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THE UNIVERSITY OF MANITOBA DEPARTMENT OF INTERNAL MEDICINE POSTGRADUATE EDUCATION PROGRAM RESIDENT RESEARCH DAY MAY 27,2008 SCIENTIFIC PROGRAM THEATRE B, BMSB DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM THURSDAY, MAY 27, 2008 THEATRE B CONCOURSE, BMSB, 2ND FLOOR IpOSTER PRESENTATIONS
AI
Time will be adhered to with 5 minutes for presentation and 5 minutes
for questions.
1315 (Clinical Investigation)
The Effectiveness of the CancerCare Manitoba (CCMB) Anticoagulation
CLinic (ACe)
Vi Dao
Supervisors: D. Szwajcer
D. Houston
1325 (Case Report)
A Case of Idiopathic Anaphylaxis
Ashraf Farag
1335 1345 (Clinical Investigation)
Cholangitis Associated Septic Shock
Therapy and Source Control
Brendan McCarthy
Supervisor: D. Szwajcer
RoLe of Rapidity of Antimicrobial
(Case Report)
A Possible Advantage for JAK2 Mutation
Sara Dunsmore
Supervisor: A. Kumar
Supervisor: D. Houston
1355 (Case Report)
When Thin Turns to Thick: The Hyperviscosity Syndrome and Lactic
Acidosis
Aaron Low
Supervisor: G. Drobot
1405 (Case Report)
Myocardial Siderosis Due to Hemochromatosis in an Individual with
Hypertrophic Cardiomyopathy
.
Ainslie Hildebrand
Supervisor: D. Jassal
1415 (ClinicaL Investigation)
Clinical Utility of Tissue Doppler Imaging in Patients with Acute
MyocardiaL Infarction Complicated by Cardiogenic Shock
Adnan Hameed
Supervisor: D. Jassal
-
--.---~---
..- - - - .
1425
(Clinical Investigation)
Contraceptive Prescription and Counseling on the General Internal
Medicine Ward
Nicola Matthews
Supervisor: K. Wiebe
1435
(Case Report)
Neurocysticercosis in Rural Manitoba: A Case Report of Seizures in a
Previously Healthy Young Man
Jonathan Gabor
Supervisor: J. Embil
1445-1515
Break
1515
(Case Report)
Hyperferritinemia: An Unexpected Result of Treatment with Danazol
Pam Skrabek
Supervisor: D. Houston
1525
(Clinical Investigation)
Electrocardiographic Predictors of In-Hospital Survival in Cardiogenic
Shock Due to Myocardial Infarction: A Prespecified Analysis from the
Manitoba Cardiogenic Shock Registry Investigators
Supervisor: F. Hussain
Robin Ducas
1535
(Case Report)
The Use of High Dose Dexamethasone. in a Palliative Care
Setting, to Preserve Quality of Life in a Patient with Breast Carcinoma
and Known Intracranial Metastases
Jonathan Wong
Supervisor: G. Crawford
1545
(Case Report)
Vasogenic Cerebral Edema: A PRES-ing Matter
Edward Tam
Supervisor: K. Humphreys
1555
(Case Report)
Disseminated Infection Due to a Unique Mycobacteria in an Elderly
Patient
Myles Horton
Supervisor: P. Orr
1605
(Case Report)
Clues to the Pathogenesis of Kikuchi-Fujimoto's Disease in Non-Twin
Siblings
Susan Teschke
Supervisor: M. Seftel
IpOSTER PRESENTATIONS 8
1
1315 (ClinicaL Investigation)
Early Changes in Serum Creatinine and Vasopressors are Associated
with Mortality in Septic Shock
Faisal Siddiqui
Supervisor: A. Kumar
1325 (Case Report)
Effect of GLuten Free Diet on Osteoporosis in Patient with Celiac Disease
Massud Ali
Supervisor: D. Duerksen
1335 (Case Report)
Hepatic PortaL Venous Gas from Perforated Diverticulitis
Gregory Deans
Supervisor: G. Drobot
1345 (Case Report)
A Case Report of Adult Presentation of Anomalous Left Coronary Artery
Originating from the Pulmonary Artery
Thang Nguyen
Supervisor: G. Drobot
1355 (Clinical Investigation)
Gestational Diabetes in Manitoba during a Twenty Year Period
Naji Aljohani
Supervisor: G. Shen
1405 (Clinical Investigation)
Observations on Internal Medicine Consults Generated in the Emergency
Department
Stephen Goulet
Supervisors: J. Horton
K. Kasper
1415 (Case Report)
Non-Neutropenic Capecitabine-Induced Enterocolitis
Vallerie Gordon
Supervisor: P. Czaykowski
1425 (Case Report)
Tricked by Trichinosis
Michael Sochocki
Supervisor: J. Embil
1435 (Clinical Investigation)
Cardiovascular Morbidity and MortaLity, and Reamputation Rates Among
Persons with Lower Extremity Amputations Due to Peripheral Vascular
Occlusive Disease - A Manitoba Perspective
Doug Priestley
Supervisor: A. Arneja
1445-1515 Break
1515 (Clinical Investigation)
ProLonged EEG-Video Monitoring in Psychogenic Non-Epileptic Seizures
Atheer AI-Kaabi
Supervisor: Y. Aghakani
1525 (Case Report)
Two cases of Neurofibromatosis Type I and Medically Intractable
Complex Partial Seizures
Abdulmuhsen Almulla
Supervisor: Y. Aghakani
1535 (ClinicaL Investigation)
Clinical Utility of Joint Spectrophotometry in Identifying SubclinicaL
Synovitis in Patients Presenting with ArthraLgia
Daniela Stroescu
Supervisor: C. Hitchon
1545 (Case Report)
Acute Kidney Injury in Patients Receiving Subcutaneous Deferoxamine
Therapy
Arjuna Ponnampalam
Supervisor: D. Houston
1555 (Case Report)
P-ANCA Positive VascuLitis Manifesting as Crescentic GLomeruLonephritis
and PuLmonary Hemorrhage
Alan Smith
Supervisor: M. Sood
1605 (Case Report)
Liver Enzyme Abnormalities Secondary to Combination Therapy with
Bosentan and Atorvastatin
Kimberley Mulchey
Supervisor: Z. Bshouty
1615 (Case Report)
An Unclassified Case of Hisitocytosis
Jonathan Gi lmore
Supervisor: Z. Bshouty
POSTER DISPLAYED IN RESIDENT'S ABSENCE
(Case Report)
Colorectal Cancer in Pregnancy: An Aggressive Malignancy
Supervisor: P. Czaykowski
Maria Ho
The Department of Internal Medicine gratefully acknowledges the participation of
our guest speaker and judge, Dr. Ralph Meyer, and our local faculty adjudication
teams: Dr. Gary Harding, Dr. Carol Hitchon, Dr. Alexandra Ilnyckyj. Dr. Clare
Ramsey. Dr. Leroy Stars ley and Dr. Kim Wiebe.
DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM THURSDAY, MAY 27, 2008 THEATRE B CONCOURSE, BMSB, 2ND FLOOR IpOSTER PRESENTATIONS
AI
Time will be adhered to with 5 minutes for presentation and 5 minutes
for questions.
1315 (Clinical Investigation)
The Effectiveness of the CancerCare Manitoba (CCMB) Anticoagulation
Clinic (ACC)
Vi Dao
Supervisors: D. Szwajcer
D. Houston
1325
(Case Report)
A Case of Idiopathic Anaphylaxis
Ashraf Farag
Supervisor: D. Szwajcer
1335 (Clinical Investigation)
Cholangitis Associated Septic Shock - Role of Rapidity of Antimicrobial
Therapy and Source Control
Brendan McCarthy
Supervisor: A. Kumar
1345 (Case Report)
A Possible Advantage for JAK2 Mutation
Sara Dunsmore
Supervisor: D. Houston
1355 (Case Report)
When Thin Turns to Thick: The Hyperviscosity Syndrome and Lactic
Acidosis
Aaron Low
Supervisor: G. Drobot
1405 (Case Report)
Myocardial Siderosis Due to Hemochromatosis in an Individual with
Hypertrophic Cardiomyopathy
Ainslie Hildebrand
Supervisor: D. Jassal
1415 (Clinical Investigation)
Clinical Utility of Tissue Doppler Imaging in Patients with Acute
MyocardiaL Infarction Complicated by Cardiogenic Shock
Adnan Hameed
Supervisor: D. Jassal
1425
(Clinical Investigation)
Contraceptive Prescription and Counseling on the General Internal
Medicine Ward
Nicola Matthews
Supervisor: K. Wiebe
1435
(Case Report)
Neurocysticercosis in Rural Manitoba: A Case Report of Seizures in a
Previously Healthy Young Man
Jonathan Gabor
Supervisor: J. Embil
1445·1515
Break
1515
(Case Report)
Hyperferritinemia: An unexpected Result of Treatment with Danazol
Pam Skrabek
Supervisor: D. Houston
1525
(Clinical Investigation)
Electrocardiographic Predictors of In-Hospital Survival in Cardiogenic
Shock Due to Myocardial Infarction: A Prespecified Analysis from the
Manitoba Cardiogenic Shock Registry Investigators
Robin Ducas
Supervisor: F. Hussain
1535
(Case Report)
The Use of High Dose Dexamethasone, in a Palliative Care
Setting, to Preserve Quality of Life in a Patient with Breast Carcinoma
and Known Intracranial Metastases
Jonathan Wong
Supervisor: G. Crawford
154 5
(Case Report)
Vasogenic Cerebral Edema: A PRES-ing Matter
Edward Tam
Supervisor: K. Humphreys
1555
(Case Report)
Disseminated Infection Due to a Unique Mycobacteria in an Elderly
Patient
Myles Horton
Supervisor: P. Orr
1605
(Case Report)
Clues to the Pathogenesis of Kikuchi-Fujimoto's Disease in Non-Twin
Siblings
Susan Teschke
Supervisor: M. Seftel
The effectiveness of the CancerCare Manitoba (CCMB) anticoagulation clinic
(ACC)
Vi Dao, Pascal Lambert, David Szwajcer and Don Houston
Venothromboembolism (VTE) in patients with active malignancy is associated with
adverse outcomes and effective anticoagulation for extended duration with either oral
vitamin K antagonist (VKA) or low molecular weight heparin (LMWH) is indicated for
as long as the cancer is active. Although current literature suggests that LMWH is more
efficacious in reducing VTE recurrence in patients with cancer when compared with oral
VKAl, the need for daily injection and high drug cost are major drawbacks to the up front
use of LMWH in this setting. At CCMB, we treat all patients with first line VKA,
managed by a specialized pharmacist-run anticoagulation clinic (ACC), switching to
LMWH if thrombosis recurs despite VKA. The aim of this retrospective review is to
access the efficacy and safety of this approach, comparing outcomes between patients
with cancer to a convenient cohort (control) on VKA managed by the same Ace.
