SESSION TYPE: Cardiovascular Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Unilateral pulmonary edema (UPE) is a rare complication of acute ischemic severe mitral regurgitation (MR) that almost always appear as a right focal lung opacity. We present a case of pulmonary edema limited to the left hemithorax associated with acute myocardial infarction (MI).

CASE PRESENTATION:

A 68-year-old woman, with known coronary artery disease, was admitted with worsening recurrent chest pain and mild dyspnea of 2 weeks duration. On examination, she was hypoxic with 80% oxygen saturation on room air which improved with lying on her right side. Blood pressure was 100/65, pulse 60/min, respiratory rate 20/min. Auscultation revealed crackles in the lower two thirds of the left lung and an apical soft pansystolic murmur. EKG showed new ST segment depression in leads V2-V5. Chest X-ray (CXR) showed left hemithorax opacification indicating UPE. Troponin level was elevated. The diagnosis of non-ST elevation MI was made and the patient was treated with Heparin, nitroglycerin, clopidogrel and asprin,in addition to IV furosemide and CPAP. Transthoracic echocardiography showed new severe eccentric MR with hypokinesis of the lateral and posterior walls and an ejection fraction of 45-50%. Urgent cardiac catheterization showed acute totally occluded left circumflex artery which was successfully opened and stent placed.The patient gradually improved clinically after the procedure with a good response to diuretics. A follow-up CXR showed complete resolution of the pulmonary edema.

DISCUSSION:

UPE is a rare, frequently misdiagnosed radiologic and clinical condition with a variety of mechanisms, both cardiac and non-cardiac. One etiology is ischemic MR. Right-sided pulmonary edema is a rare complication in various case reports with the frequent use of transesophageal echocardiography as a tool to demonstrate eccentric MR jet targeting the ostia of one of the right pulmonary veins, with reversal of flow in the veins resulting in focal pulmonary edema. Left-sided pulmonary edema is even less frequently seen possibly due to the direction of the regurgitant stream and the superior left lung lymphatic drainage. The prevalence of right pulmonary veins sharing common ostia is only 0.5%, compared to 8-14% for the left pulmonary veins. This might be a possible explanation of the focal nature of right UPE versus the UPE involving the entire left hemithorax as seen in our case.

CONCLUSIONS:

This case illustrates the possibility of acute ischemic MR being complicated by UPE involving the left hemithorax. Although it is extremely rare, it should be considered in the differential diagnosis in an appropriate clinical setting. Prompt diagnosis and aggressive treatment is necessary as both acute ischemic MR and UPE are independently associated with increased mortality.1) Circulation. 2010 Sep 14;122(11):1109-15. Epub 2010 Aug 30. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.DISCLOSURE: The following authors have nothing to disclose: Manju Bengaluru Jayanna, Susan Schima, Ahmed AboetaNo Product/Research Disclosure InformationCreighton University Medical Center, Omaha, NE.

Central retinal vein occlusion (CRVO) is frequent in patients with systemic lupus erythematosus (SLE), but the treatment of the macular edema with this disease is extremely difficult. We report a case of cystoid macular edema (CME) secondary to unilateral CRVO in a patient with SLE that responded to intravitreous injection of an anti-vascular endothelial growth factor (VEGF) agent. A 33-year-old Japanese woman was referred to our department with unilateral impairment of vision. Microperimetry (MP-1) showed a cessation of foveal sensitivity. Fluorescein angiography showed CME without ischaemia of the macular region or peripheral retina (nonischemic CRVO). A diagnosis of CME and unilateral nonischemic CRVO combined with SLE was made and intravitreous anti-VEGF therapy was given. A sample of aqueous humor was harvested at the start of intravitreous injection after obtaining informed consent. Then the levels of VEGF and monocyte chemotactic protein (MCP)-1 were measured in the aqueous humor by enzyme-linked immunosorbent assay, revealing that VEGF was 234 pg/mL and MCP-1 was 501 pg/mL. Two weeks later, left eye vision improved to 20/20. Optical coherence tomography (OCT) showed considerable amelioration of retinal swelling and CME. MP-1 showed a marked increase of foveal sensitivity. However, she had recurrence of edema 3 months later. After harvesting aqueous humor again, intravitreous injection of an anti-VEGF agent was repeated for CME. The aqueous VEGF and MCP-1 levels were 156 pg/mL and 360 pg/mL, respectively. These findings suggest that inflammation was improved by intravitreous injection of bevacizumab. Intravitreous injection of anti-VEGF agents may be effective for CME due to nonischemic CRVO in SLE patients if their inflammatory factor levels are low.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare but well-reported clinical entity. It is classically described as symmetrical involvement of both upper extremities. Asymmetrical involvement had also been reported, but unilateral presentation is very rare. We hereby report a case of unilateral RS3PE in a patient of seronegative rheumatoid arthritis which was initially misdiagnosed as cellulitis and was given high dose antibiotics without any significant improvement. Later a rheumatologic consultation leads to a prompt diagnosis, and treatment with steroids leads to dramatic reversal of symptoms. This case demonstrates the rare presentation of this rare clinical entity and highlights the necessity of awareness regarding unilateral disease to clinicians.

