Poster Session : PS 0116 ; Cardiology : Severe Hyperkalemia and Lower Extermity Paralysis without Any Ecg Changes: A Case Report

( Veysel Ozalper ),( Ibrahim Cetindagli ),( Ergenekon Karagoz ),( Emrullah Solmazgul ),( Cihan Top ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Objective: Hyperkalemia is a common and serious clinical problem that occurs often due to impaired urinary potassium excretion because of acute or chronic kidney disease or drugs that effect renin-angiotensin-aldosterone axis. We report a hyperkalemic patient with 9.0mEq/L without any ECG changes. Case Report: A 86-year-old-woman suffering fatigue within two days had admitted emergency service because of sudden bilateral lower extremity paralysis. She had esential hypertension, ischemic heart disease and chronic kidney disease and was using Spironolactone, silazopril, asetilsalisilik, isosorbid-5-mononitrat ve karvedilol. Initial neurological examination of extremities was; 2/5 of lower extremity, 4/5 of upper extremity. Initial laboratory fi ndings potassium:9,1mmol/L, sodium:141mmol/L, creatinine: 1,9mg/dl. In his arterial blood gas analyse, pH:7.27, HCO3:16mEq/L, pCO2:30mm- Hg, potassium:9,1mmol/L. Spironolactone and silazopril treatment had stopped. With an intensive electrolyte-follow-up, She was commenced on intravenous fl uid, injection calcium gluconate and glucose/insulin infusion. Within two hours of treatment her potassium level decreased by 1.5 mmol/L. After eight hours of intensive treatment, potassium level reached below 6,5mEq/L. Five Days later, after three days of close follow-up with normal potassium level, the patient had discharged. Conclusion: ECG differancies like fl attening in U wawe, expansion in QRS, taper in T wawe, arrhytmias, asystoles can be seen in hypercalemia. Especially in the circumstances that serum potassium level is above 8 mEq/L ECG differancy is expected to be seen. So that, it is suggested that biochemical elevation in hypercalemic cases is verifi ed with ECG. Although it is rarely seen like in our cases, it shouldn`t be forgotten that severe hypercalemia can be seen without ECG differancy.

Polyglandular Autoimmune Syndrome Type-Ii Presented with Acute Renal Injury

( Veysel Ozalper ),( Ibrahim Cetindagli ),( Omer Tekin ),( Yalcin Onem ),( Yusuf Hancerli ),( Eylem Cagiltay ),( Barbaros Basbug ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Introduction: Polyglandular autoimmune syndrome (PAS) is a rare disease, characterized by failure of more than two endocrine glands. Type-II of this syndrome is the most common of the immunoendocrinopathy syndromes and characterized by the obligatory occurrence of autoimmune Addison disease in combination with thyroid autoimmune diseases and/or type-I diabetes mellitus. We report a case of PAS-TypeII presented with prerenal acute renal failure. Case Report: A twenty-two-year-old man had a hyperpigmentation of gingiva within three months, fatigue and amnesia within two months, emesis and vomit within one months, admitted because of persistent vomiting and ten kilogram weight loss. Initial laboratory fi ndings were: urea:87mg/dl, kreatinin:1.31mg/dl, sodium:125mmol/L, potassium: 5.6mmol/L, albumin:4.16g/dl, calcium:123mg/dl. In his arterial blood gas analyse, he had a normal anion gap metabolic asidosis. pH:7.24, HCO3:12.8mEq/L, pCO2:30mm- Hg. He had a prerenal acute renal injury because of persistent vomiting. Other laboratory fi ndings were Hemoglobine:12.9g/dl, TSH:0,004 uIU/ml, FreeT4:2,16ng/dl, Anti-TPO:876 IU/ml, AntiThyroglobulin:9,72IU/ml, Cpeptid:0,27ng/ml, Kortizol:0,1ug/dl, ACTH:22,8pg/ml, HbA1c: %4,7.. A thyroid-scintigraphy showed diffuse homogenous thyroid involvement. His pituitary magnetic-resonance-imaging, thoracoabdominal- tomography and esophagogastroscopy was normal. Based on his fi ndings above and intravenous ACTH stimulation test, adrenal insuffi ency and otoimmune thyroiditis were diagnosed. General condition improved gradually following the administration of hydrocortisone, fl udrocortisone, thyromazol, propranolol. Conclusions: As a conclusion, in persistant vomiting patients, endocrine functions must be performed. A patient who presents with a single autoimmune diseases must be considered at risk of other autoimmune diseases. High index of suspicion, early recognition and treatment can be life-saving, particularly when there is adrenal and thyroid component.

