Prior Medical History Research Articles

The nuances of abdominal free flap harvest: Technical and patient factors affecting abdominal donor site morbidity in autologous breast reconstruction

Abdominal donor site morbidity after autologous breast reconstruction is common and often underreported. This work aims to compare prospectively collected technical details of the procedure and patient factors and their impact on the development of symptomatic and asymptomatic abdominal bulges (ASB and SB). A review of patients undergoing abdominal-based autologous breast reconstruction from May 2012 to October 2017 by two surgeons at a single institution was performed. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were ASB or SB and wound healing complications. Overall, 196 free flaps from 117 patients were included. The average follow-up was 1.9±1.7 years. Thirteen (11.1%) patients developed ASB, and 13 (11.1%) patients developed SB. Patients with BMI ≥30, bilateral ms-TRAM reconstruction, and an onlay type of abdominal closure were 2×, 2.3×, and 8.1× more likely to develop a bulge, respectively (p=0.017, p=0.010, p=0.049). Every one-point increase in BMI above 30 increased the odds of developing a bulge by 10.8%. Prior abdominal surgery increased the risk of SB by 7-fold (p=0.017). The size of the harvested muscle, use of mesh, or nerve preservation did not affect the rate of bulge development. High BMI, bilateral ms-TRAM, onlay type of abdominal closure, and prior abdominal surgery increase the risk of ASB and SB development to varying degrees, while several other operative variables did not seem to make a difference. Breast reconstruction patients can use this information for preoperative counseling and intraoperative decision-making.

Utilization of carbonated calcium phosphate cement for contouring cranioplasty in patients with syndromic craniosynostosis.

Carbonated calcium phosphate (CCP) cement is an alloplastic material which has been increasingly utilized for cranioplasty reconstruction; however, there is a paucity of data investigating its use in patients with syndromic craniosynostosis. The purpose of this study was to characterize our institutional experience with CCP cement for secondary contouring cranioplasty in these patients to establish safety and aesthetic efficacy. Patients with syndromic craniosynostosis undergoing cranioplasty with CCP cement from 2009 to 2022 were retrospectively reviewed for prior medical and surgical history, cranioplasty size, cement usage, and postoperative complications. Aesthetic ratings of the forehead region were quantified using the Whitaker scoring system at three timepoints: preoperative (T1), < 6months postoperative (T2), and > 1year postoperative (T3). Twenty-one patients were included. Age at surgery was 16.2 ± 2.8years, forehead cranioplasty area was 135 ± 112 cm2, and mass of cement was 17.2 ± 7.8g. Patients were followed for 3.0 ± 3.1years. Whitaker scores decreased from 1.9 ± 0.4 at T1 to 1.4 ± 0.5 at T2 (p = 0.005). Whitaker scores at T2 and T3 were not significantly different (p = 0.720). Two infectious complications (9.5%) were noted, one at 4.5months postoperatively and the other at 23months, both requiring operative removal of CCP cement. Our results suggest that aesthetic forehead ratings improve after CCP contouring cranioplasty and that the improvement is sustained in medium-term follow-up. Complications were uncommon, suggesting that CCP is relatively safe though longer-term follow-up is needed before reaching definitive conclusions.

A case of hepatic intraductal papillary neoplasm of the bile duct

Introduction: Intraductal Papillary Neoplasm of the Bile ducts (IPNB) is a rare entity characterized by exophytic growth of the bile ducts. Case presentation: In this report, we present a 57-year-old male with no prior medical history consulted for upper right abdominal pain, jaundice and pruritus. Abdominal Ultrasound (US) and magnetic resonance imaging/Bili-magnetic resonance were performed. They revealed that the circumferential parietal thickening of the common hepatic duct had extended approximately 4 cm with moderate dilatation of the left intrahepatic bile ducts. Computed tomography showed no evidence of distant metastasis. Biopsy revealed a high-grade intraductal papillary neoplasm. After 40 days, the patient had left hepatectomy with resection of the main bile duct and the gallbladder. Macroscopic examination of the surgical specimen showed a dilatation duct at the hilum with thickening of their walls. The histopathology report revealed multiple intra-hepatic papillary neoplasms with high-grade dysplasia with an invasive carcinoma component in the left hepatic duct without extending to the biliary wall, classified as pT1N0. Conclusion: This premalignant lesion has the potential to transform into invasive carcinoma if not properly diagnosed. Our case illustrates how early identification can lead to potential surgical resection.

