Nguyen L, Lee D, Wise J, Patel K, Rosenbloom M. Quis Custodiet Ipsos Custodes: Who Watches the Watchmen? 7th Annual Camden Scholars’ Forum, Camden, NJ, April 2020.
Introduction:
More than 90% of stroke-causing embolisms originate from the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation.3,5 LAA occlusion devices, such as the Watchman™, provide a mechanical alternative for reducing stroke risk in patients with contraindications to long term oral anticoagulation.1,4,5 Since its FDA approval in 2015, over 50,000 Watchman™ devices have been deployed. Although complications remain rare, device migration can have severe consequences.1,2,5
Case Presentation:
An 84-year-old female with a past medical history of atrial fibrillation, hypertension, cardiomyopathy, and ventricular tachycardia with an implantable cardiac defibrillator was referred for LAA occlusion device implantation. She had suffered from several episodes of gastrointestinal bleeding and multiple falls within the past two years. These risk factors (CHA2DS2VASc= 5, HASBLED= 3) raised concerns for long term anticoagulation, and a Watchman™ device was deemed a favorable alternative to her current anticoagulation regimen.
The patient underwent the procedure under fluoroscopic guidance. Transseptal access was performed, and a 27mm Watchman™ device was delivered to the LAA. However, post-deployment surveillance with transesophageal echocardiogram (TEE) showed that the Watchman™ device had dislodged and migrated to the left ventricular outflow tract (LVOT). The patient underwent emergent open retrieval of device with left atrial ligation. Her post-operative course was complicated by pleural effusion and acute stroke, but she ultimately recovered and was discharged on postop day 23.
Discussion:
Watchman™ device embolization remains a rare (incidence rate of 0.6%) but life-threatening complication.1 For our patient, the device settled in the LVOT and compromised forward blood flow. The patient was extremely hypertensive, with TEE demonstrating severe obstruction and reflexive increase in systemic vascular resistance to maintain peripheral perfusion, secondary to significant decrease in cardiac output.
Removal of the obstruction required a midline sternotomy and aortotomy for careful assessment of the orientation of the Watchman™ device. The device was removed in its entirety along the parallel axis of the securement prongs. This experience underlies the importance of the continued relationship between cardiology and cardiac surgery, as well as the significance of having immediate availability of surgical staffing at a tertiary medical center to enact prompt and efficient surgical management of a critically ill patient.
References:
- Reddy, V. Y., et al. “Percutaneous Left Atrial Appendage Closure Vs Warfarin for Atrial Fibrillation: A Randomized Clinical Trial.” JAMA 312.19 (2014): 1988-98. Print.
- Varosy, Paul, et al. “Procedural Safety of Watchman Implantation: The Us Nested Post Approval Study.” Journal of the American College of Cardiology 71.11 Supplement (2018): A320. Print.
- Pisani, P., et al. “Left-Atrial-Appendage Occluder Migrates in an Asymptomatic Patient.” Tex Heart Inst J 41.4 (2014): 443-4. Print.
- Yu, Jiangtao, et al. “Percutaneous Retrieval of a Dislodged Watchman Left Atrial Appendage Closure Device.” Cardiology Plus 1.3 (2016). Print.
- Aminian, A., et al. “Embolization of Left Atrial Appendage Closure Devices: A Systematic Review of Cases Reported with the Watchman Device and the Amplatzer Cardiac Plug.” Catheter Cardiovasc Interv 86.1 (2015): 128-35. Print.
Long Nguyen, M3, Cooper Medical School of Rowan University
Jonas L, Westover T. Twin-Twin Transfusion Syndrome: Pathophysiology and Literature Review. 7th Annual Camden Scholars’ Forum, Camden, NJ, April 2020.
Introduction:
Twin-twin transfusion syndrome (TTTS) is a potential complication of monochorionic twin pregnancies and complicates 10-15% of monochorionic/diamniotic pregnancies. In TTTS, there is a chronic net blood transfer from one twin (“donor”) to the other twin (“recipient”) via placental vascular anastomoses. Treatment options include the more conservative amnioreduction or the more invasive fetoscopic laser ablation or fetal reduction.
