Nephrogenic diabetes insipidus after esophagectomy in a patient with remote history of lithium treatment: A case report

INTRODUCTION: Nephrogenic diabetes insipidus occurs in patients on chronic lithium treatment even after lithium discontinuation. Patients affected by this disorder are highly vulnerable to hypernatremia when they cannot respond to their thirst mechanism. We report a rare case of hypernatremia due to undiagnosed nephrogenic diabetes insipidus post esophagectomy in a patient with remote history of lithium use. PRESENTATION OF CASE: A 70-year-old female with past medical history of bipolar disorder, chronic kidney disease and pheochromocytoma underwent an elective esophagectomy for esophageal adenocarcinoma. Lithium was discontinued 10 years prior to her presentation. She was kept nil per os post operatively and subsequently developed altered mental status necessitating intubation. Her sodium level was found to be 156 mmol/L. A water deprivation test and desmopressin trial confirmed nephrogenic diabetes insipidus. Days after dextrose 5% in water infusion, free water flushes through the jejunostomy tube and hydrochlorothiazide, her hypernatremia improved slowly with subsequent improvement in her mental status. DISCUSSION: Several mechanisms have been described in literature to explain the persistent damage caused by lithium on the kidneys. When patients lose access to a source of free water and are resuscitated with normal saline post operatively, they are at risk of developing life-threatening hypernatremia. This can be avoided by aggressive hydration with appropriate fluid replacement. CONCLUSION: Surgeons should be aware of the persistent renal defects caused by long term lithium use and development of nephrogenic diabetes insipidus even years after medication cessation

Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy in the Super-Obese and Super-Super-Obese: An Analysis of the Metabloic and Bariatric Surgery Accreditation and Quality Improvement Program Database

Background: With the increase in the prevalence of obesity and the need for bariatric surgery, there continues to be contradictory evidence for the perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients. The purpose of this is study is to investigate 30-day morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods: All patients undergoing LSG and LRYGB between the years 2015 and 2017 in the MBSAQIP database were identified. Patients were divided into three groups based on body mass index (BMI): obese (BMI 35 – 50 kg/m2), SO (BMI 50 – 60 kg/m2), and SSO (BMI ≥ 60 kg/m2). Primary outcomes included the occurrence of any complication or mortality. Secondary outcomes included readmission, reoperation, renal events, cardiac events, respiratory events, unplanned intensive care admission, surgical site infections, venous thromboembolic events, transfusion, and reintervention. These were compared between the BMI groups using Pearson X2 test or Fischer’s exact test. Multivariate logistic regression was then used to adjust for demographics, co-morbidities, and operative variables and adjusted odds ratio (AOR) was reported for each outcome. Results: A total of 356,621 patients met inclusion criteria: 71.6% LSG and 28.4% LRYGB. SSO and SO groups was associated with marginally longer operative times and conversion to open. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for the SO group (AOR = 1.20 for LSG; AOR = 1.08 for LRYGB) and SSO group (AOR = 1.44 for LSG; AOR = 1.31 for LRYGB). Mortality rate was also significantly higher for the SO group (AOR = 1.65 for LSG; AOR = 1.85 for LRYGB) and SSO group (AOR = 3.30 for LSG; AOR = 3.32 for LRYGB). Conclusion: SO and SSO patients are at increased risk of 30-day morbidity and mortality compared to patients with BMI ≤ 50 kg/m2. Despite this statistically significant increase, the risks remain low and acceptable especially that bariatric surgery is the only reliable treatment option for obesity.https://scholarlycommons.henryford.com/merf2019clinres/1054/thumbnail.jp

Rate of guideline consistent monitoring of thyroid stimulating hormone and liver function test in patients on long term amiodarone treatment.

Long term amiodarone treatment can lead to thyroid dysfunction as well as hepatic toxicity. Amiodarone-induced thyroid dysfunction can occur in about 32% of treated patients. Thus, periodic monitoring of thyroid stimulating hormone (TSH) and liver function tests (SGPT and SGOT) is recommended. However, data is limited regarding rates of adherence to guidelines. Using an urban center population, we aimed to characterize the patient population with long-term amiodarone use and assess rates of adherence to current guidelines for TSH, SGPT and SGOT monitoring. All patients aged 18 years or older who were prescribed amiodarone for more than 1 year in Henry Ford Hospitals, Detroit and West Bloomfield, Michigan were retrospectively identified between January 2013 and December 2017. Patients younger than 18 years and those who had amiodarone prescribed for less than 3 months were excluded. The medical records were examined for patient\u27s characteristics including age, gender and race. Patients prescribed amiodarone were also analyzed for adherence with established guidelines, defined as TSH measurement at time of amiodarone initiation and 3-6 months after. Adherence to liver function tests monitoring was also monitored at time of initiation of treatment and 6months after. Indication of amiodarone use, prescribers of amiodarone and TSH, concomitant statin use were also analyzed. A total of 295 patients were included in the study. The majority of these patients were males ( 62%) and white (50%) with average age of 69.9. Amiodarone was prescribed for atrial fibrillation/flutter in 79% of the cases and ventricular arrhythmias in 19%. 73% of the patients used amiodarone concomitantly with statin. Amiodarone was prescribed mainly by cardiologists (75%) and TSH was prescribed by cardiologists (50%), primary care physicians (35%), cardiac surgeons (3%) and endocrinologists (3%). Baseline testing of TSH was done in 71% whereas baseline testing of SGPT and SGLT was at 12.5 %. At 3-6 months, only 51% had thyroid function tests and 9 % had liver function tests. Monitoring of thyroid and liver function tests in patients on amiodarone is less than optimal. This is probably due to lack of awareness of current guidelines

