Investor Presentaiton

IJMS INTERNATIONAL JOURNAL of MEDICAL STUDENTS 11th WIMC $70 Abstracts Abstracts of other diseases. The clinical features such as lymphadenopathy may accompany conditions like sarcoidosis-lymphoma syndrome or tuberculosis. The first-line treatment includes glucocorticoid therapy which modulates immunological response and may predispose to the reactivation of the latent infections or acquirement of new ones. The complex assessment is mandatory to differentiate the treatment complications from coexisting conditions and disease progression, before proper therapy implementation. 25 A Case Of Fever With A Twist Ritwick Mondal Department of Medicine Background: Fever is one of the commonest symptoms; clinicians come across both in outpatient and inpatient on a daily basis. This is quite often treated with the broad spectrum antibiotics without even an attempt to get to a diagnosis. It is true that one of the very causes is infection and the fever often responds to antibiotics. However we should not forget the basis of medicine i.e. History taking and clinical examination. Case: A 65 years old lady who lives alone with no co- Morbidity started having fever for two weeks prior to her admission. The fever was between 100-103F.This settled only with Paracetamol therapy. Fever was in association with chill, rigor, and mild cough with mucoid expectoration. There was no other systemic symptom. No urinary, Bowel syndrome, No pain anywhere. At the time she extremely weak so much so that she could not even walk up to the toilet. She was treated with three courses of oral and IV antibiotic. outside with no benefit. Physical examination showed an alert and conscious lady with no evidence of meningism, ear discharge, or any focal neurological sign. Chest examination revealed few inspiratory crepitations over Right base. Respiratory rate was 24/min.Sp02 was 97%. Her pulse rate was 80/min, when her temperature was 100.80F. Other systemic examination was normal. On specific questioning the patient admitted to have several parrots as pets for sometimes.Pro- visional diagnosis of psittacosis was made. All antibiotics were stop- ped. She was started on Doxicycline. She started feeling better with in appropriately 12 hrs. Fever settled with in 24hrs. Patient started to mobilize the next day. She became almost normal except her weak- ness which was significantly less than before. She was discharged on Doxicycline to be taken for 3 weeks. Conclusions: Psittacosis is acquired on contact with birds (Parrots, pigeons, chickens), which may or may not be ill. Psittacosis in human is caused by the bacte- ria Chlamydia Psittaci. The onset is usually rapid, with fever, Chills, myalgia, Dry cough and headache. Signs include high temperature and pulse dissociation. Psittacosis is indistinguishable from other bacterial or viral pneumonias by radiography. The organism is rarely isolated from cultures. The diagnosis is usually made serologically; antibodies appear during the second week and can be demonstrated by the complement fixation or immunofluoroscence. 26 Miliary Sarcoidosis Case Report And Review Of Literature Nina Miązek, Irmina Michałek, Piotr Zapała Department of Dermatology, Medical University of Warsaw Background: Sarcoidosis is a multisystemic noncaseating granuloma- tous disorder with peak incidence between 25 and 40 years. The ori- gin of sarcoidosis remains unclear. One fourth of patients have spe- cific and non-specific skin manifestations. Miliary sarcoidosis [MS] is one of clinical skin variable with no systemic involvement and rela- tively benign course. Macular, papular or nodular lesions in MS are mostly multiple and affect face, occipital region, extensor surfaces of the extremities and the trunk. We report the case of a patient with MS previously misdiagnosed as acne. Case: A 28-year-old Caucasian woman presented to the Dermatology Department with micropapu- lar skin lesions on submalar and perioral region, relapsing from six months. Inflammatory changes were burning and pruritic. No syste- mic symptoms or other abnormalities in general examination were observed. Clinical signs originally suggested acne, which was treated with first generation topical retinoid and tetracycline with poor effec- tiveness achieved. Uneffective therapy suggested misdiagnosis. A. punch biopsy was performed