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P0528 RIGHT AORTIC ARCH AS CAUSE OF CACHEXIA
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 and this feature could be related with a decrease of intracellular cholesterol synthesis as a main expla
P0527 LOW T3 SYNDROME IS A PREDICTOR OF MORTALITY IN INTENSIVE CARE UNIT
Süleyman Günay 1 , Feza Bacako˘glu 2 , Sercan Ertürk 1 , Sezai Ta¸sbakan 2 , Sabri Derelı 1 . 1 Ministry of Health Izmir Education and Research Hospital, Department of Internal Medicine, Izmir, Turkey; 2 Ege University Faculty of Medicine, Department of Pulmonary Medicine, Izmir, Turkey Introduction: Euthyroid sick syndrome is described as abnormal finding on thyroid function test that occurs in the setting of a nonthyroidal illness (NTI)without preexisting hypothalamic-pituitary and thyroid gland dysfunction. Multiple alterations in serum thyroid function test finding have been recognized, the most prominent alterations are low serum triiodothyronine (T3) and elevated reverse T3(rT3), leading to general term low T3 syndrome. Thyroid stimulating hormone (TSH), thyroxine (T4), free T4, and free T4 index also are affected in variable degrees based on severity of and duration of the NTI. As the severity of NTI increases both serum T3 and T4 level drop and gradually normalize as the patient recovers. Euthyroid sick syndrome can be seen in most of acute and chronic illnesses. Objectives: The aim of this study is to show the low T3 syndrome is a independent predictor of mortality in intensive care unit. Materials & methods: This single center prospective study conducted in Aegean University Faculty of Medicine Pulmonary Diseases Intensive Care Unit in between the dates of March 2008-July 2008. Consecutive sixty patients included. Of those 4 were excluded due to thyroidal diseases. Fifty-six patient (33 man, 23 women) were evaluated. Blood exams was assed all patient in the first 24 hours after the admission of intensive care unit (ICU) before the medications such as dopamin, dobutamine systemic corticosteroids and amiodorone which effect thyroid hormones level. After collecting venous sample complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, laktat dehidrogenaz (LDH), procalcitonin (PCT), Activated partial thromboplastin time (aPTT), free serum T3(fT3), free serum T4(fT4), Thyroid stimulating hormone (TSH) were all measured. On the basis of fT3, fT4 and TSH values, patient were diveded into two subgroups: group 1, patients with low T3 syndrome, ie, fT4 and TSH are normal, fT3 below the lower limits of fT3, and group 2, patient with normal fT3. Results: Of the 56 patient, according to variety of thyroid hormones values 46 (%82.2) had euthyroid sick syndrome, 34(%60.7)had low T3 syndrome. When considering two groups, groups 1 had a statistically significant poor prognoss (p=0.003) (table 1). Free T3 tended to slightly but significantly decrease with age. APACHE II and other parameters were similar in two groups (table2).
S177
undestood, although the common belief is in favour of an adaptive mechanism to preserve energy. Low T3 syndrome was correlated with APACHE II score in some studies, in this study except for age there is no correlations between low T3 syndrome and the other parameters including APACHE II. Low T3 syndrome predicts the mortality in ICU. In conclusion, Low T3 syndome is a strong independent predictor of mortality in ICU. Keywords: Low T3 syndrome, intensive care unit, predictor of mortality.
