Contusion Research Articles

ODP304 Cyclic Cushing Disease: A Diagnostic Challenge

Abstract Background Cyclic Cushing syndrome is a clinical challenging diagnosis due to an unpredictable duration of periodic hypercortisolemia shifting with normocortisolemia periods. Only small proportion of such cases are due to a corticotroph pituitary adenoma with cyclic activity. Clinical case: 27-year-old after she stopped nursing her baby, she had no resumption of menses. She then developed mild headache and weight gain of 20kg throughout 3 months. She also developed facial hair, acne, easy bruising and striae. She was evaluated by a local physician where Cushing syndrome (CS) was suspected. Local testing showed the following results: UFC: 1117 and 1572 mcg/24h (<403mcg/24h), low dose DST of 595.8 nmol/l (<50nmol/l) and ACTH 60 pg/mL (10-100pg/mL). An MRI identified a 6 mm pituitary adenoma. The patient was sent to our pituitary clinic under the diagnosis of Cushing disease (CD). Upon examination at our institution, the patient reported asthenia, mood changes, depression and hirsutism. The physical examination revealed classical signs of CS. No other comorbidities were detected. A seven-hour 7mg dex infusion testwas performed (1), with basal cortisol of 187.5 nmol/l, early suppression of 12.6 nmol/l and late suppression of 27.5 nmol/l which is negative for hypercortisolism. As the high suspicion of CS, the patient was followed monthly with UFC and serum cortisol. During this normocortisolemia period the patient lost 10kg of weight, recovered its menses and coloration changes of striae. Laboratory follow up UFC of 67, 71 mcg/24h and serum cortisol of 124, 270, 103.4, 358.6 and 413 nmol/l ACTH 20, 21, 23, 28, 25 pg/mL. After 6 months of no clinical sign of hypercortisolism the patient reached to us as she noticed her striae changed, started gaining weight, lost menses and changed headache frequency. Laboratories revealed UFC was 754.6 mcg/24h and low dose DST was 751.1 nmol/l and ACTH of 70 pg/mL. We conducted another continuous 7mg dex infusion for seven hours with basal cortisol of 669.2 nmol/l, early suppression of 90.2 nmol/l (>50% suppression) and late suppression of 691.5 nmol/l which was compatible with CD. Additional testing was performed, with a 18F-NOTA-Octreotide and a full body CT that did not reveal an ectopic ACTH producing tumor neither an adrenal mass. Patient underwent a transsphenoidal surgery and reached remission of her hypercortisolism. Conclusion CD may be difficult to be confirmed but also it is important to consider that some cases showed cyclic activity. As far as we could acknowledged, this is the first case showing a 6-month period of normocortisolemia in a cyclic ACTH-secreting pituitary adenoma. Bibliography Biemond P, de Jong FH, Lamberts SW. Continuous dexamethasone infusion for seven hours in patients with the Cushing syndrome. A superior differential diagnostic test. Ann Intern Med. 1990 May 15;112(10): 738–42. Presentation: No date and time listed

ODP050 Oncocytic Adrenocortical Carcinoma Presenting with Hematuria

Abstract Introduction Adrenocortical carcinoma (ACC) is rare and aggressive endocrine tumor. It is commonly noticed due to symptoms of hormone excess, mass-effect, or incidentalomas. Different histological variants are noted, which include: oncocytic, myxoid, sarcomatoid, and the conventional subtype. The oncocytic variant is usually seen on the left side, and usually presents with symptoms of mass-effect. Only around 17% were noted to be functional. We present an interesting case of ACC (oncocytic type) which presented with hematuria. Case Presentation 70-year-old female with a history of morbid obesity, hypertension, anxiety, GERD, tubular adenoma, hyperlipidemia, and lumbar radiculopathy came in to see her primary care for hematuria and back pain. She has a long-standing history of back pain, for which she has had an EMG, which showed mild axonal polyneuropathy and bilateral L5 radiculopathy. Apart from hematuria, she denies any other urinary complaints. Additionally, she denied any fever, chills, nausea, abdominal pain, sweating, tremor, headache, palpitations, easy bruising, fractures, muscle weakness, hirsutism, or changes in her weight. She has a family history of pancreatic cancer and is currently retired, and denies alcohol, tobacco, or recreational drug use. A KUB X-ray was ordered which showed calcification in the left upper quadrant, concerning for a splenic artery aneurysm; this led to a CTA abdomen, which showed a large 7.2 cm heterogenous enhancing solid left adrenal mass, concerning for primary adrenal carcinoma, which was new compared to imaging 2 years ago. Also seen was a 0.7 cm enhancing right hepatic lobe lesion, along with a 1.5 cm splenic artery aneurysm. Following this, an abdomen MRI with contrast showed a 7×7×7 cm solid heterogeneously enhancing left upper quadrant mass beside the left adrenal gland and pancreas. Subsequently, a CT guided needle biopsy was done, which revealed scant adrenal tissue. PET scan showed a hypermetabolic mass, arising from the left adrenal, consistent with adrenal carcinoma. At this point, an endocrinology referral was placed, and other lab work including 24-hour urine free cortisol, DHEA-S, 24-hour urine metanephrine, and aldosterone/renin ratio was done. DHEA-S level was elevated at 264 mcg/dl (12-133). She was then transferred to a tertiary care facility, where she underwent a left adrenalectomy, para-aortic lymphadenectomy, nephrectomy, splenectomy, and distal pancreatectomy. Pathology confirmed adrenal cortical carcinoma (oncocytic type), with negative margins, Ki-67 labelling index of 25%, and no lymphovascular invasion, pT2pNO. She was then discharged home with visiting nurses. Conclusion Oncocytic ACC is an infrequent tumor, which presents with symptoms of mass effect, and definitive diagnosis requires histopathological assessment. The Lin–Weiss–Bisceglia (LWB) system and Helsinki score help establish malignant potential. Fortunately, it has a decreased tendency to metastasize and a better prognosis than other ACC subtypes. Further studies to understand oncocytic ACC are needed. Presentation: No date and time listed

