1/1051. Lessons from an unusual case: malignancy associated hypercalcemia, pancreatitis and respiratory failure due to ARDS. A 37-year old woman, presenting with severe hypercalcaemia-associated pancreatitis with pseudocyst formation, was admitted to intensive care because she developed ARDS with respiratory failure. Skeletal metastasis from non-small cell bronchial carcinoma were subsequently diagnosed. After she developed arterial occlusion in the lower limb, supportive treatment was withdrawn. Severe pancreatitis is an exceedingly unusual presentation of non-small cell bronchial carcinoma. Concepts of diagnostic and therapeutic strategies in the context of suspected unusual pathology, and the concept of futility are briefly discussed. ( info) |
2/1051. Pylephlebitis associated with appendicitis. Pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system. A most common antesecent focus of infection is diverticulitis and the most common blood isolate is E. coli (54%), followed by proteus mirabilis (23%). overall mortality is 32% and most of the patients who had died had severe sepsis prior to the initiation of antibiotic therapy. We describe a case of pylephlebitis which had appendicitis and consequent septic thrombosis of the portal vein and its branches, with dissemination of infection to the liver. The patient had recovered due to timely antibiotic treatment alone and resulted in complete resolution. early diagnosis and treatment are basic to a favorable clinical course. ( info) |
3/1051. Developing venous gangrene in deep vein thrombosis: intraarterial low-dose burst therapy with urokinase--case reports. Two patients with developing venous gangrene of the lower extremity and contraindications to systemic thrombolytic therapy are presented. Low-dose intraarterial burst therapy with urokinase provided rapid amelioration of symptoms and avoided amputation without any serious bleeding complications in both patients. ( info) |
4/1051. Anticoagulant-induced skin necrosis in a patient with hereditary deficiency of protein S. skin necrosis is a rare but debilitating complication of treatment with vitamin k antagonist anticoagulants such as warfarin. A clinically similar syndrome has been reported less frequently with heparin therapy. We recently managed a thirty-year-old female patient who developed skin necrosis on her left lower extremity while on warfarin for postpartum DVT. The lesions started to develop 48 hr after stopping heparin therapy. Discontinuation of warfarin and reinstitution of heparin was complicated by a rapid decrease in platelet count consistent with heparin-induced thrombocytopenia (HIT) and its associated risk of platelet activation and thrombosis. The diagnosis was supported by the identification of antibodies against heparin/platelet factor 4 complexes in the patient's serum. The platelet count recovered and the patient improved after switching to therapy with the heparinoid danaparoid. Evaluation for a hypercoagulable state revealed a partial deficiency of protein S, a condition that previously was identified in two of her family members. It is not clear if this patient suffered from warfarin-induced skin necrosis, a manifestation of heparin-mediated platelet activation, or a complex condition in which both drugs contributed. HIT may affect 1-3% of patients who receive unfractionated heparin, and this case raises the possibility that heparin may contribute to, or cause, some episodes of skin necrosis attributed to warfarin. Because many patients who develop warfarin-induced skin necrosis have been treated initially with heparin, it would seem prudent to consider HIT in these situations. ( info) |
5/1051. Left leg paralysis in a renal transplant. The postoperative course of renal transplant patients is often complicated by opportunistic infection. Up to 4% of posttransplant infections are caused by nocardia species. We present an unusual case of a nocardial spinal cord abscess that caused left leg paralysis. ( info) |
6/1051. Resistance to activated protein c as an etiology for stroke in a young adult: a case report. Resistance to activated protein c (R-APC) is an inherited, autosomal dominant, coagulation abnormality that is increasingly recognized as an important etiology for thromboembolic disease and stroke in young adults. This report describes the case of a 27-year-old woman taking oral contraceptives who experienced an acute thrombotic right hemispheric stroke. Three days after rehabilitation admission (33 days after stroke) she developed a left femoral deep venous thrombosis (DVT) despite appropriate prophylaxis. Further diagnostic workup for the stroke and DVT identified R-APC, possibly exacerbated by oral contraceptives, as the etiology. hematology consultation recommended lifetime anticoagulation with warfarin. The patient's family history revealed that a 19-year-old cousin had died of a stroke several years earlier. Several months after discharge, an acute DVT occurred in the patient's 28-year-old brother, who tested positive for factor v Leiden, a genetic abnormality closely associated with R-APC. A thrombotic stroke occurred in her grandfather a few months later, but he was not tested. Her father demonstrated a "borderline" positive R-APC test and probably represents the genetic link. Indications for patient and family screening regarding R-APC and other forms of hereditary thrombophilia and implications for rehabilitation medicine physicians are discussed. ( info) |
| Septic thrombophlebitis of the portal vein, or pylephlebitis, is an extremely rare complication of intraabdominal infection, most commonly caused by diverticulitis (1). The following case report describes a patient without previous significant medical history presenting with painless jaundice and presumed malignancy. Workup revealed pylephlebitis due to an ileal abscess secondary to Crohn's disease. The patient was successfully treated with broad spectrum antibiotics and terminal small bowel and right colon resection. To our knowledge, this is the first reported case of Crohn's disease diagnosed after presentation with pylephlebitis. ( info) |
8/1051. factor v Leiden and antibodies against phospholipids and protein S in a young woman with recurrent thromboses and abortion. We describe the case of a 39-year-old woman who suffered two iliofemoral venous thromboses, a cerebral ischemic infarct and recurrent fetal loss. Initial studies showed high levels of antiphospholipid antibodies (APAs) and a moderate thrombocytopenia. After her second miscarriage, laboratory diagnosis revealed that the woman was heterozygous for the factor v Leiden mutation and had a functional protein s deficiency as well as anti-protein S and anti-beta 2-glycoprotein i antibodies. The impairment of the protein c pathway at various points could well explain the recurrent thromboses in the patient and supports the role of a disturbed protein c system in the pathophysiology of thrombosis in patients with APAs. ( info) |
9/1051. CT diagnosis of tumor thrombosis of the renal vein and inferior vena cava. Four cases of tumor thrombosis of the inferior vena cava and renal veins were diagnosed by computed tomography. In two, the thrombus itself was demonstrated within the vascular lumen after intravenous injection of urographic contrast material. The diagnosis was made in the other two patients by identification of massive enlargement of the vascular diameter. ( info) |
10/1051. Traumatic inferior vena caval obstruction. A 57-year-old male sustained an injury to the supradiaphragmatic portion of the inferior vena cava, which presented as progressive lower extremity thrombophlebitis culminating in thrombosis of his inferior vena cava. The indications for operative intervention centered around impaired renal, hepatic, and intestinal circulation. extracorporeal circulation permitted extraction of the clot and repair of the injury. ( info) |