P0528 RIGHT AORTIC ARCH AS CAUSE OF CACHEXIA
Isabel Pinheiro, Ana Catarina Guerra, Ana Amorim, Angelo Nobre, Maria José Metrass. Hospital Santa Maria Introduction: Embryological anomalies of the aortic arch and great vessels are frequently incidental findings. Despite the fact that the variations in question are usually asymptomatic, they may cause upper airway and oesophagus compression with dyspnea or dysphagia, resulting in non-cardiac morbidity and misinterpretation of radiological examinations. Furthermore, these variations may be accompanied by other congenital abnormalities. Materials & methods: Black female, 29 years old, born and living in Cabo Verde, referred because of dysphagia and cachexia. She was healthy till 1 year before, when she began to complain about dysphagia for solids and progressively also for liquids. She developed intense odynophagia, thoracic and abdominal pain, sialorrhea and significant weight loss of 23kg. She was evacuated to our hospital for study. She had a right aortic arch on chest X-ray and thoracic CT didn’t show significant extrinsic compression of esophagus. On physical examination she was cachectic, with important muscular fusion, pale but hydrated, BMI 17, pulse: 66bpm; PA: 124/88mmHg, TT: 35.9°C; normal cardio-pulmonary examination, painless abdomen without any masses. The braquial and radial left pulses were reduced, without associated deep vein thrombosis signs. She had anemia (11g/dl) and hypoalbuminemia. She was submitted to several non-invasive diagnostic procedures such as: transthoracic echocardiogram that was normal, upper digestive endoscopy and esophagogram with esophagus impression by the aortic arch but without significant stenosis and good peristalsis; abdominal ultrasound without associated malformations. Results: Finally she was submitted to cardiothoracic surgery where we confirmed the presence of a right aortic arch with aberrant left subclavian artery and left ligamentum arteriosus. The surgery allowed her to return to normal body weigth and she became asymptomatic. Conclusions: This case illustrates the clinical repercussion of a right aortic arch easily resolved with proper surgical treatment. The diagnosis needs high clinical suspicion because esophageal stenosis doesn’t need to be complete to produce cachexia. Keywords: right aortic arch, dysphagia, cachexia
Table 1. Mortality difference between Group 1 and Group 2 Results Patients
Group 1 Group 2
Total
Number Percent of group 1 Number Percent of group 2 Number % Within results
P
Discharge
Ex
Total
14 41,2% 18 %81,8 32 %55,6
20 58,8% 4 %18,2 24 %44,4
34 %100 22 %100 56 %100
0.003
Abbrevations: Group 1 = low T3 syndrome, Group 2 normal T3. Table 1. Prognostic factor between group 1 and group 2
Number of patient Age APACHE II WBC (mm3 ) Hb (g/dl) ESR (mm/saat) CRP (mgr/L) PCT (ng/ml) Albumin (gr/dl) aPTT (seconds) LDH (u/L)
Group 1
Group 2
p
34 59,7±18,1 19,5±6,0 13,1 ±5,1 11,8±3,1 63,8±29,1 12,9±11,1 17,3±48,0 2,8±0,7 30,1±9,5 814,0±529,0
22 68,6±14,6 19,5±6,9 14,0±6,3 11,0±2,3 63,2±39,9 11,0±10,8 1,4±2,4 3,2±0,7 26,3±7,4 903,0±1250,0
0.035 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
Abbrevations: WBC, white blood cell; hb, hemoglobin; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; LDH, lactat dehidrogenaz; PCT, procalcitonin; APACHE, acute physiological and cronic health status; aPTT, activated partial tromboplastin time.
Discussion & conclusion: Eutyhroid sick syndrome, in particular low T3 syndrome, is a common finding in ICU. Its pathophysiological role is not well
P0529 MULTIPLE PULMONARY ARTERIOVENOUS FISTULAE — TO TREAT OR NOT TO TREAT, THAT IS THE QUESTION