Simultaneous bilateral quadriceps tendon rupture in a healthy young male: a case report

BackgroundSimultaneous bilateral quadriceps tendon rupture is rare, particularly in young individuals with no prior medical history. We present the case of a young man who presented with bilateral quadriceps tendon rupture.Case presentationA 27-year-old Japanese man missed a step while descending a flight of stairs, stumbled, and became aware of severe pain in both knees. He had no past medical history, but was severely obese, with a body mass index of 43.7 kg/m2 (height 177 cm, weight 137 kg). Five days after injury, he was referred to our hospital for examination and treatment. Bilateral quadriceps tendon rupture was diagnosed based on magnetic resonance imaging, and quadriceps tendon repair with suture anchor was performed on both knees 14 days after injury. The postoperative rehabilitation protocol was to immobilize both knees in extension for 2 weeks, then to gradually proceed with weight-bearing and gait training using hinged knee braces. Both knees obtained a range of motion from 0° to 130° without any extension lag by 3 months postoperatively. One year postoperatively, tenderness was evident at the suture anchor in the right knee. That suture anchor was therefore removed in a second operation, and histological evaluation of the tendon of the right knee revealed no pathological changes. As of 19 months after the primary surgery, the patient showed a range of motion from 0° to 140° in both knees, did not complain of any disability, and had fully returned to normal daily activities.ConclusionsWe experienced simultaneous bilateral quadriceps tendon rupture in a 27-year-old man with no past medical history other than obesity. Suture anchor repair was performed for both quadriceps tendon ruptures and achieved a favorable postoperative outcome.

Metabolic Health, Obesity, and Intraocular Pressure.

Obesity has been associated with increased intraocular pressure (IOP), but the results are inconsistent. Recently, a subgroup of obese individuals with good metabolic profiles were suggested to have better clinical outcomes than normal-weight individuals with metabolic diseases. The relationships between IOP and different combinations of obesity and metabolic health status have not been investigated. Therefore, we investigated the IOP among groups with different combinations of obesity status and metabolic health status. We examined 20,385 adults aged 19 to 85 years at the Health Promotion Center of Seoul St. Mary's Hospital between May 2015 and April 2016. Individuals were categorized into four groups according to obesity (body mass index (BMI) ≥ 25 kg/m2) and metabolic health status (defined based on prior medical history or abdominal obesity, dyslipidemia, low high-density lipoprotein cholesterol, high blood pressure, or high fasting blood glucose levels upon medical examination). ANOVA and ANCOVA were performed to compare the IOP among the subgroups. The IOP of the metabolically unhealthy obese group (14.38 ± 0.06 mmHg) was the highest, followed by that of the metabolically unhealthy normal-weight group (MUNW, 14.22 ± 0.08 mmHg), then, the metabolically healthy groups (p < 0.001; 13.50 ± 0.05 mmHg and 13.06 ± 0.03 mmHg in the metabolically healthy obese (MHO) and metabolically healthy normal-weight groups, respectively). Subjects who were metabolically unhealthy showed higher IOP compared to their counterparts who were metabolically healthy at all BMI levels, and there was a linear increase in IOP as the number of metabolic disease components increased, but no difference between normal-weight vs. obese individuals. While obesity, metabolic health status, and each component of metabolic disease were associated with higher IOP, those who were MUNW showed higher IOP than those who were MHO, which indicates that metabolic status has a greater impact than obesity on IOP.

Psoriasiform rash after initiation of treatment with olanzapine and carbamazepine.

