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P0529 MULTIPLE PULMONARY ARTERIOVENOUS FISTULAE — TO TREAT OR NOT TO TREAT, THAT IS THE QUESTION
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
S178
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
to moderate exertion efforts. Physical exam without alterations, except for the referred exuberant digital clubbing and a slight labial cyanosis. Gasometric analyses revealed pO2 of 43%, pCO2 of 35.1, SatO2 of 83.2% with a hemoglobin of 22.1 g/dL. Two phlebotomies were performed and oxygen was initiated. The chest X-ray and an echocardiogram showed no abnormal alteration and the abdominal ultrasound was also normal, without splenomegaly. A thoracic CT-scan was requested, showing multiple several sized arteriovenous fistulae (AVF) dispersed bilaterally through both pulmonary fields, involving all lobes. The diagnosis of polycythemia secondary to pulmonary AVF was admitted and the patient was discharged, with indication of maintaining domiciliary oxygen therapy and referenced to our hospital’s immunohemotherapy and pulmonary consults, to continue eventual necessary phlebotomies and to discuss the possibility of eventual AVF embolization, respectively. After listening to different medical opinions on whether being submitted to AVF embolization or not, she is now waiting for the procedure. In spite of limited information about the natural history of PAVM, available data suggest that most patients should be treated, thus preventing neurological complications, progressive hypoxia and its resultant effects, and high output cardiac failure. However, the procedure is not trivial, and significant complications (e.g. rupture of blood vessels, pleuritic pain, air embolism, device migration, a new or increased pulmonary hypertension ...) may occur in 6% of procedures. The authors present a discussion on the several options and indications for PAVM treatment as well as the complications that may retard or cancel the decision of medical intervention.
P0530
Table 1
Demographics Number of patients Age mean (SD) Males Surgical: medical: A&E Risk factors and prophylaxis for CIN CIN risk factors noted on CT request intravenous fluid pre-hydration received NAC nephrotoxic medications withheld Diabetic Post-CT renal function assessed Baseline and change in renal function Baseline eGFR mls/min mean (SD) CKD stage and % fall in eGFR (n, % fall) (where negative indicates an increase) Stage 1 and 2 (eGFR >60) Stage 3 (eGFR 30-60) Stage 4 (eGFR <30) >25% fall in eGFR Patients requiring renal replacement therapy
% n (%) n n % n (%)
n (%) n
Pre-intervention
Post-intervention
52 72 (14) 27 18:32:2
40 69 (15) 25 12:27:1
52 5 (11) 1 1 10 45 (86)
60 11 (28) 1 4 13 22 (55)
68 (24)
70 (20)
-3 , -3.4 6.5, 19.8 1.5, 5.97 3,5.7 0
46.9, -6.0 -9.7, 25.35 0, 0 2, 5 0
when an electronic ordering system incorporating compulsory renal function information is installed. References: 1. The Royal College of Radiologists (2005). Standards For Iodinated Intravascular Contrast Agent Administration To Adult Patients 2. Ann Intern Med. 2008;148:284-294. 3. Arch Med Sci 2006:256-261
AUDIT OF CONTRAST INDUCED NEPHROPATHY IN A DISTRICT GENERAL HOSPITAL
Matthew Sword 1 , Hazel Fendley 1 , Henry Marshall 2 , Craig Dick 1 . 1 Dorset County Hospital NHS Foundation Trust, Dorchester, UK; 2 The Prince Charles Hospital, Brisbane, Australia Introduction: Nephropathy is a well recognised side-effect of contrast media used in radiological examinations & is the 3rd commonest cause of acute renal failure in hospitalised patients. Contributing factors include pre-existing renal impairment, heart failure, nephrotoxic medications, dehydration & diabetes. Even small increases in serum creatinine have been associated with increased length of hospital stays & inpatient mortality. We were aware of anecdotal cases of contrast-induced nephropathy (CIN) in in-patients at our hospital, a 401 bed district general unit. We conducted an audit against national guidelines published by the Royal College of Radiologists (1) Objectives: 1) Document whether guidelines for prophylaxis for at-risk patients were followed 2) Assess post contrast monitoring of renal function 3) Quantify the incidence of CIN (>20% reduction in eGFR) 