Case Description:
A 28-year-old African American G5P2022 presented for a prenatal visit where a fetal ultrasound was performed which revealed a twin live intrauterine pregnancy with monochorionic/diamniotic twins. At that time, she was dated at 11 weeks and 6 days by crown-rump length average and amniotic fluid volumes (AFV) were within normal limits for both fetuses. At 15 weeks and 6 days, fetal ultrasound revealed a discordancy in fetal weights and differences in AFVs for the two amniotic sacs. Subsequent ultrasounds showed increasingly discrepant AFVs indicating oligohydramnios in one twin and polyhydramnios in the other twin, and the patient underwent two uneventful amnioreductions at 18 weeks and 5 days and 23 weeks and 5 days with removal of 1100ml and 1500ml, respectively, of clear yellow amniotic fluid. At 26 weeks and 6 days, the patient presented to Cooper University Hospital in active labor, fully dilated with a bulging bag, and delivered her twins by spontaneous vaginal delivery.
Discussion:
Models for the pathogenesis of TTTS propose that TTTS results from chronic net blood transfer from one twin to the other twin through uneven unidirectional artery-to-vein placental anastomoses. As a result, the donor twin suffers from anemia, hypovolemia, and consequently oligohydramnios. The recipient twin, on the other hand, develops polycythemia, hypervolemia, polyhydramnios, severe cardiac enlargement, hypertrophy, valvular and ventricular dysfunction, and is at high risk for fetal demise. Staging of the severity of TTTS is accomplished by the Quintero staging system. Management options include serial amnioreductions, intrauterine laser coagulation of placental anastomoses, or fetal reduction. Placental laser ablation has been proven to be the most effective treatment for patients diagnosed with TTTS before 26 weeks of gestation.
Lauren Jonas, M3, Cooper Medical School of Rowan University
Jonas L, McMackin K, Fadoul M, Meyermann K, Trani J. Axillary Stump Syndrome as a Cause of Upper Extremity Ischemia. 7th Annual Camden Scholars’ Forum, Camden, NJ, April 2020.
Introduction:
Acute limb ischemia (ALI) of the upper extremity is a rare occurrence, typically cardio-embolic in nature. We present the case of recurrent upper extremity ALI following explant of an axillary-femoral bypass with retained axillary cuff.
Case Description:
A 67-year-old male with a history of diabetes, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and peripheral vascular disease status-post right axillary-femoral and femoral-popliteal bypass with polytetrafluoroethylene (PTFE) four years previously and right above knee amputation two months prior was transferred from an outside hospital to Cooper University Hospital (CUH) with a herald bleed from an extra-dermal prosthetic with purulent femoral drainage. He was taken urgently to the operating room for explantation of his axillary-femoral and femoral-popliteal residual prosthetic. A cuff of well incorporated PTFE was oversewn at the axillary anastomosis. The patient re-presented one month later with pain, numbness and cyanosis in his right hand. Computed Tomography angiography demonstrated occlusion of the distal brachial artery; open thrombectomy via exposure of the right distal brachial artery was performed restoring flow to the right arm. The patient was discharged on Xarelto. He re-presented one month later to an outside facility with recurrent thrombosis of the right upper extremity. A second open thrombectomy was performed and a Viabahn stent was concomitantly placed across the axillary anastomosis to exclude the PTFE cuff. One month later, he re-presented to CUH with a necrotic right hand. After source control via debridement and fasciotomy, an unsuccessful attempt at an open right brachial and radial artery thrombectomy was performed. Ultimately, the patient underwent a transradial amputation of the right arm.
Discussion:
Leaving a cuff of PTFE during explant of an axillary-femoral bypass is common practice due to the risk and difficulty of re-exposing the axillary artery. A potential complication of this practice is axillary stump syndrome: turbulent flow in the retained cuff predisposes to thrombus and subsequent embolus formation in the upper extremity. Due to the recurrent episodes of upper extremity thrombosis, the events were likely thromboembolic originating from the cuff despite anticoagulation. Placing a stent across the axillary anastomosis served to exclude the source, minimizing the risk of recurrent thromboembolism formation.
Lauren Jonas, M3, Cooper Medical School of Rowan University
Jonas L, Zilberman B, Doktor K, Shersher D. Pulmonary Echinococcosis in the Adult: Case Report and Literature Review. 7th Annual Camden Scholars’ Forum, Camden, NJ, April 2020.
Introduction:
The Echinococcus genus of parasitic tapeworms is spread to humans via fecal-oral transmission from hosts such as dogs and sheep. Although they are incidental hosts, humans manifest a variety of diseases following infection. In cystic echinococcosis, the most common disease caused by Echinococcus granulosus, the liver and lungs are the most commonly affected organs, with the latter infrequently found in adult populations.