Introductionolanzapine and carbamazepine are effectively used in treatment of schizoaffective disorder but they can have numerous side effects including skin eruptions that can be severe sometimes.ObjectivesTo study the relationship between toxidermia and treatment with Olanzapine and Carbamazepine.MethodsWe report the case of a patient who developed a psoriasiform skin rash following the intake of Olanzapine and Carbamazepine.ResultsMrs SL, 46 years old, with no prior medical or surgical history, has been diagnosed with schizophrenia since the age of 26. She was initially treated with Haloperidol and Risperidone with an irregular follow-up. Then, due to the emergence of mood disorder symptoms, the patient was put on 20 mg/day of Olanzapine and 400 mg/day of carbamazepine. One month later, the patient presented a generalized rash requiring the discontinuation of the current medications. She was treated with corticosteroids, and then she was referred to our department to make the appropriate adjustment of her psychiatric treatment.In view of the persistence of a dry erythroderma with erosive lesions of scratching and palmoplantar keratoderma, a skin biopsy was performed showing a psoriasiform and eosinophilic dermatosis that could be consistent with a toxidermia. The pharmacovigilance investigation concluded the incrimination of Olanzapine and carbamazepine in this symptomatology and recommended to avoid their prescription for this patient.The need for a mood stabilizer presented us with a challenge, particularly in view of the potential risk of cross-toxicity. We opted for the reintroduction of Risperidone with strict monitoring of the skin condition.ConclusionsEach prescribed drug must be considered as potentially capable of causing cutaneous reactions as an adverse effect. Both the prescriber and the patient must be made aware of this phenomenon.Disclosure of InterestNone Declared

Secondary Mania in Older Adults: a case report and review of literature

IntroductionAlthough mania is commonly associated with bipolar disorder, it can have many etiologies. Thus, “primary mania” results from bipolar disorder, whereas “secondary mania” results from pharmacological, metabolic, or neurologic causes. Older adults are at risk for secondary mania because of increased medical comorbidities and neurological changes. In one retrospective study of 50 patients with mania who were older than 65 years, it was the first manic episode for 28% of the patients and 71% had a comorbid neurological disorder.ObjectivesThe etiology of mania is important because although acute symptomatic treatment of both primary and secondary mania may be similar, appropriate treatment of secondary mania includes addressing the cause. We present here two case histories of secondary mania in older adults, discuss their presentations and differential diagnosis in turn, and discuss treatment.MethodsWe will present a clinical case of a patient. Ms. A, a 63-year-old divorced woman with no prior medical or psychiatric history, was seen for an acute manic episode with mixed features. She was in her usual state of health until 2 weeks before admission, when she presented with a status epilepticus requiring a one-week hospitalization in the neurology département and treated by Carbamazepine. She then developed an abnormally excited and labile mood, motor excitability accompanied by rapid thoughts, with a total loss of desire and pleasure and thoughts of death.ResultsIn our study, the patient presented a manic episode with mixed characteristics secondary to a status epilepticus.The patient was treated both somatically and psychologically, and the evolution was positive. The patient was stabilised after being put on an antiepileptic drug associated with an antipsychotic drug.In our study, the patient presented with a manic attack with mixed characteristics secondary to a status epilepticus.The patient was treated both somatically and psychologically, and the evolution was favourable. The patient was stabilised after being put on an antiepileptic drug associated with an antipsychotic drug.ConclusionsLate onset psychiatric disorders often represent a challenge for the psychiatrists as far as the diagnosis and management issues are concerned. The elderly patients have generally been reported to have associated medical, especially neurological illnesses and are also prone to side effects of various psychotropic medications.Disclosure of InterestNone Declared

Abstract Number ‐ 219: Spinal cord infarct in young: Fibrocartilaginous Embolism with Occlusion of Anterior Spinal Artery

Introduction Spinal cord infarctions are rare and account for fewer than 1% of all strokes. Diagnosis is usually established by clinical symptoms of sudden onset paraplegia and sensory dysfunction along with radiographic evidence of a non‐enhancing, diffusion‐restricted T2 hyperintense lesion on spinal cord MRI. We describe an interesting case of anterior spinal artery infarct from suspected fibrocartilaginous embolus from intervertebral disc. Methods Case report. Demographics and clinical history were obtained by chart review. MRI and cerebral angiogram images were reviewed and compared to radiology reports. Results 21‐year‐old female with no prior medical history presented with sudden onset headache, bilateral arm tingling, and neck stiffness that rapidly progressed within the hour to quadriplegia with numbness below the T2 sensory level. She continued to worsen, developed respiratory failure and required intubation. MRI of the cervical cord revealed a longitudinally extensive, non‐enhancing, diffusion‐restricted lesion extending from the bilateral medial medulla to the ventral spinal cord at C5/6 vertebral level. Cerebral and spinal digital subtraction angiography was notable for non‐opacification of the cervical anterior spinal artery. She had extensive work up for dissection, vasculitis, hypercoagulable state, autoimmune conditions that were all negative. However, there was a diminished T2 signal in her C5‐6 intervertebral disc with subtle loss of intervertebral disc space concerning for disc compression, likely related to her job requiring intensive heavy lifting. It was surmised that she developed a ventral cervical cord infarct secondary to fibrocartilaginous embolization and occlusion of anterior spinal artery, from recent mechanical compression of her C5‐6 disc. Cases of spinal cord infarcts following mechanical trigger, such as heavy lifting or falls, with histopathological confirmation of fibrocartilaginous material in the vasculature postmortem are well reported. It is postulated as a mechanism of spinal cord infarct in young patients that compressive forces on the intra‐vertebral body trigger embolization of nucleus pulposus material through persistent nuclear anastomoses to the spinal circulation. Conclusions Ischemic infarct should be considered in the differential diagnosis for sudden onset of symptoms localizable to spinal cord, especially when spinal MRI shows restricted diffusion in a vascular distribution. Demonstrating non‐opacification of the anterior spinal artery on digital subtraction angiography confirms the diagnosis. In case of negative work up for spinal cord infarct, the presence of an abnormal signal in the intervertebral disc on MRI may suggest fibrocartilaginous embolism as a mechanism of infarction in young patients.