PMON98 High-dose dexamethasone suppression test in ACTH-dependent Cushing's syndrome: Lessons learned on the lack of cortisol suppression

Abstract Background The overnight 8-mg high-dose dexamethasone suppression test (HDDST) has been used to discern Cushing's disease from ectopic ACTH production. However, because of its reported low diagnostic accuracy, its use is limited to the assessment of ACTH-dependent Cushing's disease when combined with a corticotropin releasing hormone (CRH) or a desmopressin stimulation test. We evaluated a patient with Cushing's disease in whom the HDDST failed to identify the pituitary source. We point to limitations in test interpretation and highlight the need of future studies to enhance understanding of the clinical utility of this non-invasive test. Clinical Case A 42-year-old male presented with lower extremity cellulitis and hypertensive emergency. He reported increased abdominal girth, easy bruising, severe back pain and proximal muscle weakness and noted headache and blurred vision. Exam was pertinent for obesity (body mass index 31.5 kg/m2), moon facies, dorso-cervical hump and prominent abdominal striae. Lumbar and thoracic compression fractures were noted on imaging. The elevated 24-hour urinary free cortisol level (198 ug/dL; reference: 10-100 ug/24hr) and lack of suppression on the overnight 1-mg dexamethasone suppression test (morning cortisol 23.7 ug/dL) confirmed Cushing's syndrome; a high ACTH level of 92 pg/dL defined it as ACTH-dependent. The 8-mg HDDST resulted in only a 9.7% reduction of his baseline morning cortisol. The patient was not on any medications that enhanced dexamethasone clearance. Serum dexamethasone levels were measured to aid in test interpretation and, although a level was provided, reference values for the single overnight 8-mg dose of dexamethasone were lacking. A CRH stimulation test was performed and resulted in a 60% increase in ACTH levels from baseline, supporting the diagnosis of Cushing's disease. Additionally, a pituitary MRI revealed a suprasellar 2.5×1.5×1.3 cm mass. Due to ambiguity posed by the HDDST result, despite tumor size, neurosurgery requested inferior petrosal sinus sampling (IPSS). Prior to this procedure, the patient underwent an overnight 16-mg HDDST. While limited information remains on the diagnostic performance of this test, we observed that the baseline morning cortisol decreased by 53.9%. IPSS confirmed the diagnosis of Cushing's disease and pathology identified a corticotroph adenoma. Conclusion The diagnosis of Cushing's disease is complex and recommendations continue to evolve. Th role of the HDDST in combination with another dynamic test remains clinically relevant. It is important that when considering a HDDST, clinicians review medication history to exclude agents that may interfere with dexamethasone metabolism. Our case highlights the need of studies that determine an appropriate reference range for dexamethasone plasma levels after a single 8-mg overnight dose and that evaluate the diagnostic performance of the HDDST in this context. It also brings attention to the need of further elucidating the diagnostic utility of a higher dexamethasone dose in the evaluation of ACTH-dependent Cushing's syndrome. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