Results: The quality of anticoagulation with oral VKA is inferior in patients with VTE
and active cancer when compared to control patients (%TSTR 54% versus 64%, p<O.OOl)
but rate ofVTE recurrence and bleeding is similar. However, patients with cancer is
more likely to experience VKA failure (OR 7.22; 95% CI 1.47-35.5) and risk of death
(OR 4.48; 95% CI 2.72-7.34). No significant predictors were identified for recurrent
VTE but those with poor INR control were more likely to suffer from bleeding
complications. Thus, oral VKA remains an effective option for anticoagulation for most
patients and LMWH can be reserved for patients with additional risks such as VKA
failure and those with poor INR control due to increased risk of bleeding.
A Case 0/ Idiopathic Anaphylaxis
Ashraf Farag MD, David Szwajcer MD, Kristine Roland MD
Introduction:
Systemic mastocytosis (SM) denotes a spectrum of disorders and is characterized by the dysregulated
proliferation and accumulation of mast cells in different organs. The rarity of SM and the fact that many
of its recognized symptoms are shared by other more common disorders serve to delay or hinder its
diagnosis. Clinical manifestations of SM are ascribed to the local or remote effects of mast cell­
generated mediators which may lead to facial flushing, tachycardia, hypotension, headache, nausea,
vomiting, diarrhea, urticaria, anaphylaxis and syncope.
case description:
50 year-old male farmer presented with recurrent attacks of syncope preceded by dyspnea, palpitations,
tongue swelling, throat tightening and flushing. His first seriOUS attack occurred in 1998 following
several bee stings. Following this episode an epinephrine pen was prescribed. The frequency of attacks
has gradually increased and over the last several years have been unprovoked. When seen in early
January of 2008 attacks were occurring every other day. He was being managed with a combination of
cetrizjne, montelukast, prednisone, ranitidine as well as the epinephrine pen. Physical examination was
unremarkable. Laboratory investigations revealed an elevated eosinophil count of 0.51X109/L with an
elevated serum tryptase of 31 mcg/l. Bone marrow aspirate examination showed an excess of spindle
shaped mast cells. Flow cytometry revealed a population of C0117+, C02+ complex granular cells.
Cytochemical staining of the core biopsy for toluidene blue confirmed increased spindle shaped mast
cells scattered diffusely throughout the specimen. CKIT and FIP1li-POGFRA mutations were not
demonstrated. Diagnosis: Indolent Systemic Mastocytosis (World Health Organization)
Discussion:
Systemic mast cell disorders are uncommon and will occur at any age. While cutaneous manifestations
are more common in childhood, systemic mastocytosiS is more common after the third decade of life.
Systemic mast cell disorders fall on a spectrum from Indolent Systemic Mastocytosis (ISM) to Mast Cell
leukemia. The case presented has several uncharacteristic features. While the majority of patients with
ISM have cutaneous involvement there was no evidence of characteristic maculopapular rash. The
patient's idiopathic anaphylactic episodes have been unresponsive to a combination of therapy
consisting of systemic corticosteroids, histamine Hi and H2 blockade and leukotriene inhibition. ISM is
usually managed with a conservative approach, however given the debilitating nature of the patient's
symptoms a course of'cytoreductive therapy with cladribine was initiated.
Conclusion:
When conSidering the differential diagnosis of Hymenoptera venom allergy when there are mUltiple
episodes of unprovoked anaphylaxis a serum tryptase should be obtained to exclude systemic mast cell
disorders. The majority of patients with ISM may only require infrequent conservative therapy however
certain cases may benefit from a more aggressive approach.
CHOLANGITIS ASSOCIATED SEPTIC SHOCK - ROLE OF RAPIDITY OF ANTIMICROBIAL
THERAPY AND SOURCE CONTROL
McCarthy B, Fu W, Sullivan K, Peters C, Muggaberg S, Kravetsky L, Bohmeier R, Kumar R, Kosick T,
Chan C, Ren J, Paulin H, Khan F, Campbell L, Kumar A and the CATSS Database Research Group
University of Manitoba, Winnipeg, Manitoba
Objective: The aim of this study is to evaluate the mortality differences with delays of appropriate
antibiotic therapy and source control in patients with cholangitis associated with septic shock admitted to
intensive care units.
Methods: A retrospective analysis was performed using medical records from ICU admissions to multiple
centres. From these records 126 patients were collected and analysis focused on timing of effective anti­
microbial therapy and appropriate source control and their combined effects on mortality.
Results: Of the 126 patients, mean age was 68years with a mean APACHE score of24. Overall 30 day
mortality was 3 I % with a mean ICU length of stay of9 days. Of patients with positive bacterial cultures
the most common isolates were E.coJi, Klebsiella and Enterobacter(41%,20% and 5.5% respectively). After
the development of septic shock the median time to effective antibiotic therapy and effective source control
was 4 hours and 8.5 hours respectively. The rate of mortality was found to increase with increased delays in
antibiotic therapy and source control. The survival rates for patients with effective antibiotics within
6hours, 6-12hours and >12hours were 78%, 62.5% and 33% respectively. The survival rates for patients
with source control performed within 9hours, 9-24hours and >24hours were 89%, 76% and 50%
respectively. There was noted to be a synergistic effect with early combined therapy as compared to
delayed effective therapeutics(96% survival vs. 54%).
Conclusion: This study reveals that early effective antibiotics and source control in patients with septic
shock from cholangitis results in increased survival.
A POSSIBLE ADVANTAGE FORJAK2 MUTATION
Sara Dunsmore, Internal Medicine Resident, University of Manitoba, Winnipeg, MB.
Supervisor: Don Houston, Professor, Hematology, University of Manitoba, Winnipeg, MB
The JAK2V617F activating mutation has been well documented as an important factor in the
myeloproliferative disorders (MPDs). It is found in over 95% of polycythemia vera patients and 50-60% of
those with essential thrombocythemia and idiopathic myelofibrosis. Mutation in the JAK2 tyrosine kinase
results in increased intracellular signalling in erythroid and myeloid cells. This process is independent of
erythropoietin and other stimulating factors and results in proliferation of cell lines in the MPDs. The
JAK2V617F mutation is also seen in up to 5% ofmyelodysplastic syndromes (MDS). This is unlikely due
to random chance as other similar disorders, such as chronic myelogenous leukemia (CML), have a very
low prevalence ofJAK2V617F. Unlike the MPOs, the development ofJAK2V617F does not have a clear
causative role in marrow failure states such as MDS.
A 42 year old woman initially presented at the age of six with anemia and was subsequently
diagnosed with congenital dyserythropoietic anemia (CDA) type 1. At initial presentation the other blood
counts, including platelets, were normal. When she returned to hematology clinic as an adult, her anemia
was unchanged but she had elevated platelet and white blood counts. Bone marrow biopsy showed changes
consistent with essential thrombocythemia superimposed on COA type I, and testing for the JAK2V617F
mutation showed it was present.
This patient has a unique pairing of congenital dyserythropoietic anemia and a myeloproliferative
disorder. Archival tissue is not available so it is impossible to be certain which disorder arose first. The
normal platelet count and WBC at age 6 support the inference that the myeloproliferative disorder arose
later as an acquired somatic mutation. Among patients with essential thrombocythemia, those who have the
JAK2V617F mutation tend to have higher hemoglobin levels, though in her case the development of the
JAK2V 617F mutation did not lead to improvement of her anemia. We hypothesize that the hematopoietic
failure state associated with CDA may, like that ofMDS, create an environment in which a genetically­
mediated proliferative advantage due to an acquired mutation may be especially favoured, and may thus
have been a factor in the development ofthe myeloproliferative disorder.
When Thin turns to Thick: The Hyperviscosity Syndrome and Lactic Acidosis
R. Aaron Low
Supervisor: Dr. G. Drobot
Waldenstrom's macroglobulinemia is a malignant lymphoproliferative disorder
characterized by monoclonal synthesis and secretion of IgM antibodies. It commonly presents
with fatigue, weakness, weight loss or epistaxis, and in approximately 15% to 31 % of patients is
associated with the hyperviscosity syndrome. Common features of this entity include oronasal
and retinal bleeding, headache, as well as focal neurological deficits.
In this report, we describe the case of an 80-year-old female who was brought to the ER
after several days of diarrhea and a syncopal episode. In hospital, she was noted to have
intermittent periods of significant lactic acidosis (L-Iactate > I 0 mmol/L) and synthetic liver
dysfunction. I~vestigations revealed a mild anemia, an IgM level of 80.60 (normal 0.6-2.6g1L),
and a serum viscosity of 5.4 (normal 1.1-1.8 centipoises). She was accordingly diagnosed with
Waldenstrom's macroglobulinemia and associated hyperviscosity syndrome. Plasmapheresis
was initiated, and her episodes oflactic acidosis and hypoglycemia did not recur. To our
knowledge, this is the first reported case of the hyperviscosity syndrome presenting with lactic
acidosis and synthetic liver dysfunction.