Abstract Number ‐ 196: The Impact of Pre‐existing Depression on Functional Outcomes After Endovascular Treatment of Ischemic Stroke

Introduction Stroke is a leading cause of morbidity and mortality, and many factors predict a poor outcome, including age, NIH Stroke Scale (NIHSS), ambulatory status, and ability to swallow1. Mood disorders have previously been associated with an increased risk of cardiovascular disease2. The association between pre‐existing mood disorders and stroke outcome, however, has not been well studied. The objective of the current study was to explore the impact of pre‐existing depression on functional outcomes post‐endovascular treatment. Methods We reviewed the records of 178 patients who received mechanical thrombectomy (MT) at our institution[BH1][BM2] from 2019–2022. We collected data on baseline characteristics and demographics, including functional outcome at 90 days as measured by modified Rankin Scale (mRS), which was categorized as favorable (mRS 0–2) or unfavorable (mRS 3–6). Results Of patients who received MT, 54 (30.3%) had a prior medical history of depression. On univariate analysis, patients with a history of depression had 2.5 times higher odds of an mRS score of 3–6 (cOR = 2.47, 95% CI = 1.11‐5.48). Multivariate analysis included history of smoking, hypertension, obesity, Alberta Stroke Program Early CT Score (ASPECTS)[YC1][KC2], time to recanalization, and discharge NIHSS score, along with history of depression. We found that the odds of having an unfavorable mRS were 5 times higher in those with a history of depression than those with no history (aOR = 5.15, 95% CI = 1.09‐23.31). Additionally, discharge NIHSS was associated with 1.5 times higher odds of unfavorable mRS for each point increase in NIHSS score (aOR = 1.47, 95%CI = 1.25‐1.74). While pre‐existing depression was associated with poorer functional outcomes, it was not associated with mortality, cOR = 1.12, 95%CI = 0.55‐2.27. Conclusions In this study, we found that a prior medical history of depression is associated with unfavorable functional outcomes at 90 days in patients who received MT. Future studies should investigate the association between the severity of depression and stroke outcomes and explore methods to mitigate the impact of depression on stroke outcomes.

L’état antérieur : quelle incidence pour l’adulte, quelle incidence chez l’enfant ?

IntroductionSearching for a previous state is a common act in all medical disciplines, it corresponds to what appears in clear in any medical or social record: the prior medical history. The history is a time marker and an indicator of a possible symptomatological evolution or the risks incurred regardless of the medical specialty concerned. When they are searched for with an indemnity purpose, they are named prior state. MethodologyThe author draws on his experience of the contradictory expertise of victims (adult or child) terrorist attacks and on the analysis of the Dintilhac mission and missions emanating from CIVI (commission d’indemnisation des victimes d’infraction) and limits the study to psychic injuries during an attack. Objectives and ResultsAn assessment requested as part of a legal process is intended to assess the sequelae attributable to a fact, a harmful event (assault, attack) and the damages resulting from it. It is then necessary to check if there was a previous state in order to determine the impact of the harmful facts on the sequelae state. Based on clinical cases, the author describes the specificities of the psychiatric and psychopathological reasoning on which the expert relies depending on whether the previous condition was revealed before the attack or whether it was aggravated or revealed by the attack. ConclusionFor the psychiatrist, there is a global analysis to be carried out on what represents the previous state in the life course of the victim, the meaning it ascribes to him, and a more specific, medical aspect, which concerns the nature of the previous state.