Poster Session : PS 0722 ; Rheumatology ; SystemIc Lupus Erythematosus and Castleman Disease Co-Existence in a Patient with Weight Loss and Lymphadenopathy

( Yusuf Hancerli ),( Veysel Ozalper ),( Abdullah Haholu ),( Ramazan Arikan ),( Emrullah Solmazgul ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Objective: Castleman`s disease (CD) is quite rare and its etiology is not clearly unravelled yet. It is a lymphoproliferative disease with giant lymph node hyperplasia. This report presents newly diagnosed SLE and CD association on a 21 year old male who was transferred to our hospital with weight loss, fatigue and multiple lymphadenopathy (LAP) complaints along with the pre-diagnosis of lymphoma. Case Report: In September 2013, the patient was admitted to our Hematology Clinic with the complaints of weakness, neck and arm pit swelling and weight loss. The patient was at 68 kg in November 2012, while admitted to the hospital in September 2013 he was at 47 kg. On physical examination, bilateral cervical, supraclavicular, inguinal and axillary LAP which reached 3-4 cm in size and hepatomegaly was identifi ed. He had pain in both hand`s mid-interfalengeal joints and was unable to move comfortably. Labarotary fi ndings were hemoglobin:10. 5 g/dl, direct coombs +2 positive, platelet 79100 u/l, sedim 96, C-reactive protein 26. 6, ANA: 2. 672 (cut off<0,896), AntidsDNA:2. 517 (cut off<0,947), nRNP/Sm positive, C3: 0. 675 g/dl, C4 :0. 0871 g/ dl,24- hour urine protein 1481. 24 mg. The patient was diagnosed as SLE with the present fi ndings. The excisional biopsy from the right axillary lymph node area which showed the highest activity in PET CT ( SUVmax : 6. 4) was considered signifi cant inthe terms of CD. Conclusion: Altough LAP`s most common causes are malignancy, autoimmune diseases and infections, it would be appropriate to take into consideration lymphoproliferative diseases such as CD in the stage of diagnosis evaluation in spite of very rare occurence.

Poster Session:PS 0195 ; Endocrinology : Acute Renal Failure Due to Vitamin D Intoxication

( Yusuf Hancerli ),( Veysel Ozalper ),( Ibrahim Cetintagli ),( Barbaros Basbug ),( Seyid Ahmet Ay ),( Ramazan Arikan ),( Yalcin Onem ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Objective: Vitamin D defi ciency is associated with multpl diseases.Vitamin D becomes more popular every day with the increasing studies. Vitamin D replacement therapy cases increase as well as Vitamin D intoxication cases. We present a 80-old-female patient who developed acute renal failure due to vitamin D intoxication. Case: Patient came to the emergency room with the complaints of 4-day continuing nausea, vomiting and loss of appetite. Mucosa of the patient was dry and she was dehydrate.Tests results were urea:186mg/dL, creatinine:3.64mg/dl, albumin:3.26 g/dL, calcium:12.7mg/dL and venous blood gas results were pH:7,41,pCO2:41.9 HCO3:26.6. Calcium,urea and creatinine levels were normal in a test that was performed 2 months ago. She was diagnosed with acute pre-renal failure connected to dehydration. A detailed medical history showed that 2.5 months ago, the patient was tested vitamin d3-25-0H (kalsifediyol):6.2 ng/ml and vitamin d3 300 000 IU bulb total of 3 was prescribed to her to be taken orally once a week, however, it was realized that the relatives of the patient gave her total of 10, once a week. After this fi nding, performed test results were detected as vitamin d3-25-0H (kalsifediyol):365 ng/ml, parathyroid hormone:16.8pg/ml. The patient was hospitalized with a diagnosis of vitamin D intoxication and intravenous hydration with saline and IV furosemide infusion therapy was applied. At the end of second day her complaints have decreased and at the end of third day calcium level were 9.3mg/dl. At the tenth day test results were urea:30 mg/ dL,creatinine:1.12 mg/dL, and the patient was discharged. Conclusion: Due to growing interest in vitamin D, it is very important that clinicans should be aware and alerted of that overdose vitamin D replacement therapy can cause vitamin D intoxication.

Poster Session : PS 0280 ; Gastroenterology : Subileus Caused by Infl ammation and Edema After Use of Surgical Silky Suture: Case Report

( Omer Tekin ),( Veysel Ozalper ),( Mesut Tiglioglu ),( Yalcin Onem ),( Fehim Diker ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Objective: Gastrointestinal foreign bodies(GFB) may cause problems in all age groups. After gastrointestinal bleeding, they are second common indication for urgent gastrointestinal endoscopy. Case Report: A 20-year-old male was admitted to our Emergency Service complaining of vomiting and severe abdominal pain. The patient reported postprandial nausea and vomiting for last 2 days and a repair operation for perforated duodenal ulcer a year ago. Physical examination revealed an abdominal distension with the lack of peritoneal irritation signs (e. g. rebound, rigitidy). Laboratory tests including complete blood count, acute phase reactants, serum electrolytes, liver function tests, amylase and lipase levels were normal. Plain abdominal X-ray showed that the stomach was distented with intestinal gas and 3 signifi cant air-fi uid levels were seen in bowels at different heights(fi gure-1). Upper gastrointestinal endoscopy was performed for ruling out the mechanical obstruction. Endoscopy revealed that infi ammation and edema caused by three silky stitchs remained ex-surgery. Infi ammation and edema caused to subileus were seen on the duodenal mucosal wall affected by silky suture materials( fi gure-2). Patient required a therapeutic intervention with proper methods of extraction to alleviate the symptoms. Non absorbable surgical suture material was taken out by endoscopic procedure. After the endoscopic intervention patient`s complaints decreased signifi cantly. He was treated with a proton pump inhibitor and a prokinetic agent. The symptoms improved by treatment. Conclusion: Long standing GFB may conclude infiammation, edema, ulceration or perforation in the gastric and duodenal wall. Many foreign bodies pass the gastrointestinal tract, spontaneusly. But iatrogenic foreign body (silky suture-mediated) need urgent intervention.