Case Description:
A 59-year-old Hispanic female with no past medical history initially presented to an outside hospital with a three-month history of initially dry and then productive cough, chest pain, and headache. She emigrated from Guatemala to New Jersey two years ago. The patient was found to have a left upper lobe lung cyst on imaging for which she was treated with voriconazole for a suspected aspergilloma with no improvement. Further work up included a fine needle aspiration biopsy that was consistent with an echinococcal cyst. CT chest showed a stable persistent 5.6cm x 4.1cm cavitary left upper lobe lung lesion for which the patient was started on albendazole and was transferred to CUH for surgical evaluation, eventually undergoing a successful video-assisted thoracoscopic (VATS) left upper lobectomy to remove the lesion entirely. The patient was discharged home on a 30-day course of albendazole following an unremarkable post-operative recovery and has remained asymptomatic at all post-operative appointments.
Discussion:
Surgical excision of a pulmonary echinococcal cyst is the treatment of choice; however, it is of utmost importance to remove the cyst intact as to avoid intraoperative leakage of cystic contents to prevent seeding or dissemination and subsequent anaphylactic shock. A minimally invasive approach utilizing VATS is an effective and safe treatment modality for management of pulmonary echinococcal cysts. Utilizing a VATS lobectomy eliminates the surgical morbidity of open thoracotomy and has been shown to be successful in maximally preserving healthy tissue while also avoiding spillage of cystic contents. In addition, post-operative antimicrobial therapy with albendazole has been shown to help prevent disease recurrence.
Lauren Jonas, M3, Cooper Medical School of Rowan University
Winte M, Trivedi A, Contino K, Dharbhamulla N, Gaughan J, Deitch C, Phadtare S. Comparative Outcomes of Patients undergoing Surgical Aortic Valve Replacement (SAVR) versus Transcatheter Aortic Valve Replacement (TAVR). Poster presentation at Camden Scholars’ Forum, Camden, NJ; April 2020.
Introduction:
Sarcoidosis is a granulomatous disease that can affect any organ system, including the myocardium. Although rare, cardiac sarcoidosis can represent the initial presentation of sarcoidosis, even in the absence of other organ involvement. Myocardial scarring from inflammation can lead to complications, such as complete heart block, bundle branch block, ventricular tachycardia, congestive heart failure, and sudden cardiac death (SCD), but often patients are asymptomatic.
Case:
A 44-year-old African American female who presented with a one-month history of recurrent intermittent chest pain, palpitations, and shortness of breath for evaluation of non-sustained ventricular tachycardia (NSVT) refractory to nadolol and metoprolol. Her lab work and physical exam were unremarkable. She received lidocaine to suppress the NSVT but continued to have intermittent episodes. She had no family history of rheumatologic disease. Past medical history included hypertension, anemia, anxiety and a spinal canal neural stimulator for back pain. Electrocardiogram (EKG) showed normal sinus rhythm and first-degree AV block with a bifasicular block. Echocardiogram (ECHO) revealed right ventricular dilatation and an ejection fraction of 55%. Cardiac magnetic resonance imaging (cMRI) showed late gadolinium enhancement of the septal, anterior and inferior left ventricular walls; right ventricular free wall; and right inferior wall. She underwent an endocardial ablation and placement of an implantable cardioverter-defibrillator (ICD). She received trials of sotalol and metoprolol. Due to recurrent symptomatic episodes of NSVT, she underwent a second endocardial ablation. She subsequently developed torsades de pointes despite resumption of sotalol. Cardiac F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) was suggestive of cardiac sarcoidosis. She was presumptively treated for cardiac sarcoidosis with prednisone and continued sotalol. An endomyocardial biopsy (EMB) was not performed due to the consensus that it would not change medical management. The patient remains asymptomatic.
Discussion:
Cardiac sarcoidosis is a difficult diagnosis to make as it can imitate common cardiac diseases. Additionally, the affected myocardium is not easily detected with EKG or ECHO. Although cMRI and FDG-PET aid in diagnosis, they are not diagnostic. EMB, an invasive procedure with low sensitivity, is the gold standard for diagnosis. Cardiac sarcoidosis is an important diagnosis to make given the risk for sudden death.
Maria Winte, M3, Cooper Medical School of Rowan University
Bourdot K, Rockower H. An Atypical Presentation of Systemic Lupus Erythematosus. In: Cooper University Healthcare’s 7th Annual Camden Scholars’ Forum; April 20-24, 2020; Camden, NJ.
