- Email: [email protected]
TAKOTSUBO: A CASE REPORT
S58
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112
HBA1C CORRELATES WITH FASTING GLUCOSE OR POST PANDRIAL GLUCOSE BUT ALWAYS? Miguel Marques, Helga Martins, Ângela Coelho, Lara Maia, Alice Pinheiro, David Silva, Nuno Cardoso, Celeste Guedes. Centro Hospital Médio Ave – Unidade de Famalicão, Serviço Medicina I, Portugal Background and aims: Diabetes is well known for his direct and indirect costs – a share of those directly related to HbA1c, starving glucose and postprandial glucose measurements. The study was developed to determine if HbA1C correlated better with fasting glucose or post pandrial glucose. Methods: We selected all patients that were followed in Diabetes Consultations (N=856), being excluded those that didn’t had three values of HbA1C, fasting glucose and post pandrial glucose values within the last year or diagnosed as gestational diabetes. We tested correlation of median HbA1c with starving glucose and postprandial glucose using Spearman’s and Pearson coefficient. Data was analyzed using SPSS Statistics Version 18.0 Results: We included 533 patients, 43.7% male, median age of 62, median years of disease 18.4 years. HbA1c correlates moderately with starving glucose (Spearman’s=0,526 Pearson=0.573) and postprandial glucose (Spearman’s=0,459 Pearson=0.522), still as time of evolution rises the degree of correlation decreases to a weak correlation (Spearman and Pearson lower than 0.3). Conclusions: HbA1c correlates moderately with both fasting glucose and postprandial glucose, still as time of disease increases the correlation gets weaker. This raises the question of utility of fasting glucose and postprandial glucose, especially in patients with long-time disease, representing an important cost to all health systems. BONE METASTASIS FROM GASTRIC CARCINOMA AFTER EIGHT-YEAR DISEASE-FREE INTERVAL Juan Marti1, Marta Sainz2. 1Department of Internal Medicine, Hospital Zumarraga. Guipuzcoa. Spain; 2Clinical Pathology, Hospital Zumarraga. Guipuzcoa. Spain Introduction: Skeletal metastasic lesions and /or bone marrow metastasis is relatively uncommon. A 68-year-old woman presented with metastatic disease in lumbar spine and pelvis 8 years after total gastrectomy for gastric carcinoma Case: A 68 year-old woman was admitted with a 4 months history of diffuse lower back pain and weight loss. Eight years previously, a diagnosis of gastric adenocarcinoma poorly differentiated with areas of signet ring cell carcinoma was carried out,.Surveillance for 8 years that include. Abdominal ultrasound, chest X-ray, blood count cell, liver function test, tumours markers (CEA, Ca 19.9) were normal with apparent remission. At time of admission. Physical examination showed no abnormal sign. Laboratory studies showed: Hb 9 gr/dl, WBC 6500/PL, platelets 8700 P/L, LDH 578 U/L, alkaline phosphatase 1350 U/L, CEA was 7.1 ng/mL, Ca 19.9 1580 U/ml. CT scan of chest, abdomen and lumbar MRI showed, multiple mixed osteolytic-osteoblastic lesion on lumbar spine and pelvis without evidence of extra-osseous metastasis.Transiliac bone biopsy revealed an infiltrating adenocarcinoma poorly differentiated with signet ring cell. Outcome was unfavourable and patient died 2 months after diagnosis. Discussion: Metastasis to the bone from gastric tumours is rare and has been estimated to appear in 1.2 %-13.4%, are a late complication occurring years after total removal of primary tumour. Scirrhous carcinomas and poorly differentiated adenocarcinoma were the predominant types of gastric cancer which resulted in bone metastasis. Main symptoms of metastasis are pain (70%), fractures (8.5%) paraplegia but 21 % are asymptomatics. Bone marrow aspiration and biopsy provide the evidence of malignancy Prognosis remains poor and therapy is mainly aimed at relieving pain and discomfort. DYSPNEA AND PALPITATION. JUST AN ORDINARY HEART FAILURE? Alexandra Martins, Gina Guerreiro, Ana Baptista, Andreia Cruz, Jose Amado, François Alves, Idálio Mendonça, Pastor Silva. Hospital De Faro EPE Introdution: Primary tumours of the heart are rare. The majority of these tumours are benign, with myxomas located in the left atrium being the most common form. Almost all malignant tumours are sarcomas and occur prefer-