MYOCARDIAL SIDEROSIS DUE TO HEMOCHROMATOSIS IN AN INDIVIDUAL WITH
HYPERTROPHIC CARDIOMYOPATHY
Ainslie M. Hildebrand MDI
Davinder S. Jassal MD, F ACC, FRCPC 2-4
J. Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
2. Section of Cardiology, Department of Cardiac Sciences, University of Manitoba, Winnipeg, Manitoba,
Canada.
3. Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada.
4. Institute of Cardiovascular Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
It is well known that hypertrophic cardiomyopathy (HCM) may transition to a stage resembling
the morphologic and functional features of a dilated cardiomyopathy with systolic dysfunction and left
ventricular dilation. However, given the poor prognosis associated with this dilated phase, consideration of
potentially reversible etiologies of a concomitant dilated cardiomyopathy is important.
We report a case ofa patient with HCM and transfusion dependent sideroblastic anemia, who
presented with decompensated heart failure. Cardiac magnetic resonance (CMR) imaging demonstrated a
dilated cardiomyopathy with marked signal hypo intensity on T2-weighted images within the left
ventricular myocardium, liver, and pancreas with relative sparing of the spleen, consistent with the
diagnosis of primary hemochromatosis.
This case demonstrates the utility of CMR as a non-invasive modality to assess the etiology of
new systolic dysfunction in the setting ofHCM. CMR is able to differentiate between the dilated 'burned­
out' phase of HCM and a concomitant dilated cardiomyopathy secondary to myocarditis or
hemochromatosis.
Clinical ntility of tissue Doppler imaging in patients with acute myocardial infarction
complicated by cardiogenic shock
3
Adnan K. Hameed l , Tirath Gosatz, Tielan Fang3, Roien Ahmadie , Matthew Lytwyn 3, Ivan
Barac3, Shelley Zieroth2, Farrukh Hussain 2 and Davinder S. Jassal*2.34
lDepartment of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada, 2CardioJogy
Division, Department of Cardiac Sciences, St. Boniface General Hospital, University of
Manitoba, Winnipeg, Manitoba, Canada, 3Institute of Cardiovascular Sciences, Cardiology
Division, Department of Cardiac Sciences, St. Boniface General Hospital, University of
Manitoba, Winnipeg, Manitoba, Canada and 4Department of Radiology, St. Boniface General
Hospital, University of Manitoba, Winnipeg, Manitoba, Canada.
Background: Echocardiography is widely used in the management of patients with cardiogenic
shock (CS). Left ventricular ejection fraction (EF) has been shown to be an independent
predictor of survival in CS. Tissue Doppler Imaging (TDI) is a sensitive echocardiographic
technique that allows for the early quantitative assessment of regional left ventricular
dysfunction. TDI derived indices, including systolic velocity (S'), early (E') and late (A') diastolic
velocities of the lateral mitral annulus, are reduced in heart failure patients (EF < 30%) and
portend a poor prognosis. In CS patients, the application ofTDI prior to revascularization
remains unknown.
Objective: To characterize TDI derived indices in CS patients as compared to patients with
chronic CHF.
Methods: Between 2006 and 2007, 100 patients were retrospectively evaluated who underwent
echocardiography for assessment of LV systolic function. This population included: Group I) 50
patients (30 males, 57 ± l3 years) with chronic CHF as controls; and Group II) 50 patients (29
males, 58 ± 10 years) with CS. Spectral Doppler indices including peak early (E) and late (A)
transmitral velocities, EI A ratio, and E-wave deceleration time were determined. Tissue Doppler
indices including S', E' and A' velocities of the lateral annulus were measured.
Results: Of the entire cohort, the mean LVEF was 25 ± 5%. Cardiogenic shock patients
demonstrated significantly lower lateral S', E' and a higher EIE' ratio (p < 0.01), as compared to
CHF patients. The in-hospital mortality in the CHF cohort was 5% as compared to the CS group
with an in hospital mortality of 40%. In the subset ofCS patients (n = 30) who survived, the
mean S' at presentation was higher as compared to those patients who died in hospital (3.5 ± 0.5
vs. 1.8 ± 0.5 cm/s).
Conclusion: Despite similar reduction in LV systolic function, CS patients have reduced
myocardial velocities and higher filling pressures using TDi, as compared to CHF patients.
Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery
following revascularization is yet to be determined.
CONTRACEPTIVE PRESCRIPTION AND COUNSELING ON THE GENERAL INTERNAL
MEDICINE WARD.
NE Mattbews, KL Wiebe.
Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.
Background: The care of women of reproductive age has always been tempered by a need to consider the
potential effects of any medical therapy on fertility and pregnancy. In no area is this more obvious than in
the prescription of medications, many of which are known to have potentially harmful effects on the
growing fetus. Despite the knowledge that many medications have the potential to cause harm to the fetus
during pregnancy a number of studies have shown that 4- 7% of women are prescribed class D or X drugs
during pregnancy. Given the known risks of many medications. patients taking these drugs should receive
contraceptive counseling and/or prescription of contraception to prevent fetal exposures. A recent study,
however, showed that fewer than 20% of women prescribed potentially teratogenic medications received
contraceptive counseling or prescriptions. Women with chronic diseases, many of whom may be seen in an
internal medicine setting, are more likely to be prescribed class D and X drugs during pregnancy.
Furthermore, in the United States general internists along with family physicians, accounted for 43% of
prescriptions for class D and X medications. To date, no Canadian data is available regarding
contraceptive counseling or prescription of teratogens to at-risk populations.
Objectives: To determine the proportion of female inpatients of child-bearing age admitted to the general
internal medicine ward that are at risk secondary to comorbid conditions or prescription of teratogenic
medications. To determine current practices on the internal medicine ward regarding contraceptive
prescription and counseling.
Methods: The WRHA medicine database was used to identify all women aged 18-44 years admitted to an
internal medicine ward at Health Sciences Centre between January 151 and December 31 $1 2007. The
database also provided comorbid conditions for each patient. Charts were reviewed to identify medications
on admission and discharge and to document contraceptive counseling.
Results: One hundred and thirty women were admitted to the ward during the study period. Most patients
either had a moderate to high risk comorbidity or were on a pregnancy Class D or X medication at
discharge. The majority of patients were not using contraception either at the time of admission or
discharge. No patients received contraceptive counseling from the internal medicine service including
those with moderate-high risk comorbidities or potentially teratogenic medications.
Conclusions: Most women of child-bearing age admitted to the internal medicine service are potentially at
risk for pregnancy complications secondary to chronic disease or medications. These patients are not
receiving counseling regarding pregnancy planning and contraception during their admission.
NEUROCYSTICERCOSIS IN RURAL MANITOBA: A CASE REPORT OF SEIZURES IN A
PREVIOUSLY HEALTHY YOUNG MAN
Jonathan Y. Gabor and John M Embil Departments ofMedicine and Medical Microbiology & Infectious Diseases, Faculty ofMedicine, University ofManitoba, Winnipeg, Manitoba Introduction: A 27-year-old previously.well man presented to a rural emergency department with two
simple partial seizures occurring over several hours. Both seizures were self-terminating and lastt:d no
longer than several minutes.
Case Description: There was no history of previous seizures. He did not have a significant past medical
history and did not take any medications. here was no history of alcohol abuse, illicit drug use, or other
risk factors for infection with the Human Immunodeficiency Virus (HIV). There was no history of
infectious prodrome or contacts. The patient lived in a small rural farming community and was employed
as a truck driver. He denied recent travel out of Canada; however he had immigrated to Canada from
Mexico during his childhood approximately 20 years earlier. While in Mexico he lived on a farm where
cattle and pork were routinely slaughtered and prepared. On examination, the patient was alert however
confused and agitated. Vital signs were unremarkable and the patient was afebrile. Neurological
examination was significant for confusion, dysarthria, myoclonus of the right leg, and diminished reflexes
and strength in the right upper extremity. Meningismus was not observed. The remainder of the
neurological examination was unremarkable. Examinations of the head and neck, cardiorespiratory
systems, abdomen and periphery were likewise unremarkable and non-contributory. Laboratory
investigations revealed a leukocytosis of 13.7 (xlOe9 cells/L) with neutrophil predominance. Serum
biochemical profile was normaL Computed axial tomographic (CT) scan of the brain demonstrated the
presence of numerous intraparechymal cysts in both cerebral hemispheres, with most of the cysts
demonstrating a central dot of high attenuation. The radiographic appearance of the cysts was considered
very suggestive of infection with Taenia solium larvae, and the history of prior residence in Mexico added
further substantiation. Subsequent serology for T solium was positive.
Discussion: The patient was treated with a l5-day course of praziquantel 50 mglkg. Phenytoin was
prescribed for control of seizures and dexamethasone was given to attenuate the host inflammatory
response to the disintegration of encysted T solium larvae. The patient's neurological deficits resolved
promptly. No further seizures occurred and the patient remained asymptomatic. Repeat CT-scans at two
weeks and four months after presentation continued to demonstrate regression of the cysts, however with
increasing areas of punctate calcification. The patient has since returned to work as a truck driver. This
case illustrates the use of computed tomography in the diagnosis of neurocysticercosis and the importance
of a high index-of-suspicion in evaluating patients from areas where T solium is endemic.
HYPERFERRITINEMIA; AN UNEXPECTED RESULT OF TREATMENT WITH DANAZOL
Pam Skrabek MDI. Donald S. Houston MD FRCPC I.
2
Department oflnternal Medicine l and Section ofHematology/Oncology2. University of Manitoba. Winnipeg. Manitoba Hyperferritinemia is most often found in patients as a result of iron overload, infection, inflammation, or
malignancy. Danazol. a synthetic derivative ofethinyl testosterone, has not been reported to cause
hyperferritinemia.
We present three patients observed to have an extreme increase in serum ferritin during treatment with
danazol. The first two cases are of a 67 year old male with autoimmune hemolytic anemia and a 79 year old female
with immune thrombocytopenic purpura. The third case had the most dramatic fmdings. This is a 56 year old
female wit.l} autoimmune hemolytic anemia characterized by both warm and cold agglutinins with a refractory
course. After less than one month on danazol (200 mg twice daily) her ferritin increased from 521 JlglL to 2877flglL.
