Poster Session : PS 0383 ; Infectious Disease ; From a Thoracic Pain to a Cervical Spondilolyscitis

( Armando Braz ),( Marta Rosario ),( Conceicao Quadrado ),( Jose Braz Nogueira ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

A 68-year-old patient with atrial fibrillation, sleep apnea doing nocturnal Cpap, hypertension and ischemic heart failure, went to the emergency department with complaints of chest pain radiating to the neck for 3 days. In the emergency room he couldn`t take a deep breath despite being medicated with painkillers. On the blood work there was an increase of the infi ammatory parameters, but the cardiac enzymes, the EKG and the chest X-ray were normal. Nitrates were also administered but without improvement. The diagnosis of infective endocarditis was plausible due to the clinical and laboratorial fi ndings, but the echocardiogram showed a hypertrophic left ventricle but no vegetation. Without a defi nitive diagnosis, the patient was admitted in the internal medicine department. Blood cultures were taken and started the empirical treatment for infective endocarditis with penicillin and fi ucloxaciline. After 3 days, a MSSA was isolated, sensitive to fi ucloxaciline and clindamicine, but the patient became hemodynamicaly instable and got worse. The symptoms also changed, having intense neck pain, dysphagia and odynophagia. A neck and thorax CT-scan was performed showing a large retropharyngeal abscess extending to the posterior mediastinum. Due to kidney failure, the patient needed to start doing hemodialysis, where he had a cardiac arrest. Upon stabilization, a surgical drainage of the abscess was performed and he was transferred to the intensive care unit where he stayed for 97 days due to cervical spondylodiscitis. There were several problems including: thoracic empyema, right brachial plexus damage due to destruction of the c3-c6 vertebrae and more. He returned to the ward, starting intense physiotherapy with a quick and full recovery. This is a success story of a patient who was discharged after a serious condition, walking by his own feet, but the origins of the abscess still a mystery.

Poster Session:PS 0569 ; Oncology : Pancreatic Cancer Causing Heart Failure

( Armando Lopes Braz ),( Tiago Mascarenhas ),( Conceicao Quadrado ),( Jose Braz Nogueira ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

A 67-year-old patient was sent to the internal medicine consultation due to dyspnea, orthopnea and lower limb edemas for 6 month, which got worse in the past 2 weeks, with diffi cult stabilization and control, even with intense therapy for heart failure. The therapy was improved and an echocardiogram was requested. One month later she was reevaluated showing no clinical improvement, so she was admitted in the internal medicine ward. The echocardiogram showed an ejection fraction of 21%, increased right chambers, severe pulmonary hypertension and left ventricle dilatation with depressed cardiac function. The therapy for heart failure was optimized and a ventilation-perfusion scyntigraphy was performed to evaluate the respiratory system. It revealed areas of pulmonary collapse and pulmonary embolism. On the ward she suffered a sudden episode of dyspnea and left leg edema and experienced severe pain. An ultrasound of the lower limbs proved the existence of bilateral severe deep venous thrombosis. For a further investigation the patient did a body CT-scan and cancer markers were searched. The CA19.9 was 253679 and there were several metastatic lesions on the liver and an infracentrimetic mass on the pancreatic tail on the CTScan. She started anticoagulation for prevention of other pulmonary embolism, while waiting for a pancreatic biopsy. The patient died 3 month after the diagnosis due to a sudden Myocardial infarction. The symptoms of heart failure dominated the whole clinical picture, being the DVT the wind of change to establish the diagnosis of pancreatic cancer, a scary disease that was silent for so long. This case shows the importance of the paraneoplastic symptoms such the bilateral DVT which was the important milestone for a further investigation and the fi nal diagnose.

Poster Session:PS 0576 ; Oncology : Diversity Creates Confusion: Carcinosarcoma in the Anterior Abdominal Wall of a Young Adult Male

( Conceicao Quadrado ),( Jose Braz Nogueira ),( Joao Gomes Pereira ),( Rita Azenha Cardoso ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Objective: To present a case of anterior abdominal wall mass in a young adult male with histopathologic diagnosis of carcinosarcoma. Design: Case Report Setting: Tertiary Hospital in Davao City, Philippines This is a case of a 22-year-old male who presented with progressive knee pain and an incidental fi nding of anterior abdominal wall mass with spinal cord compression symptoms. He underwent posterior decompression and screw fi xation of vertebra, and excision of anterior abdominal wall mass. Microscopic fi ndings of tissue specimens revealed malignant small round cell tumor. Immunohistochemical stain done on abdominal wall mass was strongly positive for cytokeratin and vimentin, negative for leukocyte common antigen (LCA), non-specifi c esterase (NSE), desmin, and chromogranin A. The stained cells were distinctive and separated but admixed which was more compatible with carcinosarcoma. The patient however succumbed to sepsis prior to further management. This paper serves to report a highly aggressive tumor in a previously- well young man whose histopathologic diagnosis with basic microscopy yielded diverse differentials. Further workup with immunohistochemistry came up with a fi nal diagnosis of carcinosarcoma in the anterior abdominal wall metastatic to bone, spine, and soft tissue in the head.