PMON17 Impaired cortisol regulation in Myotonic dystrophy

Abstract Introduction - Myotonic dystrophy (MD) is the most common cause of adult-onset muscular dystrophy. It has impaired HPA axis regulation with exaggerated ACTH response to CRH mediated stimuli and abnormal cortisol metabolism. We present a case of myotonic dystrophy in a male with elevated cortisol levels. Case report - 54-year-old male with a past medical history of type 1 myotonic dystrophy (MD1) presented for evaluation of hypogonadism with complaints of feeling fatigued, progressive weakness of muscles. During the workup, he was noted to have elevated cortisol levels 30.2 mcg/dL (6-18.4) with elevated ACTH 220 pg/mL (10-48). Other notable lab results included low total testosterone levels of 231, 185 with elevated LH of 17.3 m IU/ml (2-9) and FSH 37.7 m IU/ml (1-12). Prolactin levels were minimally elevated to 21.4 ng/mL (4-15.2). On further inquiry, the patient did not have headaches or vision changes. The patient did not report weight gain, easy bruising, change in facial appearance. Physical exam was significant for bilateral gynecomastia and small testes. No cushingoid facies, abdominal stria, proximal myopathy was noted. Given elevated ACTH and cortisol levels, further laboratory data showed a lack of suppression of cortisol levels with 1 mg dexamethasone - cortisol 2.9 micro g/dL (<1.8), elevated midnight salivary cortisol - 0.130, 0.102 ug/dl (0.010-0.090), and normal 24-hour urine cortisol levels -15 mcg/24 hours. Discussion – Even though Cushing's disease is one of the differential diagnoses for the above case, high cortisol levels have been reported in MD. Few mechanisms suggested causing this abnormality are increased ACTH responsiveness to CRH-mediated stimuli and abnormal cortisol metabolism. Patients with MD have high pro-inflammatory (IL-1 and TNF-a) markers, which mediate the increased ACTH responsiveness to CRH-mediated stimuli centrally by stimulating the HPA axis.1 In addition, IL-6 chronically stimulates steroidogenesis from the adrenal gland, whereas TNF-α inhibits ACTH-induced adrenal steroid synthesis and increases 11BHSD1 activity. Along with the impaired HP axis, abnormal metabolism of cortisol also contributes to elevated cortisol levels. Increased activity of 11 BHSD1 has been hypothesized to cause impaired clearance of cortisol.2 Impaired diurnal variation for cortisol is also seen in MD with elevated 24-hour cortisol levels. Elevated cortisol levels as in our case can be a diagnostic dilemma given impaired cortisol regulation as seen in MD. References Åsa Johansson et.al. Abnormal Cytokine and Adrenocortical Hormone Regulation in Myotonic Dystrophy, The Journal of Clinical Endocrinology & Metabolism, Volume 85, Issue 9, 1 September 2000, Pages 3169–76.Åsa Johansson et.al. Glucocorticoid Metabolism and Adrenocortical Reactivity to ACTH in Myotonic Dystrophy, The Journal of Clinical Endocrinology & Metabolism, Volume 86, Issue 9, 1 September 2001, Pages 4276–83 Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

ODP278 A rare case of Ectopic ACTH secretion associated with Primary Gastric Choriocarcinoma

Abstract Background Ectopic ACTH production contributes to 10-15% of cases of Cushing's syndrome. Most cases are caused by neuroendocrine tumors of the lung, pancreas, or thymus. Other rare tumors causing ectopic ACTH secretion include esophageal tumor, gastric carcinoid tumor and squamous cell carcinoma of the larynx (1). We present a rare case of ectopic ACTH production causing Cushing syndrome due to primary gastric choriocarcinoma. Case Presentation A 27-year-old lady, not known to have any chronic illnesses, presented with two days history of epigastric pain. The patient also reported facial puffiness, leg swelling, generalized weakness and oligomenorrhea for the last four months. There was no history of easy bruisability or weight. She was not taking any medications. The patient did not smoke or use alcohol. Physical examination revealed conjunctival pallor, facial acne, wide striae on her thighs and hepatomegaly. The rest of the examination was normal. Lab tests showed microcytic anemia with hemoglobin of 7 gm/dl (12-15 gm/dl), hypokalemia (2.5 mmol/L; normal 3.5-5.3 mmol/L), AST 38 U/L (0-40 U/L) and ALT 45 U/L (0-41 U/L). β HCG was 1,506 mIU/mL (0 -5 mIU/ml). An abdominal ultrasound showed hepatomegaly with multiple echogenic solid mass lesions suspicious of metastatic origin. A CT abdomen showed a solid lesion in the fundal region of the stomach with multiple liver metastases and moderate ascites. An esophagogastroduodenoscopy showed fungating mass originating from the stomach fundus. Biopsy of the gastric mass revealed primary gastric adenocarcinoma, which was positive forCK 7, CK 19, beta hCG, CDX2 and CEA, consistent with the diagnosis of primary gastric choriocarcinoma. Due to widespread metastasis, the patient was started on palliative chemotherapy with dexamethasone 2 mg injection once daily along with capecitabine, cisplatin and pembrolizumab. In view of persistent hypokalemia and physical examination findings, a workup for Cushing's syndrome was performed. Early-morning serum cortisol was 1054 nmol/L (138–689 nmol/L), and plasma ACTH was 174 pg/ml (7.2-63.3 pg/ml) despite the patient being on intravenous 2 mg dexamethasone once daily for more than ten days. An MRI of the brain showed a normal pituitary gland. Based on these findings, the patient was diagnosed with Cushing's syndrome due to ectopic ACTH secretion. Unfortunately, her hospital course was complicated by massive upper gastrointestinal bleeding from the tumor, leading to her demise. Conclusion Gastric choriocarcinoma is a rare tumor associated with ectopic ACTH secretion leading to Cushing's syndrome. Reference: Imura H, Matsukura S, Yamamoto H, Hirata Y, Nakai Y. Studies on ectopic ACTH-producing tumors. II. Clinical and biochemical features of 30 cases. Cancer. 1975 May;35(5): 1430-7 Presentation: No date and time listed