entially in the right side of the heart with the exception of leiomyosarcomas that occurs predominantly in the left atrium. Case Report: The authors report the case of a 77 year old woman that presented with complaints of a non-painful nodule on the left side of the neck with rapid growth. A biopsy of the nodule revealed a non-differentiated carcinoma. Three months later, the patient was admitted in the emergency room with dyspnea and palpitations. Transthoracic echocardiogram showed a large heterogeneous mass in the left atrium that obstructed the flow into the ventricle. The patient was submitted to an incomplete resection of the mass. Pathohistological examination demonstrated a pleomorphic leiomyosarcoma. A two months post-operative echocardiogram revealed re-growth of the tumour. The patient did no adjuvant chemotherapy or radiotherapy. She died 4 months after diagnosis. Conclusion: The prognosis of Leiomyosarcomas is very poor with a mean survival after diagnosis of 6 months. Since this is a rare disease the therapeutic experience is still poor, the role of adjuvant chemotherapy or radiotherapy is not defined especially in patients with metastatic Leiomyosarcoma. Local recurrence is common and usually occurs soon after surgery as happened in the presented case. THE INFLUENCE OF DIABETES IN STROKE: AN OBSERVATIONAL STUDY Helga Martins, Ana Luísa Cruz, João Pedro Pinho, Pedro Beleza, Augusto Duarte. Department of Medicine, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, Portugal Background: Diabetes is a major risk factor for cerebrovascular events. It has been suggested that the mortality and disability grade in stroke patients are higher in the diabetics. The purpose of this study is to characterize diabetic and non-diabetic patients admitted to our department for transient ischemic attack or stroke. Methods: We conducted a 9 month observational study. The patients were divided in two groups, diabetic (Dg) and non-diabetic (NDg), and characterized by gender, age, type of stroke, Oxfordshire classification, vascular risk factors, functional outcome, hospital length of stay and mortality. Data were analyzed with the SPSS Statistics 18.0. Results: 187 patients were enrolled, 52.9% in Dg. The mean age was 72.7±11.0 years (Dg) and 75.4±12.0 years (NDg). The most frequent diagnosis was cerebral infarction, 82.8% (Dg) vs 77.3% (NDg). There was a higher prevalence of hypertension (88.9%, p<0.001) and dyslipidemia (55.6%, p<0.05) in the Dg. There was no difference in the average length of stay (Dg 9.9±5.0 days; NDg 9.5±4.6 days). Mortality was higher in Dg (7.1% vs 5.7%). At hospital discharge 50.6% of diabetics and 53.0% of non-diabetics had disabling neurological deficits. Conclusion: Comparative analysis of both groups showed that stroke occurred at younger ages in the Dg. Contrary to other studies we found no association between diabetes and the degree of disability. We did observe a higher mortality in the Dg, although not statistically significant. We also found an association between diabetes and a greater number of risk factors, with special emphasis to hypertension and dyslipidemia. TAKOTSUBO: A CASE REPORT Sónia Martins1, Jorge Alcaravela2, Pedro Cunha1, Carla Gil1, Margarida Carvalho1. 1Internal Medicine Department, Rainha Santa Isabel Hospital, Torres Novas, Portugal; 2Cardiology Department, Rainha Santa Isabel Hospital, Torres Novas, Portugal The authors describe the case of a 72-year old female patient, with known cardiovascular risk factors - tobacco smoking and hypertension, who presented to the casualty department with sudden onset dyspnea at rest and intense prolonged retrosternal pain the day prior to presentation. Her admission ECG revealed scarring consistent with anterior and inferior necrosis, with ST-segment elevation in V1 to V6, negative T waves in leads I and aVL, and positive biological markers for myocardial necrosis (Troponin I 2.59ng/ml), compatible with acute ST-segment elevation myocardial infarction. The patient’s echocardiogram revealed a non-dilated, non-hypertrophied left ventricle, with major segmental alterations: apical dilatation, medial akinesis and significantly compromised systolic function. A control echocardiogram documented improvement of systolic function, no apical ectasia and severe hypokinesis of the anterior wall, with conserved inferior, septal and lateral wall motility.