Poster Session : PS 0389 ; Infectious Disease ; Vasculitis Caused by Infectious Agent or Allergic Reaction

( Armando Lopes Braz ),( Tiago Mascarenhas ),( Conceicao Quadrado ),( Jose Braz Nogueira ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

The clinical case is about a 44 years old male patient who was transferred to our hospital due to vasculitis. He was living in Angola for 8 years, being healthy until 2 weeks before being transferred. He started to feel abdominal cramps, muscular and joint pain over a period of 3 days. He was admitted in a clinic suspecting of malaria, starting antimalarial medication. On the 3rd day, the blood results for infectious diseases and maliaria were negative. He stooped the treatment and was discharged. After 4 days the patient started to complain of the same symptoms aggravated with asthenia, tiredness and diarrhea. He was readmitted and treated with antibiotics. Three days later some petequial lesions appeared in the lower limbs, getting spread arms and ears. These lesions got bigger over the next 2 days becoming macules and then changed to penfi - goid lesions with central necroses. The lesions covered the all lower limbs and part of the upper limbs, spearing the trunk. Corticosteroids were added to the treatment but he got worse, being later transferred to our hospital. The fi rst evaluation revealed a severe lower limbs edema, hypoalbuminemia and renal failure. All the treatment was stooped apart of pain killers and done some skin biopsies. The result was positive for leukocytoclastic vasculitis. Because of the GIT symptoms an endoscopy and colonoscopy was performed. The gut was covered with extense ulcerative lesions and was identifi ed inside them CMV. The body CT and Abdominal ultrasound were normal. The patient started the treatment with Valaciclovir during 15 days, followed with 6 weeks of Ganciclovir. This case still covered in dough, because it`s impossible to know if the hypersensibility reaction to the anti-malary drugs started the vasculites, triggering the CMV infection or the CMV developed the vasculitis.

Poster Session : PS 0316 ; Hematology : A Case of Pancytopenia

( Filipe Filipe ),( Joana Martins ),( Catarina Espirito Santo ),( Ligia Peixoto ),( Ines Vendrell ),( Helena Luna Pais ),( Alba Acabado ),( Paulo Cantiga Duarte ),( Jose Braz Nogueira ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Megaloblastosis represents a wide group of disorders sharing a common pathophysiological pathway, due to defi cient intake or absorption of Vitamin B12 and folic acid. Major causes for this condition include alcoholism, achlorhydria, pernicious anemia or gastrectomy and celiac disease. It leads to abnormal DNA replication, impaired protein synthesis and nuclear maturation. It presents with macrocytosis, hypersegmented neutrophils, and elevated Lactate dehydrogenase (LDH) levels. It is more prevalent in underdeveloped countries and older populations, having similar gender distribution. Authors present the case of a 69-year-old man, with a previous known history of essential thrombocytosis, medicated with hydroxyurea (with irregular adherence to treatment), congestive heart failure and chronic alcoholism. He was admitted at the emergency room (ER) with symptoms of confusion, slurred speech and fatigue for a week. He presented mucosal palor, fever (38. 1ºC), splenomegaly, and a left lateral maleolar ulcer with a purulent exsudate. Blood values revealed pancytopenia (macrocytic anemia Hb 4. 1 g/dL and MCV 123 fi); Leukocytes 1110x106/L; Platelet count 30. 000x106/L), acute renal failure (blood urea nitrogen 97 mg/dL; creatinine 2. 5 mg/ dL) LDH 1545 U/L. He underwent blood transfusions at the ER, without previous iron tests screening. On subsequent evaluation, authors found levels of Vitamin B12 of 172 pg/mL and folate 0. 9 nmol/L. Patient underwent a bone marrow aspiration with bone biopsy, compatible with megaloblastic anemia. An endoscopy was performed, with histological fi ndings suggestive of atrophic gastritis, with no H. pylori bacilli found. Additional tests such as anti-gastric parietal cells antibodies and anti-intrinsic factor antibodies, were negative. The patient was medicated with Vitamin B12 injections and folic acid, with good reticulocitary response. At discharge he presented, blood values of Hb 8. 7 g/dL; Leukocytes 7110x106/L; and platelet count of 862. 000x106/L. This represents a case of severe pancytopenia, enhancing the relevance of megaloblastosis as differential diagnosis for this entity.

Poster Session:PS 0184 ; Endocrinology : Multiple Endocrine Neoplasia Type 2B - A Late Presentation

( Ines Vendrell ),( Filipe Filipe ),( Helena Luna Pais ),( Joana Martins ),( Catarina Espirito Sabto ),( Antonio Pedro Machado ),( Paulo Cantiga Duarte ),( Jose Braz Nogueira ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Background: Multiple Endocrine Neoplasia (MEN) is a rare condition which occurs 1-2/100.000 people and results from rearranged during transfection (RET) protooncogene mutations. MEN B is a particularly infrequent subtype of MEN (5% of all MENs) that usually presents during childhood with pseudo-hirschprung`s disease and skeletal abnormalities (marfanoid habitus). Medullary thyroid carcinoma occurs in almost all individuals and phaeochromocitoma can also be present. MEN 2B is an autosomal dominant disease. Yet, less than 50% of the patients have a family history (de novo mutations), as many perish before reproductive age. The authors describe the case of a 33-year-old male who presented with hypertension, tachycardia and high blood sugar levels. He had a history of cryptorchidism and bowel obstruction both surgically corrected during childhood. Moreover at the age of 30 he was diagnosed with ruptured diverticulitis and underwent a total colectomy (specimen showed reactive lymphoid hyperplasia and multiple diverticula). This patient had the classic marfanoid habitus and mucosal neuromas (lips and tongue), which prompted urine cathecolamine and metanephrine dosing. Abdominal CT scan showed bilateral adrenal masses (25mm and 77mm diameter) compatible with phaeochromocytoma. Given the phenotype, serum calcitonin dosing (over 2000 pg/mL), thyroid ultrasound (multiple nodules) and biopsy were performed, confi rming medullary thyroid carcinoma. Genetic testing reveled a germline point mutation in RET (p.M918T) known to be associated with MEN 2B. The patient later underwent total thyroidectomy with lymphadenectomy and bilateral adrenalectomy. Conclusions: Even in the presence of its classical features, MEN 2B is a challenging diagnosis. This case emphasizes the complexity of this disease and the need for recognizing this rare, yet potentially lethal condition.