PSAT051 Posterior Reversible Leukoencephalopathy Syndrome Associated With Cushing's Syndrome

Abstract Background Corticosteroids can induce hypertension through a variety of mechanisms such as vasoconstriction, increased hepatic production of angiotensinogen, sympathetic activity, and possible direct cardiotoxic effect. Posterior reversible leukoencephalopathy syndrome (PRES), a syndrome with unclear pathogenesis, can be the consequence of blood pressure elevation in these patients, which can present with headaches, altered consciousness, visual disturbances, or seizures. CASE REPORTA 57-year-old African American woman with a history of hypertension on Lisinopril 40mg as an outpatient, who was brought to the emergency department (ED) by family members due to altered mental status (AMS). Daughter reports that a day prior to the admission the patient has complained of feeling unwell, with mild shortness of breath and anxiety. On admission, she was found to be on sinus tachycardia with heart rate between 100-140bpm and severely hypertensive at 203/107mmHg. Toxicology screen was positive for cannabinoids, which the patient admitted to vapping the night prior. At the ED, Stroke alert was called due to altered mentation and weakness, however CT brain showed no large infarct or hemorrhage. MRI was obtained and showed patchy t2/flair hyperintense signal abnormality predominantly of the subcortical white matter in the bilateral frontoparietal lobes, most conspicuous at the vertex. Findings could reflect acute hypertensive encephalopathy (PRES). The patient had a Cushingoid appearance, with truncal obesity, moon face and reported easy bruising. Given the clinical findings and severe hypertension, serum cortisol was obtained at night and was found to be elevated at 34. 08UG/DL (3.44 - 16.76 ug/dl). ACTH was mildly low at 5 pg/mL (6-50pg/mL). 24-hour urine cortisol was then ordered and also found to be elevated at 818mcg/24h (4-50mcg/24h). Blood pressure was controlled with antihypertensive medications (nifedipine 60mg and carvedilol 12.5mg), AMS resolved and patient was discharged home with follow up with endocrinology for further Cushing's workup. Conclusion Cushing Syndrome is a known cause of secondary hypertension that should not be neglected. Patients that present with severe or resistant hypertension regardless of age should be worked up for possible secondary cases. Patients with Cushing syndrome are at elevated cardiovascular risk and the sooner the diagnosis is made, the better, so they can receive appropriate treatment. Hypertensive crisis can present as PRES syndrome and patients with clinical suspicion for Cushing should be worked up for the condition. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Spontaneous Hematoma of Upper Extremities in a Patient with Antiphospholipid Antibody Syndrome: A Case Report

A 44-year-old woman with underlying systemic lupus erythematosus and antiphospholipid antibody syndrome presented with nausea and vomiting after her 2nd vaccination for coronavirus disease 2019 (COVID-19). Thirteen days after warfarin injection was administered along with steroid therapy, the patient suffered sudden right shoulder pain, paresthesia, and swelling, suggesting acute compartment syndrome. The warfarin regimen was bridged to low molecular weight heparin and fasciotomy was performed. Multiple hematoma evacuation after fasciotomy was done and the patient was referred for skin necrosis. Frequent debridement and negative pressure wound therapy were performed to heal the right upper extremity skin defect. Afterwards, the patient experienced hemorrhage in her left upper extremity and was treated conservatively with simple compression. This report suggests that patients undergoing anticoagulation therapy for antiphospholipid syndrome should be closely monitored for subcutaneous hemorrhage, and that prompt diagnosis and treatment may prevent adverse results. If massive skin necrosis occurs, multiple surgical debridement procedures and application of negative pressure wound therapy may be an option.