4) Assess the impact of raising awareness of CIN through a specific teaching programme. Materials & methods: In the 1st phase, a prospective audit of practice of all in-patients undergoing a contrast-enhanced CT over a 10 day period was carried out. Case: notes & medication charts were analysed. Demographics, risk factors for nephropathy & renal function (estimated glomerular filtration rate, eGFR) pre & 24-48 hours post CT (where performed) were recorded. The contrast used was Optiray 300. In the 2nd phase, we aimed to increase junior doctor awareness of CIN through teaching sessions & information posters in clinical ward areas. We then re-audited using the methodology above. Results: see Table 1. Discussion & conclusion: The initial phase of the audit showed that local practice did not conform to the RCR guidelines. Of the 16 patients with a pre-scan eGFR <60 mls/min, 6 were on nephrotoxic medication but only 2 had them withheld. Out of the 4 patients for whom prophylactic N-acetyl cysteine (NAC) should have been considered, none received it. 1 patient did have NAC but had good renal function. Following our intervention, 4 patients had nephrotoxic medication stopped prior to scanning & 1 patient appropriately received prophylactic NAC. 3 patients were on nephrotoxic agents when scanned 1 of whom had a 26% reduction in renal function afterwards. The changes in eGFR reported have to be interpreted with some caution as severity of illness, treatment in the period between scanning & rechecking may mask any contrast induced changes. Despite this, there does seem to be a preventable drop in a subset of patients that with rigorous enforcement of guidelines could be prevented. Simple education does not seem to be enough to ensure adherence to guidelines for preventing CIN. We plan to reaudit
P0531 GUILLAIN-BARRE SYNDROME-A RARE FORM OF PRESENTATION
Joao Luis Ferraz Aguiar Gaspar, Ana Sofia Silva, Joao Miguel Freitas, Margarida Jardim, Maria Da Luz Brazao. Hospital Central Funchal Summary: The authors present a 75-year-old patient with a previous medical history of hypertension, TIA and dyslipidaemia who presented to the emergency department with parestesias on the right upper limb, loss of power on his lower limbs and unsteady gait. The examination on admission was unremarkable for abnormal findings as well the blood tests and the CT scan. He was admitted to the Medicine ward with the standing diagnosis of ischaemic stroke/TIA. During his stay, he continued to complain of weakness on his lower limbs and parestesias on right upper limb. A repeat CT scan is performed which revealed a right parietal lacunar hipodensity. On the 10th day from admission the patient develops muscle weakness on the upper limbs and lower limbs (tetraparesis) and generalized arreflexia. A MRI was requested and whilst in the MRI scanner the patient suffered a respiratory arrest, which lead to orotracheal intubation and mechanical ventilation and was admitted to ITU. A lumbar puncture was performed and well as electromyography studies which were unremarkable, which suggested the diagnosis of Guilain-Barre Syndrome. The patient was started on immunoglobulin therapy and physiotherapy, which was continued after discharge to the neurology ward. There was gradual improvement of neurological function, with grade 4 tetraparesia, arreflexia e diminished pain sensation on the distal part of the lower limbs. The authors end by mentioning this uncommon form of presentation of Guillian-Barre Syndrome leading to a late diagnosis on a later stage of this disease. Key words: Guillain-Barre Syndrome, Arreflexia, parestesias
P0532 ANTICONVULSIVANT HYPERSENSITIVITY SYNDROME WITH HEPATITIS AND RENAL FAILURE
Tania Gaspar, Patrícia H. Monteiro, Catarina Gomes, Luís Santos Pinheiro, Margarida Lucas, Rui Victorino. Clinica Universitaria De Medicina 2, Hospital De Santa Maria - Faculdade De Medicina De Lisboa, Lisboa Portugal Introduction: Anticonvulsant hypersensitivity syndrome (AHS) is a rare idiosyncratic reaction (1/1000-10000), characterized by fever, arthralgias, rash and hepatitis. It is more common with aromatic anticonvulsivants, such as phenytoin (PHT) and carbamazepine (CBZ). We present a case of a probable interstitial nephritis associated with AHS. Case description: A 59 year-old man was admitted with 10 days of fever,
