Small cell lung carcinoma with three paraneoplastic syndromes in one patient

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: This is a case of patient who was diagnosed with Small Cell Lung Carcinoma(SCLC)after presenting with symptoms of Dermatomyositis(DM), SIADH and Lambert–Eaton myasthenic(LEMS)syndrome CASE PRESENTATION: Patient initially presented to the clinic with erythematous patches scattered on the trunk, extremities, and scalp associated with pain, itchiness and hair loss for two months. Biopsy from rash showed perifollicular and mild superficial perivascular inflammation. The patient was treated for viral exanthem with steroids. Patient subsequently presented to the hospital with worsening pruritic patches on scalp and entire body and periorbital edema. This was associated with weakness and generalized malaise. The weakness and pain were worse with neck and shoulder movements and the weakness improved on exertion. Other symptoms were productive cough, rhinorrhea, nasal congestion and sore throat for a month associated with 20 pounds weight loss. Physical exam showed decreased breath sounds in the left upper and middle field.No lower extremity swelling.Skin findings were violaceous edematous periorbital erythema(heliotrope rash), erythema of neck, upper chest, and entire back, erythematous slightly scaly plaques overlying MCPs and PIPs(Gottron\u27s papules). Labs showed CPK of 868, Aldolase of 8.9, serum sodium of 115(Serum osmolality 248, Urine osmolality 497, TSH 1.7, random cortisol 20.7)and ANA(1:320)was positive. Chest x-ray showed left upper lobe mass. CT chest showed malignant process arising from the left upper lobe and to the mediastinum. She underwent bronchoscopy with FNA and endobronchial biopsy which showed SCLC. DISCUSSION: Paraneoplastic syndromes occur in approximately 10% of patients with lung cancer(1). SIADH occurs in 15% of SCLC patients. LEMS is present in approximately 1% to 3% of patients with SCLC. Off all cases of DM only 5.9% have lung cancer. In some cases these syndromes can be presenting sign of cancer. The early recognition of paraneoplastic syndromes may contribute to the detection of a highly treatable, early-stage tumor. At other times, the syndromes may occur late in the course of disease or may appear as the first sign of recurrence DM is associated with poor prognosis and improved SCLC tumor survival are seen in patients with LEMS(2). Management of hyponatremia is very important as it is associated with a poor prognosis regardless of an extensive or limited stage. SCLC patients with serum sodium less than 129 mmol/l had a median survival of 8.63 months compared to 13.6 months in patients with normal sodium, and the degree of hyponatremia is a significant predictor for prognosis(3). CONCLUSIONS: SCLC is associated with large number of paraneoplastic syndromes which can also be the initial presentation in some cases. Ability to identify these syndromes especially in high risk population can lead to early diagnosis and might carry a better prognosis in some patients

Gaps in osmolal gap: A case of mistaken osmolal gap in a patient with diabetic ketoacidosis.

Introduction: The presence of an osmolal gap is often used as an aide to detect osmotically active substances like toxic alcohol. However, inappropriately calculated osmolality in hypertonic hyponatremia in the setting of diabetic ketoacidosis (DKA) can falsely elevate the osmolal gap resulting in inappropriate management decisions. Case Presentation: A 64-year-old male known to have history of alcohol abuse and recurrent pancreatitis presented to the emergency room with nausea, vomiting and abdominal pain of 3-days duration. His vital signs were notable for a normal blood pressure (97/73 mm of hg), tachycardia (140 bpm), temperature of 36.6 °C, tachypnea (32 beats/min) and a normal oxygen saturation (97%). He was found to have dry mucous membranes, and slowed mentation on physical examination. Pertinent laboratory data revealed a BUN of 66 mg/dl, creatinine of 3.47 mg/dl, sodium of 133 mmol/dl, potassium of 4.6 mmol/dl, bicarbonate 5 meq/dl, beta hydroxybutyrate of 19 mmol/L and an elevated serum glucose (1290 mg/dl). His calculated anion gap was 46. Patient\u27s serum alcohol and standard urine drug screen were negative. His measured serum osmolality was 406 mOs/kg. Patient was erroneously thought to have an osmolal gap of 45 mOs/kg. This was due to incorrect derivation of calculated osmolality without factoring in for hyperglycemia. In lieu of a severely elevated osmolal gap, a volatile alcohol screen was sent. He was started on fomepizole and transferred to the intensive care unit (ICU). In the ICU, his osmolal gap was re-evaluated, but now accounting for hyperglycemia, corrected sodium was 152 meq/dl thus an osmolality of 399 mOs/Kg yielding a normal osmolal gap (7 mOs/Kg). Fomepizole was discontinued and therapy target to treat his DKA. Subsequently, the patient\u27s volatile alcohol screening was positive for only acetone. Discussion: This case illustrates key pathophysiology that influences the interpretation of an osmolal gap. An error prone step in assessing the osmolal gap in DKA is to omit the correction factor for translocational hyponatremia in DKA. Another key concept is to recognize that an osmolal gap is not an unusual finding in DKA and should not be confused for the presence of toxic alcohols. An osmolal gap in DKA is attributable to the metabolism of beta-hydroxybutrate to acetone by way of acetoacetate. Acetone, being electrochemically inactive, does not alter the anion gap but imparts osmolality. Our patient underscores the importance of recognizing the limitation and varying etiology of an elevated osmolal gap that could avert management pitfalls

Cardiac Stroke Volume Index Is Associated With Early Neurological Improvement in Acute Ischemic Stroke Patients

Early neurological improvement as assessed with the NIH stroke scale (NIHSS) at 24 h has been associated with improved long-term functional outcomes following acute ischemic stroke (AIS). Cardiac dysfunction is often present in AIS, but its association with outcomes is incompletely defined. We performed a pilot study to evaluate the association between non-invasively measured cardiac parameters and 24-h neurological improvement in prospectively enrolled patients with suspected AIS who presented within 12 h of symptom-onset and had an initial systolic blood pressure\u3e140 mm Hg. Patients receiving thrombolytic therapy or mechanical thrombectomy were excluded. Non-invasive pulse contour analysis was used to measure mean arterial blood pressure (MAP), cardiac stroke volume index (cSVI), cardiac output (CO) and cardiac index (CI). Transcranial Doppler recorded mean middle cerebral artery flow velocity (MFV). We defined a decrease of 4 NIHSS points or NIHSS ≤ 1 at 24-h as neurological improvement. Of 75 suspected, 38 had confirmed AIS and did not receive reperfusion therapy. Of these, 7/38 (18.4%) had neurological improvement over 24 h. MAP was greater in those without improvement (108, IQR 96-123 mm Hg) vs. those with (89, IQR 73-104 mm Hg). cSVI, CO, and MFV were similar between those without and with improvement: 37.4 (IQR 30.9-47.7) vs. 44.7 (IQR 42.3-55.3) ml/m(2); 5.2 (IQR 4.2-6.6) vs. 5.3 (IQR 4.7-6.7) mL/min; and 39.9 (IQR 32.1-45.7) vs. 34.4 (IQR 27.1-49.2) cm/s, respectively. Multivariate analysis found MAP and cSVI as predictors for improvement (OR 0.93, 95%CI 0.85-0.98 and 1.14, 95%CI 1.03-1.31). In this pilot study, cSVI and MAP were associated with 24-h neurological improvement in AIS