and revealed noncaseating granulomas with epithelial cells and lymphocytes. Chest x-ray showed no abnor- malities. The results of complete blood count, metabolic panel and the Mendel-Mantoux test were within normal limits. Clinical manifes- tation and histological picture allowed us to establish final diagnosis of MS. Initially, the patient was treated with oral corticosteroids (30) mg daily; 0,5mg/kg), with further therapy extension with chloroquine diphosphate (250mg daily) showing almost complete remission of skin lesions. To prevent complications from long-term treatment with systemic steroids and chloroquine, potassium chloride and omepra- zole were implemented. Conclusions: Skin changes in MS are often nonspecific, which remains a clinical challenge. In the diagnosis of sarcoidosis, distinction its skin variant from systemic involvement seems crucial, thus appropriate diagnostic panel is recommended. Solid response to steroids, observed in our clinic confirms literature data and supports its use in MS especially in combined therapy. 27 Unrecognized Congenital Coronary Artery Anomaly Resulting In The Need For Transcatheter Heart Valve Procedure Maria Różańska, Martyna Zaleska Centralny Szpital Kliniczny MSW Warszawa, Klinika Kardiolo- gii Zachowawczej i Nadciśnienia tętniczego Background: The treatment of chronic functional mitral regurgitation (MR) include: medical therapy for heart failure(HF) or left ventricular systolic dysfunction (LVSD), cardiac resynchronization therapy(CRT) in selected patients, and possibly mitral valve surgery or heart trans- plantation. Transcatheter heart valve (THV) procedures may also be considered, especially in patients who are not referred for surgery, like those with severe LVSD. Case: We present a case of a male patient, age 38, who originally underwent a cardiothoracic surgery in 1999: closure of patent ductus arteriosus and aortic valve repla- cement due to HF. Procedure was complicated by massive infero- lateral myocardial infarction. It resulted in post operational iatroge- nic congestive heart failure with left ventricle ejection fraction(LVEF) of 20%. In following years patient required implantable cardioverter defibrillator, and later cardiac resynchronization therapy(CRT) im- plantations. Also in the following years patient required numerous hospitalizations, both diagnostic and due to exacerbations of chronic heart failure. Almost all the times there were different complications of diagnostic procedures in example hematoma of some sort, resul- ting in extended hospitalizations. Between February 2012 and June 2012 patient suffered from several viral infections. His clinical status severely deteriorated. Between February 2012 and December 2013 his LVEF gradually lowered from 40% to 22% and MR progressed. In January 2014 "Heart Team" met to discuss options for MR treatment. During discussion possibility of circumflex artery anomaly and con- sequent improper cardioplegia during 1999 operation was raised up. So in march 2014 computed tomography was performed and showed congenital circumflex artery anomaly (separate origin from right co- ronary artery). Eventual patient was considered high risk for redo operation. Propose possibilities were: MitraClip and THV in the mi- tral position. Conclusions: Although the incidence of abnormal aortic origin of the coronary arteries is low, this case illustrates that its recognition is crucial to appropriate management of cardioplegia and avoidance of severe complications, including severe HF. The optimal treatment of chronic functional MR is still a matter of controversy and should be discussed by the Heart Team. The constantly evolving percutaneous treatment techniques may be an alternative for pa- tients with contraindications for open heart surgery. 