Severe hyperferritinemia persisted until danazoJ was discontinued. At this time, there was an abrupt fall from
26281lg/L to 191 j.tg/L. In each case, there was no alternative explanation for the changes in ferritin.
Synthesis of mUltiple plasma proteins by hepatocytes is known to be influenced by androgenic receptor
interaction, but this has not been reported to be the case for ferritin. It is thought that higher ferritin levels in men
are a result of higher iron stores (due to the absence of menstrual blood losses). The effect of danazol in the cases
presented may thus represent either an indirect effect or a non-specific effect ofthe drug. One possibility is a
previously-unreported influence of androgens on ferritin synthesis. This may be most apparent in patients with
moderate iron overload (two of our patients had elevated baseline ferritin levels). The rapid return to baseline after
discontinuation of danazol shows that the effect was not due to a change in iron stores. Finally, the possibility exists
that danazol (or a metabolite thereof) interferes with the assay of ferritin in serum.
This observation should be considered when measuring ferritin in patients receiving danazol.
Hyperferritinemia in these patients is an unreliable marker of iron overload. Whether there is any implication of this
observation for toxicity of danazol is not known.
ELECTROCARDIOGRAPHIC PREDICTORS OF IN-HOSPITAL SURVIVAL IN CARDIOGENIC SHOCK DUE TO MYOCARDIAL INFARCTION: A PRESPECIFIED ANALYSIS FROM THE MANITOBA CARDIOGENIC SHOCK REGISTRY INVESTIGATORS Ducas R, Hussain F, Philipp R, Ducas J, Hodge S, Kashour T, Elliott J, Jassal DS, Shaikh N, Tam J, Raabe M, Menkis A, Dzavik V, Light B, Roberts D, Moussa T, Schaeffer A, Daba L, Garber PJ, Munoz A, Loeza­ Aceves S, Chateau D. University of Manitoba, Faculty of Medicine, Department of Intemal Medicine, Winnipeg, MB. Objective: To identify independent electrocardiographic (ECG) predictors of in-hospital survival from a large Canadian cardiogenic shock (CGS) registry in a prespecified analysis. Methods: All consecutive patients with a diagnosis of CGS who also had cardiac catheterization during the same admission were included over a four year period from Sept. 2002-Sept. 2006 in two teniary care centers in Manitoba. Detailed chart review of multiple electrocardiographic parameters and outcomes were analyzed. ECG analysis was performed within 24 hours prior to and following coronary angiogram! revascularization. Infarct location, ST segment analysis pre and post angiogram!revascularization, q waves, ST resolution, automated QT. interval, QRS duration and presence of heart block were measured. Patients with LBBB or paced rhythm were excluded. Descriptive statistical methods were utilized to summarize the data, with a negative binomial logistic regression model used to identify univariate and multivariate independent predictors of in-hospital survival. Results: ECG analysis was performed in 210 patients. Eight patients underwent both PCI and CABG. ST elevation infarctions were present in 140 (67%) cases (PCI - 1111130, CABG 27/47, Medical therapy 9141) and Non-ST elevation was present in 70 cases (PCI - 19/130, CABG 20/47, Medical therapy 32/41). In the overall group, ST deviation (elevation/depression) resolution;::: 50% occurred in 6'J01o of patients while ST abnormality resolution;::: 70% occurred in 57% of patients. In the PCI group ST resolution ~ 50% occurred in 891116 (77%) patients vs. 26/38 (68%) in the CABG group vs. 13/33 (39%) in the medical therapy arm. Type of infarction, maximal ST deviation location and ECG intervals did not predict survival. Univariate predictor of death included: cumulative ST elevation post procedure (p=o.02,l::: 5.6). Univariate predictors of survival to discharge included: ST resolution;::: 50% (p=0.0037,X 2 "" 8.4) and ST resolution;::: 70% (P=0.027,X2 4.9). The only multivariable predictor of survival from the above was ST resolution;::: 50% (p""O.04, OR::: 0.48, 95% CI 0.24-0.97), showing a reduction in mortality. Conclusion: Multiple ECG characteristics are outlined in this substudy for a cardiogenic shock cohort. ST resolution;::: 50% is an easily obtainable independent predictor of survival to hospital discharge in this' cohort and can be utilized routinely to predict in-hospital prognosis. To our knowledge, this has not been described previously in this popUlation. ~---
..
~
Wong. J., Crawford. G.
Case study: The use of high dose dexamethasone (48 mg/d), in a palliative care setting, to preserve
quality of life in a patient with breast carcinoma and known intracranial metastases.
Abstract: Corticosteroids have been widely used to treat symptomatic brain edema secondary to
intracranial tumours or metastases. Where appropriate, dexamethasone is administered at a low to
moderate dose (4-16 mg/d) in order to achieve symptomatic relief while minimizing inevitable side effects
such as steroid induced myopathies, emotional lability and altered glycemiC control. Due to the well
established but variable side effects of dexamethasone treatment. dosing should be tailored to individual
patient responses to minimize toxicity. The use of high dose dexamethasone (>16 mg/d) to treat
symptomatic brain edema in a palliative care setting, however, has not been adequately explored.
This case study will highlight the use of high dose dexamethasone (48 mg/d) in a palliative care patient
suffering from breast carcinoma with metastatic disease to brain, bone and liver. This patient was
admitted to the SBGH palliative care unit for increased nausea, vomiting, headache and decreased level
of consciousness unrelieved by other medications. Her symptoms were thought to be secondary to
increasing intracranial pressure as imaging of her head demonstrated Significant mass effect from
intracranial metastatic disease. Through discussions with her family, it was decided to upwardly titrate her
dexamethasone treatment in hopes of providing symptomatic relief. The treatment was successful at
controlling her admission symptoms and more importantly, was able to improve her functional status and
quality of life, albeit for only a matter of weeks. before she succumbed to her disease.
In addition to highlighting the above case, this case report will review the current use of dexamethasone
for the treatment of symptomatic brain edema secondary to intracranial tumours and metastases. the use
of dexamethasone in a palliative care setting as well as to propose future directions for research.
VASOGENIC CEREBRAL EDEMA: a PRES-ing MAITER
E.Tam, K. Humphreys
Department of Medicine, University of Manitoba, Winnipeg, MB
Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical-radiographic diagnosis
characterized by headache, altered mental status, visual disturbances, and seizures, occurring in
the setting of changes on brain imaging indicative of posterior vasogenic cerebral edema. It is an
important diagnostic consideration in certain clinical scenarios, as the findings, both clinical and
radiographic, are potentially reversible.
A 62 year-old woman presented to the Emergency Room with a 1-day history of fluctuating level
of consciousness, confusion, and lethargy. On physical examination she was alert, but
disoriented and unable to follow simple commands. She was afebrile, with blood pressure 123/60
and heart rate 80. No focal neurological deficits were present, and there was an absence of
meningeal signs. Initial laboratory investigations revealed normal electrolytes, complete blood
count, and urinalysis. Uninfused computed tomography (CT) scan of the head was also normal.
Despite multiple attempts at lumbar puncture, a cerebrospinal fluid sample was not attainable and
empiric antimicrobial coverage for both bacterial meningitis and herpes simplex encephalitis was
initiated.
The patient continued to have a fluctuating level of consciousness, and on the third post­
admission day, had a witnessed tonic-clonic seizure. Repeat CT scan of the head at that time
revealed bilateral white matter hypodensities in the occipital lobes, which in the setting of the
clinical findings were consistent with a diagnosis of PRES. A medication and literature review
revealed no potentially offending agents among the patient's regimen. Antimicrobial coverage
was discontinued, and focus was instead shifted to seizure prophylaxis and judicious
normalization of the patient's blood pressure, which although normal on presentation, was noted
to be moderately elevated during the admission. Within five days the patient recovered to her
previously normal neurologic baseline, and was discharged from hospital.
This case illustrates the importance of considering a diagnosis of PRES in the appropriate clinical
scenario. When this clinical-radiographic syndrome is suspected, close collaboration with
radiology is instrumental in establishing the diagnosis. Most often described in the setting of
hypertenSion, PRES is also associated with immunosuppressive medications and other medical
conditions. Treatment of the causative medical condition or withdrawal of the offending
medication often results in reversal of the clinical and radiographic abnormalities.
DISSEMINATED INFECTION DUE TO AN UNIQUE MYCOBACTERIA IN AN ELDERLY
PATIENT
Abstract
Dr. Myles Horton, R2 Neurology, University of Manitoba (Winnipeg, MB)
Dr. Pamela Orr, Professor, Internal Medicine and Medical Microbiology, University of Manitoba
(Winnipeg, MB)
.
Many different species of identified mycobacteria have been known to cause various forms of
infection in diverse groups of individuals. We present a single case of disseminated infection due to a
unique unnamed mycobacteria species.
A 70-year-old male patient with Type II Diabetes, hypertension, and a history of chronic alcohol
abuse presented to hospital with progressive muscle weakness, fatigue, and weight loss over the course of
one year. He had also developed sensory loss in the distal extremities, gait abnormalities resulting in
several falls, and dysphagia. There was no history of travel outside of Southern Manitoba in the previous
decade and he denied sick contacts.
Physical examination revealed cachexia with diffuse weakness. The patient was able to move his
limbs against gravity or mild resistance only. Perception of all sensory modalities was lost distally from
the mid-humerus and from the mid-femur bilaterally. Reflexes were hypoactive in the upper limbs and
absent in the lower limbs. The remainder of the examination was unremarkable.
