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P0324 ATYPICAL PRESENTATION OF ACUTE MYELOID LEUKEMIA – CASE REPORT
S112
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
The authors present the case of a 37 year-old caucasian woman, premenopausal, referred to our Oncology clinics with the diagnosis of ACC of the right breast, peculiar due to its multiple dissemination pattern – nodal, lung, hepatic, bone and, afterwards, brain involvement (cerebral stem and cerebellum) which revealed to be fatal. This is the first reported case of cerebral metastization in ACC of the breast.
P0322 CARDIAC TAMPONADE AS PRESENTATION OF NON-SMALL CELL LUNG CARCINOMA
Elsa Sousa, Joana Macedo, Mafalda Santos. Hospital São Sebastião Cardiac tamponade is the decompensate phase of cardiac compression caused by effusion accumulation and the increase in intrapericardial pressure. Cardiac tamponade may rarely be the initial manifestation of systemic malignancy. In literature there are two large series, were neoplasia was responsible for approximately six percent of cases of acute pericardial disease (acute pericarditis or tamponade without apparent cause). The most common malignancies are lung and breast cancer and Hodgkin’s disease. It is recognized by the classic Beck triad: hypotension, muffled heart sounds, jugular venous distension. Echocardiography plays major role in the identification and assessing the hemodynamic significance. Pericardiocentesis, hemodynamic support and treatment of the underlying cause are the basis of therapy. The authors report a case a 59 years old female patient, non-smoker, with hypertension, who presented to emergency department with repeated syncope. She had hypotension, jugular venous pressure at 45°, diminished pulmonary murmur and normal cardiac sounds, no peripheral oedema. Blood tests showed: anaemia, normal kidney function, high DHL. ECG: sinus rate, low voltage. Chest CT scan: apical right mass, bilateral pleural effusion, large pericardial effusion. Echocardiography: moderate pericardial effusion with right atrial and ventricular compression at diastole. Diagnostic pericardiocentesis: adenocarcinoma cells. Two days after she developed a cardiac tamponade, and an emergent pericardiocentesis was performed. After clinical stability, she started chemotherapy with docetaxel 60mg/m2 with a 3-week interval. She was discharged asymptomatic, BNP: 333ng/mL, a chest radiograph without pleural effusion and minimal pericardial effusion in the echocardiogram. After six cycles of docetaxel she had a partial response, and was submitted to six cycles of vinorelbine (25mg/m2 D1) and gemcitabine (1000mg/m2 , D1, D8 and D15), followed by thoracic radiotherapy. At her last clinical and imagiological evaluation she had stable disease and is in follow-up at the Oncology Department. Cardiac tamponade covers a spectrum of clinical severities, determined by the volume of pericardial fluid, the rate at which the effusion accumulates and the characteristics of the pericardium. Although unusual in cancer presentation, malignant disease’s should always be suspected so that a prompt diagnosis be achieved.
function had cytolysis changes with transaminases 3x higher than normal, without colestases, normal amylase, creatinine 1,8 mg/dL and ureia 71mg/dL, PCR 25mg/dL. At admission he had a CT scan that showed densification of small intestine, multiple abdominal ganglios, moderated ascites, densification of the lower 1/3 of the oesophagus and multiple focal hepatic lesions, with no other organ affected. He had a digestive endoscopies with biopsies that only showed ulcerative fundus, without neoplasic cells. CA 19-9 analysis measure 1558 U/mL. The ascites analysis were also negative to neoplasic cells. A skin incisional biopsy specimen revealed lymphocytic panniculitis with necrosis of fat cells, some appearing as ghostlike cells, consistent with pancreatic panniculitis. During hospitalization there were no response to the treatment and a multiple organ failure were aggravated. After one week after the first CT scan, a new were made, and showed a