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112 To establish the differential diagnosis between Takotsubo Syndrome and myocardial reperfusion syndrome, the patient was submitted to a coronary angiography and ventriculography which revealed normal coronary arteries and normal ventricular function. This result permitted the diagnosis of Takotsubo Syndrome which, although rare, should be considered in the differential diagnosis of acute chest pain. HEPCIDIN AS A NEW ACUTE PHASE REACTANT IN HEPCIDIN AS A NEW ACUTE PHASE REACTANT IN INTRAABDOMINAL BACTERIAL SEPSIS. RELATIONS TO A SET OF CYTOKINES AND ACUTE PHASE PROTEINS Pavel Maruna, Roman Frasko, Jaroslav Lindner. Institute of Pathological Physiology and the 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University in Prague Background: Hepcidin, a small cystein-rich peptide produced by the liver, was first described as an antimicrobial peptide and subsequently discovered as a key regulator of iron homeostasis. The aim of this study was to characterize the dynamics of circulating hepcidin and its precursor prohepcidin in relation to systemic inflammatory response associated with bacterial sepsis. Methods: The prospective study was performed on patients with proven intraabdominal bacterial sepsis after large abdominal surgery. Plasma levels of hepcidin, prohepcidin, tumor necrosis factor (TNF)D, interleukin (IL)-1E, IL-6, IL-8 (ELISA analysis), C-reactive protein and D1-antitrypsin (nephelometry analysis) were evaluated after admission to ICU and repeatedly in 12-h intervals to day 5. Results: 26 patients were enrolled into study during 3 years. Significant elevation of plasma hepcidin was found 48 h after admission to ICU compared to initial levels (p=0.025). Currently prohepcidin decreased during initial phase of sepsis reaching minimal concentrations 48 h after admission to ICU. Maximum concentrations of hepcidin measured 48 h after admission to ICU correlated with IL-6 (r=0.744, p=0.015) and with C-reactive protein at the same time (r=0.718, p=0.044). No other tested inflammatory parameter correlated with hepcidin on p<0.05. Conclusion: Bacterial sepsis stimulated the increase of hepcidin, and the course of hepcidin was related to IL-6 dynamics. The findings are in conformity with recent experimental studies defining hepcidin as a type II acute-phase protein and suggesting different regulation of hepcidin and its precursor prohepcidin by inflammatory stimuli. The study was supported with a grant MSM0021620819 of the Ministry of Education, Czech Republic. HOSPITAL AT HOME (UHD): A HEALTHCARE ALTERNATIVE – A 4 YEARS EXPERIENCE Beatriz Massa, Laura Alepuz. Hospital Marina Baixa, Villajoyosa, Alicante, Spain Background: The UHD is a healthcare alternative in the Comunidad Valenciana (Spain) that provides specialized hospital level in-home patient care when patient no longer needs the hospital infrastructure. Methods: All patients admitted by the UHD of Marina Baixa Hospital (Alicante, Spain) have been reviewed, valuing which kind of pathological group is the rightful and which hospital service has referred them. In addition, the medical team identifies the most outstanding procedures and common pathologies. Results: During 4 years of operation the UHD has attended 910 patients, this have generated 3.409 outpatients. Four pathological groups are defined: day hospital, chronic patient hospitalization, terminal patient hospitalization and acute processes. The most notable one, has been the chronic patient hospitalization (34,6%). Terminal patients hospitalization accounted for the 24%, comparable to the day hospital group with 26,6%. It should be noted the progressive increase in patients admitted for acute diseases: 6% Among acute diseases, infectious are the most prevalent: skin infection and soft tissues, infection of joint prosthesis and infective endocarditis. Breaking down the different services, Internal Medicine stands out with 28% of the patients, followed by oncology with 18.25%. Other medical specialities patients have reached in similar range. Conclusions: The UHD is a healthcare efficient alternative as part of the process attended by internal medicine, making possible to approach the most prevalent diseases in our hospital wards, preventing nosocomial infections and save costs to our sanitary service.