Introduction:
Systemic Lupus Erythematosus (SLE) is a disease that encompasses many symptoms and often presents atypically. Its diagnosis is easy to miss if one only considers an acute symptom rather than a patient’s full history of evolving disease manifestations. The updated 2019 EULAR/ACR diagnostic criteria for SLE are helpful for evaluating these symptoms using an algorithm that has been shown to have both high sensitivity (96.1%) and high specificity (93.4%).
Case Description:
Our patient is an African American male in his 50s with a history of left chest wall schwannoma, recurrent pleural effusions, and pericarditis who presented to the emergency room with acute pleuritic chest pain for the eleventh time within the past twelve months. He was found to have a new pericardial effusion and pleural effusions. On admission he also endorsed recent weight loss, dysphagia, and Raynaud’s phenomenon in his hands. Given these symptoms, the history of recurrent pleural effusions, and a new pericardial effusion, the team was concerned for an autoimmune process. A comprehensive diagnostic work-up revealed a positive ANA 1:1280 with speckled pattern and a positive Anti-Smith Antibody >8 (normal is <1). Our patient noted immediate improvement of his shortness of breath following thoracentesis and his pain was well controlled during a two-week course of colchicine, ibuprofen, and oxycodone. At his follow-up appointments, he was found to have recurrent pleuritic chest pain after completing his colchicine treatment. He was initiated on hydroxychloroquine to manage further exacerbation.
Discussion:
The differential diagnosis of pleuritic chest pain includes cardiovascular, pulmonary, esophageal, infectious, and autoimmune etiologies. While previous visits were focused on symptomatic management, our patient’s most recent hospitalization demonstrated the importance of questioning why he had these repeat presentations. A full investigation of his symptoms pointed to an autoimmune process that had previously gone undetected. We were able to reach a definitive diagnosis per the updated 2019 EULAR/ACR criteria. This case is an important reminder for practitioners to consider that autoimmune diseases may present differently among patients of various genders, ages, and races.
Kia Bourdot, M3, Cooper Medical School of Rowan University
Chang A, Hutchinson D. Vascular Complications of Behcet Syndrome. Poster presented at: Camden Scholars’ Forum Poster Contest. April 20, 2020; Camden, NJ.
Introduction:
Behçet syndrome is a multisystem vasculitis that affects small, medium, and large vessels. It most commonly affects individuals of Turkish descent, but it is known to affect anyone born along the ancient silk road, extending from eastern Asia to the Mediterranean. Aside from the rarity of this syndrome in those native to North America, it is remarkable for its widespread clinical presentation. Painful oral aphthous ulcers are a hallmark clinical feature. The eyes, vasculature, and CNS are other commonly affected organs. Infrequently, kidney and peripheral nervous system involvement occur.
Case Report:
A 29-year-old Turkish male with Behçet syndrome, kidney transplant (2004), diabetes mellitus secondary to drug-induced pancreatitis, legal blindness, and recent bilateral toe amputation of his 4th and 5th digits presented with bilateral foot pain. He underwent the toe amputations of his right foot in 2017, and most recently of his left foot in 2019. Noncompliance with proper wound care led to the patient developing signs of infection. The patient recently experienced increased bilateral foot pain, erythema, and discharge, which brought him to the ED. On physical exam, multiple foot ulcers with purulence were present with tendon and bone exposure, bilaterally. He received bilateral foot imaging, and the MRI confirmed the suspected diagnosis of osteomyelitis. Her underwent irrigation and debridement with bone biopsy and skin graft application. Post-operatively, he was started on chronic IV antibiotics. His hospital course was complicated by an AKI. The patient reported a history of noncompliance with his immunosuppressants in the setting of his kidney transplant.
Discussion:
Individuals with Behçet syndrome are challenging to manage due to the various organ involvement and secondary complications. When patients develop kidney damage severe enough to warrant an organ transplant, the complications more often result from the immunosuppressants rather than disease progression itself. Not only can these medications lead to drug-induced diabetics mellitus, but subsequent peripheral neuropathies can develop from poor glycemic control. This can be further complicated by Behçet vascular disease progression, ultimately impairing peripheral sensation, wound healing, and increasing infection susceptibility in distal extremities. Medication compliance, surveillance for adverse effects, and routine foot checks are highly encouraged.
Alyssa L. Chang, M3, Cooper Medical School of Rowan University
Chang A, Kellish A, Soal V, Aguilar F. A Biopsychosocial Approach to the Management of Stiff Person Syndrome in a Patient with Psychiatric Comorbidities. Poster presented at: Camden Scholars’ Forum Poster Contest. April 20, 2020; Camden, NJ.