Poster Session : PS 0382 ; Infectious Disease ; Clinical Usefulness of Measuring Neutrophil to Lymphocyte Ratio in Patients with Hepatitis B

( Ergenekon Karagoz ),( Alpaslan Tanoglu ),( Asim Ulcay ),( Veysel Ozalper ),( Vedat Turhan ),( Muammer Kara ),( Levent Gorenek ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Background: The neutrophil to lymphocyte ratio (NLR), an infi ammation index, has been suggested to predict prognosis of various infi ammatory and neoplastic diseases. However, there are only a few studies examining the relationship between NLR and liver fi brosis score in HBV infected cases in literature. In this study, we aimed to determine the relationship between neutrophil to lymphocyte ratio (NLR) and fi brosis level. Methods: 144 biopsy proven naive chronic hepatitis B cases and 42 healthy subjects were included in the study. Previously treated patients by antiviral therapy and patients with anti-Delta positive were excluded from the study. Hepatitis B patients were divided into two groups with fi brosis scores of 0-1 and 2-6 according to ISHAC score. Results: Of the 144 cases, 125 (86.9 %) were male, 19 (13.1%) were female. fibrosis scores of 84 cases (58.3 %) were = 2 while 60 cases had fi brosis scores < 2 (41.7 %). There was a significant difference between Naive chronic hepatitis B group and healthy subjects in terms of NLR.The mean serum NLR was 1.822±0.853 in chronic hepatitis B patient group while it was found to be 2.29±1.408 in healthy subjects (p<0,05).There was not a signifi cant correlation existed between fi brosis score and NLR. NLR level was 1,906±1.027 in patients with fi brosis score 0-1 while this level was 1.762±0.702 in patients with fi brosis score 2-6 (p=0,576). Conclusions: In comparisons of healthy subjects with Hepatitis B infected patients, NLR was found to be lower in patients with Hepatitis B. Further studies are needed to determine the relationship between NLR and Hepatitis B.

Poster Session : PS 0601 ; Pulmonology ; Pulmonary Nodules Due to Brucellosis

( Seyit Ahmet Ay ),( Yusuf Hancerli ),( Suna Secil Ozturk Deniz ),( Mustafa Hatipoglu ),( Asım Ulcay ),( Muzaffer Saglam ),( Veysel Ozalper ),( Ferhat Deniz ),( Arif Yonem ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1

Objective: Brucellosis is a characterized zoonotic disease by multisystem involvement. Although musculoskeletal involvement is the most frequent case, the pulmonary system is rarely involved. Nodular involment is one of the rarest amoung pulmonary involvements. This study presents a 21- year-old-male with pulmonary involvement without any musculoskeletal system involvement and he was received a diagnosis in the early days of hospitalization. Case: The patient had complaints of one -month-long cough and sputum production and he informed that he used different antibiotics. After the last center he went detected hypogonadism in the patient, he was referred to our hospital`s endocrinology clinic. Physical examination showed fever:37.2,nb:112 beats/min and fi ndings in accordance with the hypogonadism and also late inspiratory crackles had been heard by oscultation. The captured chest radiograph indicated suspicious nodular appearance and suspected infi ltrated area. The laboratory tests erythrocyte sedimentation rate:41mm/saat,C-Reactive Protein:14.1,WBC : 4.08 x103/ul. The patient stated that he was working as a village shephard 1 month ago who did not suffer from signifi - cant weight loss nor fever. Detailed medical history stated that the last examination indicated brucella rosebengal positive, and the antiglobulin (coombs) test in brucellosis 1/160 was also positive. Altough the sputum culture and tuberculosis acid fast stain were negative, the patient had a positive blood culture regarding brucella melitensis. The thorax CT image showed nodules in the lungs with the ground glass opacity and infi ltrative image has been detected in subpleural area. There was nothing in bones scintigraphy. The patient was treated rifampicin 1x600 mg and doxycycline 2x100 mg for 6 weeks. Along with the treatment the patient`s complaints disappeared, and post-treatment blood cultures was negative. Control thorax CT reveals disappearanceof lesions in the lung area. Conclusion: Anamnesis and disease suspicion are the most important things regarding diagnosis of Brucellosis.