S59
HIGH SERUM PANCREATIC ENZYMES IN PATIENTS WITH ISCHEMIC AND HEMORRHAGIC STROKE Maria Bakola, Konstantina Mavridou, Christina Tsitou, Thomas Tzimas, Maria Mastora, Nikolaos Akritidis. Department of Internal Medicine, “G. Hatzikosta” General Hospital, Ioannina, Greece Background: High serum concentrations of pancreatic enzymes in patients with non pancreatic diseases are difficult to interpret in clinical practice. This elevation is associated with various conditions. Among them, increased serum amylase and lipase, have been noted after brain damage. The aim of this prospective study is to determine the incidence and significance of hyperamylasemia and hyperlipasemia in patients with ischemic and hemorrhagic stroke. Methods: We evaluated 104 patients who were hospitalized with stroke, at the internal medicine department of our institute, during the first 5 months of 2011. The group comprised 57 female patients and 47 male, aged 44-96 years (mean age 77 years). The normal ranges of the two enzymes established in our laboratory were 28-100 IU/l for amylase, and 21-67 IU/l for lipase. To be eligible for the study, the patients had to be free of pancreatic and billiary tract disease involvement, concomitant abdominal trauma, tumors, digestive diseases, renal insufficiency, macroamylasemia, burns, gestation, myeloma, history of thoracic surgery, alcoholism, salivary gland diseases, diabetic ketoacidosis and head injury. Results: Serum amylase and lipase were measured in 104 patients. 88(84,62%) patients presented with ischemic stroke and 16(15,38%) with hemorrhagic. The overall incidence of hyperamylasemia was 27,88% (29 patients : 23 with ischemic stroke and 6 with hemorrhagic. Median 93,32 IU/l, range 12-474 IU/l). The incidence of hyperlipasemia was 8,65% (9 patients: 6 with ischemic stroke and 3 with hemorrhagic. Median 45,90 IU/l, range 6,5-458 IU/l). Conclusions: The present study shows that elevated serum pancreatic enzyme concentrations in patients with stroke are note-worthy and this knowledge can save them from invasive and costly examinations. SEVERE HSV 2-HEPATITIS ASSOCIATED WITH REACTIVE HEMOPHAGOCYTIC SYNDROME IN AN IMMUNOCOMPETENT PATIENT Meckenstock Roderich1, Therby Audrey1, Monnier Sebastian1, Khau David1, Lebas Constance2, Greder-Belan Alix1. 1Department of Internal and Infectious Medecine, Versailles Hospital 78150 Le Chesnay, France; 2Department of Geriatric Medecine, Versailles Hospital 78150 Le Chesnay, France Background: Severe herpes simplex hepatitis (HSH) occurs rarely in immunocompetent patients. It must be suspected in case of extensive cytolysis and thrombopenia but diagnosis is frequently missed or delayed because of the absence of mucocutaneous ulcers [1,2]. Case presentation: A 41 year old caucasian immunocompetent man admitted for fever (40°), weight loss since 3 weeks, cough and severe pharyngitis with dysphagia presented with denutrition, jaundice, ascites and hepatomegaly. Medical history: gastric ulcers, B- hepatitis 5 years ago, and alcoholism. Biology: Hb 9,2g/dl, WBC 15,5/nl, platelets 84/nl, CRP 200mg/l, AST 13N, ALT 20N, bilirubine 45Pmol/l, PT 55%, ferritinemia 20000 Pg/l (glycolysated fraction 24%), triglycerides 2,9 g/l. HBs antigen negative, anti-HBs 7,6, anti-HBc >1000mU.I/ml, EBV reactivation with transitory PCR elevation, HSV2: IgG/ IgM positive, HSV1, HIV, HCV negatives. PCR HSV2 was positive in blood, liver biopsy, CSF, ascites and pleural effusion. CT-body-scan: bilateral pleural effusion, hepatomegaly with micro-nodular pattern, ascites. Liver biopsy: acute hepatitis with extensive coagulation and necrosis. Patient received iv aciclovir (10 mg/kg x 3/d, 3 weeks) then valaciclovir (3g/d, 5 weeks), and iv etoposid 150 mg (2x) for associated reactive hemophagocytic syndrome (RHS). Outcome was slowly favourable with PCR of HSV2 remaining positive at 7 months. Patient is lost for follow-up, with alcohol dependence persisting. Conclusion: We describe another case of severe HSH in a patient without immunodeficiency, besides alcoholism as possible risk factor. Association with RHS has been described in only one other immunocompetent patient with HSH [3]. Prognosis of HSH is severe even under rapidly introduced aciclovir treatment [2]. References 1. Lakhan SE, Harle L. Fatal fulminant herpes simplex hepatitis secondary to tongue piercing in an immunocompetent adult: a case report. J Med Case Reports;2008:356 2. Farr RW, Short S, Weissman D. Fulminant hepatitis during herpes simplex virus infection in apparently immunocompetent adults: report of two cases and review of the literature. Clin Infect Dis 1997;24:1191-4