Introduction:
Stiff Person Syndrome (SPS) is a rare, unpredictable and progressive neurodegenerative disease characterized by abnormal motor unit activity in muscles, leading to excruciating muscle spasms. As with most chronic medical conditions, psychiatric symptoms are often comorbid with the disease, complicating the evaluation, management, and treatment of patients. We present the psychiatric evaluation and management of a patient with a diagnosis of SPS following admission for a suicide attempt.
Case Presentation:
A 45-year-old Caucasian female with a past medical history of hypothyroidism, anxiety, post-traumatic stress disorder, depression, and SPS presented following a suicide attempt with self-inflicted stab wounds to the neck and abdomen. She endorsed longstanding suicidal thoughts and feelings of hopelessness that recently reached a peak because of agonizing pain secondary to her SPS medical condition. She was working as a neurology nurse practitioner when she was diagnosed with SPS in 2012. Shortly after the diagnosis, her depressive symptoms developed. During the psychiatric interview, the primary driver of her depression and suicidality was her medical illness. She had multiple risk factors for completion of suicide: including prior attempt, sickness, depression, and rational thinking loss, yielding a SAD PERSON’s scale score of 7 (medium/high risk). However, she had multiple protective factors including a strong support system with her daughter and husband, secure housing, medical insurance, and access to care. Over the course of her hospitalization, a strong therapeutic relationship was built through emphasizing communication among the medical team, psychiatric team, and the patient. The patient’s mental health was addressed, and her physical and emotional challenges were validated. She was also seen by the social worker to address her complex needs from arranging medical transportation for follow up appointment to navigating the visits from the Department of Child Protection and Permanency in response to the suicide attempt.
Conclusion:
This clinical case highlights the importance of a multi-disciplinary, team-based approach to address the complex biopsychosocial needs of a patient with SPS. Greater understanding of not only the biological and pathophysiological impact of SPS, but also the psychological and social impact can result in the delivery of higher quality, comprehensive care.
Alyssa L. Chang, M3, Cooper Medical School of Rowan University
Tung, S and Bisaria, S. My, oh myositis! What a way to Mi-2 you: A Case Report. Poster presented at: 7th Annual Camden Scholar’s Forum. April 20, 2020. Camden, NJ.
Introduction:
Polymyositis is an autoimmune inflammatory condition causing progressive proximal skeletal muscle weakness.[1] When active, lab abnormalities such as elevated creatine kinase (CK), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lactate dehydrogenase, aldolase, aspartate transaminase (AST), alanine transaminase (ALT), and myositis-specific autoantibodies are seen. [2] In polymyositis, ALT/AST tend to be borderline high and CK can be up to fifty times the reference range.,[2,3] However, even higher levels have rarely been reported. Diagnosis is confirmed with a muscle biopsy, which shows perimysial and endomysial inflammatory infiltrates.[4]
Case Description:
Α 53 y/o African American male with past medical history significant for coronary artery disease and hyperlipidemia presented to the emergency department with progressively worsening bilateral lower extremity weakness. He denied fevers, chills, recent illnesses, cough, or rashes. Medications included aspirin, atorvastatin, and carvedilol. CK was markedly elevated at 70,780 u/L. Aldolase was elevated at 830.6 u/L. ALT and AST were markedly elevated at 1,350 u/L and 3,680 uL, respectively. CRP and ESR were also elevated at 4.19 mg/dL and 39 mm/h, respectively. From the myositis-specific antibody panel, Anti-Mi-2 Beta and Anti-EJ were positive. Anti-HMGCR and hepatitis panel were negative. A muscle biopsy was ordered to confirm the diagnosis of polymyositis, which is pending. He was started on oral steroids. CK, aldolase, and ALT/AST trended down and disease-modifying antirheumatic drugs were discussed for outpatient therapy.
Discussion:
The differential diagnoses included statin-induced myopathy, rhabdomyolysis, viral induced myopathy, and polymyositis/inclusion body myositis. Significantly elevated ALT/AST suggests an acute infection, autoimmune or drug induced etiology. Statin-induced myopathy was suspected since the acute hepatitis panel was negative, but anti-HMGCR was also negative.[5]The myositis-specific antibody panel includes Jo-1, PL-7, PL-12, EJ, OJ, Mi-2, and SRP. Anti-Jo-1 has a 30% specificity for polymyositis.[6] Anti-Mi-2 has been shown to have specificity.