Major adverse cardiovascular event risk following androgen deprivation therapy initiation by personal history of cardiovascular events.

351 Background: Associations between androgen deprivation therapy (ADT) and increased cardiovascular (CV) risk in prostate cancer (PCa) patients have been reported; however, how many of these major adverse CV events (MACE) are caused by ADT itself has been debated. One risk factor for increased CV risk is a prior history of CV events; an analysis found that each new CV event increased the probability of a future event. This study aims to evaluate the incidence of MACE after ADT initiation for patients with and without a prior medical history of MACE. Methods: Analyses of US electronic medical records (2010 to 2020) of PCa patients (n=45,059) receiving LHRH agonist and antagonist injections were conducted to evaluate MACE incidence after ADT initiation in patients with and without MACE history. Exclusion criteria included lack of ADT initiation date or myocardial infarction (MI)/stroke within 6 months prior to ADT initiation. MACE was defined as MI, stroke, and death from any cause. Kaplan-Meier event-free survival curves were constructed, and Cox regression was used to compare the MACE hazard rates between patients with and without a personal history of MACE. Multivariate Cox regression adjusted for agonists vs antagonist, increasing age per year, BMI (&lt;18.5 vs ≥18.5 kg/m2), race (White vs Black), family MACE history, ethnicity (Hispanic vs non-Hispanic), urology vs oncology setting, history of hypertension, and history of hypercholesterolemia. Results: Overall, MACE incidence was 3.9% and 19.6% for the cohort at one year and four years after ADT initiation, respectively. MACE risk following ADT initiation was higher for patients with history of prior MACE (unadjusted: (HR=2.76, 95% CI [2.49, 3.06], p&lt;0.001); adjusted: HR=2.29, 95% CI [1.93, 2.71], p&lt;0.001). When MACE was divided into component events, the risks of myocardial infarction and stroke were higher for patients with a prior MACE history compared to those without (8 vs. 1% and 8 vs. 2%, respectively), and the risk of any-cause death was similar (13 vs. 14%). Conclusions: MACE incidence in PCa patients in the first year of ADT was consistent with previous publications.(3). When MACE risk was analyzed in detail, ADT patients with a personal history of stroke or myocardial infarction (MI) had a 4- and 8-fold greater risk of a subsequent stroke and MI, respectively, compared to those without a history of stroke or MI. Given the large sample size (~45,000 PCa patients) of this data set over the recent past decade, these results likely reasonably reflect the real world. Urologists and oncologists should work with cardiologists, cardio-oncologists, and primary care practitioners to ensure the highest quality CV care is delivered.

Un cas rare de thrombose artérielle secondaire à une endocardite aortique à Aerococcus viridans

Infective endocarditis is an uncommon, yet serious disease responsible for high morbidity and mortality, its incidence is estimated at 3–10 cases per 100,000 person-years. Most infective endocarditis cases emanate from streptococcus and staphylococcus. The incrimination of Aeroccocus viridans is rarely described in the literature and it has a high rate of embolic complication.We report the case of a 31-year-old male patient, with no prior medical history, who was admitted to the cardiology department of Ibn Rochd university center due to a prolonged fever for over 6 months. At admission, his general condition was preserved, he was febrile at 38.7 °C, claudication in the right lower limb with a decrease in the peroneal artery pulse, a graded 4/6 diastolic aortic murmur on auscultation, and no signs of heart failure. The transthoracic echocardiography revealed a type I bicuspid aortic valve disease, severe aortic regurgitation, moderate aortic stenosis, and vegetation implanted on the ventricular side of the right coronary cusp. CT angiography of the lower limbs revealed a bilateral total occlusion of the tibioperoneal trunks extended to the proximal portions of the posterior tibial arteries and peroneal arteries with collateral circulation, endovascular collection, and occlusive calcified plaque of the proximal part of the right anterior tibial artery and the collateral circle. Blood tests showed an inflammatory syndrome. Blood cultures detected Aerococcus viridans.The patient was first put on ceftriaxone, gentamycin, unfractionated heparin, and analgesic-antipyretic when necessary, he was then transferred to the cardiovascular surgery department for replacement of the aortic valve and permeabilization of the lower limbs by the FOGARTY technique. Post-surgical results were satisfying.In conclusion, infective endocarditis secondary to Aerococcus viridans is rare but appears to be virulent because most often discovered at the stage of complications. Therefore, good antibiotic therapy adapted to the antibiogram results in a good prognosis.