Retinal swelling, leading to irreversible visual impairment, is an important early complication in retinal ischemia/reperfusion (I/R) injury. Diosmin, a naturally occurring flavonoid glycoside, has been shown to have antioxidative and anti-inflammatory effects against I/R injury. The present study was performed to evaluate the retinal microvascular protective effect of diosmin in a model of I/R injury.Unilateral retinal I/R was induced by increasing intraocular pressure to 110 mm Hg for 60 min followed by reperfusion. Diosmin (100 mg/kg) or vehicle solution was administered intragastrically 30 min before the onset of ischemia and then daily after I/R injury until the animals were sacrificed. Rats were evaluated for retinal functional injury by electroretinogram (ERG) just before sacrifice. Retinas were harvested for HE staining, immunohistochemistry assay, ELISA, and western blotting analysis. Evans blue (EB) extravasation was determined to assess blood-retinal barrier (BRB) disruption and the structure of tight junctions (TJ) was examined by transmission electron microscopy.Diosmin significantly ameliorated the reduction of b-wave, a-wave, and b/a ratio in ERG, alleviated retinal edema, protected the TJ structure, and reduced EB extravasation. All of these effects of diosmin were associated with increased zonular occluden-1 (ZO-1) and occludin protein expression and decreased VEGF/PEDF ratio.Maintenance of TJ integrity and reduced permeability of capillaries as well as improvements in retinal edema were observed with diosmin treatment, which may contribute to preservation of retinal function. This protective effect of diosmin may be at least partly attributed to its ability to regulate the VEGF/PEDF ratio.

Everolimus is a potent immunosuppressive agent that has antiproliferative activities. This study sought to share our experience among renal transplanted children who required conversion from calcineurin inhibitors (CNIs) to the mammalian target of rapamycin inhibitor everolimus.Exclusion criteria were multiple organ transplantations, loss of a previous graft due to immunologic reasons, receipt of an organ donated after cardiac death, donor age <5 years or >65 years, panel reactive antibodies >25%, platelets <75,000/mm(3), absolute neutrophil count of <1,500/mm(3), leucocytes <2,500/mm(3), hemoglobin <6 g/dL, severe liver disease, cold ischemia time >40 hours or anti-HLA panel-reactive antibodies >50%.Eighteen renal transplant patients (10 male, 8 female) underwent conversion to everolimus from CNI: 8 from cyclosporine (CsA) and 10 from tacrolimus. The mean age was 12.6 ± 0.9 years and the mean body mass index 21.8 ± 1.7 kg/m(2). The mean 2-hour postdose level of CsA before conversion was 671 ± 142 ng/mL; the patients on tacrolimus showed a mean trough concentration of 4.5 ng/mL. Six (33,3%) were taking mycophenolate mofetil and 12 (66.6%) enteric-coated mycophenolate sodium. No significant changes were observed in either hepatic functions, serum lipids, or hemograms. There was no mortality or graft loss. The mean level of serum creatinine was 1.3 ± 0.7 mg/dL before and 1.09 ± 0.6 mg/dL after conversion. Proteinuria observed in only 1 patient was well controlled with angiotensin-converting enzyme inhibitor therapy. All patients responded to statin therapy. One patient developed unilateral lower extremity edema and 1 a lymphocele. Although there were 3 cases (14%) of biopsy-confirmed acute rejection, there was no mortality or graft loss.Everolimus conversion has become an excellent choice, offering safety and efficacy with good outcomes.