Electromyography and nerve conduction studies recorded evidence of a severe generalized
sensorimotor axonal neuropathy with a superimposed myopathy. Computed tomography scans of the chest
and abdomen revealed paraesophageal, paraaortic, and inguinal lymphadenopathy . Subsequent biopsies of
inguinal lymph node, muscle, and nerve tissues as well as sputum analysis revealed positive staining for
acid-fast bacilli. Microscopic analysis of all samples revealed mycobacterial infection. Further
investigations at the National Mycobacterial Laboratory included PCR methodology and gene sequencing
on the obtained tissues. These techniques revealed that organism was a unique mycobacterial species that
had not been previously recorded. Extensive investigations for the presence of a paraneoplastic process,
rheumatologic disease, or pathology specific to the immune system were negative. After several months in
hospital, the patient eventually succumbed to his illness despite antimycobacterial therapy. A subsequent
autopsy revealed additional mycobacterial infiltration of the esophagus, spleen, and lungs.
This case illustrates the potential severity of non-tuberculous mycobacterial infections and the
diagnostic utility of histopathological examination of biopsy material. Clinicians should be aware that non­
tuberculous mycobacterial infection may affect multiple systems within a single patient Although
encounters are rare, infections with mycobacterial species that have not been previously documented
represent exceptional diagnostic and therapeutic challenges.
CLUES TO THE PATHOGENESIS OF KIKUCHI-FUJIMOTO'S DISEASE IN NON­
TWIN SIBLINGS Susan Teschke, Resident] Allison Stasi uk, Medical Studene Gaynor Williams, Associate Professor Don Houston, Associate Professor] Matthew SefieI, Assistant Professor] 1 - Department of Intemal Medicine, University of Manitoba, Winnipeg, Manitoba 2 - Department of Pathology, University of Manitoba, Winnipeg, Manitoba Kikuchi's disease, also known as Kikuchi.Fujimoto disease (KFD), is a self.limiting, benign
condition which typically presents with cervical lymphadenopathy, fever, and leukopenia, most
commonly in young women. The etiology of this syndrome remains unknown, although
associations have been made with various infections and systemic lupus erythematosus (SLE).
Additionally, human leukocyte antigens (HLA) associations have been found in non-familial cases
(All, DRI2), and recently in a single case report offamilial KFD (B35). We report two non-twin
sisters with similar presentations of KFD within the space of three years. The first, a 19 year old
woman presented with a three week history of bilateral cervical lymphadenopathy, nausea,
vomiting, chills, and weight loss. A lymph node aspirate was not diagnostic. Before excisional
biopsy could be performed the lymphadenopathy spontaneously resolved, and she has remained
healthy since hospital discharge. No acute infectious cause was revealed. Two years later, her
younger sister presented at the same age with a one month history of night sweats, weight loss,
anorexia and diffuse lymphadenopathy. Excisional biopsy established the diagnosis ofKFD.
Within one month of presentation, she became afebrile and the lymphadenopathy resolved. An
infectious disease work up was negative. Given the amount of time between presentation, and the
lack of an identifiable environmental/infectious cause, these cases are suspicious for a genetic
association. To this end HLA typing will be completed to confirm or contrast the only other
familial case report.
IpOSTER PRESENTATIONS]j
1315 (Clinical Investigation)
Early Changes in Serum Creatinine and Vasopressors are Associated
with Mortality in Septic Shock
Faisal Siddiqui
Supervisor: A. Kumar
1325 (Case Report)
Effect of Gluten Free Diet on Osteoporosis in Patient with Celiac Disease
Massud Ali
Supervisor: D. Duerksen
1335 (Case Report)
Hepatic Portal Venous Gas from Perforated Diverticul1tis
Gregory Deans
Supervisor: G. Drobot
1345 (Case Report)
A Case Report of Adult Presentation of Anomalous Left Coronary Artery
Originating from the Pulmonary Artery
Thang Nguyen
Supervisor: G. Drobot
1355 (Clinical Investigation)
Gestational Diabetes in Manitoba during a Twenty Year Period
Naji Aljohani
Supervisor: G. Shen
1405 (Clinical Investigation)
Observations on Internal Medicine Consults Generated in the Emergency
Department
Stephen Goulet
Supervisors: J. Horton
K. Kasper
1415 (Case Report)
Non-Neutropenic Capedtabine-Induced Enterocolitis
Vallerie Gordon
Supervisor: P. Czaykowski
1425 (Case Report)
Tricked by Trichinosis
Michael Sochocki
Supervisor: J. Embil
1435 (Clinical Investigation)
Cardiovascular Morbidity and Mortality, and Reamputation Rates Among
Persons with Lower Extremity Amputations Due to PeripheraL Vascular
Occlusive Disease - A Manitoba Perspective
Doug Priestley
Supervisor: A. Arneja
1445-1515 Break
1515 (Clinical Investigation)
Prolonged EEG-Video Monitoring in Psychogenic Non-Epileptic Seizures
Atheer AI-Kaabi
Supervisor: Y. Aghakani
1525 (Case Report)
Two cases of Neurofibromatosls Type I and Medically Intractable
Complex Partial Seizures
Abdulmuhsen Almulla
Supervisor: Y. Aghakani
1535 (Clinical Investigation)
Clinical Utility of Joint Spectrophotometry in Identifying Subclinical
Synovitis in Patients Presenting with Arthralgia
Daniela Stroescu
Supervisor: C. Hitchon
1545 (Case Report)
Acute Kidney Injury in Patients Receiving Subcutaneous Deferoxamine
Therapy
Arjuna Ponnampalam
Supervisor: D. Houston
1555 (Case Report)
P-ANCA Positive Vasculitis Manifesting as Crescentic Glomerulonephritis
and Pulmonary Hemorrhage
Alan Smith
Supervisor: M. Sood
1605 (Case Report)
Liver Enzyme Abnormalities Secondary to Combination Therapy with
Bosentan and Atorvastatin
Kimberley Mulchey
Supervisor: Z. Bshouty
1615 (Case Report)
An Unclassified Case of Hisitocytosis
Jonathan Gilmore
Supervisor: Z. Bshouty
POSTER DISPLAYED IN RESIDENT'S ABSENCE
(Case Report)
CoLorectaL Cancer in Pregnancy: An Aggressive Malignancy
Maria Ho
Supervisor: P. Czaykowski
The Department of Internal Medicine gratefully acknowledges the participation of
our guest speaker and judge, Dr. Ralph Meyer, and our local faculty adjudication
teams: Dr. Gary Harding, Dr. Carol Hitchon, Dr. Alexandra Ilnyckyj, Dr. Clare
Ramsey. Dr. leroy Storsley and Dr. Kim Wiebe.
EARLY CHANGES IN SERUM CREATININE AND VASOPRESSORS ARE ASSOCIATED
WITH MORTALITY IN SEPTIC SHOCK
Siddiqui FI, Chateau D2, Kumar Al and the CATSS Database Research Group
I Division o/Critical Care Medicine and1Department o/Community Health Sciences,
Faculty 0/ Medicine, University 0/ Manitoba, Winnipeg, MB, Canada
Objective: Mortality prediction in patients with septic shock have relied on clinical and laboratory data
taken in the first 24 hours after presentation to the intensive care Wlits (SAPS, APACHE II, MPM 24 ).
This study attempts to detennine if early changes in serum creatinine are associated with outcome to a
comparable degree as 24 hr change in pressors and APACHE II.
Methods: Using a database of5410 septic shock cases, the change in serum creatinine (septic shock
presentation to 3·9 hours-post), pressors in the (ITst 24 hours and APACHE II were compared in relation to
survival to hospital discharge. Pressor change was scored as decreased (Group 1=31.4% of patients),
uncertain (Group 2=31.1%) or increased (Group 3=37.5%). Change in creatinine and APACHE II score
was divided into 3 comparably sized groups (low, intennediate and high values).
Results: The average age was 62.5 years (;;I; 16.4 SE). APACHE II score of26.2 (± 8.4 SE) and admission
s represented below.
% Survival in each group Decreased No Change Increased
24 h pressor change
56.3
68.5
21.6
24 h APACHE II
49.4
65.8
22.9
3-9 hr creatinine change
68.4
45.6
26.0
Correlation to survival for all 3 variables as measured by Chi-squared test was p<.OOOI. No variable
exhibited significant superiority (similar X2 values) and each had independent predictive power. Other
admission laboratory values (lactate, platelet count, INR) did not correlate to outcome.
Conclusion: The correlation between early change in serum creatinine and mortality is comparable the
correlation with 24 hr pressor change and APACHE II score. The 3-9 hr changes in serum creatinine may
be useful for early stratification of septic shock mortality risk.
EFFECT OF GLUTEN FREE DIET ON OSTEOPOROSIS IN PATIENT WITH
CELIAC DISEASE.
Massud Ali MD. And Donald Duerkesn MD.
Abstract
It is well known that the celiac disease (CD) is associated with low bone mineral density
(BMD) and osteoporosis. The pathogenesis is unclear, and potential mechanisms
include malabsorption of nutrients including calcium and vitamin D and increased
inflammatory mediators causing increased bone resorption.
It is also well known that the treatment of celiac disease with gluten free diet (GFD) can
improve the bone mineralization density (BMD), but in general the benefit is modest.
The role of additional treatment of osteoporosis treatment in newly diagnosed patients
with celiac disease is unclear. In this report we describe a patient with severe
malnutrition with a dramatic improvement in BMD with a gluten free diet.
A39 year old premenopausal female patient was diagnosed with CD based on a positive
endomysial antibody and duodenal biopsy. She presented with manifestations of severe
malabsorption including weight loss, amenorrhea, muscle weakness, bone pain in lower
back and hip region, and was found to have low albumin, low calcium, low iron and
increased cholestatic and hepatocellular liver enzymes. Because of her severe
malnutrition, she required short term hospitalization and treatment with total parentral
nutrition. A baseline BMD demonstrated a T score of -4.7 and - 4.0 in spine and hip
respectively. In addition to a GFD she was started on calcium supplements. She was
also started on didrocal approximately 6 months after her BMD. Two years later her
BMD improved to - 0.9 T and -1.4 T in the spines and hip respectively. Four years after
starting a GFD her BMD was (-1.0 and -1.4 T score) of the spine and hip bone
respective Iy.