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
S178
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
to moderate exertion efforts. Physical exam without alterations, except for the referred exuberant digital clubbing and a slight labial cyanosis. Gasometric analyses revealed pO2 of 43%, pCO2 of 35.1, SatO2 of 83.2% with a hemoglobin of 22.1 g/dL. Two phlebotomies were performed and oxygen was initiated. The chest X-ray and an echocardiogram showed no abnormal alteration and the abdominal ultrasound was also normal, without splenomegaly. A thoracic CT-scan was requested, showing multiple several sized arteriovenous fistulae (AVF) dispersed bilaterally through both pulmonary fields, involving all lobes. The diagnosis of polycythemia secondary to pulmonary AVF was admitted and the patient was discharged, with indication of maintaining domiciliary oxygen therapy and referenced to our hospital’s immunohemotherapy and pulmonary consults, to continue eventual necessary phlebotomies and to discuss the possibility of eventual AVF embolization, respectively. After listening to different medical opinions on whether being submitted to AVF embolization or not, she is now waiting for the procedure. In spite of limited information about the natural history of PAVM, available data suggest that most patients should be treated, thus preventing neurological complications, progressive hypoxia and its resultant effects, and high output cardiac failure. However, the procedure is not trivial, and significant complications (e.g. rupture of blood vessels, pleuritic pain, air embolism, device migration, a new or increased pulmonary hypertension ...) may occur in 6% of procedures. The authors present a discussion on the several options and indications for PAVM treatment as well as the complications that may retard or cancel the decision of medical intervention.
P0530
Table 1
Demographics Number of patients Age mean (SD) Males Surgical: medical: A&E Risk factors and prophylaxis for CIN CIN risk factors noted on CT request intravenous fluid pre-hydration received NAC nephrotoxic medications withheld Diabetic Post-CT renal function assessed Baseline and change in renal function Baseline eGFR mls/min mean (SD) CKD stage and % fall in eGFR (n, % fall) (where negative indicates an increase) Stage 1 and 2 (eGFR >60) Stage 3 (eGFR 30-60) Stage 4 (eGFR <30) >25% fall in eGFR Patients requiring renal replacement therapy
% n (%) n n % n (%)
n (%) n
Pre-intervention
Post-intervention
52 72 (14) 27 18:32:2
40 69 (15) 25 12:27:1
52 5 (11) 1 1 10 45 (86)
60 11 (28) 1 4 13 22 (55)
68 (24)
70 (20)
-3 , -3.4 6.5, 19.8 1.5, 5.97 3,5.7 0
46.9, -6.0 -9.7, 25.35 0, 0 2, 5 0
when an electronic ordering system incorporating compulsory renal function information is installed. References: 1. The Royal College of Radiologists (2005). Standards For Iodinated Intravascular Contrast Agent Administration To Adult Patients 2. Ann Intern Med. 2008;148:284-294. 3. Arch Med Sci 2006:256-261
AUDIT OF CONTRAST INDUCED NEPHROPATHY IN A DISTRICT GENERAL HOSPITAL
Matthew Sword 1 , Hazel Fendley 1 , Henry Marshall 2 , Craig Dick 1 . 1 Dorset County Hospital NHS Foundation Trust, Dorchester, UK; 2 The Prince Charles Hospital, Brisbane, Australia Introduction: Nephropathy is a well recognised side-effect of contrast media used in radiological examinations & is the 3rd commonest cause of acute renal failure in hospitalised patients. Contributing factors include pre-existing renal impairment, heart failure, nephrotoxic medications, dehydration & diabetes. Even small increases in serum creatinine have been associated with increased length of hospital stays & inpatient mortality. We were aware of anecdotal cases of contrast-induced nephropathy (CIN) in in-patients at our hospital, a 401 bed district general unit. We conducted an audit against national guidelines published by the Royal College of Radiologists (1) Objectives: 1) Document whether guidelines for prophylaxis for at-risk patients were followed 2) Assess post contrast monitoring of renal function 3) Quantify the incidence of CIN (>20% reduction in eGFR) 4) Assess the impact of raising awareness of CIN through a specific teaching