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112
HBA1C CORRELATES WITH FASTING GLUCOSE OR POST PANDRIAL GLUCOSE BUT ALWAYS? Miguel Marques, Helga Martins, Ângela Coelho, Lara Maia, Alice Pinheiro, David Silva, Nuno Cardoso, Celeste Guedes. Centro Hospital Médio Ave – Unidade de Famalicão, Serviço Medicina I, Portugal Background and aims: Diabetes is well known for his direct and indirect costs – a share of those directly related to HbA1c, starving glucose and postprandial glucose measurements. The study was developed to determine if HbA1C correlated better with fasting glucose or post pandrial glucose. Methods: We selected all patients that were followed in Diabetes Consultations (N=856), being excluded those that didn’t had three values of HbA1C, fasting glucose and post pandrial glucose values within the last year or diagnosed as gestational diabetes. We tested correlation of median HbA1c with starving glucose and postprandial glucose using Spearman’s and Pearson coefficient. Data was analyzed using SPSS Statistics Version 18.0 Results: We included 533 patients, 43.7% male, median age of 62, median years of disease 18.4 years. HbA1c correlates moderately with starving glucose (Spearman’s=0,526 Pearson=0.573) and postprandial glucose (Spearman’s=0,459 Pearson=0.522), still as time of evolution rises the degree of correlation decreases to a weak correlation (Spearman and Pearson lower than 0.3). Conclusions: HbA1c correlates moderately with both fasting glucose and postprandial glucose, still as time of disease increases the correlation gets weaker. This raises the question of utility of fasting glucose and postprandial glucose, especially in patients with long-time disease, representing an important cost to all health systems. BONE METASTASIS FROM GASTRIC CARCINOMA AFTER EIGHT-YEAR DISEASE-FREE INTERVAL Juan Marti1, Marta Sainz2. 1Department of Internal Medicine, Hospital Zumarraga. Guipuzcoa. Spain; 2Clinical Pathology, Hospital Zumarraga. Guipuzcoa. Spain Introduction: Skeletal metastasic lesions and /or bone marrow metastasis is relatively uncommon. A 68-year-old woman presented with metastatic disease in lumbar spine and pelvis 8 years after total gastrectomy for gastric carcinoma Case: A 68 year-old woman was admitted with a 4 months history of diffuse lower back pain and weight loss. Eight years previously, a diagnosis of gastric adenocarcinoma poorly differentiated with areas of signet ring cell carcinoma was carried out,.Surveillance for 8 years that include. Abdominal ultrasound, chest X-ray, blood count cell, liver function test, tumours markers (CEA, Ca 19.9) were normal with apparent remission. At time of admission. Physical examination showed no abnormal sign. Laboratory studies showed: Hb 9 gr/dl, WBC 6500/PL, platelets 8700 P/L, LDH 578 U/L, alkaline phosphatase 1350 U/L, CEA was 7.1 ng/mL, Ca 19.9 1580 U/ml. CT scan of chest, abdomen and lumbar MRI showed, multiple mixed osteolytic-osteoblastic lesion on lumbar spine and pelvis without evidence of extra-osseous metastasis.Transiliac bone biopsy revealed an infiltrating adenocarcinoma poorly differentiated with signet ring cell. Outcome was unfavourable and patient died 2 months after diagnosis. Discussion: Metastasis to the bone from gastric tumours is rare and has been estimated to appear in 1.2 %-13.4%, are a late complication occurring years after total removal of primary tumour. Scirrhous carcinomas and poorly differentiated adenocarcinoma were the predominant types of gastric cancer which resulted in bone metastasis. Main symptoms of metastasis are pain (70%), fractures (8.5%) paraplegia but 21 % are asymptomatics. Bone marrow aspiration and biopsy provide the evidence of malignancy Prognosis remains poor and therapy is mainly aimed at relieving pain and discomfort. DYSPNEA AND PALPITATION. JUST AN ORDINARY HEART FAILURE? Alexandra Martins, Gina Guerreiro, Ana Baptista, Andreia Cruz, Jose Amado, François Alves, Idálio Mendonça, Pastor Silva. Hospital De Faro EPE Introdution: Primary tumours of the heart are rare. The majority of these tumours are benign, with myxomas located in the left atrium being the most common form. Almost all malignant tumours are sarcomas and occur prefer-