heterogeneous celiac region pancreas, with a 3cm nodule, conditioned VBP dilation. It also showed the changes that we had visualized before. The diagnosis of pancreas carcinoma were made by analytic and imagiologic criteria, since the patient had no conditions to make a pancreatic biopsy. The patient died 15 days after admission at ICU. There are no direct treatment to the pancreatic panniculitis, but because skin lesions can appear many months before other manifestations, the right diagnosis using the skin biopsy lesions is mandatory. The few manifestation of pancreas disease, made mandatory to look for other clinic, been skin manifestation
P0324 ATYPICAL PRESENTATION OF ACUTE MYELOID LEUKEMIA – CASE REPORT
Jean François Dantas Alves. Internal Medicine Department, Hospital De Faro, E.p.e Introduction: Myeloid leukemias are a group of diseases characterized by infiltration of the blood, bone marrow and others tissues by neoplastic cells of the hemapoietic system. The incidence of acute myeloid leukemia
P0323 PANCREATIC PANNICULITIS AS FIRST PRESENTATION OF PANCREAS CARCINOMA
Patricia Patricio 1 , Marisa André 2 , M. Gomes Da Costa 2 , Isabel Serra 3 , P. Telles De Freitas 3 . 1 Internal Medicine 2 Department, Hospital Santa Maria, Portugal; 2 Dermatology Department, Hospital Santa Maria, Portugal; 3 Intensive Care Unit, Hospital Fernando Fonseca, Portugal Pancreatic panniculitis is an entity occurring in 2-3% of all patients with pancreatic disorders and have a mortality of 75%. Although pancreatic panniculitis is rare, the incidence is higher in acute or chronic pancreatitis (especially alcohol related) and pancreatic carcinoma (usually acinar cell carcinoma, less frequently islet cell carcinoma). Rarely are other pancreatic disorders associated with pancreatic panniculitis, including posttraumatic pancreatitis, pancreatic pseudocysts, pancreas divisum and vascular pancreatic fistulas. Pancreatic panniculitis has recently been reported in association with primary human immunodeficiency virus (HIV) infection and a hemophagocytic syndrome. Clinical case: 64° years-old, male, farmer, with hyperuricemia, medicated with alopurinol 300mg/d. He had no other medical history, but had an alcohol consumption of 100mg/d alcohol a day. He was admitted in the hospital in oliguria and had skin lesions. Rapidly he had respiratory failure, and sent to intensive care unit. At admission he had multiple red-brown, tender and painful subcutaneous nodules, supuratives, with 2-3 cm diameter, at the limbs. He also had hepatomegaly. The rest of objective exam were normal. Lab test show normocitic normocromic anaemia (Hg 9g/dL), with no white blood count changes and thrombocytopenia (64 000uL). Coagulation test were normal. Hepatic
Left: Skin involvement of acute myeloid leukemia in the first observation. Right: Skin involvement of acute myeloid leukemia one month later.
Skin involvement of acute myeloid leukemia one month later.
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 (AML) is 3,7/100000 people per year and is higher in men than in women. Approximately 10% of these patients have a skin involvement. Case report: We report a case of a 78-years-old man with coronary heart disease who presented fatigue and a florid, nonpruritic, nonblanching, maculopapular erythematous skin eruption developed on the patient’s anterior chest wall from the last 2 months. History taking and physical examination revealed no abnormal findings. The man was followed up and blood test, cutaneous biopsy, bone marrow aspiration and bone biopsy were performed. The blood test revealed pancytopenia and the bone marrow aspiration was normal. The cutaneous biopsy revealed a diffuse infiltration suggestive of cutaneous manifestation of AML. Conventional induction chemotherapy was performed but the patient died two months later. Conclusion: Sixty to 85% of the patients with AML have a complete remission of the disease with chemotherapy and the 5-years survival rates approach 10 to 30%. It is very important to make the diagnosis quickly in order to start the treatment as soon as possible.
