher age (P = .030) and was lower in natalizumab-treated patients (P < .001). The mean anti-JCV antibody index of immunosuppressant-naive patients was 1.5 ± 1.3 (n = 378). The main reasons for performing the test were clinical characterization (35.5%) and medication change (26.2%). In patients who switched treatments (n = 109), fingolimod (47.7%) and natalizumab (26.6%) were the most commonly chosen new treatments. ConclusionsThe study confirmed the high anti-JCV antibody prevalence in Portuguese RRMS patients and its association with age. These data can be used to better understand the benefit-risk profile of natalizumab treatment in Portuguese patients and to support progressive multifocal leukoencephalopathy risk management strategies.

Women who contributed to past research in multiple sclerosis

Background: The history of multiple sclerosis (MS) is dominated by the discoveries of famous men. However, women would like to feel part of the story and to know that women have contributed to MS research. Objective: To identify women who contributed to the history of discovery in MS. Method: This was a personal survey from my knowledge of previous work. Results: There were no women participants in the early stages of MS research. However, since 1950 there are many women who have contributed to MS research. In the 20th century, there were famous women who contributed to the scientific fields that form the basis of MS research. In the 21st century, more women participate in MS research but studies suggest that they are under-represented in positions of prominence. Conclusion: Women have been part of the effort to understand MS, but are not well recognized.

Annals for Educators - 2 April 2019.

Annals for Educators - 2 April 2019.

THE MANY FACES OF CORONARY VASOSPASM

Coronary vasospasm can present as diffuse multi-vessel disease on coronary angiography, often mimicking multi-vessel obstructive coronary artery disease (CAD). A 50 year old female with a history of multiple sclerosis, tobacco use, and family history of CAD presented with chest pain. She was found

Application of an artificial neural network model for early outcome prediction of gamma knife radiosurgery in patients with trigeminal neuralgia and determining the relative importance of risk factors

ObjectivesStereotactic radiosurgery (SRS) is a minimally invasive modality for the treatment of trigeminal neuralgia (TN). Outcome prediction of this modality is very important for proper case selection. The aim of this study was to create artificial neural networks (ANN) to predict the clinical outcomes after gamma knife radiosurgery (GKRS) in patients with TN, based on preoperative clinical factors. Patients and methodsWe used the clinical findings of 155 patients who were underwent GKRS (from March 2000 to march 2015) at Iran Gamma Knife center, Teheran, Iran. Univariate analysis was performed for a long list of risk factors, and those with P-Value < 0.2 were used to create back-propagation ANN models to predict pain reduction and hypoesthesia after GKRS. Pain reduction was defined as BNI score 3a or lower and hypoesthesia was defined as BNI score 3 or 4. ResultsTypical trigeminal neuralgia (TTN) (P-Value = 0.018) and age>65 (P-Value = 0.040) were significantly associated with successful pain reduction and three other variables including radiation dosage >85 (P-Value = 0.098), negative history of diabetes mellitus (P-Value = 0.133) and depression (P-Value = 0.190). On the other hand, radio dosage>85 (P-Value = 0.008) was significantly associated with hypoesthesia, other related risk factors (with p-Value<0.2), were history of multiple sclerosis (P-Value = 0.106), pain duration more than 10 years before GKRS (P-Value = 0.115), history of depression (P-Value = 0.139), history of percutaneous ablative procedures (P-Value = 0.148) and history of diabetes mellitus (P-Value = 0.169).ANN models could predict pain reduction and hypoesthesia with the accuracy of 84.5% and 91.5% respectively. By mutual elimination of each factor in this model we could also evaluate the contribution of each factor in the predictive performance of ANN. ConclusionsThe findings show that artificial neural networks can predict post operative outcomes in patients who underwent GKRS with a high level of accuracy. Also the contribution of each factor in the prediction of outcomes can be determined using the trained network.