Ana Sofia Ventura 1 , José Carlos Pereira 1 , Paula Rosa 2 , Nuno Bragança 1 , Teresa Cruz 1 . 1 Hospital Fernando Fonseca, Internal Medicine Department 3, Portugal; 2 Hospital Fernando Fonseca, Pneumology Department, Portugal Pulmonary arteriovenous malformations (PAVM) are rare vascular anomalies, more frequent in females and in the first three decades of life. Although most patients are asymptomatic, PAVMs can cause dyspnea from right-toleft shunt. Because of paradoxical emboli, various central nervous system complications have been described including stroke and brain abscess. Chest X-ray, contrast enhanced CT-scan and angiography are essential diagnostic tools. Therapeutic options include angiographic embolization with metal coil or balloon occlusion and surgical excision. The authors present a case of a 64 year old Caucasian woman with a history of hypertension, hypercholesterolemia and neurosurgery procedure in 2000 due to cerebral abscesses, left leg melanoma operated in 1990 and digital clubbing, more evident in the 1st, 3rd and 5th left hand fingers, with an evolution of 20 years. She was referenced to our hospital’s internal medicine consult to be investigated for polycythemia (erythrocytes: 6.64×1012 /L; hemoglobin: 20.9 g/dL) and thrombocytopenia (platelets: 73000/dL). On admission, she denied smoking habits and family history of hematologic diseases. She was asymptomatic except for progressive tiredness and dyspnea
P0527 LOW T3 SYNDROME IS A PREDICTOR OF MORTALITY IN INTENSIVE CARE UNIT
Süleyman Günay 1 , Feza Bacako˘glu 2 , Sercan Ertürk 1 , Sezai Ta¸sbakan 2 , Sabri Derelı 1 . 1 Ministry of Health Izmir Education and Research Hospital, Department of Internal Medicine, Izmir, Turkey; 2 Ege University Faculty of Medicine, Department of Pulmonary Medicine, Izmir, Turkey Introduction: Euthyroid sick syndrome is described as abnormal finding on thyroid function test that occurs in the setting of a nonthyroidal illness (NTI)without preexisting hypothalamic-pituitary and thyroid gland dysfunction. Multiple alterations in serum thyroid function test finding have been recognized, the most prominent alterations are low serum triiodothyronine (T3) and elevated reverse T3(rT3), leading to general term low T3 syndrome. Thyroid stimulating hormone (TSH), thyroxine (T4), free T4, and free T4 index also are affected in variable degrees based on severity of and duration of the NTI. As the severity of NTI increases both serum T3 and T4 level drop and gradually normalize as the patient recovers. Euthyroid sick syndrome can be seen in most of acute and chronic illnesses. Objectives: The aim of this study is to show the low T3 syndrome is a independent predictor of mortality in intensive care unit. Materials & methods: This single center prospective study conducted in Aegean University Faculty of Medicine Pulmonary Diseases Intensive Care Unit in between the dates of March 2008-July 2008. Consecutive sixty patients included. Of those 4 were excluded due to thyroidal diseases. Fifty-six patient (33 man, 23 women) were evaluated. Blood exams was assed all patient in the first 24 hours after the admission of intensive care unit (ICU) before the medications such as dopamin, dobutamine systemic corticosteroids and amiodorone which effect thyroid hormones level. After collecting venous sample complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, laktat dehidrogenaz (LDH), procalcitonin (PCT), Activated partial thromboplastin time (aPTT), free serum T3(fT3), free serum T4(fT4), Thyroid stimulating hormone (TSH) were all measured. On the basis of fT3, fT4 and TSH values, patient were diveded into two subgroups: group 1, patients with low T3 syndrome, ie, fT4 and TSH are normal, fT3 below the lower limits of fT3, and group 2, patient with normal fT3. Results: Of the 56 patient, according to variety of thyroid hormones values 46 (%82.2) had euthyroid sick syndrome, 34(%60.7)had low T3 syndrome. When considering two groups, groups 1 had a statistically significant poor prognoss (p=0.003) (table 1). Free T3 tended to slightly but significantly decrease with age. APACHE II and other parameters were similar in two groups (table2).
S177
undestood, although the common belief is in favour of an adaptive mechanism to preserve energy. Low T3 syndrome was correlated with APACHE II score in some studies, in this study except for age there is no correlations between low T3 syndrome and the other parameters including APACHE II. Low T3 syndrome predicts the mortality in ICU. In conclusion, Low T3 syndome is a strong independent predictor of mortality in ICU. Keywords: Low T3 syndrome, intensive care unit, predictor of mortality.