Chronic viral coinfections differentially affect the likelihood of developing long COVID.

BACKGROUNDThe presence and reactivation of chronic viral infections, such as EBV, CMV, and HIV, have been proposed as potential contributors to long COVID (LC), but studies in well-characterized postacute cohorts of individuals with COVID-19 over a longer time course consistent with current case definitions of LC are limited.METHODSIn a cohort of 280 adults with prior SARS-CoV-2 infection, we assessed the presence and types of LC symptoms and prior medical history (including COVID-19 history and HIV status) and performed serological testing for EBV and CMV using a commercial laboratory. We used covariate-adjusted binary logistic regression models to identify independent associations between variables and LC symptoms.RESULTSWe observed that LC symptoms, such as fatigue and neurocognitive dysfunction, at a median of 4 months following initial diagnosis were independently associated with serological evidence suggesting recent EBV reactivation (early antigen-diffuse IgG positivity) or high nuclear antigen (EBNA) IgG levels but not with ongoing EBV viremia. Serological evidence suggesting recent EBV reactivation (early antigen-diffuse IgG positivity) was most strongly associated with fatigue (OR = 2.12). Underlying HIV infection was also independently associated with neurocognitive LC (OR = 2.5). Interestingly, participants who had serologic evidence of prior CMV infection were less likely to develop neurocognitive LC (OR = 0.52).CONCLUSIONOverall, these findings suggest differential effects of chronic viral coinfections on the likelihood of developing LC and association with distinct syndromic patterns. Further assessment during the acute phase of COVID-19 is warranted.TRIAL REGISTRATIONLong-term Impact of Infection with Novel Coronavirus; ClinicalTrials.gov NCT04362150.FUNDINGThis work was supported by NIH/National Institute of Allergy and Infectious Diseases grants (3R01AI141003-03S1, R01AI158013, and K24AI145806); the Zuckerberg San Francisco General Hospital Department of Medicine and Division of HIV, Infectious Diseases, and Global Medicine; and the UCSF-Bay Area Center for AIDS Research (P30-AI027763).

Uso de fluidoterapia en la práctica clínica

The use of intravenous fluid therapy must meet a need that cannot be met by oral administration and is not free from risk. No perfectly physiological intravenous solution is currently available. Intravenous solutions are classified into crystalloids and colloids. For the majority of indications, optimal intravenous fluid therapy is based on the use of crystalloids. The choice of fluid therapy must be personalised based on the patient’s characteristics and prior medical history, the current clinical situation, the osmolality and association of hydroelectrolytic imbalances and the acid-base equilibrium. The use of synthetic colloids is subject to significant restrictions given their negative effects on health outcomes, mainly anaphylactic reactions.

PS-BPR03-8: MALIGNANT HYPERTENSION WITH ACUTE KIDNEY INJURY AND THROMBOTIC MICROANGIOPATHY SUCCESSFULLY TREATED WITH ANGIOTENSIN RECEPTOR NEPRILYSIN INHIBITOR