Nitrogen inhalation suicide pacts

Suicide pacts usually result in simultaneous deaths by mutual arrangement. While nitrogen and helium gas inhalation are being increasingly used in solitary suicide attempts, for some reason they have been rarely utilised in suicide pacts. A search of autopsy files at Forensic Science SA over a 15-year period (2003-2017) was undertaken to determine how often this method of joint suicide occurs. Only two cases were found. Case 1 comprised a 64-year-old husband and wife (who had a history of multiple sclerosis). They were found deceased in a vehicle with two empty cylinders of nitrogen gas. Case 2 comprised an 87-year-old man (who had a history of ischaemic heart disease) and his 81-year-old wife who were found deceased with plastic bags over their heads, with plastic tubes connecting the bags to opened cylinders of nitrogen. The deaths in all cases were due to nitrogen-induced asphyxiation, in the latter instance augmenting plastic-bag asphyxia. Although suicide pacts have previously usually involved carbon-monoxide toxicity or drug overdose, it is possible that dissemination of information on the use of inert gases in individual suicide attempts may alter the methods used in future.

Management of Moderate to Severe Psoriasis in Routine Clinical Practice in Spanish Hospitals

BackgroundThere is currently little information available on the management of patients with psoriasis in the routine clinical practice of dermatologists in Spain. ObjectiveThe aim of this study was to survey a group of Spanish dermatologists with particular expertise in the management of psoriasis to determine their opinions on the protocols used in routine clinical practice. Material and methodsA cross-sectional study based on an online survey about the management of psoriasis sent to 75 dermatologists. The survey, which was specifically designed for the study, included 12questions on different aspects of clinical practice in the treatment of moderate to severe psoriasis. ResultsThe response rate was 96% (n=72). Biologics were the most widely used monotherapy option. In total, 64.3% of respondents reported that their patients used conventional systemic therapies for 1 to 2years before switching to a biologic drug and that the main reason for the switch was unstable control of disease activity. Overall, 85.7% assigned “high” or “very high” importance to the use of a Psoriasis Area Severity Index score of <3 as a treatment goal. The drugs of choice among the respondents were etanercept for pediatric patients (78.6%), adalimumab and etanercept for patients with psoriatic arthritis (64.3%), and ustekinumab in patients frequently away from home (78.6%) and patients with a history of multiple sclerosis, demyelinating diseases (64.3%), or poor adherence to treatment (71.4%). ConclusionThis study provides a unique overview of the opinions of a representative sample of expert dermatologists on the current use of biologics for the treatment of psoriasis in Spain.

Manejo de la psoriasis moderada-grave en condiciones de práctica habitual en el ámbito hospitalario español

BackgroundThere is currently little information available on the management of patients with psoriasis in the daily clinical practice of dermatologists in Spain. ObjectiveThe aim of this study was to survey a group of Spanish dermatologists with particular expertise in the management of psoriasis to determine their opinions on the protocols used in routine clinical practice. Material and methodsA cross-sectional study based on an online survey about the management of psoriasis sent to 75 dermatologists. The survey, which was specifically designed for the study, included 12questions on different aspects of clinical practice in the treatment of moderate to severe psoriasis. ResultsThe response rate was 96% (n=72). Biologics were the most widely used monotherapy option. In total, 64.3% of respondents reported that their patients used conventional systemic therapies for 1 to 2years before switching to a biologic drug and that the main reason for the switch was unstable control of disease activity. Overall, 85.7% assigned a “high” or “very high” importance to the use of a Psoriasis Area Severity Index score of <3 as a treatment goal. The drugs of choice among the respondents were etanercept for pediatric patients (78.6%), adalimumab and etanercept for patients with psoriatic arthritis (64.3%), and ustekinumab in patients frequently away from home (78.6%) and patients with a history of multiple sclerosis, demyelinating diseases (64.3%), or poor adherence to treatment (71.4%). ConclusionThis study provides a unique overview of the opinions of a representative sample of expert dermatologists on the current use of biologics for the treatment of psoriasis in Spain.

An unusual presentation of inflammatory myopathy in a patient on natalizumab treatment for multiple sclerosis: A case report and review of myopathological classification of inflammatory myopathy

Acquired immune and inflammatory myopathies (IIMs) are traditionally subdivided into dermatomyositis, polymyositis, inclusion body myositis (IBM) and necrotizing autoimmune myopathy (NAM). Our patient is a 38-year old female who had history of Multiple Sclerosis and was on Natalizumab. Almost a year later, she presented with acute proximal bilateral upper extremity weakness with elevated CPK. She was initially labeled as having ‘viral myositis’. Her subsequent two admissions demonstrated worsening of muscle weakness with dysphagia which was initially unresponsive to high dose of steroids. She had an EMG which showed irritative myopathy and a muscle biopsy which showed IMPP. She eventually responded to pulse dose of steroids and IVIG and Natalizumab was held. The temporal relationship between the development of inflammatory myopathy in our patient and subsequent improvement in her course after discontinuation of the drug suggests that natalizumab may have played a role in our patient’s disease and warrants further investigation and vigilance. In addition to the case report, we hope to elaborate on the myopathological descriptions increasingly being used to describe the IIMs and to explore the potential link between natalizumab and the onset of IIM in our patient.