entially in the right side of the heart with the exception of leiomyosarcomas that occurs predominantly in the left atrium. Case Report: The authors report the case of a 77 year old woman that presented with complaints of a non-painful nodule on the left side of the neck with rapid growth. A biopsy of the nodule revealed a non-differentiated carcinoma. Three months later, the patient was admitted in the emergency room with dyspnea and palpitations. Transthoracic echocardiogram showed a large heterogeneous mass in the left atrium that obstructed the flow into the ventricle. The patient was submitted to an incomplete resection of the mass. Pathohistological examination demonstrated a pleomorphic leiomyosarcoma. A two months post-operative echocardiogram revealed re-growth of the tumour. The patient did no adjuvant chemotherapy or radiotherapy. She died 4 months after diagnosis. Conclusion: The prognosis of Leiomyosarcomas is very poor with a mean survival after diagnosis of 6 months. Since this is a rare disease the therapeutic experience is still poor, the role of adjuvant chemotherapy or radiotherapy is not defined especially in patients with metastatic Leiomyosarcoma. Local recurrence is common and usually occurs soon after surgery as happened in the presented case. THE INFLUENCE OF DIABETES IN STROKE: AN OBSERVATIONAL STUDY Helga Martins, Ana Luísa Cruz, João Pedro Pinho, Pedro Beleza, Augusto Duarte. Department of Medicine, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, Portugal Background: Diabetes is a major risk factor for cerebrovascular events. It has been suggested that the mortality and disability grade in stroke patients are higher in the diabetics. The purpose of this study is to characterize diabetic and non-diabetic patients admitted to our department for transient ischemic attack or stroke. Methods: We conducted a 9 month observational study. The patients were divided in two groups, diabetic (Dg) and non-diabetic (NDg), and characterized by gender, age, type of stroke, Oxfordshire classification, vascular risk factors, functional outcome, hospital length of stay and mortality. Data were analyzed with the SPSS Statistics 18.0. Results: 187 patients were enrolled, 52.9% in Dg. The mean age was 72.7±11.0 years (Dg) and 75.4±12.0 years (NDg). The most frequent diagnosis was cerebral infarction, 82.8% (Dg) vs 77.3% (NDg). There was a higher prevalence of hypertension (88.9%, p<0.001) and dyslipidemia (55.6%, p<0.05) in the Dg. There was no difference in the average length of stay (Dg 9.9±5.0 days; NDg 9.5±4.6 days). Mortality was higher in Dg (7.1% vs 5.7%). At hospital discharge 50.6% of diabetics and 53.0% of non-diabetics had disabling neurological deficits. Conclusion: Comparative analysis of both groups showed that stroke occurred at younger ages in the Dg. Contrary to other studies we found no association between diabetes and the degree of disability. We did observe a higher mortality in the Dg, although not statistically significant. We also found an association between diabetes and a greater number of risk factors, with special emphasis to hypertension and dyslipidemia. TAKOTSUBO: A CASE REPORT Sónia Martins1, Jorge Alcaravela2, Pedro Cunha1, Carla Gil1, Margarida Carvalho1. 1Internal Medicine Department, Rainha Santa Isabel Hospital, Torres Novas, Portugal; 2Cardiology Department, Rainha Santa Isabel Hospital, Torres Novas, Portugal The authors describe the case of a 72-year old female patient, with known cardiovascular risk factors - tobacco smoking and hypertension, who presented to the casualty department with sudden onset dyspnea at rest and intense prolonged retrosternal pain the day prior to presentation. Her admission ECG revealed scarring consistent with anterior and inferior necrosis, with ST-segment elevation in V1 to V6, negative T waves in leads I and aVL, and positive biological markers for myocardial necrosis (Troponin I 2.59ng/ml), compatible with acute ST-segment elevation myocardial infarction. The patient’s echocardiogram revealed a non-dilated, non-hypertrophied left ventricle, with major segmental alterations: apical dilatation, medial akinesis and significantly compromised systolic function. A control echocardiogram documented improvement of systolic function, no apical ectasia and severe hypokinesis of the anterior wall, with conserved inferior, septal and lateral wall motility.
Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112 To establish the differential diagnosis between Takotsubo Syndrome and myocardial reperfusion syndrome, the patient was submitted to a coronary angiography and ventriculography which revealed normal coronary arteries and normal ventricular function. This result permitted the diagnosis of Takotsubo Syndrome which, although rare, should be considered in the differential diagnosis of acute chest pain. HEPCIDIN AS A NEW ACUTE PHASE REACTANT IN HEPCIDIN AS A NEW ACUTE PHASE REACTANT IN INTRAABDOMINAL BACTERIAL SEPSIS. RELATIONS TO A SET OF CYTOKINES AND ACUTE PHASE PROTEINS Pavel Maruna, Roman Frasko, Jaroslav Lindner. Institute of Pathological Physiology and the 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University in Prague Background: Hepcidin, a small cystein-rich peptide produced by the liver, was first described as an antimicrobial peptide and subsequently discovered as a key regulator of iron homeostasis. The aim of this study was to characterize the dynamics of circulating hepcidin and its precursor prohepcidin in relation to systemic inflammatory response associated with bacterial sepsis. Methods: The prospective study was performed on patients with proven intraabdominal bacterial sepsis after large abdominal surgery. Plasma levels of hepcidin, prohepcidin, tumor necrosis factor (TNF)D, interleukin (IL)-1E, IL-6, IL-8 (ELISA analysis), C-reactive protein and D1-antitrypsin (nephelometry analysis) were evaluated after admission to ICU and repeatedly in 12-h intervals to day 5. Results: 26 patients were enrolled into study during 3 years. Significant elevation of plasma hepcidin was found 48 h after admission to ICU compared to initial levels (p=0.025). Currently prohepcidin decreased during initial phase of sepsis reaching minimal concentrations 48 h after admission to ICU. Maximum concentrations of hepcidin measured 48 h after admission to ICU correlated with IL-6 (r=0.744, p=0.015) and with C-reactive protein at the same time (r=0.718, p=0.044). No other tested inflammatory parameter correlated with hepcidin on p<0.05. Conclusion: Bacterial sepsis stimulated the increase of hepcidin, and the course of hepcidin was related to IL-6 dynamics. The findings are in conformity with recent experimental studies defining hepcidin as a type II acute-phase protein and suggesting different regulation of hepcidin and its precursor prohepcidin by inflammatory stimuli. The study was supported with a grant MSM0021620819 of the Ministry of Education, Czech Republic. HOSPITAL AT HOME (UHD): A HEALTHCARE ALTERNATIVE – A 4 YEARS EXPERIENCE Beatriz Massa, Laura Alepuz. Hospital Marina Baixa, Villajoyosa, Alicante, Spain Background: The UHD is a healthcare alternative in the Comunidad Valenciana (Spain) that provides specialized hospital level in-home patient care when patient no longer needs the hospital infrastructure. Methods: All patients admitted by the UHD of Marina Baixa Hospital (Alicante, Spain) have been reviewed, valuing which kind of pathological group is the rightful and which hospital service has referred them. In addition, the medical team identifies the most outstanding procedures and common pathologies. Results: During 4 years of operation the UHD has attended 910 patients, this have generated 3.409 outpatients. Four pathological groups are defined: day hospital, chronic patient hospitalization, terminal patient hospitalization and acute processes. The most notable one, has been the chronic patient hospitalization (34,6%). Terminal patients hospitalization accounted for the 24%, comparable to the day hospital group with 26,6%. It should be noted the progressive increase in patients admitted for acute diseases: 6% Among acute diseases, infectious are the most prevalent: skin infection and soft tissues, infection of joint prosthesis and infective endocarditis. Breaking down the different services, Internal Medicine stands out with 28% of the patients, followed by oncology with 18.25%. Other medical specialities patients have reached in similar range. Conclusions: The UHD is a healthcare efficient alternative as part of the process attended by internal medicine, making possible to approach the most prevalent diseases in our hospital wards, preventing nosocomial infections and save costs to our sanitary service.