P0325 CANCER:EASY TO SEE BUT HARD TO FIND
Monica Levy, Paula Augusto, Raquel Nazareth, João Pacheco Pereira, Francisco Da Silva, José Pimenta Da Graça. Hospital Egas Moniz Approximately 20 percent (%) of patients have distant metastatic disease at the time of presentation. The incidence of bone metastases in colorectal cancer is small, generally less than 10%. A 63 years old man, resident in Mozambique, was hospitalized with rectal bleeding, fatigue, weight loss of 10kg over the previous 3 months. He had a recent history of malaria treated with Artesiance and back pain medicated with diclofenac and prednisone. Physical examination showed a blood pressure of 150/84 mmHg, pallor, pethequiae in the lower legs, sub-icteric sclera. The results of laboratory studies were as follows: hemoglobin, 7.3 g/dL, white blood cells, 6.8×109 /L; with normal differential count, platelets, 17×109 /L, mean corpuscular volume, 85,7fL, LDH, 5.253UI/L, total bilirrubin, 1.46mg/dL (unconjugated bilirrubin elevated); thick blood smear for plasmodium was negative, alanine aminotransferases, 79UI/L; negative serology to HIV1. Peripheral blood smear showed schistocytes, suggesting hemolytic anemia. Direct and indirect Coombs test and anti-platelets antibodies were negatives. Abdominal ultra-sound revealed:”enlarged spleen (∼14cm), normal liver”. Lumbar and sacral spine CT showed: “diffuse infiltration of lumbar and sacral vertebraes by lytic lesions, pathological fracture of L4”. The bone marrow aspirate and biopsy histology was compatible with colon adenocarcinoma metastasis, Ck20+; CK7-;PSA-. Thoracic, abdominal and pelvic CT identified “exuberant thining of the rectosigmoidal transition, suggesting stenosant lesion”. The patient clinical condition (anemia, thrombocytopenia, with frequent blood transfusions) didn’t allow systemic therapy or radiotherapy. Palliative measures were instituted. This case shows a very rare clinical manifestation of colon cancer in which microangiopathic hemolytic anemia and thrombocytopenia were present, secondary to bone marrow metastasis, in the absence of liver dissemination.
Hematology
S113
giving rise to thought of multiple myeloma.Lambda monoclonal gammapathy in the serum immunofixation electrophoresis, lambda light chain band in the urine immunofixation electrophoresis were found. Bone marrow biopsy was performed to confirm the diagnosis of multiple myeloma. %55 atypic plasma cells were found in the BM biopsy. Also the right pleural effusion was aspirated. Pleural effusion protein level was detected high (114 gr/L). Pleural immunofixation electrophoresis was compatible with IgG lambda paraproteinemia. Pleural effusion IgG level was 106 gr/L, meaning, pleural involvement of multiple myeloma. We diagnosed the myelomatous involvement with IgG monoclonal gammapathy in the electrophoresis. Discussion & conclusion: Pleural myelomatotic involvement is diagnosed by one of the three criterias. The first criteria is the monoclonal gammapathy shown by electrophoresis of the pleural fluid. The second criteria is the atypic plasmacytes depicted in the pleural fluid cytology. The third one is pleural biopsy demonstrating histological myelomatous involvement. Myelomatous pleural effusion is seen very rarely. We diagnosed multiple myeloma in a patient applying to our clinic with pleural effusion and no significant diagnosis before. We chose this patient as a case report. Because myelomatous pleural involvement of multiple myeloma is seen occasionally. Our patient had rightsided pleural effusion with IgG lambda monoclonal gammapathy despite the the fact that left-sided effusions and IgA-type myelomatous involvement are the most commonly seen ones. Keywords: Multiple Myeloma, Pleural effusion
P0327 PURIFICATION AND PARTIAL CHARACTERIZATION OF PROCOAGULANT FACTOR (FACTOR V ACTIVATOR FROM IRANIAN VIPERA LEBETINA)
Zohreh Amoozgari 1 , Abbas Zare 2 , Mozhgan Noor Behbahani 1 . 1 Dept. of Biochemistry, Faculty of Medicine, Ahwaz Jundishapour University of Medical Sciences, Iran; 2 Razi, Vaccine Serum Institute, Tehran, Iran Introduction: The Venom of many viperidae snakes appeared to contain proteins that affect blood coagulation. Vipera lebetina is one of the poisonous snakes of Iran. Its venom has been found to have potent effects on coagulation, through both pro and anticoagulant mechanisms of blood coagulation. Factor V is a single chain glycoprotein which plays an important role in procoagulant and anticoagulant pathways. Thrombin activates factor V in to factor Va. Factor V can also be activated by a wide variety of snake venoms. Material and methods: Our studies of the Iranian vipera lebetina venom have demonstrated the existence of both coagulant and anticoagulant effects of heamostasis system. Further analysis by purified systems, it was demonstrated that this venom contain factor V activation activity. The factor V activator present in the venom was sepatrated by gel filtration on sephadex G-100 followsd by ion exchange chromatography on DEAE cellulose and affinity chromatography on heparin agarose Results and conclusion: It was shown that a single protein band in sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS PAGE) under nonreducing conditions. The molecular weight was estimated to be 29KDa by SDS PAGE. This compound activated factor V to VA in the presence of calcium ions. It had arginine esterase activity toward substrate BAEE (Benzoyl arginine ethylester). It also had weak amidase activity on S-2222 (benzoyl Arg nitroanilide). Keywords: Factor V activity, coagulant and anticoagulant, snake venom vipera lebetina.