28 latrogenic Life-Threating Condition In A Patient With Multiple Rare Disorders Martyna Zaleska Warsaw Medical University, Department of Cardiology and Hypertension, Central Clinical Hospital of the Ministry of Interior, Warsaw Background: Background: Andersen-Tawil syndrome (ATS) is a rare inherited disorder, characterized by periodic paralysis, long QT, ven- tricular arrhythmias and skeletal developmental abnormalities. Case: We report a case of 52 year old female with history of congenital long QT-syndrome (LQTS) who was admitted to our Department due to electrical storm caused by endocarditis. In the past patient un- derwent implantable cardioverter defibrillator (ICD) in secondary pre- vention of cardiac arrest procedure. During current hospitalization smear from the tip of ventricular electrode proved bacterial cause of electrical storm and blood cultures showed 4 bacterial species (none the same as the tip of the electrode). After a course of antibiotics due to mitral regurgitation she was referred for cardiac surgery. Tri- cuspid valve repair was also performed. The patient had biological mitral prosthesis (Perimount 29 mm) and tricuspid annulus (Edwards MC3 30mm) implanted. Post operational period was uneventful. She was admitted again 26 days after discharge due to chronic heart failure (CHF) exacerbation. Additionally tests showed acute renal and hepatic failure, severely reduced left ventricular ejection fraction, left crus deep vein thrombosis. During hospitalization patient re- quired bridging vitamin K antagonists (VKA) with, which resulted in heparin induced thrombocytopenia. Fondaparinux was required for further inhospital antithrombotic treatment. Due to low potassium level she underwent 3 cardiac arrests calmed with defibrillation. De- tailed medical history revealed potential cause of CHF exacerbation, multiorgan failure and deep vein thrombosis - primary care physi- cian withdrawn oral steroids and VKA most likely due to liable INR results. It resulted in exacerbation of vasculitis with antyPR3-ANCA antibodies and left crus deep vein thrombosis. Aggressive treatment in the cardiac intensive care unit was introduced and from the 4th day of stay we observed gradual improvement of both clinical outco- mes and laboratory data. Due to characteristic dysmorphic futures (low-set ears, small mandible, hypertelorism) suspicion of ATS was raised up. It was confirmed with genetic tests. On the 25th day she was discharged in good condition. After 6 months patient's clinical status is stable. She stays fully functional with NYHA class II. Conclusions: To sum up the fact, that patient has one rare disorder should not exclude him from further diagnostic process and very detailed, even if sometimes challenging, outpatient care. 29 Improving Of Myocardial Function After Lvad Therapy In Pa- tient With Idiopathic Cardiomyopathy Aleksandra Brutkiewicz Institute of Cardiology, Warsaw Background: Vetricular Assist Device (VAD) is a mechanical cardiac support used in the treatment of refractory to pharmacological the- rapy heart failure. In Poland it is usually used as a bridge to heart transplantation. In small amount of cases, usually acute myocarditis, post-partum cardiomyopathy or post-cardiotomy shock, VAD serves as a bridge to recovery. The successful explantation of VAD in other cases of cardiomyopathy is incidental. Case: A 30-year old women was admitted to Cardiac Intensive Care Unit with acute heart failure. She presented with severe dyspnea, lasting for 3 weeks, which ini- tially was recognized as respiratory tract infection. Moreover, hypo- tonia, tachycardia and oliguria were observed. Blood tests revealed CRP 1.81 mg/dl, WBC 18.3*103/μl, NT-proBNP 6106 pg/ml, troponine- negative. Chest X-ray showed congestion with no signs of pneu- monia. In echocardiography generalized hypokinesis was described (LVEF-10%), with enlarged left ventricle (LVEDD 6,5 cm). As inotropic support and further IABP did not result in improving of clinical sta- tus, the decision of left ventricle assist device (LVAD) implantation in category bridge-to-transplant was made. Myocardial biopsy showed no specific changes except from focal fibrosis. Myocardium contrac- tility recovered partially during LVAD therapy and LVEF raised to 40%. LVAD was explanted in 63rd day of therapy. Patient was followed up for the next 8 months. She remained stable in NYHA class II and was suspended on the heart transplant waiting list. Magnetic resonan- ce revealed moderate enlargement of both ventricles with reduced contractility (LVEF 47%, RVEF 41%) and small areas of intramyocardial fibrosis/necrosis indicating other than ischemic etiology of cardiom- yopathy. onclusions: Although the inflammatory factor could not be excluded, clinical data suggest idiopathic cardiomyopathy as a bac- kground of heart failure in the patient described. The adequate assessment of potential reversibility of severe cardiac dysfunction is always a challenge, especially in patient with cardiomyopathy of unknown etiology and first presentation of the disease. LVAD the- rapy could win the time to final decision in this particular group of patients. 