S59
HIGH SERUM PANCREATIC ENZYMES IN PATIENTS WITH ISCHEMIC AND HEMORRHAGIC STROKE Maria Bakola, Konstantina Mavridou, Christina Tsitou, Thomas Tzimas, Maria Mastora, Nikolaos Akritidis. Department of Internal Medicine, “G. Hatzikosta” General Hospital, Ioannina, Greece Background: High serum concentrations of pancreatic enzymes in patients with non pancreatic diseases are difficult to interpret in clinical practice. This elevation is associated with various conditions. Among them, increased serum amylase and lipase, have been noted after brain damage. The aim of this prospective study is to determine the incidence and significance of hyperamylasemia and hyperlipasemia in patients with ischemic and hemorrhagic stroke. Methods: We evaluated 104 patients who were hospitalized with stroke, at the internal medicine department of our institute, during the first 5 months of 2011. The group comprised 57 female patients and 47 male, aged 44-96 years (mean age 77 years). The normal ranges of the two enzymes established in our laboratory were 28-100 IU/l for amylase, and 21-67 IU/l for lipase. To be eligible for the study, the patients had to be free of pancreatic and billiary tract disease involvement, concomitant abdominal trauma, tumors, digestive diseases, renal insufficiency, macroamylasemia, burns, gestation, myeloma, history of thoracic surgery, alcoholism, salivary gland diseases, diabetic ketoacidosis and head injury. Results: Serum amylase and lipase were measured in 104 patients. 88(84,62%) patients presented with ischemic stroke and 16(15,38%) with hemorrhagic. The overall incidence of hyperamylasemia was 27,88% (29 patients : 23 with ischemic stroke and 6 with hemorrhagic. Median 93,32 IU/l, range 12-474 IU/l). The incidence of hyperlipasemia was 8,65% (9 patients: 6 with ischemic stroke and 3 with hemorrhagic. Median 45,90 IU/l, range 6,5-458 IU/l). Conclusions: The present study shows that elevated serum pancreatic enzyme concentrations in patients with stroke are note-worthy and this knowledge can save them from invasive and costly examinations. SEVERE HSV 2-HEPATITIS ASSOCIATED WITH REACTIVE HEMOPHAGOCYTIC SYNDROME IN AN IMMUNOCOMPETENT PATIENT Meckenstock Roderich1, Therby Audrey1, Monnier Sebastian1, Khau David1, Lebas Constance2, Greder-Belan Alix1. 1Department of Internal and Infectious Medecine, Versailles Hospital 78150 Le Chesnay, France; 2Department of Geriatric Medecine, Versailles Hospital 78150 Le Chesnay, France Background: Severe herpes simplex hepatitis (HSH) occurs rarely in immunocompetent patients. It must be suspected in case of extensive cytolysis and thrombopenia but diagnosis is frequently missed or delayed because of the absence of mucocutaneous ulcers [1,2]. Case presentation: A 41 year old caucasian immunocompetent man admitted for fever (40°), weight loss since 3 weeks, cough and severe pharyngitis with dysphagia presented with denutrition, jaundice, ascites and hepatomegaly. Medical history: gastric ulcers, B- hepatitis 5 years ago, and alcoholism. Biology: Hb 9,2g/dl, WBC 15,5/nl, platelets 84/nl, CRP 200mg/l, AST 13N, ALT 20N, bilirubine 45Pmol/l, PT 55%, ferritinemia 20000 Pg/l (glycolysated fraction 24%), triglycerides 2,9 g/l. HBs antigen negative, anti-HBs 7,6, anti-HBc >1000mU.I/ml, EBV reactivation with transitory PCR elevation, HSV2: IgG/ IgM positive, HSV1, HIV, HCV negatives. PCR HSV2 was positive in blood, liver biopsy, CSF, ascites and pleural effusion. CT-body-scan: bilateral pleural effusion, hepatomegaly with micro-nodular pattern, ascites. Liver biopsy: acute hepatitis with extensive coagulation and necrosis. Patient received iv aciclovir (10 mg/kg x 3/d, 3 weeks) then valaciclovir (3g/d, 5 weeks), and iv etoposid 150 mg (2x) for associated reactive hemophagocytic syndrome (RHS). Outcome was slowly favourable with PCR of HSV2 remaining positive at 7 months. Patient is lost for follow-up, with alcohol dependence persisting. Conclusion: We describe another case of severe HSH in a patient without immunodeficiency, besides alcoholism as possible risk factor. Association with RHS has been described in only one other immunocompetent patient with HSH [3]. Prognosis of HSH is severe even under rapidly introduced aciclovir treatment [2]. References 1. Lakhan SE, Harle L. Fatal fulminant herpes simplex hepatitis secondary to tongue piercing in an immunocompetent adult: a case report. J Med Case Reports;2008:356 2. Farr RW, Short S, Weissman D. Fulminant hepatitis during herpes simplex virus infection in apparently immunocompetent adults: report of two cases and review of the literature. Clin Infect Dis 1997;24:1191-4