P0326 PLEURAL INVOLVEMENT OF MULTIPLE MYELOMA WITH ELEVATED IMMUNOGLOBULIN G: A CASE REPORT 1
1
1
P0328 2
Engin Sennaroglu , Sibel Ureyen , Narin Imga , Cagin Mustafa Ureyen , Fatih Yildiz 1 , Cumali Efe 1 , Hasan Tunca 1 . 1 Ankara Numune Education and Research Hospital Department of 4 Internal Medicine; 2 Ankara Numune Education and Research Hospital Department of Cardiology Introduction: Multiple myeloma is the malign proliferation of plasma cells leading to bone pain, pathological bone fractures, renal failure, infections, anemia, hypercalcemia, coagulation disorders and hyperviscosity syndrome. A 44 years old male patient was admitted to our clinic for management of high fever, epistaxis, hematuria and one month lasting unilateral pleural effusion.The findings of the patient were elevated erythrocyte sedimentation rate, anemia, rouleau formation in peripheral smear, hypercalcemia, elevated total protein level, hypoalbuminemia, hematuria, low serum immunoglobulin levels, elevated serum BUN and creatinine levels, lytic lesion on the 6th thoracal vertebra and monoclonal gammapathy in serum protein electrophoresis,
SAME PRESENTATION, DIFFERENT DISEASES
Teresa Amaral, Ana Gonçalves, Victor Ramalhinho. Centro Hospitalar Lisbo Norte, Hospital De Santa Maria Introduction: Although we always learn that the different symptoms in the same patient should be connected to one single disease, sometimes patients get to surprise us, and they actually have more than one medical condition. Here we present a clinical case in which a common disease can easily be mistaken with another common disease, if we don’t think outside the box. B.E.L. male Caucasian, 76 years old presents to the emergency department with non-specific complains of asthenia and anorexia for the last two weeks. The patient also referred diffuse bone and joint pain. It was not possible to determine the exact time when these symptoms began. He has a personal medical history of prostatic cancer operated 9 years ago, under hormonotherapy, arterial hypertension, chronic anaemia, renal insufficiency grade 1 and obesity.
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
The authors present the case of a 37 year-old caucasian woman, premenopausal, referred to our Oncology clinics with the diagnosis of ACC of the right breast, peculiar due to its multiple dissemination pattern – nodal, lung, hepatic, bone and, afterwards, brain involvement (cerebral stem and cerebellum) which revealed to be fatal. This is the first reported case of cerebral metastization in ACC of the breast.
P0322 CARDIAC TAMPONADE AS PRESENTATION OF NON-SMALL CELL LUNG CARCINOMA
Elsa Sousa, Joana Macedo, Mafalda Santos. Hospital São Sebastião Cardiac tamponade is the decompensate phase of cardiac compression caused by effusion accumulation and the increase in intrapericardial pressure. Cardiac tamponade may rarely be the initial manifestation of systemic malignancy. In literature there are two large series, were neoplasia was responsible for approximately six percent of cases of acute pericardial disease (acute pericarditis or tamponade without apparent cause). The most common malignancies are lung and breast cancer and Hodgkin’s disease. It is recognized by the classic Beck triad: hypotension, muffled heart sounds, jugular venous distension. Echocardiography plays major role in the identification and assessing the hemodynamic significance. Pericardiocentesis, hemodynamic support and treatment of the underlying cause are the basis of therapy. The authors report a case a 59 years old female patient, non-smoker, with hypertension, who presented to emergency department with repeated syncope. She had hypotension, jugular venous pressure at 45°, diminished pulmonary murmur and normal cardiac sounds, no peripheral oedema. Blood tests showed: anaemia, normal kidney function, high DHL. ECG: sinus rate, low voltage. Chest CT scan: apical right mass, bilateral pleural effusion, large pericardial effusion. Echocardiography: moderate pericardial effusion with right atrial and ventricular compression at diastole. Diagnostic pericardiocentesis: adenocarcinoma cells. Two days after she developed a cardiac tamponade, and an emergent pericardiocentesis was performed. After clinical stability, she started chemotherapy with docetaxel 60mg/m2 with a 3-week interval. She was discharged asymptomatic, BNP: 333ng/mL, a chest radiograph without pleural effusion and minimal pericardial effusion in the echocardiogram. After six cycles of docetaxel she had a partial response, and was submitted to six cycles of vinorelbine (25mg/m2 D1) and gemcitabine (1000mg/m2 , D1, D8 and D15), followed by thoracic radiotherapy. At her last clinical and imagiological evaluation she had stable disease and is in follow-up at the Oncology Department. Cardiac tamponade covers a spectrum of clinical severities, determined by the volume of pericardial fluid, the rate at which the effusion accumulates and the characteristics of the pericardium. Although unusual in cancer presentation, malignant disease’s should always be suspected so that a prompt diagnosis be achieved.