programme. Materials & methods: In the 1st phase, a prospective audit of practice of all in-patients undergoing a contrast-enhanced CT over a 10 day period was carried out. Case: notes & medication charts were analysed. Demographics, risk factors for nephropathy & renal function (estimated glomerular filtration rate, eGFR) pre & 24-48 hours post CT (where performed) were recorded. The contrast used was Optiray 300. In the 2nd phase, we aimed to increase junior doctor awareness of CIN through teaching sessions & information posters in clinical ward areas. We then re-audited using the methodology above. Results: see Table 1. Discussion & conclusion: The initial phase of the audit showed that local practice did not conform to the RCR guidelines. Of the 16 patients with a pre-scan eGFR <60 mls/min, 6 were on nephrotoxic medication but only 2 had them withheld. Out of the 4 patients for whom prophylactic N-acetyl cysteine (NAC) should have been considered, none received it. 1 patient did have NAC but had good renal function. Following our intervention, 4 patients had nephrotoxic medication stopped prior to scanning & 1 patient appropriately received prophylactic NAC. 3 patients were on nephrotoxic agents when scanned 1 of whom had a 26% reduction in renal function afterwards. The changes in eGFR reported have to be interpreted with some caution as severity of illness, treatment in the period between scanning & rechecking may mask any contrast induced changes. Despite this, there does seem to be a preventable drop in a subset of patients that with rigorous enforcement of guidelines could be prevented. Simple education does not seem to be enough to ensure adherence to guidelines for preventing CIN. We plan to reaudit
P0531 GUILLAIN-BARRE SYNDROME-A RARE FORM OF PRESENTATION
Joao Luis Ferraz Aguiar Gaspar, Ana Sofia Silva, Joao Miguel Freitas, Margarida Jardim, Maria Da Luz Brazao. Hospital Central Funchal Summary: The authors present a 75-year-old patient with a previous medical history of hypertension, TIA and dyslipidaemia who presented to the emergency department with parestesias on the right upper limb, loss of power on his lower limbs and unsteady gait. The examination on admission was unremarkable for abnormal findings as well the blood tests and the CT scan. He was admitted to the Medicine ward with the standing diagnosis of ischaemic stroke/TIA. During his stay, he continued to complain of weakness on his lower limbs and parestesias on right upper limb. A repeat CT scan is performed which revealed a right parietal lacunar hipodensity. On the 10th day from admission the patient develops muscle weakness on the upper limbs and lower limbs (tetraparesis) and generalized arreflexia. A MRI was requested and whilst in the MRI scanner the patient suffered a respiratory arrest, which lead to orotracheal intubation and mechanical ventilation and was admitted to ITU. A lumbar puncture was performed and well as electromyography studies which were unremarkable, which suggested the diagnosis of Guilain-Barre Syndrome. The patient was started on immunoglobulin therapy and physiotherapy, which was continued after discharge to the neurology ward. There was gradual improvement of neurological function, with grade 4 tetraparesia, arreflexia e diminished pain sensation on the distal part of the lower limbs. The authors end by mentioning this uncommon form of presentation of Guillian-Barre Syndrome leading to a late diagnosis on a later stage of this disease. Key words: Guillain-Barre Syndrome, Arreflexia, parestesias
P0532 ANTICONVULSIVANT HYPERSENSITIVITY SYNDROME WITH HEPATITIS AND RENAL FAILURE
Tania Gaspar, Patrícia H. Monteiro, Catarina Gomes, Luís Santos Pinheiro, Margarida Lucas, Rui Victorino. Clinica Universitaria De Medicina 2, Hospital De Santa Maria - Faculdade De Medicina De Lisboa, Lisboa Portugal Introduction: Anticonvulsant hypersensitivity syndrome (AHS) is a rare idiosyncratic reaction (1/1000-10000), characterized by fever, arthralgias, rash and hepatitis. It is more common with aromatic anticonvulsivants, such as phenytoin (PHT) and carbamazepine (CBZ). We present a case of a probable interstitial nephritis associated with AHS. Case description: A 59 year-old man was admitted with 10 days of fever,