Previous studies have demonstrated an approximate 7% improvement in BMD in newly
diagnosed celiac disease on a GFD. In this case we describe a case where the BMD
improved 60% on a GFD. This patient also received short term bisphosphonate therapy
but it is unlikely that this would account for the dramatic improvement in BMD. This
patient had severe malnutrition and evidence of malabsorption and correction of this with
a GFD may have resulted in the dramatic improvement in bone density. Further studies
are needed to determine which patients with celiac disease and low BMD are likely to
improve their BMD with a GFD and the role of bisphosphonate therapy in those with
osteoporosis.
HEPATIC PORTAL VENOUS GAS FROM PERFORATED DIVERTICULITIS
Deans GD, Drobot GR
Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba
A 48-year-old man was seen in the emergency department after an episode of near syncope. He had been
unwell for 10 days beginning with chills, rigors, and intermittent lower abdominal cramps. On the third
day after symptom onset, his stools became loose and his urine became dark in colour. Over the next few
days he began to experience nausea and vomiting; he continued to have occasional episodes of abdominal
pain but was more troubled by increasing anorexia and weakness. On the day of presentation he became
pre syncopal during a bowel movement and was brought to the emergency department. Apart from a 30
pack-year smoking history and daily ethanol consumption he had no history of medical or surgical illness.
On arrival in the emergency department the patient was alert and pain-free but diaphoretic. His initial
blood pressure of 60/40 mmHg improved significantly after resuscitation with crystalloid fluid. His body
temperature was 37.6° C. On physical examination he was volume depleted with scleral icterus. His
abdomen was soft and nontender with no palpable mass. Investigations revealed that his leukocyte count
was 32.3 x JQ9 1L; alkaline phosphatase 212 UfL; gamma-glutamyl transpeptidase 219 UfL; and his total
and direct bilirubin were 142 and 140 J,1mollL respectively. Serum lactate was within normal limits. He
was started on broad-spectrum intravenous antibiotics and sent for imaging of his hepatobiliary tree.
His liver was initially visualized with ultrasound which found a large amount of air within the portal
venous system. On this basis he was sent immediately for computed tomographic (CT) scan of the
abdomen. The CT showed sigmoid diverticulitis with rupture of a sigmoid diverticulum into a 9 x 8 em
abscess anterior to the rectum. This gas-filled abscess appeared to be communicating with the inferior
mesenteric vein resulting in gas being seen in the inferior mesenteric vein, splenic vein, main portal vein,
and intrahepatic portal veins. There were no other findings to suggest intestinal ischemia.
Emergency laparotomy revealed perforated diverticulitis at the rectosigmoid junction associated with a
feculent pelvic abscess. The patient underwent an anterior resection with colostomy. Blood cultures from
his initial presentation grew Escherichia coli. The immediate postoperative course was uneventful but he
required readmission one month later for a newly-developed hepatic abscess. He responded well to a
prolonged course of intravenous antibiotics. His colostomy was reversed I year later.
Hepatic portal venous gas (HPVG) is a rare clinical occurrence that is most commonly associated with
intestinal ischemia. Complicated diverticulitis has also been reported to cause HPVG and, based on a
recent review of the literature, may be the second most common cause. The mechanism of air gaining
access to the venous system is not clear but one theory suggests that gas under pressure in the lumen or
abscess cavity passes through disrupted mucosa into the mesenteric veins. Early surgical intervention is
recommended in most cases as the complications leading to HPVG are often life-threatening. There are no
known sequellae from the HPVG itself once the underlying cause has been treated.
A CASE REPORT OF ADULT PRESENTATION OF ANOMALOUS LEFT
CORONARY ARTERY ORIGINATING FROM THE PULMONARY ARTERY
Thang Nguyen, Glen Drobot
University of Manitoba
Introduction:
Bland-White-Garland Syndrome is characterized by an anomalous left coronary artery
originating from the pulmonary artery. It is a rare congenital anomaly that usually
presents in the pediatric population. The syndrome may lead to ischemia, congestive
heart failure or sudden cardiac death.
Case Description:
A 51 year-old male presented to the emergency room with complaints of palpitations and
dypsnea. He was found to be in atrial fibrillation with a rapid ventricular rate. The
patient eventually converted to normal sinus rhythm after medications and electrical
cardioversion. Bloodwork revealed rising troponin T levels deemed out of proportion for
atrial fibrillation. He was treated as a non-ST-elevation myocardial infarction and a
coronary angiogram was arranged.
The coronary angiogram revealed an extremely large right coronary artery (RCA) with an
extensive collateral system. The left main (LM) coronary artery originated from the
pUlmonary artery. Pulmonary artery (PA) pressures were 48 mmHg 122 mmHg. The
LM artery demonstrated a 1.1: 1 left to right shunt fraction. Echocardiography
demonstrated a left ventricular ejection fraction of 50-60% with no regional wall motion
abnormalities. Extensive subendocardial infarction of the anterior wall of the left
ventricle was seen on cardiac magnetic resonance imaging. Exercise stress technetium
sestamibi exhibited a fixed defect in the anterior wall with a large reversible area of the
anterior and lateral wall of the left ventricle.
Eventually, the patient was discharged after consultations with interventional cardiology
and cardiac surgery. He was arranged for an elective percutaneous procedure at a larger
cardiac centre. Unfortunately, before the procedure occurred, the patient had a cardiac
arrest with subsequent anoxic brain injury. It was then decided to proceed with a surgical
ligation of his LM artery and a bypass graft of his left internal mammary artery to his left
anterior descending artery. Prior to discharge, the patient received an implantable cardiac
defi bri lIator.
Discussion:
The above case demonstrates a rare occurrence of Bland-White-Garland syndrome that
was asymptomatic until the 5th decade. It further demonstrates that despite many years of
good cardiac function, patients are still at risk for sudden cardiac death and require urgent
surgical intervention.
GESTATIONAL DIABETES IN MANITOBA DURING A TWENTY YEAR
PERIOD. Naji Aljohani l , Brenda M. Rempel!, Sora Ludwi~l,2, Margaret Morris l , Kelly
McQuillen2 , Mary Cheang l , Robert Murrayl, Garry X. Shen . University of Manitoba 1
and Manitoba Health2 , Winnipeg, MB, Canada
Objective: Gestational diabetes mellitus (GDM) is associated with postnatal obesity and
type 2 diabetes. We conducted a retrospective database study to determine the prevalence
ofGDM in the province of Manitoba in the years 1985-2004 and its relationship with
advanced age, ethnicity, rural residence and history ofGDM of pregnant women.
Methodology: Manitoba Health collected computerized data on 324,605 deliveries by
165,969 Manitoban women during the time frame. Other parameters examined in the
present study included maternal age, delivery date, self-declared First Nation status, rural
or urban residence and previous history of GDM. The data were analyzed using
multivariate logistic regression models.
Results: The prevalence ofGDM during the 20 year period was 2.92%. Statistically
significant increases in the prevalence of GDM were detected over the time, from 1.95%
in 1985-86 to 3.72% in 2003-04 (p<0.01). The trend of increase in the prevalence of
GDM in Manitoba sustained after modifications in the diagnostic criteria of GDM in the
Canadian Diabetes Association Clinical Practice Guidelines. The prevalence of GDM
was substantially higher in First Nation women (6.94%) than that in non-First Nation
women (2.36%, p<O.Ol). The prevalence ofGDM was higher in pregnant women living
in rural regions (3.12%) compared to those in urban areas (2.70%, p<O.Ol). The
prevalence ofGDM in pregnant women who were 2::35 years old (5.92%) was greater
than those <35 years of age (2.60%, p<O. 01). The prevalence of recurrent GDM in First
Nations was 48.12% compared to 42.39% in non-First Nations pregnant women
(p<0.01). Adjusted odds ratios (95% confidence interval) ofGDM for First Nation status,
advanced maternal age and previous history of GDM were 2.20 (2.00, 2.42) , 2.38 (2.24,
2.54) and 25.09 (23.15, 27.19). The adjusted odds ratio for rural residence was 0.77
(0.74, 0.82), but had an interaction of 1.66 (1.48, 1.86) when associated with First Nation
status.
Conclusion: The results of the present study indicate that the prevalence of GDM
increased in Manitoba during the 20 year time frame. First Nation status, advanced
maternal age and a history of GDM are independent risk factors for GDM in Manitoba.
Further research to determine the cause and consequence of the increase in prevalence of
GDM is required (Supported by Canadian Institutes of Health Research and The Lawson
Foundation).
OBSERVATIONS ON INTERNAL MEDICINE CONSULTS GENERA TED IN THE
EMERGENCY DEPARTMENT
Presenting: Stephen Goulet, MD
Supervisors: J. Horton, MD, and K. Kasper, MD
Department oflnternal Medicine, University of Manitoba, Winnipeg, Manitoba
Objectives: To examine the consults generated in the emergency department and answered by the internal
medicine service. The goal of the data collection is to characterise the type of consults according to reasons
for referral, time of the consult, what service generated the consult, and the disposition of the patients for
whom the consults are generated.
Methods: Over a period of three months in 2007, July to September, internal medicine residents were
asked to keep a log of consults generated in the emergency department and answered by the internal
medicine service at the Health Sciences Centre (HSC) and Saint Boniface General Hospital (SBGH), two
tertiary care facilities. This log included the following characteristics about the consults: time of consult
generation, time to seeing consult. service generating the consult, the reason for referral, and whether the
consult resulted in admission to a clinical teaching unit (CTU) under internal medicine. A subjective scale
was used to judge the appropriateness of the consult by the internal medicine resident answering the
consult. The consult was judged on a numbered scale between 0 and 5 for appropriateness, least to most
appropriate, respectively.