function had cytolysis changes with transaminases 3x higher than normal, without colestases, normal amylase, creatinine 1,8 mg/dL and ureia 71mg/dL, PCR 25mg/dL. At admission he had a CT scan that showed densification of small intestine, multiple abdominal ganglios, moderated ascites, densification of the lower 1/3 of the oesophagus and multiple focal hepatic lesions, with no other organ affected. He had a digestive endoscopies with biopsies that only showed ulcerative fundus, without neoplasic cells. CA 19-9 analysis measure 1558 U/mL. The ascites analysis were also negative to neoplasic cells. A skin incisional biopsy specimen revealed lymphocytic panniculitis with necrosis of fat cells, some appearing as ghostlike cells, consistent with pancreatic panniculitis. During hospitalization there were no response to the treatment and a multiple organ failure were aggravated. After one week after the first CT scan, a new were made, and showed a heterogeneous celiac region pancreas, with a 3cm nodule, conditioned VBP dilation. It also showed the changes that we had visualized before. The diagnosis of pancreas carcinoma were made by analytic and imagiologic criteria, since the patient had no conditions to make a pancreatic biopsy. The patient died 15 days after admission at ICU. There are no direct treatment to the pancreatic panniculitis, but because skin lesions can appear many months before other manifestations, the right diagnosis using the skin biopsy lesions is mandatory. The few manifestation of pancreas disease, made mandatory to look for other clinic, been skin manifestation
P0324 ATYPICAL PRESENTATION OF ACUTE MYELOID LEUKEMIA – CASE REPORT
Jean François Dantas Alves. Internal Medicine Department, Hospital De Faro, E.p.e Introduction: Myeloid leukemias are a group of diseases characterized by infiltration of the blood, bone marrow and others tissues by neoplastic cells of the hemapoietic system. The incidence of acute myeloid leukemia
P0323 PANCREATIC PANNICULITIS AS FIRST PRESENTATION OF PANCREAS CARCINOMA
Patricia Patricio 1 , Marisa André 2 , M. Gomes Da Costa 2 , Isabel Serra 3 , P. Telles De Freitas 3 . 1 Internal Medicine 2 Department, Hospital Santa Maria, Portugal; 2 Dermatology Department, Hospital Santa Maria, Portugal; 3 Intensive Care Unit, Hospital Fernando Fonseca, Portugal Pancreatic panniculitis is an entity occurring in 2-3% of all patients with pancreatic disorders and have a mortality of 75%. Although pancreatic panniculitis is rare, the incidence is higher in acute or chronic pancreatitis (especially alcohol related) and pancreatic carcinoma (usually acinar cell carcinoma, less frequently islet cell carcinoma). Rarely are other pancreatic disorders associated with pancreatic panniculitis, including posttraumatic pancreatitis, pancreatic pseudocysts, pancreas divisum and vascular pancreatic fistulas. Pancreatic panniculitis has recently been reported in association with primary human immunodeficiency virus (HIV) infection and a hemophagocytic syndrome. Clinical case: 64° years-old, male, farmer, with hyperuricemia, medicated with alopurinol 300mg/d. He had no other medical history, but had an alcohol consumption of 100mg/d alcohol a day. He was admitted in the hospital in oliguria and had skin lesions. Rapidly he had respiratory failure, and sent to intensive care unit. At admission he had multiple red-brown, tender and painful subcutaneous nodules, supuratives, with 2-3 cm diameter, at the limbs. He also had hepatomegaly. The rest of objective exam were normal. Lab test show normocitic normocromic anaemia (Hg 9g/dL), with no white blood count changes and thrombocytopenia (64 000uL). Coagulation test were normal. Hepatic
Left: Skin involvement of acute myeloid leukemia in the first observation. Right: Skin involvement of acute myeloid leukemia one month later.