Background: Malignant hypertension is a disease characterized by severe hypertension and multi-organ damage. Sacubitril/valsartan, a first-in-class angiotensin receptor neprilysin inhibitor (ARNi), has already demonstrated the superiority of reducing blood pressure versus olmesartan in patients with hypertension. ARNi has also been shown to improve cardiac biomarkers, cardiac remodeling, and prognosis in patients with heart failure, and a new AHA/ACC/HFSA guideline (2022) redefined to recommend ARNi as first-line renin-angiotensin-system inhibitors (class 1a) in patients with HFrEF (heart failure with reduced ejection fraction). However, the evidence about the efficacy and safety of ARNi in end-stage renal disease (ESRD) patients undergoing hemodialysis has been limited. Presentation: A 23-year-old man with no prior medical history was admitted to the previous hospital with severe hypertension (blood pressure 224/159 mmHg) associated with acute kidney injury (BUN 228.5 mg/dl, serum creatinine 25.50 mg/dl) and was referred to our hospital with the initiation of hemodialysis. He was also complicated with hypertensive heart failure with a preserved ejection fraction (NT-proBNP 172113 pg/ml). Blood test results also revealed thrombocytopenia (platelet 11.9 x 103/μL), hemolytic anemia (hemoglobin 7.4 g/dl, LDH 1076 U/L, haptoglobin &lt; 10 mg/dl), and schistocyte on the blood smear, which was suggestive of thrombotic microangiopathy. His blood cell counts and serum LDH levels improved after antihypertensive treatment. Secondary hypertension, such as primary aldosteronism, Cushing's syndrome, pheochromocytoma, and renal artery stenosis, was deniable by further examination. The elevated levels of renin (65.5 ng/ml/hr) and aldosterone (685 pg/ml) were consistent with malignant hypertension. Serum antibody tests for screening of autoimmune disease were all negative. Renal biopsy revealed findings of malignant nephrosclerosis: glomerular collapse, glomerulosclerosis, endothelial swelling, and media thickening of the arteries. Oliguria recovered during the clinical course; however, his renal function did not fully recover. An arterio-venous fistula was created, and maintenance hemodialysis two times per week was continued during hospitalization. Even though his dry weight was adjusted to normal by repeated dialysis, his blood pressure was poorly controlled to systolic blood pressure of 160–170 mmHg by calcium channel blockers, angiotensin II receptor blocker (ARB), and alpha/beta-blockers. After switching from ARB to ARNi by increasing the dose to a maximum of 400 mg, his systolic blood pressure improved to 130–140 mmHg and was stable throughout the day, assessed by ambulatory blood pressure monitoring. Conclusion: Through our experience, it is conceivable that ARNi may be helpful in the settings of resistant hypertension in ESRD patients undergoing hemodialysis.

What You See Is Not What You Get: Germ Cell Tumor Mimicking Disseminated Coccidioidomycosis.

We present the case of a 30-year-old man with no prior medical history who presented to the hospital with a myriad of symptoms such as shortness of breath, generalized weakness, lower limb weakness, and urinary retention. He was recently diagnosed with "disseminated coccidioidomycosis" by an outside provider on an outpatient basis and started on fluconazole orally. However, due to a lack of improvement and significant symptoms, he was sent to the hospital to initiate liposomal amphotericin B treatment. After a comprehensive workup, an alternative diagnosis was suspected and eventually confirmed as metastatic germ cell carcinoma. Due to the vast dissemination and his poor functional status despite chemotherapy initiation, the patient elected for palliative care and expired shortly after at hospice. This case demonstrates the similarity of clinical findings between disseminated infections and malignancies.

Novel Approach for Assessing Postinfarct Myocardial Injury and Inflammation Using Hybrid Somatostatin Receptor Positron Emission Tomography/Magnetic Resonance Imaging.

Novel Approach for Assessing Postinfarct Myocardial Injury and Inflammation Using Hybrid Somatostatin Receptor Positron Emission Tomography/Magnetic Resonance Imaging.

1009 INTRAMYOCARDIAL HEMORRHAGE: A DIFFERENTIAL DIAGNOSIS OF HYPERTROPHY

Abstract Hypertrophic cardiomyopathy (HCM) is a muscle disorder with impairment of microvascular circulation. Intramyocardial hemorrhage (IMH) represents a possible complication in patients with myocardial infarction (MI) involving left ventricular (LV) myocardial tissue and micro vascularization. We describe a case of a HCM patient with anterior STEMI with evidence of IMH. Case Report A 61-years-old male patient from Sri Lanka with no prior medical history presented to the emergency Department with persistent chest pain started from 3 hours. He was a smoker. The first ECG revealed ST-segment elevation in V2-5 leads and symmetric negative T-wave in I and aVL leads. Primary percutaneous coronary intervention (PCI) was performed, revealing sub-obstructive stenosis in the proximal left anterior descending artery (LAD) associated with extensive endoluminal thrombus. Invasive coronary angiogram also showed a critical stenosis in distal right coronary artery (RCA) and a chronic occlusion in the proximal left circumflex coronary artery (LCx). After tirofiban intravenous administration and rheolytic thromboaspiration, drug-eluting stent (DES) implantation of the LAD artery was performed successfully. Transthoracic echocardiography, performed after primary PCI, documented akinesia of proximal LAD territories and LV ejection fraction (EF) of 45%. The curious feature was the evidence of concentric hypertrophy in absence of an apparent reason. Therefore, three days later, the patient underwent cardiac magnetic resonance (CMR), showing mildly reduced LV function (LVEF 42%). CMR images also showed subendocardial late enhancement in proximal LAD territory and transmural LGE with no-reflow phenomenon in mid-apical anteroseptum. (Figure) On T2-weighted images, there was an hypointense core enclosed in the transmural hyperintense area in basal-mid anteroseptum, likely in keeping with intramyocardial hemorrhage (Figure). After a staged PCI with the implant of another DES in RCA, patient was discharged in DAPT (aspirin + ticagrelor). Conclusion IMH is considered a severe form of MVO, which occurs in the core of the infarcted area in patients with myocardial infarction. We describe an intriguing case with IHM in HCM patient. Moreover, it raises several questions on which is the best treatment option.