Retinal Lesions and Renal Impairment Associated with Interferon β1α Therapy for Multiple Sclerosis: A Case Report

Background: Recombinant interferon β is now the mainstay of maintenance therapy for multiple sclerosis in many countries. Retinal lesions are rarely related with subcutaneous interferon β1α in multiple sclerosis. Interferon nephrotoxicity is also an extremely rare side effect. We report a case of interferon-associated retinopathy and nephropathy in a patient with multiple sclerosis receiving subcutaneous interferon β1α. Case report: A 42 years old Caucasian female with a history of multiple sclerosis on continuous treatment with interferon β1α, presented with anemia, thrombocytopenia, albuminouria, mild elevation of liver enzymes, renal impairment and sudden hypertension without visual disorders. Ocular fundus exam showed several retinal cotton wool spots indicating interferon-retinopathy and the drug was discontinued. Biochemical and immunological analyses were negative for autoimmune renal diseases. The retinopathy disappeared without specific therapy 2 months after discontinuing interferon β1α and kidney function restored. Interferon β1α resumed 16 weeks after stopping treatment due to multiple sclerosis relapse. On an iterative fundus exam 3 months after resumption of interferon β1α, no further cotton wool spots have recurred. 6 and 12 months later, with the patient on interferon β1α treatment, the ocular fundus was free of lesions and kidney function was within normal range. Conclusions: In our patient, both complications resolved after drug cessation and the diagnosis of interferon β1α retinopathy and nephropathy was retained due to the lack of any other etiology.

Primary Omental Infarct: A Radiological Curiosity or a Real Disease?

Primary Omental Infarction (POI) is a rare cause of acute abdominal pain. Patients may present with severe abdominal pain mimicking acute abdomen or could be completely asymptomatic. This large variation in presentation makes diagnosis confusing and challenging. Here we present two cases of omental infarction with very different presentations. A 25 year old woman who presented with right upper quadrant (RUQ) abdominal pain with radiation to her flank, exacerbated with any movement or cough. Her exam revealed severe tenderness over the RUQ. Lab work was remarkable for elevated transaminases (ALT: 122 U/L, AST: 93 U/L), ESR: 120 mm/h, CRP: 18mg/dL, CPK: 144U/L, WBC count of 15.5 k/uL. Her CT scan of the abdomen revealed right upper quadrant omental fat stranding with trace intrahepatic fluid representing omental infarct (OI). Her viral hepatitis panel and autoimmune panel were negative except for a low titer (1:40) antismooth muscle antibody. Liver inflammation from surrounding omental infarct was thought to be the etiology of elevated AST/ALT. Symptoms gradually improved with morphine. Patient was discharged home with down trending CRP (8.8 mg/dL) and liver tests (ALT: 62U/L, AST: 24 U/L). A 51 year old man with history of multiple sclerosis, presented with urinary retention, fever, diagnosed with urinary tract infection. He denied any abdominal pain. Lab work was remarkable for elevated transaminases (ALT: 76 U/L, AST: 67 U/L) and WBC count of 4.3 k/uL. His CT scan of abdomen with oral contrast revealed incidental finding of RUQ omental infarct. He was discharged home after treatment of infection. POI is a unusual disease with a wide variation in clinical presentation from asymptomatic imaging finding to severe abdominal pain requiring extensive work up and hospital admission. In acute cases it can be misconstrued with acute appendicitis, pancreatitis, and peptic ulcer disease. A diagnosis of primary OI is made when no discernable etiology is found. Secondary causes for OI include hypercoagulability, vasculitis, and polycythemia. POI is commonly found in the right side of the abdomen. Sudden movement, violent exercise, and hyperperistalsis have been reported as causes of POI. CT scan is the diagnostic test of choice. In the absence of clinical deterioration, watchful waiting and pain control seems to be appropriate but laproscopy and omental necrosectomy might be necessary if the diagnosis is not clear by imaging or if there is no improvement in 48hours.Figure: Omental infarct below the liver in case1.Figure: RUQ omental infarct in case 2.