Results: Over a period three months, a total of 1175 consults were generated, 712 at HSC and 463 at
SBGH. This resulted in an average number consults of 8.5 per day and 6 per day at HSC and SBGH,
respectively. The percentage of those consults that ultimately resulted in admission to a CTU was 74.3% at
HSC and 77.3% at SBGH. It was observed that 74% and 81% of consults seen by residents were judged to
have an appropriateness rating of 4 or greater at HSC and SBGH, respectively. Also observed was a linear
relationship between the rating of the appropriateness of a consult and the percentage of those admitted to a
CTU. Of those consults with a rating of 0 or 1, < 12% were admitted to a CTU, while about 95% of those
with a rating of 5 were admitted to a CTU. Thus, the higher the appropriateness rating, the higher
percentage of consults, in that category, that resulted in admission to a CTU. It was observed that only
30% and 40.6% of consults generated from the emergency departments at HSC and SBGH, respectively,
were generated between the regular working hours of 8:30 a.m. to 5:00 p.m., with higher proportions
tending to occur bewteen 7:00 p.m. and midnight. A wide variety of reasons for referral were seen at both
sites, with some differences in the proportion of certain types bewteen the two hospitals. The largest
difference was in the amount of consults generated for ACS: 7.3% vs. 1.9% of all consults at HSC and
SBGH, respectively. However, a higher percentage of consults regarding CHF were seen at SBGH (8.6%
of all consults) vs. HSC (4.2%).
Conclusions: Over a three month period, consults generated in the emergency departments at two tertiary
care teaching hospitals, HSC and SBGH, and answered by residents on the internal medicine service, it was
observed that while the majority of the were judged to be appropriate consults, the majority of these
consults were generated outside of regular working hours of the hospitals, when many of the usual
supports, allied health, interventions, and diagnostic modalities are not available.
NON-NEUTROPENIC CAPECITABINE-INDUCED ENTEROCOLITIS
Vall erie Gordon, Gary Harding, Piotr Czaykowski.
University of Manitoba
Winnipeg, Manitoba
Enterocolitis is an infrequent, but potentially serious complication reported with the use
of the chemotherapy agent fluorouracil, amongst others. Very few cases are reported in
the literature in association with the use of oral fluorouracil pro-drugs (e.g. capecitabine).
Reported cases are seen in the setting of neutropenia, or more rarely in association with
Clostridium difficile induced pseudomembranous colitis. We report on two cases of non­
neutropenic enterocolitis associated with capecitabine therapy, and one case oftransient
neutropenia associated enterocolitis.
TRICKED BY TRICHINOSIS
Mike Sochocki, MD, John M. Emhil, MD, FRCPC, FACP (Associate)
1.
2.
Faculty of Medicine, University of Manitoba , Winnipeg, Manitoba, Canada
Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
Trichinosis is enzootic in arctic and sub-arctic regions of North America. Infected polar bear and walrus
meat have been the most frequent sources of human trichonosis in the Canadian Arctic. A 40-year-old
previously healthy Inuit male presented with an 8-day history of generalized weakness, dyspnea, malaise,
nausea, vomiting, watery diarrhea associated with abdominal cramping and passage of mucous, calf and
thigh pain.
Physical examination revealed an otherwise well looking man, in moderate distress. Vital signs:
oral temperature: 36.5C; heart rate: 68 beats/minute; respiratory rate: 24 breaths/minute; lying blood
pressure: 119170 mmHg without a postural drop or postural tachycardia. The abdomen was diffusely
tender, however, the rest of the examination was unremarkable. Initial laboratory investigations revealed:
white blood cell count, 13.7 x lO'JIL; hemoglobin, 162 gIL; platelets of 465 x I091L. Serum chemistry
revealed: potassium, 2.9 mmollL; creatinine, 80 umollL; creatinine kinase (CPK) was not initially
measured, but 3 days after presentation measured 939 lUlL (normal 55-170).
A diagnosis of rhabdomyolysis was considered, the differential diagnosis included myocardial
ischemia, trauma, seizures or illicit drug use, but these were all excluded by history, physical and
investigations. Upon further questioning, the patient noted that a walrus had been killed in his community
and that he had eaten some of the meat raw approximately 10 days prior to presentation. Presumptive
diagnosis was entertained and, the patient was subsequently evacuated from his home community to a
tertiary care centre for management of the rhabdomyolysis. Over the ensuing 2 weeks, 12 additional
persons from the same community presented to medical attention with nausea, vomiting, myalgia and were
found to have elevated CPK values. All 12 persons had consumed meat from the same walrus as our
patient. Microscopy of some of the uneaten walrus meat was examined revealing forms compatible with
Trichinella spp cysts. The trichinella serology from our patient at the time of admission yielded a titre of
"high positive" with a reading of> 1.20 od.
Walrus is the most important source of human trichonosis in the arctic of the western hemisphere.
Human infection occurs by ingestion of raw or suboptimally cooked meat, although trichinella prevention
programs exist in Northern Canada. Unfortunately, trichonosis remains a significant health concern due to
difficulty in controlling the etiologic agent as diverse popUlations of infected wild carnivores are common
food sources.
Although trichinosis is infrequently considered in the differential diagnosis of
rhabdomyoJysis, this entity must be considered in the correct epidemiologic setting so that the caregivers
are not "tricked by trichinosis" and so therapy may be instituted promptly. The patient received
mebendazole, an oral prednisone with a prompt resolution of symptoms.
Cardiovascular Morbidity and Mortality, and Reamputation
Rates Among Persons with Lower Extremity Amputations
Due to Peripheral Vascular Occlusive Disease - A Manitoba
Perspective
D Priestley, A. Arneja
University of Manitoba, Winnipeg, Manitoba
Department of Physical Medicine and Rehabilitation
Background: The primary cause oflower extremity amputation is peripheral
vascular occlusive disease (PVOD); accounting for up to 80% in some studies.
Known independent risk factors for PVOD are smoking, diabetes. HTN.
hyperlipidemia. and hyperhomocysteinemia. Prior US studies have shown that
up to 26% of individuals undergoing LE amputations require subsequent
amputations within 12 months. and up to 33% die within I year of their index
amputation, despite appropriate management of risk factors. To date, there are
no Canadian studies looking at reamputation or cardiavascular complication
rates or the difference between the aboriginal and non-aboriginal populations
in complication rates. Methods: In this retrospective study, we looked at the
number of reamputation andlor cardiovascular complications in LE amputees
over a five-year period (January 2001 to January 2006) for those admitted to
our amputee rehabilitation unit (and followed in our outpatient clinic for
management of risk factors and prosthesis fit) at Health Science Center in
Winnipeg, Manitoba. We excluded LE amputation secondary to trauma,
malignancy, or vascularl rheumatologic cause. Results: Of the 204 patients
admitted through our unit, 185 met exclusion criteria. 79 (42.7%) had
complications (40 revisionsl reamputations, and 39 cardiovascular
complications ~ including 27 deaths) with an average duration to complication
of 17.6 months. Our I-year complication rate was 10.3% revisions!
reamputations, and 6.5% deaths. The aboriginal population had a slightly
higher reamputation! revision rate (11.8%), but a lower death rate (3.9%)
compared to the non~aboriginal population (9.8% and 7.5%). They also tended
to be younger at first amputation (60.6 +/~ 11.5 yrs compared to 66.5 +/~ 12.6
years, p<O.O I). In the aboriginal population, the greatest risk factors were
diabetes (96.1%), HTN (88.2%), prior smoking (49%) then hyperlipidemia
(37.3%). In the non-aboriginal population, the risk factors were HTN (84.2%),
diabetes (78.2%), hyperlipidemia (50.4%) then prior smoking (46.6%).
Homocysteine was not being routinely measured throughout the study period,
so its importance could not be determined. Conclusions: This study showed
for the first time the prevalence of complications in Manitoban LE amputees
secondary to PVOD. We demonstrated lower I-year complication rates
compared to the published data. We also saw a difference in complication
rates between the aboriginal and non-aboriginal popUlation, specifically
between revision! reamputation rates and death rates. Further studies are
needed to identify risk factors, which, if more stringently controlled in the
outpatient setting, may improve our complication rates in LE amputees
secondary to PVOD. Funding for this project was by the War Amps of
Canada.
PROLONGED EEG-V1DEO MONITORING IN PSYCHOGENIC NON-EPILEPTIC SEIZURES
Atheer AI-Kaabi, Nagib Yahmad, Alexie Yankovsky, Yahya Aghakhani
University of Manitoba, Winnipeg, Manitoba
Introduction: Psychogenic non-epileptic seizures (PNES) are often misdiagnosed as epileptic seizures if
routine interictal electroencephalography (EEG) shows epileptiform abnormalities. We conducted this
study to investigate the frequency of interictal EEG abnormalities seen during prolonged EEG-video
monitoring in patients with PNES.
Methods: We reviewed a retrospective case series of patients with PNES admitted for prolonged EEG­
Video monitoring at the University of Manitoba between April 2004 and July 2007. Twenty-three patients
were included in the study. We included patients who had at least one clinical event atypical for an
epileptic seizure and not associated with any ictal epileptifonn discharge on EEG. Dictated EEG reports
were reviewed for the presence and location of any interictal EEG abnormalities during the admission.
Results: Five patients were thought to have both PNES and epileptic seizures. Of the 18 patients with only
PNES, 22% had normal interictal EEGs, 11 % had only non-specific slowing and 67% had epileptiform
abnormalities. The most common locations of the epileptiform abnormalities in descending order were
bilateral temporal independently, followed by right or left temporal, frontal, and multifocal.
Conclusion: One previous study found interictal epileptiform EEG abnormalities in 12.3% of PNES
patients. We found a higher percentage at 67%. This may be explained by selection bias as our patients
were admitted after an extensive outpatient workup. Our study emphasizes the importance of interpreting
interictal EEGs only in the context of a thorough clinical assessment in patients with suspected PNES. The
gold standard remains the ictal EEG-video assessment.
Two cases of Neurofibromatosis type I and medically intractable complex partial seizures
Abdulmuhsen Almulla, Owen Williams, Alexei E. Yankovsky, Yahya Aghakhani
Background: Neurofibromatosis type I (Nfl) is a neurocutaneous disorder associated on occasion with epilepsy.