Case Report On Cirrhosis Of Liver

Introduction: - The liver is irrevocably damaged and replaced with scar tissue as a result of the late-stage liver disease cirrhosis. Scar tissue prevents your liver from functioning properly. Cirrhosis typically develops decades after the onset of chronic liver disease. Men experience it twice as frequently as women. Clinical Findings:-Weakness, loss of appetite, easy bruising, skin yellowing (jaundice), itching, and weariness are all symptoms of cirrhosis. Diagnostic Evaluation: -Blood test: - HB % = 9.3gm%, total RBC count = 2. 99cu.mm, total WBC count = 11800cu.mm, total platelet count = 1.23 lac cu.mm, total protein = 6.5g/L, total bilirubin = 15.8g/L, lymphocytes = 10%, monocytes = 0.2%, albumin =2.2. Peripheral Smear: - RBCs - Normocytic mildly hypochromic Platelets - Reduced on smear APC - 38000 cells/mm³ as per cell counter no Haem parasite seen. Ultrasonography:- Options include liver needle biopsy, ultrasonography, and magnetic resonance imaging (MRI). an innovative imaging technique called electrography. Therapeutic Intervention: - Inj. Albumin 20% × OD, Inj. Vitamin K 10mg ×OD, Inj. Optineuron ×OD, Inj. Pan 40mg × OD, Inj. Emset 4mg × SOS, Inj. Levoflox 500mg × OD.
 Outcome: - After treatment the patient show
 Improvement. His appetite is improved and skin condition is also improved and his Weakness is reduced.
 Conclusion:- With a known case of liver cirrhosis, the patient was admitted to the hospital with complaints of weakness, loss of appetite, easy bruising, jaundice, itching, and weariness. His condition improved after receiving the proper care.

Approach to: Bleeding

This article presents a basic approach to the bleeding patient and is intended for medical students in their pre-clinical and clerkship years. Easy bruising and abnormal bleeding are relatively common symptoms, and may present as excessive bleeding post-injury, epistaxis, menorrhagia, prolonged bleeding after surgery or spontaneous bleeding. Identification and appropriate medical management of abnormal bleeding and bruising can decrease associated morbidity and mortality.

Een 57-jarige man met hoge koorts, hevige spierpijn, trombocytopenie, icterus en acute nierinsufficiëntie: diagnostische sleutels tot een vergeten, maar opkomende ziekte

A 57-year-old man with a high fever, severe muscle aches, thrombocytopenia, icterus and acute renal failure: diagnostic keys to a forgotten but emerging disease Leptospirosis is a well-known disease in (sub)tropical regions, but in these areas it is often forgotten and unrecognised. In recent years, however, there has been an increasing incidence in these regions, mainly due to recreational exposure. Leptospirosis is a zoonosis. The rat is the main reservoir. Transmission of leptospires usually occurs via exposure of skin and mucous membranes to an environment contaminated by rat urine. The disease has a biphasic course with an initial phase of bacteremia followed by a fierce immune response provoked by vasculitis. The clinical presentation is variable, but in the vast majority of the cases the condition presents as a non-specific flu-like syndrome characterised by pronounced myalgia. A typically fulminant disease course with severe acute renal failure, haemorrhagic rash, submucosal and subcutaneous haemorrhage, icterus and thrombocytopenia is rather rare but has a significant mortality despite the current intensive care. The final diagnosis is most often confirmed by the detection of antibodies against leptospirosis. PCR tests are also available. Mild forms are often self-limiting, therefore antibiotic treatment is not always necessary. In case of a fulminant course of the disease, hospitalisation for maximum supportive care and antibiotic therapy is primordial. In this article, the pathogenesis, clinical presentation, diagnosis and treatment of leptospirosis are discussed based on a clinical case.

Effect of mángzhēn huīcì (relaxing needling with sharp long needle) for iliotibial band friction syndrome: A randomized clinical trial 芒针恢刺治疗髂胫束摩擦综合征-随机临床试验