A Fatal Case of Hemophagocytic Lymphohistiocytosis Due to Extra-Pulmonary Sarcoidosis

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening condition of overwhelming systemic inflammation. It can lead to multi-organ failure and circulatory shock with high reported intensive care unit mortality rate of 50-80%. Sarcoidosis association with HLH is very rare, as only eight previous cases have been reported in literature so far. In our case report, we present a fatal case of HLH associated with non-pulmonary sarcoidosis to raise awareness of the diagnosis and facilitate earlier treatment. CASE PRESENTATION: The patient was a 48-year-old male newly diagnosed with sarcoidosis who was transferred to our intensive care unit with persistent fever and chest pain. Two months prior to his presentation, imaging of his abdomen showed a large mesenteric mass, large splenic masses, and heterogeneous liver parenchyma. Biopsies showed non- necrotizing granulomatous inflammation. The patient was diagnosed with sarcoidosis and started on oral steroids. On presentation, he was febrile, tachycardic and hypotensive. His blood work was significant for pancytopenia, elevated liver function, low fibrinogen and high serum ferritin. He was fluid resuscitated and empirically treated with broad spectrum antibiotics for presumed severe sepsis. An extensive infectious work up was negative. A bone marrow biopsy exhibited a hypo-cellular bone marrow with histiocytic hemophagocytosis. Patient was started on dexamethasone, intravenous immunoglobulin and etoposide as part of the HLH treatment protocol. His medical condition deteriorated, as he developed a shock state unresponsive to maximum vasopressors. Patient expired soon after. DISCUSSION: HLH results from uncontrolled activation of histiocytes, natural killer cells and cytotoxic T-cells which lead to persistent systemic inflammatory response syndrome. The HLH -2004 protocol defines the diagnostic criteria as fever, splenomegaly, cytopenia, hypertriglyceridemia and/or hypofibrinogenemia, low NK -cell activity, hyperferritinemia, elevated serum soluble interleukin 2 receptor and hemophagocytosis in tissue biopsy. The presentation of HLH in the intensive care unit is very similar to sepsis, however the development of cytopenia in the setting of severe sepsis and multi-organ failure should raise the suspicion of HLH. Infections and malignancies are the most common triggers of HLH. Some autoimmune diseases such as systemic lupus erythematous are also complicated by HLH. Association with sarcoidosis, however, is extremely rare. Out of the eight cases of HLH associated with sarcoidosis, four were triggered by an infectious cause. In our patient no infectious trigger was identified CONCLUSIONS: It is imperative to diagnose and differentiate HLH from sepsis in the ICU in a timely manner. Early recognition and prompt treatment of this disorder is needed to prevent fatal outcomes. Reference #1: Henter JI, Horne A, Aricó M, et al. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007. Reference #2: Kapoor S, Morgan CK, Siddique MA, Kalpalatha K Guntupalli. Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases. World J Crit Care Med. 2018;7(6):73-83. Reference #3: Filipovich AH. Hemophagocytic Lymphohistiocytosis and Other Hemophagocytic Disorders. Immunol Allergy Clin North Am. 2008

Severe phlebitis-like abnormal reaction following great saphenous vein cyanoacrylate closure

The VenaSeal closure system is a nonthermal, nontumescent technique that was approved by the U.S. Food and Drug Administration in 2015 for the treatment of superficial venous insufficiency. Studies have demonstrated a comparable efficacy and safety profile to thermal ablation procedures. We report a case of a middle-aged woman who developed a severe, prolonged phlebitis-like reaction requiring treatment with steroids and antihistamines after cyanoacrylate adhesive embolization. This adverse reaction is uncommon but usually self-limiting and is believed to be a type IV hypersensitivity reaction to the cyanoacrylate compound. Knowledge of this potential complication and its treatment are key, because the reaction may be severe with significant morbidity

Nephrogenic diabetes insipidus after esophagectomy in a patient with remote history of lithium treatment: A case report