References:
[1] Mammen A. Dermatomyositis and polymyositis: Clinical presentation, autoantibodies, and pathogenesis. Ann. N.Y. Acad. Sci. 1184 (2010):134-153.
[2] Volochayev R, Csako G, Wesley R, Rider LG, Miller FW. Laboratory Test Abnormalities are Common in Polymyositis and Dermatomyositis and Differ Among Clinical and Demographic Groups. Open Rheumatol J. 2012;6:54–63. doi:10.2174/1874312901206010054
[3] Dalakas MC. Inflammatory muscle diseases. N Engl J Med. 2015;372(18):1734–1747.
[4] Mantegazza R, Bernasconi P. Inflammatory Myopathies: Dermatomyositis, Polymyositis and Inclusion Body Myositis. In: Madame Curie Bioscience Database [Internet]. Austin (TX): Landes Bioscience; 2000-2013.
[5] Mohassel P, Mammen AL. Anti-HMGCR Myopathy. J Neuromuscul Dis. 2018;5(1):11–20. doi:10.3233/JND-170282[1] Arnett FC, Hirsch TJ, Bias WB, Nishikai M, Reichlin M. The Jo-1 antibody system in myositis: relationships to clinical features and HLA. J Rheumatol. 1981;8:925–930.
[6] Arnett FC, Hirsch TJ, Bias WB, Nishikai M, Reichlin M. The Jo-1 antibody system in myositis: relationships to clinical features and HLA. J Rheumatol. 1981;8:925–930.
Shouli Tung, M3, Cooper Medical School of Rowan University
Ackerman N, Soal V, Pradhan B, Sedky K. Cost and Treatment Effectiveness of Electroconvulsive Therapy (ECT) in the Uninsured Patient: An updated literature review and case based illustration. Poster presented at 7th Annual Camden Scholar’s Forum. April 20, 2020. Camden, NJ.
Background:
Electroconvulsive therapy (ECT) is an alternative treatment option for severe and treatment-resistant depression (TRD), as well as for management of catatonic symptoms. However, it remains an underutilized treatment option due to the perceived cost, lack of access to this treatment, the negative portrayal of this treatment modality by the media, and the legal restrictions to consenting. Therefore, we sought to examine the cost and treatment effectiveness of ECT in the uninsured patient with TRD. We hypothesize that ECT is both cost and treatment effective in this patient population.
Methods:
We investigated our hypothesis through a literature review and case-based illustration. A systematic computerized search of English articles using PubMed was performed. In addition, an extensive chart review and analysis was completed, utilizing the electronic medical record of an uninsured, Hispanic female from one of the poorest cities in the US.
Results:
The literature review revealed that ECT is both cost and treatment effective. One retrospective observational cohort study found a decline in the mean number of hospitalizations per year (0.64 vs 0.32, P = 0.031) as well as in the average number of inpatient days per year (23.7 vs 6.1 days, P <0.001), and the mean duration of hospital stays (41.6 vs 22.1 days, P = 0.031) for patients who received maintenance ECT. Furthermore, our cased-based illustration indicated similar findings. The patient’s 17-item Hamilton Depression Rating Scale (Ham-D17) score decreased 4 points after one ECT session. Additionally, the patient’s inability to continue maintenance ECT due to her uninsured status resulted in a cost to the hospital of $115,763. In comparison, one outpatient ECT treatment was found to cost between $300-$1120.
Discussion:
Through a literature review and case-based illustration, we showed that ECT is both effective and economical in treating TRD in the uninsured patient. While our patient initially responded favorably to electroconvulsive therapy, the feasibility of continuing it due to associated cost led to its discontinuation and subsequent patient relapse. These findings suggest that physicians should strongly consider ECT as an economical and effective treatment option for uninsured patients with treatment-resistant depression.
Nicole Ackerman, M4, Cooper Medical School at Rowan University
Victoria Soal, M4, Cooper Medical School at Rowan University
Ackerman N, Zhu C, Gruner R. Emergent Mastectomy for Hemorrhaging Invasive Ductal Carcinoma: A Case Report. Poster presented at 7th Annual Camden Scholar’s Forum. April 20, 2020. Camden, NJ.
Introduction:
Per the National Comprehensive Cancer Network (NCCN) guidelines, it is typical for patients with stage IIIB triple negative breast cancer to receive neoadjuvant chemotherapy with the goal of downstaging disease. Upon completion, the tumor response may be determined through a combination of physical examination and diagnostic imaging, and the residual tumor burden yields a strong, independent prognostic indicator of disease recurrence.