Objectiveto observe the clinical effect of acupuncture by mángzhēn huīcì (relaxing needling with sharp long needle) on iliotibial band friction syndrome (ITBS). Designthis was a two-arm randomized controlled trial with blinding of participants, outcome assessment and statistician. Settingacupuncture-Moxibustion, Tuina and Orthopedics Department and the Orthopedics Department of Shanghai the Sixth People's Hospital, June 2018 to January 2021. Participantsa total of 64 patients with iliotibial band friction syndrome (ITBS). Interventionswith a 1:1 ratio the patients were randomly assigned to either the conventional acupuncture group (CA, n=32) or the Relaxing Needling with Sharp Long Needle group (RNSLN, n=32). The CA group was treated by applying acupuncture at Jūliáo (居髎GB 29), Fēngshì (风市GB 31), Liángqiū (梁丘ST 34), Yánglíngquán (阳陵泉GB 34), and Ashi points (阿是穴) of the affected side, and the RNSLN group was treated by applying relaxing needling with sharp long needle at Jūliáo (居髎GB 29), Liángqiū (梁丘ST 34), and Ashi points of the affected side. Both groups were treated once every other day, 10 times as one course of treatment. Outcome measuresthe treatment effect was evaluated after one course of treatment by comparing their KSS scores and VAS scores, as well as overall response rate. ResultsSixty-four patients were included in the final data analysis. There was no difference in KSS and VAS scores between the two groups before treatment (P>0.05). After treatment, the KSS score of the two groups was higher than that before treatment, the VAS score of the two groups was lower than that before treatment (P<0.05). The KSS score of the RNSLN group was higher than that of the CA group, and the VAS score of the RNSLN group was lower than that of the CA group (P<0.05). The overall response rate of the RNSLN group was 93.75%, higher than 75% of the control group (P<0.05). Each group has 1 case of subcutaneous bleeding as adverse event. ConclusionRelaxing Needling with Sharp Long Needle could be more beneficial for iliotibial band friction syndrome (ITBS) compared with conventional acupuncture, and more evidence is required for its effectiveness before introducing the approach widely to clinical practice.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients.

Background:Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises.Purpose:To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises.Results:Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise.Conclusion:MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

HEMORRHAGIC PLEURAL EFFUSION IN A PATIENT WITH CHRONIC LYMPHOCYTIC LEUKEMIA ON IBRUTINIB THERAPY

HEMORRHAGIC PLEURAL EFFUSION IN A PATIENT WITH CHRONIC LYMPHOCYTIC LEUKEMIA ON IBRUTINIB THERAPY

Von Willebrand Disease-Specific Aspects in Women.

Von Willebrand disease (VWD) is the most common inherited bleeding disorder, which results from a deficiency or dysfunction of von Willebrand factor (VWF). The major symptoms of patients affected by VWD include mucocutaneous and gastrointestinal bleeding, easy bruising, and prolonged provoked bleeding due to injury or surgery. Although women and men are equally likely to be affected by VWD, women continue to be disproportionately affected by the bleeding challenges. Women with VWD suffer from sex-specific symptoms, such as menorrhagia, and are at higher risk of reproductive problems and recurrent miscarriage. Furthermore, pregnant women with VWD are more likely at higher risk of suffering from primary and secondary peripartal hemorrhage and anemia and the need for transfusions. Despite being affected by gynecologic and obstetrical bleeding, women face multiple barriers in obtaining an accurate diagnosis. This constitutes a problem that needs to be addressed, and early appropriate medical care should be ensured. There are several effective treatment options for women with VWD that can significantly improve their quality of life, including desmopressin, VWF concentrates, hormonal therapy, and antifibrinolytic therapy. During pregnancy, the monitoring of VWF activity levels is essential. The peripartal management depends on the type of VWD and on the measured levels of VWF levels and activity prior to delivery.

Complete Closed Rupture of the Medial Bundle of the Flexor Hallucis Brevis Tendon Off the Medial Sesamoid Insertion

Category: Midfoot/Forefoot; Basic Sciences/Biologics; Sports; Trauma Introduction/Purpose: Flexor tendon injuries of the hallux are uncommon overall but when they happen, the flexor hallucis longus (FHL) tendon is the most frequent one affected. The rupture of FHL usually results from open injuries and deep cuts in the sole at the base of the toe;4 complete subcutaneous ruptures are extremely rare.5 There are around 36 cases reported of complete or partial closed ruptures of the FHL tendon along its entire course6 and the majority of the partial ruptures correspond to dancers and athletes.7 As far as FHB, we found a few reports of calcific tendinitis of the medial bundle and cases of calcifying tendinitis.8 To the best of our knowledge, this is the only case report of isolated closed rupture of the FHB tendon. Methods: A 33-year-old man, amateur soccer player, presented with mild swelling, ecchymosis, and increasing pain in the left hallux triggered by movement and palpation, relieved by rest. He sustained a direct axial blow and blunt force trauma with a soccer ball plus hyperextension. Standard bilateral weightbearing feet radiographs were normal. Physical exam revealed the left hallux normally aligned but with limited painful motion of 20° each way and no obvious instability. Palpation of the left first metatarsophalangeal joint was tender but not particularly over the sesamoids. MRI revealed an avulsion of the flexor Hallucis Brevis tendon off the proximal aspect of the medial sesamoid accompanied by fluid and edema, effusion in the first MTP joint and bone contusions in the first metatarsal head and dorsal base of the first proximal phalanx. Treatment with a toe spacer and postop sandal with the toe straight with an extension block was decided. Results: Tendon's blood flow around the sesamoids is limited making it susceptible to degenerative rupture. The most common mechanism of complete tendon rupture is direct open injury. Closed rupture is very rare and complete rupture in closed injury is even more. We did not find reports on third degree type of injuries, neither for any kind of isolated rupture of FHB. In our patient's case, dorsiflexion stretched all plantar soft tissue around the first MTP but he was able to do active movement of the great toe probably due to the FHL and lateral FHB insertion integrity. We found few reports of second-degree strain injury of FHL and FHB in a chronic setting, all treated conservatively with partial immobilization and strapping of the hallux to prevent extension. After conservative treatment at 3 months follow-up, our patient presented with no subjective complains, normal motion, stability and alignment of the hallux. Conclusion: Despite an extensive literature search, we did not find a similar injury, and this is probably the first time it is described. As found in our research, the most common injury related to the flexor tendons of the hallux are in soccer players and involve the FHL or both.23 These findings made us conclude that these injuries are either under-diagnosed or exceptional.