Skin involvement of acute myeloid leukemia one month later.
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 (AML) is 3,7/100000 people per year and is higher in men than in women. Approximately 10% of these patients have a skin involvement. Case report: We report a case of a 78-years-old man with coronary heart disease who presented fatigue and a florid, nonpruritic, nonblanching, maculopapular erythematous skin eruption developed on the patient’s anterior chest wall from the last 2 months. History taking and physical examination revealed no abnormal findings. The man was followed up and blood test, cutaneous biopsy, bone marrow aspiration and bone biopsy were performed. The blood test revealed pancytopenia and the bone marrow aspiration was normal. The cutaneous biopsy revealed a diffuse infiltration suggestive of cutaneous manifestation of AML. Conventional induction chemotherapy was performed but the patient died two months later. Conclusion: Sixty to 85% of the patients with AML have a complete remission of the disease with chemotherapy and the 5-years survival rates approach 10 to 30%. It is very important to make the diagnosis quickly in order to start the treatment as soon as possible.
P0325 CANCER:EASY TO SEE BUT HARD TO FIND
Monica Levy, Paula Augusto, Raquel Nazareth, João Pacheco Pereira, Francisco Da Silva, José Pimenta Da Graça. Hospital Egas Moniz Approximately 20 percent (%) of patients have distant metastatic disease at the time of presentation. The incidence of bone metastases in colorectal cancer is small, generally less than 10%. A 63 years old man, resident in Mozambique, was hospitalized with rectal bleeding, fatigue, weight loss of 10kg over the previous 3 months. He had a recent history of malaria treated with Artesiance and back pain medicated with diclofenac and prednisone. Physical examination showed a blood pressure of 150/84 mmHg, pallor, pethequiae in the lower legs, sub-icteric sclera. The results of laboratory studies were as follows: hemoglobin, 7.3 g/dL, white blood cells, 6.8×109 /L; with normal differential count, platelets, 17×109 /L, mean corpuscular volume, 85,7fL, LDH, 5.253UI/L, total bilirrubin, 1.46mg/dL (unconjugated bilirrubin elevated); thick blood smear for plasmodium was negative, alanine aminotransferases, 79UI/L; negative serology to HIV1. Peripheral blood smear showed schistocytes, suggesting hemolytic anemia. Direct and indirect Coombs test and anti-platelets antibodies were negatives. Abdominal ultra-sound revealed:”enlarged spleen (∼14cm), normal liver”. Lumbar and sacral spine CT showed: “diffuse infiltration of lumbar and sacral vertebraes by lytic lesions, pathological fracture of L4”. The bone marrow aspirate and biopsy histology was compatible with colon adenocarcinoma metastasis, Ck20+; CK7-;PSA-. Thoracic, abdominal and pelvic CT identified “exuberant thining of the rectosigmoidal transition, suggesting stenosant lesion”. The patient clinical condition (anemia, thrombocytopenia, with frequent blood transfusions) didn’t allow systemic therapy or radiotherapy. Palliative measures were instituted. This case shows a very rare clinical manifestation of colon cancer in which microangiopathic hemolytic anemia and thrombocytopenia were present, secondary to bone marrow metastasis, in the absence of liver dissemination.