P0528 RIGHT AORTIC ARCH AS CAUSE OF CACHEXIA
Isabel Pinheiro, Ana Catarina Guerra, Ana Amorim, Angelo Nobre, Maria José Metrass. Hospital Santa Maria Introduction: Embryological anomalies of the aortic arch and great vessels are frequently incidental findings. Despite the fact that the variations in question are usually asymptomatic, they may cause upper airway and oesophagus compression with dyspnea or dysphagia, resulting in non-cardiac morbidity and misinterpretation of radiological examinations. Furthermore, these variations may be accompanied by other congenital abnormalities. Materials & methods: Black female, 29 years old, born and living in Cabo Verde, referred because of dysphagia and cachexia. She was healthy till 1 year before, when she began to complain about dysphagia for solids and progressively also for liquids. She developed intense odynophagia, thoracic and abdominal pain, sialorrhea and significant weight loss of 23kg. She was evacuated to our hospital for study. She had a right aortic arch on chest X-ray and thoracic CT didn’t show significant extrinsic compression of esophagus. On physical examination she was cachectic, with important muscular fusion, pale but hydrated, BMI 17, pulse: 66bpm; PA: 124/88mmHg, TT: 35.9°C; normal cardio-pulmonary examination, painless abdomen without any masses. The braquial and radial left pulses were reduced, without associated deep vein thrombosis signs. She had anemia (11g/dl) and hypoalbuminemia. She was submitted to several non-invasive diagnostic procedures such as: transthoracic echocardiogram that was normal, upper digestive endoscopy and esophagogram with esophagus impression by the aortic arch but without significant stenosis and good peristalsis; abdominal ultrasound without associated malformations. Results: Finally she was submitted to cardiothoracic surgery where we confirmed the presence of a right aortic arch with aberrant left subclavian artery and left ligamentum arteriosus. The surgery allowed her to return to normal body weigth and she became asymptomatic. Conclusions: This case illustrates the clinical repercussion of a right aortic arch easily resolved with proper surgical treatment. The diagnosis needs high clinical suspicion because esophageal stenosis doesn’t need to be complete to produce cachexia. Keywords: right aortic arch, dysphagia, cachexia
Table 1. Mortality difference between Group 1 and Group 2 Results Patients
Group 1 Group 2
Total
Number Percent of group 1 Number Percent of group 2 Number % Within results
P
Discharge
Ex
Total
14 41,2% 18 %81,8 32 %55,6
20 58,8% 4 %18,2 24 %44,4
34 %100 22 %100 56 %100
0.003
Abbrevations: Group 1 = low T3 syndrome, Group 2 normal T3. Table 1. Prognostic factor between group 1 and group 2
Number of patient Age APACHE II WBC (mm3 ) Hb (g/dl) ESR (mm/saat) CRP (mgr/L) PCT (ng/ml) Albumin (gr/dl) aPTT (seconds) LDH (u/L)
Group 1
Group 2
p
34 59,7±18,1 19,5±6,0 13,1 ±5,1 11,8±3,1 63,8±29,1 12,9±11,1 17,3±48,0 2,8±0,7 30,1±9,5 814,0±529,0
22 68,6±14,6 19,5±6,9 14,0±6,3 11,0±2,3 63,2±39,9 11,0±10,8 1,4±2,4 3,2±0,7 26,3±7,4 903,0±1250,0
0.035 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
Abbrevations: WBC, white blood cell; hb, hemoglobin; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; LDH, lactat dehidrogenaz; PCT, procalcitonin; APACHE, acute physiological and cronic health status; aPTT, activated partial tromboplastin time.
Discussion & conclusion: Eutyhroid sick syndrome, in particular low T3 syndrome, is a common finding in ICU. Its pathophysiological role is not well
P0529 MULTIPLE PULMONARY ARTERIOVENOUS FISTULAE — TO TREAT OR NOT TO TREAT, THAT IS THE QUESTION
Ana Sofia Ventura 1 , José Carlos Pereira 1 , Paula Rosa 2 , Nuno Bragança 1 , Teresa Cruz 1 . 1 Hospital Fernando Fonseca, Internal Medicine Department 3, Portugal; 2 Hospital Fernando Fonseca, Pneumology Department, Portugal Pulmonary arteriovenous malformations (PAVM) are rare vascular anomalies, more frequent in females and in the first three decades of life. Although most patients are asymptomatic, PAVMs can cause dyspnea from right-toleft shunt. Because of paradoxical emboli, various central nervous system complications have been described including stroke and brain abscess. Chest X-ray, contrast enhanced CT-scan and angiography are essential diagnostic tools. Therapeutic options include angiographic embolization with metal coil or balloon occlusion and surgical excision. The authors present a case of a 64 year old Caucasian woman with a history of hypertension, hypercholesterolemia and neurosurgery procedure in 2000 due to cerebral abscesses, left leg melanoma operated in 1990 and digital clubbing, more evident in the 1st, 3rd and 5th left hand fingers, with an evolution of 20 years. She was referenced to our hospital’s internal medicine consult to be investigated for polycythemia (erythrocytes: 6.64×1012 /L; hemoglobin: 20.9 g/dL) and thrombocytopenia (platelets: 73000/dL). On admission, she denied smoking habits and family history of hematologic diseases. She was asymptomatic except for progressive tiredness and dyspnea