Valsalva maneuver, uncontrolled hypertension, asymmetric septal hypertrophy and dynamic outflow obstruction: a case report

A 83-year-old woman presented with a 25-year history of hypertension which was long-standing, uncontrolled, severe hypertension because of irregular oral administration of antihypertensive drug underwent an echocardiographic examination as part of an evaluation of hypertension. She described chest distress associated with activity, syncope for three times in the past one year. On physical examination, she was in no acute distress, with a regular pulse rate and blood pressure of 185/115 mmHg. On auscultation, her lung fields were clear. There was a III/VI late peaking crescendo/decrescendo systolic murmur along the left sternal border radiating to the apex, which increased with standing and Valsalva's maneuver and decreased with squatting. There was no report of provocative maneuvers performed during auscultation. There was no edema. Transthoracic echocardiography showed a hyperdynamic left ventricle with markedly increased left ventricular wall thicknesses and asymmetrical septal hypertrophy. M-mode echocardiography showed systolic anterior motion of the mitral valve apparatus and midsystolic closure of the aortic valve. A dynamic left ventricular outflow tract obstruction was present, with a resting maximal instantaneous gradient of 55 mmHg. With the Valsalva maneuver, the gradient increased to 114 mmHg. No any factors that could cause hypertension were found at kidney, adrenal gland and renal artery etc. by ultrasound and multislice compute tomography

Pheochromocytoma presenting as recurrent urinary tract infections : a case report

<p>Abstract</p> <p>Introduction</p> <p>Pheochromocytomas are rare, potentially fatal, neuroendocrine tumors of the adrenal medulla or extra-adrenal paraganglia. Their clinical presentation varies greatly from the classic triad of episodic headache, diaphoresis and tachycardia to include a spectrum of non-specific symptomatology.</p> <p>Case presentation</p> <p>A 43-year-old Caucasian woman was referred to us from primary care services with a three-month history of recurrent urinary tract infections on a background of hypertension, latent autoimmune diabetes of adulthood and autoimmune hypothyroidism. At 38 years she required insulin therapy. Despite medication compliance and dietary control, she reported a recent history of increased insulin requirements and uncontrolled hypertension with concomitant recurrent urinary tract infections. A renal ultrasound examination, to rule out underlying renal pathology, revealed an incidental 8cm right adrenal mass of both solid and cystic components. A subsequent computed tomography of her abdomen and pelvis confirmed a solid heterogeneous mass consistent with a pheochromocytoma. There were no other features suggestive of multiple endocrine neoplasia. Urinary collection over 24 hours revealed grossly elevated levels of catecholamines and metabolites. Following an open right adrenalectomy, our patient's insulin requirements were significantly reduced and her symptoms resolved. Two weeks post-operatively, an iodine-131-metaiodobenzylguanidine scintigraphy was negative for residual tumor and metastatic disease. Urinary catecholamine and metabolite concentrations were within the normal range at a follow-up six months later.</p> <p>Conclusion</p> <p>Pheochromocytoma is a rare catecholamine-producing tumor requiring a high index of suspicion for early diagnosis. Our case report serves to highlight the importance of considering pheochromocytoma as a differential diagnosis in the atypical setting of recurrent urinary tract infections and concomitant autoimmune disease.</p

Maternal and neonatal outcomes following a diabetic pregnancy within the context of HIV

OBJECTIVE: To characterize the demographics, comorbidities, management, and outcomes of pregnant women with pre-gestational and gestational diabetes (GDM), including overt and true GDM, taking into account HIV infection and the influence of exposure to oral hypoglycemic agents (OHAs). METHODS: A review of medical records of 1071 diabetic pregnancies (between 2012 and 2018) at a tertiary hospital in South Africa. RESULTS: Of the women, 43% had GDM, 19% had type 1 diabetes (T1DM), and 38% had type 2 diabetes (T2DM). Each group had a mean initial body mass index (BMI) >25 kg/m 2 . Despite poor initial HbA1c for pre-gestational groups, over 90% of the cohort achieved glycemic control by the time of delivery. The rate of prematurity was 30.9%. Perinatal mortality (PNM) was 5.1% for the pre-gestational group and 1.8% for GDM. Of the cohort, 23.9% was HIV infected. PNM was higher in the HIV-infected pregnancies (9.4%) than non-HIV exposed pregnancies (1.8%, P<0.001). The macrosomia rate was higher in the glibenclamide-exposed group than the insulin-alone group (12.2% vs 0%, P=0.025). CONCLUSION: Obesity is a significant predictor for macrosomia and was high in all groups. In a low-/middle-income country setting with a high prevalence of HIV and high usage of OHAs as an alternative to insulin therapy, HIV might be associated with higher PNM and glibenclamide with increased rates of macrosomia, which warrants further exploration