Case Report:
A 51-year-old African American female with a history of asthma, coronary artery disease, and prior myocardial infarction complicated by left ventricular thrombus, presented to the hospital with a fungating left breast mass with active hemorrhage. The patient reported associated unintentional twenty-pound weight loss and general malaise. She was found to be in shock with a hemoglobin of 6.9. Her initial management included IVF resuscitation, broad spectrum antibiotics, packed red blood cells, 4-factor PCC, vitamin K and tranexamic acid. CT revealed a central 15.4cm mass in the left breast and additional lobulated confluent masses spanning an area of 12.5cm x 5.8cm. Suture ligation was insufficient for hemostasis, and the patient was taken to the operating room for emergent modified radical mastectomy. Upon resection of the axillary contents, the tumor was found to be adherent to the axillary vein. A 0.3cm defect was created which required primary vein repair. The final pathology revealed a stage IIIB [pT4b(m), pN2a] invasive ductal carcinoma, grade 3, ER/PR/HER2 negative and PDL-1 positive. The patient began chemotherapy with Paclitaxel on POD 57.
Discussion:
Stage III breast cancer is typically managed first with neoadjuvant chemotherapy. However, hemorrhagic shock as a result of locally advanced disease would certainly necessitate departure from normal treatment algorithms, and stabilization may require urgent surgical intervention. This is a rare instance deviating from NCCN guidelines as most cancers are discovered early stage, before complications such as this arise. Such early stage disease is often treated with surgery first, after which patients may undergo adjuvant radiation and/or systemic therapy. Early detection through routine cancer screening leads to better patient outcomes and avoids potentially unnecessary emergent intervention.
Nicole Ackerman, M4, Cooper Medical School at Rowan University
Hejirika J, Malik A. Challenges in the Management of Severe Ovarian Hyperstimulation Syndrome—a rare complication of in vitro fertilization: Case Report and Literature Review. 7th Annual Camden Scholars’ Forum, Camden, NJ, April 2020.
Introduction:
Ovarian hyperstimulation syndrome (OHSS) is a potentially fatal complication of controlled ovarian hyperstimulation (COH) cycles for in vitro fertilization (IVF). COH involves stimulating the ovaries with hormones. Consequently, ovaries can become enlarged and undergo increased capillary permeability, which causes intravascular fluid to shift into the third space and subsequent ascites. It is necessary to examine all clinical presentations and treatment outcomes of severe OHSS given its prevalence of 0.1 to 0.2%.
Case presentation:
35-year-old G0P0000 female, with a history of polycystic ovarian syndrome undergoing IVF, presented to a local hospital with nausea, vomiting, abdominal pain, weight gain (20 lbs.), oliguria, and dyspnea ongoing for 4 days. Symptoms began after receiving a Leuprolide 20 unit injection prior to her egg retrieval procedure. She received approximately 6 L of IV fluids and on CT Abdomen/Pelvis was found to have large amount of ascites. Lab values indicated leukocytosis of 27,000 and creatinine of 2.6. She was transferred to Cooper University Hospital (CUH) for further management.
At CUH, her exam revealed tachycardia, hypotension, and a protuberant abdomen with flank dullness. Despite ascites, she showed signs of intravascular volume depletion, including acute kidney injury (AKI) and oliguria. Therefore, IV fluids were continued. She experienced worsening dyspnea and became hypoxic, requiring 4 L NC. She underwent urgent paracentesis and 1.7 L of abdominal fluid was drained. Her symptoms improved initially, however on day 2 her ascites re-accumulated. Repeat paracentesis revealed an additional 2.5 L of intra-abdominal fluid. On day 3, she experienced significant hyponatremia with nadir to 121 and worsening AKI with a creatinine of 5.97. She was initiated on IV hypertonic saline and given IV albumin to improve intravascular volume. Her urine output subsequently improved and hyponatremia resolved. She was discharged home on day 7.
Discussion:
OHSS is classified as mild, moderate, or severe based on clinical features. This patient had severe OHSS due to abdominal pain, vomiting, weight gain, oliguria, dyspnea, ascites, hyponatremia, and creatinine above 1.6. Expedited recognition and treatment of OHSS with paracentesis and proper intravascular volume repletion prevents critical sequelae, including renal failure, thromboembolic events, and Acute Respiratory Distress Syndrome.