The case of a 36 year-old male with neuroretinitis caused by Bartonella henselae is reported, whose periodic follow-up was done through optical coherence tomography (OCT). The onset of this disease was characterized by unilateral low visual acuity (VA), painless, of sudden onset, in the right eye (RE), associated to l febrile symptom. The funduscopic examination showed edema in the posterior pole which extended from the optical disc to the macular region in the RE. The OCT confirmed macular and optical disc thickening, as well as the presence of subretinal macular fluid. Systemic studies were normal except for a blood count due to the presence of leukocytosis and positive for Bartonella henselae. The follow up with CT Scan helped to evaluate the decrease in macular edema, with the subsequent improvement of visual acuity and absence of related complications. This report describes the utility of the follow up with OCT in a patient with neuroretinitis caused by Bartonella henselae.

The term 'piriformis syndrome' (PS), introduced by Robinson in 1947, implies a group of signs and symptoms caused by piriformis muscle (PM) disorders. Since PM disorders lead to irritation/compression of the anatomic structures passing under its belly, the main clinical PS signs and symptoms are actually the clinical signs and symptoms of irritation/ compression of neural and vascular structures passing through the infrapiriform foramen: sciatic nerve/SN, inferior gluteal nerve, posterior femoral cutaneous nerve, pudendal nerve, inferior gluteal artery and vein and inferior pudendal artery and vein. The clinical picture is usually dominated by signs and symptoms of irritation/compression of SN (SN irritation --> low back and buttock pain, sciatica,paresthesias in distribution of SN; SN compression --> low back and buttock pain,sciatica, paresthesias and neurologic deficit in distribution of SN). Irritation/compression of other structures can result in the following signs and symptoms: inferior gluteal nerve --> atrophy of gluteal muscles; posterior femoral cutaneous nerve --> pain, paresthesias and sensory disturbances in the posterior thigh; pudendal nerve --> pudendal neuralgia, painful sexual intercourse (dyspareunia), sexual dysfunction, urination and defecation problems; inferior gluteal artery --> ischemic buttock pain; inferior pudendal artery --> ischemic pain in the area of external sex organs, perineum and rectum, sexual dysfunction, urination and defecation problems; inferior gluteal vein --> venous stasis in gluteal area; inferior pudendal vein --> venous stasis in external sex organs and rectum. Functional/non-organic and organic PM disorders can cause PS: spasm, shortening, hypertrophy, anatomic variations, edema, fibrosis, adhesions, hematoma, atrophy, cyst, bursitis, abscess, myositis ossificans, endometriosis, tumors (functional disorders: PM spasm and shortening). The most common causes for PS are PM spasm, shortening and hypertrophy and anatomic variations of PM and SN. In 5-6% of patients with low back pain and/or unilateral sciatica, the pain is caused by PM disorders. PS diagnosis can be made on the basis of anamnesis, clinical picture, clinical examination, EMNG, perisciatic anesthetic block of PM and radiological exams (pelvis/PM MRI; MR neurography of LS plexus and SN). PS therapy includes medicamentous therapy, physical therapy, kynesitherapy, acupuncture, therapeutic perisciatic blocks, botulinum toxin injections and surgical treatment (tenotomy of PM, neurolysis of SN).

Bilateral medial medullary infarction (MMI) is a rare type of stroke with poor outcomes. Inferior olivary nucleus hypertrophy results from a pathologic lesion in the Guillain-Mollaret triangle. The relationship between inferior olivary nucleus hypertrophy and the medullary lesion is obscure. To the best of our knowledge, only 1 autopsy case with unilateral medial medullary infarction that was associated with ipsilateral inferior olivary nucleus hypertrophy has been reported. We describe a rare case with acute infarction in the bilateral medial medulla oblongata accompanied by subacute bilateral inferior olivary nucleus hypertrophy and panmedullary edema. The hypertrophy appeared to have been caused by local ischemic damage to the termination of the central tegmental tract at the bilateral inferior olivary nucleus.

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system, characterized by focal neurological dysfunction with a relapsing and remitting course. Tumor-like presentation of MS (or "tumefactive"/"pseudotumoral" presentation) has been described before with a certain frequency; it consists of a large single plaque (>2cm) with presence of edema and mass effect and it is hard to distinguish from a brain tumor. However, we present a very rare case of a 53-year-old woman with a right temporal mass that turned out to be a MS plaque, who deteriorated within hours (brain herniation with loss of consciousness and unilateral mydriasis) and required an emergency craniotomy. We also present a review of the literature. It appears that only 4 cases of emergency craniotomy/craniectomy required in a patient with a tumor-like MS plaque have been reported before.