We report two patients with complex partial seizures (CPS) and NFl one of whom also has Moya-Moya disease.
Method: A review of our epilepsy database at University of Manitoba revealed two patients with NFl and medically
intractable CPS.
Result: Patient 1 was a 26-year-old right-handed male with history of seizures since age 7. Presurgical assessment
suggested the seizures originated in the left atrophic mesial temporal structures. Interestingly, the patient was found
to have asymptomatic Moya-Moya disease during W ADA test. He underwent a left selective amygdalo­
hippocampectomy (SAH) with seizure freedom at three-month follow-up.
Patient 2 was a 25-year-old right-handed male with history of seizure onset at age 12. His presurgical assessment
including Stereo-EEG revealed his habitual clinical seizures originated from MRI negative right mesial temporal
structures. However, several pure electrographic seizures were recorded from the contralateral temporal lobe. A
right SAH was preformed which has led to a significant seizure reduction at four-month follow-up.
Conclusion: Epilepsy surgery could be considered as a therapeutic option in patients with NFl and intractable CPS.
A longer follow-up period to demonstrate durability and additional similar cases are needed to draw firm
conclusions.
Clinical Utility of Joint Spectrophotometry in Identifying Subclinical Synovitis in
Patients Presenting with Arthralgia
Daniela Stroescu Rl, Carol Hitchon MD
Objective: A proportion of patients with recent onset arthralgia might also have
subclinical synovitis at presentation. Some patients will not develop inflammatory
arthritis and others will present with clinical evidence of inflammatory arthritis at
subsequent visits. We sought to identify a method that will recognize the
subclinical inflammation in patients presenting with arthralgia.
Methods: Subjects with arthralgia only and subjects with active synovitis were
examined using spectrophotometry of the synovial fluid. These were matched
with healthy controls.
Clinical features including rheumatoid factor. disease activity (DAS3CRP).
diagnoses, and also lab parameters that would influence the 02 concentration in
the blood and synovial fluid respectively (HGB and Cr) were recorded. First three
MCP's and wrist examined at each hand.
Results: Out of 280 joint measurements (done on 160 joints) 200 were
asymptomatic (71.5%), 14 had arthralgia only (5%), 21 were swollen (7.5) and 45
both swollen and tender (16). Qualitative assessment of synovial spectra reveled
difference in spectra of swollen joints compared to inactive jOints clinically from
either healthy subjects or patients in clinical remission.
Conclusions: A significant proportion of patients presenting with arthralgia will
develop detectable synovitis. Spectrophotometry of the jOints may be a useful
investigational tool to identify patients with subclinical synovitis when presented
with arthralgia only.
ACUTE KIDENY INJURY IN PATIENTS RECEIVING SUBCUTANEOUS DEFEROXAMINE THERAPY. Ponnampaiam
AI,
HOllston, DS I .2 •
'University of Manitoba, Dept. oflntemal Medicine, Winnipeg, MB.
2University of Manitoba, Dept. of Hematology, Winnipeg, MB.
Iron chelation is an important modality in treating patients with iron overload syndromes to
minimize end organ damage. Deferoxamine is a clinically approved and effective therapy for long term
chelation, but the standard protocol (12 hour subcutaneous infusion) is cumbersome for patients. Twice
daily subcutaneous bolus injection of deferoxamine has been reported to result in equivalent iron excretion
and facilitates adherence. An orally active chelator, deferasirox, has recently become available but
nephrotoxicity is common with deferasirox raising serious concerns about long-term use. Acute kidney
injury has been described previously in patients receiving accidental overdoses of intravenous
deferoxamine, but not in patients receiving subcutaneous therapy. We describe a case series of three
patients who developed acute elevations in creatinine temporally related to b.i.d. subcutaneous bolus
deferoxamine. All of the patients were elderly and had mildly compromised baseline renal function (one
had a kidney transplant and was on cyclosporine; another had undergone a nephrectomy for renal cell
carcinoma). Two of the three patients had resolution of their renal injury on discontinuation of therapy and
the third had progressive decline in renal function on continued treatment. Conclusion: Renal toxicity
appears to be a side effect of deferoxamine chelation, which may be more prevalent ifboJus dosing is used.
Toxicity appears to be reversible on discontinuation of therapy. Careful monitoring of serial creatinine
values and minimizing other nephrotoxic agents is appropriate and prudent when managing iron overload
syndromes with deferoxamine chelation therapy.
Dr. Alan Smith, Dr. Manish Sood (Nephrology SBGH)
Abstract. Background: We report a 27 year-old female with perinuclear­
antineutrophil cytoplasmic antibody (P ANCA)-positive vasculitis manifesting as
crescentic glomerulonephritis and pulmonary hemorrhage. Case and Methods: The
patient was a previously healthy non-smoker who presented with weakness, fatigue,
fevers, cough and hemoptysis. Her creatinine was elevated and she had an active
urinalysis with blood and protein She was treated with pulse then oral steroids with
ongoing pulmonary hemorrhage and abnormal renal function. Despite her young age
and wishes for future children, cyclophosphamide was started to induce a disease
remission. Her treatment was complicated by a deep vein thrombosis of the left lower
extremity, and overwhelming sepsis on cyclophosphamide. Results: P-ANCA was
positive and she had a high level of anti-myeloperoxidase antibodies (MPO), while anti
glomerular basement membrane (GBM) antibodies were negative. Renal biopsy
showed focal segment necrotizing glomerulonephritis with crescent formations,
however no glomeruli were available for immunofluorescence. Conclusion: This case
provides an interesting description of many of the complications associated with
vasculitis and the necessary considerations when beginning therapy.
LIVER ENZYME ABNORMALITIES SECONDARY TO COMBINATION THERAPY WITH
BOSENTAN AND ATORV ASTATIN
Kimberley D. Mulchey, Internal Medicine Resident, University of Manitoba, Winnipeg, MB.
Supervisor: Dr. Z. Bshouty, Respirologist, University of Manitoba, Winnipeg, MB.
Hepatocellular enzyme elevation is a known side effect of both Bosentan, an endothelin receptor
antagonist used in the treatment of pulmonary arterial hypertension (PAH), and Atorvastatin, an antilipemic
agent. An enzyme rise higher than may be expected with either agent individually may represent a reaction
to the combination of the 2 medications that has not previously been reported.
A 71.year.old female presented to the Emergency Department complaining of chest pain and
shortness of breath. Clinical diagnoses of atrial fibrillation and congestive heart failure were made. A
coronary angiogram ruled out significant coronary artery disease. Echocardiogram showed an enlarged
right ventricle (RY) and an RY systolic pressure of6.5 mm Hg. Further investigation revealed the etiology
of her PAH to be chronic thromboembolic disease. Initial pulmonary function tests showed a restrictive
pattern with a normal diffusing capacity. Six minute walk testing revealed mildly reduced performance.
Right heart catheterization was consistent with moderate to severe PAH. Baseline liver enzyme testing
revealed very mild elevation in alanine aminotransferase and alkaline phosphatase. The patient was
currently being treated with Atorvastatin at a dose of 80 mg daily. Treatment for her PAH was initiated
with Bosentan at a dose of 62.5 mg twice daily. Liver enzymes were followed closely and remained at their
baseline values or lower for 6 weeks, at which time the Bosentan dose was increased to the usual
maintenance dose of 125 mg twice daily. The patient had a significant improvement in her exercise
performance after starting on Bosentan. Liver enzymes were first noted to be elevated 8 weeks later, but
were only 2 to 3 times the upper limit of normal. Unfortunately, six weeks later, the patient presented with
jaundice and a lO·day history of malaise and profuse vomiting. Laboratory investigations revealed a
substantial elevation in her bilirubin and hepatocellular liver enzymes of approximately 15 times the upper
limit of normal. Bosentan and Atorvastatin were immediately discontinued, and over the following 4
weeks, the patient's liver enzymes fell, and her symptoms improved.
This patient had demonstrated tolerance for Atorvastatin before the initiation of Bosentan, and
initially tolerated combination therapy at the lower dose of Bosentan (62.5 mg twice daily). Although she
tolerated the Bosentan maintenance dose of 125 mg twice daily for more than 3 months, she had a sudden
and dramatic rise in her liver enzymes necessitating discontinuation of both drugs. This enzyme rise
represents a later and more severe rise than usually seen with Bosentan alone, illustrating the need for
diligent and frequent monitoring of patients taking endothelin receptor antagonists especially in
combination with other hepatotoxic drugs.
AN UNCLASSIFIED CASE OF HISTIOCYTOSIS
Jonathan Gilmore (BSc, MSc), Z Bshouty (MD, PHD) University of Manitoba, Winnipeg, Manitoba
Pulmonary histiocytosis X (PHX) or pulmonary Langerhans cell histiocytosis X (PLCH), is an
uncommon interstitial lung disease that is epidemiologically related to tobacco smoking.
61 yr female with hypothyroidism presents with hlo Tcough. Patient also gave a history for
fatigue, night sweats and had lost about 5kg in 6 months. Laboratory and Physical exam was unremarkable
as chest exam showed good air entry with no added sounds. Cardiovascular exam was unremarkable.
There was no palpable lymphadenopathy. Abdominal exam showed no tenderness, no masses and no
hepatosplenomegaly. computed axial tomographic scan (CTscan) chest showed numerous pulmonary
nodules with hilar adenopathy. CT abdomen showed extensive intra-abdominal lymphadenopathy. Wedge
resection of the lung was sent for pathology.
Treatment was initiated that consisted of high dose Corticosteriods, to which the patient rapidly
responded
Pathological Diagnosis: lung nodules showing mixed Iympho and histiocytic proliferation with
associated inflammation of uncertain histogenesis, pale cells reminiscent of langerhans cells.
Corticosteroids may be considered in patients with a persistence of clinically significant
pulmonary or constitutional symptoms or those with documented progression of disease.