Janice Hejirika, M4, Cooper Medical School of Rowan University
Rana A, Edwards C. Cerebral venous sinus thrombosis secondary to heparin-induced thrombocytopenia (HIT): a unique presentation managed with a novel intervention. In: Camden Scholar’s Forum; April 20, 2020. Camden, NJ.
Introduction:
Heparin-induced thrombocytopenia (HIT) is a well-known phenomenon with potentially fatal side-effects caused by the immune system creating antibodies that activate platelets in the presence of heparin. This results in a pro-thrombotic state that can involve both the arterial and venous systems. A rare presentation of this includes cerebral venous sinus thrombosis (CVST).[1] We report on this unique presentation and subsequent complicated treatment course in a patient who presented with an acute intractable headache found to be a HIT-associated CVST.
Case Description:
A 44-year old male presented with a thunderclap headache, photophobia, dizziness, and decreased visual acuity. Five days prior to presentation, the patient had a percutaneous nephrolithotomy for a renal calculus and received heparin products for percutaneous nephrostomy (PCN) placement. CT imaging revealed an extensive clot in the sagittal system from the right sigmoid and transverse sinus extending to the right internal jugular. Blood test demonstrated a drop-in platelet count from 115,000 to 45,000. A heparin induced antibody with reflex serotonin release assay (SRA) came back positive, confirming HIT. The patient underwent venous thrombectomy, however re-thrombosis of the venous sinuses occurred twice more, despite continuous infusion of bivalirudin bridge to warfarin, requiring venous thrombectomy a total of three times. A subtherapeutic INR and persistent thrombocytopenia complicated the anticoagulation course. He is currently maintained on warfarin and doing well.
Discussion:
CVST secondary to HIT is a rare, fatal presentation with a mortality rate of up to 4.39%.[2] The non-specific clinical picture requires a high index of suspicion to diagnose and treat in a timely manner. Few such cases have been reported and only one other case has been successfully managed with endovascular therapy without use of heparin. Novel endovascular interventions such as mechanical thrombectomy, along with appropriate medical management, could play an important role in improving the overall outcomes of patients with this condition.
References:
[1] Ahmed I, Majeed A, Powell R. Heparin induced thrombocytopenia: diagnosis and management update. Postgrad Med J. 2007;83(983):575–582. doi:10.1136/pgmj.2007.059188
[2] Borhani Haghighi A, Edgell RC, Cruz-Flores S, Feen E, Piriyawat P, Vora N, et al.. Mortality of cerebral venous-sinus thrombosis in a large national sample.Stroke. 2012; 43:262–264. doi: 10.1161/STROKEAHA.111.635664.
Ameena Rana, M3, Cooper Medical School of Rowan University
Paulenka Y, Clemons D, Saxena S, Gefen R. Large pericardial cyst mimicking pericardial effusion. In: Camden Scholar’s Forum; April 20, 2020. Camden, NJ.
Introduction:
Pericardial cysts are rare malformations of healthy pericardium. Although typically considered to be benign, pericardial cysts with unregulated growth or rupture can result in hemodynamic compromise.
Case Report:
A 30-year-old male with a history of chronic pericarditis presented to outpatient cardiology with two weeks of worsening dyspnea, chest pain, and intermittent fevers. The patient was referred to the emergency department after an outpatient echocardiogram suggested a large loculated pericardial effusion abutting the right ventricle. A prior echocardiogram two years earlier revealed no abnormality of the pericardium. On inpatient evaluation, an electrocardiogram was unremarkable, and a repeat echocardiogram with contrast was diagnostic of a large pericardial cyst with extrinsic compression of the right ventricle. The inferior vena cava was normal in caliber, and there was no variation in transmitral flow suggestive of tamponade physiology. Left ventricular systolic function was normal. A CT chest confirmed the presence of an 11.4cm cyst in the anterior mediastinal space with mass effect on the right cardiac border. Given the symptoms caused by the large pericardial cyst with compressive symptoms, the patient underwent urgent thoracoscopic excision with cardiothoracic surgery.
Discussion:
Although pericardial cysts are benign entities, they can put patients at a considerable risk of hemodynamic instability if allowed to grow to a size large enough to compress cardiac chambers. If untreated, the mass effect created by the pericardial cyst can mimic tamponade physiology and lead to atrial and ventricular collapse. The use of both contrast echocardiogram and chest CT to identify the lesion and its effect can be essential for diagnosis. The surgical excision of large lesions or smaller lesions in symptomatic patients is recommended.
Yuliya Paulenka, M3, Cooper Medical School of Rowan University