1271: MUCINOUS ADENOCARCINOMA MIMICKING INTERSTITIAL LUNG DISEASE DISCOVERED POST-TRANSPLANT

Introduction: Mucinous adenocarcinomas typically present with cough, dyspnea and pleuritic chest pain. They have a wide range of radiographic appearances including a single nodule, lobar consolidation, or diffuse nodules. These tumors can mimic infectious and non-infectious pulmonary pathologies both clinically and radiographically. We report a rare case of invasive mucinous adenocarcinoma, mimicking interstitial lung disease discovered post bilateral lung transplant. Unfortunately, the diagnosis was made after lung transplantation posing a challenge in the management of immunosuppression in the setting of malignancy. Description: A 47-year old male with no prior medical history initially presented with progressive dyspnea on exertion for several months. Family history was significant for pulmonary fibrosis in his mother. High resolution CT chest showed extensive ground-glass opacification, upper lobe honeycombing, and consolidative changes with air bronchograms in bilateral lower lobes. Autoimmune workup and hypersensitivity pneumonitis panel were negative. Bronchoscopy and multiple sputum cultures were unrevealing. Genetic testing identified a mutation in the SFTPA2 gene, associated with familial pulmonary fibrosis. Patient’s respiratory status improved with intravenous steroids and he was discharged with oxygen supplementation, prednisone and nintedanib. However, patient was admitted two months later with clinical deterioration and acute hypoxemic respiratory failure requiring venovenous extracorporeal membrane oxygenation as a bridge to successful bilateral lung transplantation. A lung biopsy prior to transplant could not be obtained given the rapid progression of patient’s respiratory failure. Subsequently, pathology of the explanted lungs showed invasive mucinous adenocarcinoma with metastatic disease to a perihilar lymph node. PET CT scan was negative for extra thoracic metastasis. Discussion: After a multidisciplinary discussion, it was decided to continue immunosuppression with tacrolimus and a decreased dose of mycophenolate. Additionally, active surveillance with PET CT scans every three months was recommended. This case highlights the difficulties faced in the diagnosis of pulmonary adenocarcinoma due to its clinical and radiographic overlap with interstitial lung disease.

The Heavy Heart: An Unusual Cause of Ventricular Tachycardia

A 17-year-old female presented to the emergency department with a one-hour history of abdominal pain, nausea, vomiting and weakness. Physical examination on admission revealed a heart rate of 106 beats per minute, blood pressure of 136/88 mmHg and a respiratory rate of 25 breaths per minute. Her medical history was unremarkable with no prior medical comorbidities or surgical history. She denied taking any prescribed or over the counter medications. The initial ECG showed ventricular tachycardia (VT) (Figure 1), with investigations revealing a normal troponin I level of <0.03ng/ml (reference range <0.3 ng/mL), elevated N-terminal pro-brain natriuretic peptide level of 439.2 ng/L (reference range <300 ng/L) and normal serum potassium level of 4.0 mmol/L (reference range 3.5-5.3 mmol/L). Over the next hours, the patient developed shallow respirations, with rapid worsening of muscle weakness involving all four limbs. An arterial blood gas obtained on room air revealed severe acidosis (pH, 7.178) and hypoxemia (PaO2, 65.8 mmHg). A repeated blood test conducted four hours after admission noted profound hypokalemia (serum potassium, 1.9 mmol/L).