S3091 Noncirrhotic Portal Hypertension in Turner’s Syndrome: A Case Report

Introduction: Turner's syndrome is one the most common chromosomal aneuploidies in humans. Although it can affect multiple organs, involvement of gastrointestinal (GI) organs is rare. Case Description/Methods: A 20-year-old female with history of Turner's syndrome with premature ovarian failure and mild mitral regurgitation was evaluated for easy fatigability and bruising. Laboratory assessment indicated pancytopenia. Peripheral blood smear showed a variety of red cell shape abnormalities and bone marrow biopsy showed normal cellular marrow. Computed tomography of the chest, abdomen and pelvis with and without contrast showed severe splenomegaly, tiny varices in the anterior mediastinum along the gastrohepatic ligament, and no portal vein thrombosis. Abdominal ultrasound examination revealed severe diffuse heterogeneity of the liver parenchyma with a slightly nodular hepatic contour and Fibroscan indicated mild steatosis S1 with advanced fibrosis F3. She underwent liver biopsy which showed focal mature fibrous expansion of some portal tracts, with delicate bridging fibrosis, as well as patchy increase in the number of small portal arteries with occasional increased thickness of arterial wall, subtle lobular parenchymal changes, suggestive of porto-sinusoidal vascular disease with no evidence of cirrhosis. Upper GI endoscopy revealed grade 2 esophageal varices and erythematous mucosa in stomach, suggestive of portal hypertension. Considering the definitive clinical signs of portal hypertension (gastroesophageal varices), the absence of cirrhosis on liver biopsy and histologic signs of porto-sinusoidal vascular disease, she was diagnosed with non-cirrhotic portal hypertension due to porto-sinusoidal vascular disease. She was started on propranolol for gastroesophageal varices and her heart rate is currently well-controlled. Follow-up abdominal ultrasound is negative for further changes in the liver size, morphology, or masses. Discussion: Turner’s syndrome might be associated with non-cirrhotic portal hypertension. High index of clinical suspicion can lead to early diagnosis and treatment of portal hypertension in individuals with Turner’s syndrome, reducing the burden of complications of portal hypertension such as cytopenia or bleeding.

Did court dismiss gross negligence claim?

A Seton Hall women's basketball player sustained a serious knee injury during practice. The student-athlete sought medical treatment and received an MRI. She also obtained physical therapy. The MRI showed a bone bruise.

Evaluation of Knee Joint Injuries with Magnetic Resonance Imaging (MRI) and Correlation with Arthroscopy

One of the most frequent issues humans have had to deal with from the beginning of time is a knee injury. Knee injuries caused by a variety of diseases, from acute to degenerative, can affect the articular cartilage. The trauma, infection, or inflammation caused this injury. In these circumstances, a full clinical examination is not possible since the patients are in too much pain to cooperate. Then non-invasive multiplanar imaging and MRI come into play. The objective of the current study was to assess knee joint injuries using MRI and correlate those findings with arthroscopy. A total number of 225 participants were involved in this study, among them, 175 had issues with a knee injury. The patients referred with a history of knee injury were imaged with a 1.5 Tesla MRI machine. Most patients were between the ages of 35-40 years. The most frequent injuries found in the study were bone contusions, joint effusions, anterior cruciate ligament tears, and tears of the posterior horn of the medial meniscus. The accuracy percentage of ACL, PCL, LCL and MCL were 93, 100, 94.02 and 91.34%, respectively. Due to its great soft tissue contrast resolution and multiplanar imaging capabilities, magnetic resonance imaging (MRI) is a superior non-invasive investigative method for knee injuries. This allows for the most thorough evaluation of a variety of soft tissue knee joint problems. Keywords: Knee joint injury; Magnetic resonance imaging; Arthroscopy;

Skeletally Immature Patients With Classic Anterior Cruciate Ligament Bone Bruise Patterns Have a Higher Likelihood of Having an Intact Anterior Cruciate Ligament Compared With Skeletally Mature Patients.