30 Hedinger's Syndrome In Patient Treated With Peptide Recep- tor Radionuclide Therapy Mikołaj Radziszewski Students' Scientific Group "ENDOCRINUS", Department of Internal Medicine and Endocrinology, Medical University of Warsaw Background: Neuroendocrine neoplasms (NENS) are very rare tumors and can arise almost everywhere in the body. In metastatic functio- nal tumors of small intestine, symptoms are caused by the release of vasoactive substances, especially serotonin. That is called carcinoid syndrome (CS). Carcinoid heart disease (CHD) Hedinger's syndro- me develops in 40-50% of patients with the CS. Serotonin leads to tricuspid and pulmonary valves' fibrosis and their dysfunction. It is of great importance for the clinical stage and prognosis. Cu- rrently, the gold standard for the diagnosis of CHD is transthoracic echocardiography. Case: A 56-year old man was admitted to the Cli- nic of Endocrinology and Internal Medicine due to sudden face and chest flushing appearing for 3 years, with diarrhea, discomfort in the abdomen, accompanied by weakness lasting for a few months. On physical examination the patient presented facial redness, jaun- dice, teleangiectasis, hepatomegaly and symptoms of heart failure (NYHA II) with systolic murmur in the Erb's point. Abdominal ultra- sound showed multiply lesions in the liver. During the diagnostic laparoscopy, tumor biopsy was performed. Histopathological findings presented well-differentiated NEN (WHO Classification 2010: G1) with positive chromogranin A (CgA) and synaptophysin stains. Laboratory studies indicated increased blood levels of CgA, lactate dehydroge- nase, gamma-glutamylotranspeptydase and bilirubin's fractions. The concentration of 5-hydroxyindoloacetic acid in 24-hour urine collec- tion was also elevated. Echocardiography visualized advanced tri- cuspid valve's regurgitation and compound failure of the pulmonary valve. In imaging studies (abdomen computed tomography scans, Gallium-68-DOTA-TATE Positron Emission Tomography/Computed To- mography, colonoscopy) were no signs of the NEN primary origin. Diagnosis of well-differentiated neuroendocrine neoplasm G1 with unknown primary origin and carcinoid syndrome led to qualification to treatment with long-acting somatostatin analogues and peptide receptor radionuclide therapy. CHD had been diagnosed and respec- tive treatment was implemented. Patient did not agree on surgery treatment of valve replacement. Conclusions: The signs of CS appear relatively late, most frequently after metastases to the liver. It is im- portant to find out the origin of the NEN. However, in the presented case the point is to treat the disease in progress, as CHD is the most common cause of death in patients with the CS. 31 Veno-Occlusive Disease Of The Liver After Liver Transplanta- tion: Case Report Maciej Janik Medical University of Warsaw, Students' Scientific group in the Liver and Internal Medicine Unit Background: Veno-Occlusive Disease (VOD) of the liver is mainly des- cribed after chemo-irradiation therapy during hematopoietic stem cell transplantation (SCT) and has been rarely reported after liver transplantation (LT). The pathology of the VOD includes a fibrous na- rrowing of small hepatic venules. VOD is characterized by painful he- patomegaly, ascites and jaundice. Moreover, elevated serum alkaline phosphatase and bilirubin levels are the most typical indicators of VOD. Calcineurin inhibitor tacrolimus (TAC) is nowadays the primary immunosuppressive agent in the therapy after LT. However, among the numerous adverse effects of this drug, thrombotic microangio- pathy (TMA) is quite rare but severe complication. Case: A 60-year- old Caucasian women underwent LT in October 2014 for liver cirrhosis caused by primary biliary cirrhosis (PBC), which was complicated by hepatocellular carcinoma (HCC). The postoperative course was une- ventful, immunosuppressive regimen included TAC, mycophenolan INTERNATIONAL JOURNAL of MEDICAL STUDENTS www.ijms.info • 2015 Vol 3 Suppl 1 www.ijms.info . 2015 Vol 3 Suppl 1 11th WIMC INTERNATIONAL JOURNAL of MEDICAL STUDENTS S71