Hematology
S113
giving rise to thought of multiple myeloma.Lambda monoclonal gammapathy in the serum immunofixation electrophoresis, lambda light chain band in the urine immunofixation electrophoresis were found. Bone marrow biopsy was performed to confirm the diagnosis of multiple myeloma. %55 atypic plasma cells were found in the BM biopsy. Also the right pleural effusion was aspirated. Pleural effusion protein level was detected high (114 gr/L). Pleural immunofixation electrophoresis was compatible with IgG lambda paraproteinemia. Pleural effusion IgG level was 106 gr/L, meaning, pleural involvement of multiple myeloma. We diagnosed the myelomatous involvement with IgG monoclonal gammapathy in the electrophoresis. Discussion & conclusion: Pleural myelomatotic involvement is diagnosed by one of the three criterias. The first criteria is the monoclonal gammapathy shown by electrophoresis of the pleural fluid. The second criteria is the atypic plasmacytes depicted in the pleural fluid cytology. The third one is pleural biopsy demonstrating histological myelomatous involvement. Myelomatous pleural effusion is seen very rarely. We diagnosed multiple myeloma in a patient applying to our clinic with pleural effusion and no significant diagnosis before. We chose this patient as a case report. Because myelomatous pleural involvement of multiple myeloma is seen occasionally. Our patient had rightsided pleural effusion with IgG lambda monoclonal gammapathy despite the the fact that left-sided effusions and IgA-type myelomatous involvement are the most commonly seen ones. Keywords: Multiple Myeloma, Pleural effusion
P0327 PURIFICATION AND PARTIAL CHARACTERIZATION OF PROCOAGULANT FACTOR (FACTOR V ACTIVATOR FROM IRANIAN VIPERA LEBETINA)
Zohreh Amoozgari 1 , Abbas Zare 2 , Mozhgan Noor Behbahani 1 . 1 Dept. of Biochemistry, Faculty of Medicine, Ahwaz Jundishapour University of Medical Sciences, Iran; 2 Razi, Vaccine Serum Institute, Tehran, Iran Introduction: The Venom of many viperidae snakes appeared to contain proteins that affect blood coagulation. Vipera lebetina is one of the poisonous snakes of Iran. Its venom has been found to have potent effects on coagulation, through both pro and anticoagulant mechanisms of blood coagulation. Factor V is a single chain glycoprotein which plays an important role in procoagulant and anticoagulant pathways. Thrombin activates factor V in to factor Va. Factor V can also be activated by a wide variety of snake venoms. Material and methods: Our studies of the Iranian vipera lebetina venom have demonstrated the existence of both coagulant and anticoagulant effects of heamostasis system. Further analysis by purified systems, it was demonstrated that this venom contain factor V activation activity. The factor V activator present in the venom was sepatrated by gel filtration on sephadex G-100 followsd by ion exchange chromatography on DEAE cellulose and affinity chromatography on heparin agarose Results and conclusion: It was shown that a single protein band in sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS PAGE) under nonreducing conditions. The molecular weight was estimated to be 29KDa by SDS PAGE. This compound activated factor V to VA in the presence of calcium ions. It had arginine esterase activity toward substrate BAEE (Benzoyl arginine ethylester). It also had weak amidase activity on S-2222 (benzoyl Arg nitroanilide). Keywords: Factor V activity, coagulant and anticoagulant, snake venom vipera lebetina.
P0326 PLEURAL INVOLVEMENT OF MULTIPLE MYELOMA WITH ELEVATED IMMUNOGLOBULIN G: A CASE REPORT 1
1
1
P0328 2
Engin Sennaroglu , Sibel Ureyen , Narin Imga , Cagin Mustafa Ureyen , Fatih Yildiz 1 , Cumali Efe 1 , Hasan Tunca 1 . 1 Ankara Numune Education and Research Hospital Department of 4 Internal Medicine; 2 Ankara Numune Education and Research Hospital Department of Cardiology Introduction: Multiple myeloma is the malign proliferation of plasma cells leading to bone pain, pathological bone fractures, renal failure, infections, anemia, hypercalcemia, coagulation disorders and hyperviscosity syndrome. A 44 years old male patient was admitted to our clinic for management of high fever, epistaxis, hematuria and one month lasting unilateral pleural effusion.The findings of the patient were elevated erythrocyte sedimentation rate, anemia, rouleau formation in peripheral smear, hypercalcemia, elevated total protein level, hypoalbuminemia, hematuria, low serum immunoglobulin levels, elevated serum BUN and creatinine levels, lytic lesion on the 6th thoracal vertebra and monoclonal gammapathy in serum protein electrophoresis,
SAME PRESENTATION, DIFFERENT DISEASES
Teresa Amaral, Ana Gonçalves, Victor Ramalhinho. Centro Hospitalar Lisbo Norte, Hospital De Santa Maria Introduction: Although we always learn that the different symptoms in the same patient should be connected to one single disease, sometimes patients get to surprise us, and they actually have more than one medical condition. Here we present a clinical case in which a common disease can easily be mistaken with another common disease, if we don’t think outside the box. B.E.L. male Caucasian, 76 years old presents to the emergency department with non-specific complains of asthenia and anorexia for the last two weeks. The patient also referred diffuse bone and joint pain. It was not possible to determine the exact time when these symptoms began. He has a personal medical history of prostatic cancer operated 9 years ago, under hormonotherapy, arterial hypertension, chronic anaemia, renal insufficiency grade 1 and obesity.