INTRODUCTION: Nephrogenic diabetes insipidus occurs in patients on chronic lithium treatment even after lithium discontinuation. Patients affected by this disorder are highly vulnerable to hypernatremia when they cannot respond to their thirst mechanism. We report a rare case of hypernatremia due to undiagnosed nephrogenic diabetes insipidus post esophagectomy in a patient with remote history of lithium use. PRESENTATION OF CASE: A 70-year-old female with past medical history of bipolar disorder, chronic kidney disease and pheochromocytoma underwent an elective esophagectomy for esophageal adenocarcinoma. Lithium was discontinued 10 years prior to her presentation. She was kept nil per os post operatively and subsequently developed altered mental status necessitating intubation. Her sodium level was found to be 156 mmol/L. A water deprivation test and desmopressin trial confirmed nephrogenic diabetes insipidus. Days after dextrose 5% in water infusion, free water flushes through the jejunostomy tube and hydrochlorothiazide, her hypernatremia improved slowly with subsequent improvement in her mental status. DISCUSSION: Several mechanisms have been described in literature to explain the persistent damage caused by lithium on the kidneys. When patients lose access to a source of free water and are resuscitated with normal saline post operatively, they are at risk of developing life-threatening hypernatremia. This can be avoided by aggressive hydration with appropriate fluid replacement. CONCLUSION: Surgeons should be aware of the persistent renal defects caused by long term lithium use and development of nephrogenic diabetes insipidus even years after medication cessation

Severe phlebitis-like abnormal reaction following great saphenous vein cyanoacrylate closure

The VenaSeal closure system is a nonthermal, nontumescent technique that was approved by the U.S. Food and Drug Administration in 2015 for the treatment of superficial venous insufficiency. Studies have demonstrated a comparable efficacy and safety profile to thermal ablation procedures. We report a case of a middle-aged woman who developed a severe, prolonged phlebitis-like reaction requiring treatment with steroids and antihistamines after cyanoacrylate adhesive embolization. This adverse reaction is uncommon but usually self-limiting and is believed to be a type IV hypersensitivity reaction to the cyanoacrylate compound. Knowledge of this potential complication and its treatment are key, because the reaction may be severe with significant morbidity

Perioperative Outcomes of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Patients with Diabetes Mellitus: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

BACKGROUND: The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) to treat obesity and associated comorbidities, including diabetes mellitus, is well established. As diabetes may add risk to the perioperative period, we sought to characterize perioperative outcomes of these surgical procedures in diabetic patients. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we identified patients who underwent LSG and LRYGB between 2015 and 2017, grouping by non-diabetics (NDM), non-insulin-dependent diabetics (NIDDM), and insulin-dependent diabetics (IDDM). Primary outcomes included serious adverse events, 30-day readmission, 30-day reoperation, and 30-day mortality. Univariate and multivariable analyses were used to evaluate the outcome in each diabetic cohort. RESULTS: Multivariable analysis of patients who underwent LSG (with NDM patients as reference) showed higher 30-day mortality (NIDDM AOR = 1.52, p = 0.043; IDDM AOR = 1.91, p = 0.007) and risk of serious adverse events (NIDDM AOR = 1.15, p \u3c 0.001; IDDM AOR = 1.58, p \u3c 0.001) in the diabetic versus NDM groups. Multivariable analysis of patients who underwent LRYGB (with NDM patients as reference) showed higher risk of serious adverse events (NIDDM AOR = 1.09, p = 0.014; IDDM AOR = 1.43, p \u3c 0.001) in the diabetic versus NDM groups. CONCLUSIONS: Diabetics who underwent LSG and LRYGB had higher rates of several perioperative complications compared with non-diabetics. IDDM had a stronger association with several perioperative complications compared with NIDDM. This increase in morbidity and mortality is modest and should be weighed against the real benefits of bariatric surgery in patient with obesity and diabetes mellitus

Serum Ferritin as a Predictor of Outcomes in Hospitalized Patients with Covid-19 Pneumonia

Purpose: Elevated ferritin levels are associated with poor outcomes in Covid-19 patients. Optimal timing of ferritin assessment and the merit of longitudinal values remains unclear. Methods: Patients admitted to Henry Ford Hospital with confirmed SARSCoV-2 were studied. Regression models were used to determine the relation between ferritin and mortality, need for mechanical ventilation, ICU admission, and days on the ventilator. Results: 2265 patients were evaluated. Patients with an initial ferritin of \u3e 490 ng/mL had an increased risk of death (OR 3.4, P \u3c .001), admission to the ICU (OR 2.78, P \u3c .001) and need for mechanical ventilation (OR 3.9, P \u3c .001). There was no difference between admission and Day 1 ICU ferritin levels (611.5 ng/mL vs. 649 ng/ mL respectively; P=.07). The decline in ferritin over ICU days 1-4 was similar between survivors and non-survivors. A change in ferritin levels from admission to ICU Day 1 (P =.330), or from ICU Day 1 to 2 (P =.788), did not predict days on the ventilator. Conclusions: Initial Ferritin levels were highly predictive of ICU admission, the need for mechanical ventilation and in-hospital mortality. However, longitudinal measures of ferritin throughout the hospital stay did not provide additional predictive value