The incidence of anterior cruciate ligament (ACL) tears in skeletally immature patients with an ACL bone contusion pattern has been sparsely investigated. The purpose of this study is to investigate whether physeal status has an influence on the likelihood of sustaining an ACL tear when classic bipolar ACL bone bruising pattern is present. Magnetic resonance imaging reports were queried for "contusion" on all patients between 6 and 22 years between 2015 and 2019. Images were reviewed to denote all intra-articular pathology and the physeal status of the femur and tibia. The primary outcome was the incidence of ACL tears in patients with the presence of bipolar bone contusions. Fischer exact testing was used to determine associations. Of 499 patients included, 269 of those had bipolar bone contusions. Patients with bipolar bone contusions and ACL tears had a shorter duration between injury and imaging date compared with patients with ACL tears without bipolar bone contusions (6.9 vs. 38.6d, P =0.05). Patients with an open femoral physis had a higher likelihood of having an intact ACL despite the presence of bipolar bone contusions than patients with a closed femoral physis (10.8% vs. 1.0%, P <0.001). Of patients with bipolar bone contusions, those with an intact ACL were younger than patients with an ACL tear (14.6 vs. 16.4, P =0.017). Although bipolar bone contusions of the central lateral femoral condyle and posterior lateral tibial plateau are typically found after ACL injury, these bipolar contusions can be found concomitantly with an intact ACL and were more often found in relatively younger patients. Patients who have an open femoral physis have a higher likelihood to have an intact ACL despite the presence of bipolar bone contusions compared with patients who have a closed femoral physis. Level IV-cross-sectional.

P186 Disseminated Histoplasmosis in an immunocompetent patient in a tertiary care center in North India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM ObjectivesHistoplasmosis is a geographically restricted dimorphic fungi that causes disseminated infection in immune-competent as well as immunocompromised patients. Adrenal involvement is seen in disseminated disease but sometimes it may be the only site where then infection can be demonstrated. Early diagnosis and treatment are needed to save the patient from fatal adrenal insufficiency. We present a case of bilateral adrenal histoplasmosis in immunocompetent patient.MethodsA 63-year-old male presented to our hospital with a history of insidious onset of decreased appetite and unintentional weight loss for the last 6 months associated with generalized weakness. Patient had a history of mild to moderate intensity epigastric pain and discomfort which was intermittent in nature. Patient originally belongs to Azamgarh, Uttar Pradesh, but he was residing in Kolkata for the last 8 months.Patient had no history of fever, cough, hemoptysis, jaundice, chronic diarrhea, and steatorrhea. No history of orthostatic hypotension, salt craving, hyperpigmentation, headache, visual field disturbances, polyuria, behavioral changes, episodic headache, palpitation, diaphoresis, systemic hypertension with episodic all four-limb weakness. There was no history of abdominal striae, easy bruisability, difficulty in standing from squatting position. There was no history of tuberculosis among family members. On detailed history, it was revealed that he fed pigeons every day in the slum house where he lived in Kolkata.On the CECT abdomen it was found that there is an ill-defined hypodense enhancing lesion (72 × 52 × 77 mm) in right suprarenal region and bulky, necrosed 25 × 26 × 19 mm lesion in left suprarenal gland associated with multiple nonnecrotic paraaortic and aortic caval lymphadenopathy. He also received empirical anti-tubercular therapy for 15 days in the form of ethambutol and levofloxacin.ResultsIn all, 10% KOH wet mount of crushed smear of adrenal biopsy samples showed tissue debris and small narrow neck budding yeasts. Giemsa stain shows few small budding yeasts. Culture was put in SDA at 25°C and 37°C and incubated. On day 12, growth of colony in 25°C appears as white cottony growth with yellowish white reverse. On day 24, colony appears as buff brown with yellowish brown reverse. LPCB was done from the colony showing presence of characteristic tuberculate macroconidia (8–14) μm in diameter formed on short, hyaline, undifferentiated conidiophores and production of plenty round to pyriform microconidia (2–4 μm) in diameter, occurring on short branches and directly on the sides of the hyphae. Based on the direct microscopy and culture characteristics a diagnosis of Histoplasma capsulatum was given.ConclusionSystemic histoplasmosis is typically acquired through inhalation of microconidia or small hyphal elements in soil contaminated with bird and bat droppings leading to primary infection. This patient only manifested bilateral adrenal involvement with nonspecific symptoms.