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[Music] good evening everybody dr vasantha dr subramaniam dr and all my esteemed colleagues who have joined us from all over kuching as the director of academics in aster i wish to welcome all of you to this meeting and i wish you could have been here with us and that this i'm not taking much time but i want to introduce dr matthew abraham who is a friend and i really don't think he needs any introduction because he's like a monument in there's nobody in budget who doesn't know him so dr uh matthew is our senior consultant in neurology also so i invite dr mc ibrahim to take over thank you i hope you is an old friend one of my greatest well-wishers somebody you have the greatest respect and regard for dr assante everybody else in the audience on the virtual meeting friends senior colleagues and friends and my students it's pleasure to be here i've been associated with the kachin clinical society ever since it has begun dr georgina was a very close friend and he's the one who set it up he's handed it over and it dr masala has stepped in and ever since then i can only tell you that over the last so many years the quality of the discussions has improved so much the participation has been phenomenal all of us have ended up learning so much more in these meetings and i welcome each one of you to this meeting it's a pleasure to get it started as quickly as possible we have five uh case scenarios which are being presented by various departments mostly by the young trainees and for them i can assure you it is one of the best training examples or the ability to be able to present things in a way that people understand there will be a lot of questions it does not matter if you don't know the answers but it is an experience and it is a great learning experience i can assure you in any speciality the challenge is not really diagnosing some intricacy of that speciality it is always when you have a mixed medical or surgical case and you have a bias towards your own speciality but to be able to tease it out and to be able to identify the individual factors which are contributing to this condition of the patient is what is really constituting the greatest challenge in diagnosing and treating a case and sepsis is one of the great masquerades it goes on into all sorts of presentations it can be a great mimic it can be a great something that leads you the wrong way red herrings and so on and so forth and to have a very interesting case and to get the ball rolling we have none other than the head of our infectious diseases uh department doctor he has been a great help and support to me and to our department for everything that we have done he is going to present the eternal amulet in question to be or not to be done the presentations are restricted to ten minutes and we have five minutes for discussion okay so this this case which i'm presenting that probably leaves us with multiple questions at the end of it and that's the whole idea to have discussion and debate on various scenarios the to start with we had this 33 year old lady who came with the history of vaccination two weeks back she presented to the local hospital initially with sore throat and myalgia and then she had persistent cough and then breathlessness obviously because of the symptoms of protein and fever they did a covered artifice here which was negative at that place she was persistently febrile she became pakistani towards the end and hence from there they had started on europeanum and doxycycle she was on six liters oxygen when she came on physical examination there was left basal crabs this was the imaging of her chest which shows multiple patchy opacities and also some bit of plural effusion this was a radiology conformation particular opacities probably an infective etiology moderate right fusion and mild left global effusion the rooty labs and biomarkers were remarkable because it showed significant leukocytosis of seventeen thousand with neutrophilia lately terms were lower certified shade anemia crp and procure stone in the inflammatory markers were high 250 and so strangely the diameter and ferritin were very very elevated more than twenty thousand data and seventy nine thousand ferritin this was the time of uh early twenty twenty and late early twenty twenty one that phase where almost everybody coming with fever and all had this uh in many parts of our country so that's why even though k with pneumonia these d-dimer inferiors are somehow sent and it showed this kind of an elevation urine showed hematuria and aluminum lft showed moderate transformations 230 to 12 astl creatine was normal so these were the differentials which are thought of at that time we thought of a community acquired sepsis with hyperthyroid anemia and young involvements we know that sometimes illnesses like scrub typhus can have present with lung changes and this cause any severe substance can cause hyperphenemia we thought maybe that could be that there are certain community occurred infections which are known to have a lot of pulmonary and renal involvement that is because of the hematuria and alcohol creatine was normal so leptospirosis and hunter fevers a couple of these non-infectious causes were also thought of because of this abnormally high ferritin levels catastrophic laplace syndrome is possible primary vascular is a challenge but the cytopenias we have two cell lines down so excellent the criterion might needs only two and very rarely we also kept a possibility of visa because again this season at that time was on top of the mind whenever something comes with a multi-organ discussion but this patient never had a proven group only that's why those question marks at the end of it immediate management should actually continued on neurophenomenoxy which she was on eco plan was added because staph aureus is also a very common communicator pathogen which can cause severe synthesis because of this very high ferritin and non-infectious differential diagnosis which required immuno modulators she was started on hydrocortis early at that time following reports all tropical infections worked up including these tropical panel which includes pcrs the serologies were negative blood cultures large cultures fluid aspirated these cultures were all negative tb but was negative including cb hat the covet pcr was done in the ball also even though the throat swerve was positive and the chromoscopy was done even that was done that was also negative c3c4 levels were low in terms that the c3 level was slightly low by the c4 was very very low a a profile and dsdna the other automated markers were negative the apple and the acla antibodies are also negative so if you review the differentials which we thought of as it spoke first the consideration was whether it was a standard run-of-the-mill sepsis with hypertheriatomia and that is possible when you look at the treatment immediate treatment modalities you see that there are two options so there are severe multi-organ dysfunction you can go with ivig or methylprednisone if no not much of organ dysfunction you can probably start with ivig so that was the recommendations from the literature you see that all the common viruses and tropical infections can all produce success and hyper effect so that is why the antibiotic cover was mediated at that time sle with hyperphenemia even though the serological markers are negative if you look at the latest algorithm which is published in 2021 you see that there's an entity called clinical sle where if you have the clinical scores which includes what is given on the right side of the slide the different parameters and the findings under the different parameters so this patient had a score of 13 if you counted the zero sight is the thrombocytopenia the low complement so irrespective of the synology that is a and dsdna still you would end up somewhere in clinical sleep so that was also one possibility the other non-effective possibility which we kept was because of a misa now visa is traditionally not known to have pneumonias they are not known to present with pneumonia they can present with myocarditis but not pulmonary infiltrates so when we look at the literature this is uh two references one twenty twenty one and another abc 2022 including the systematic review so nearly one third of these visa patients who landed up actually had findings which would attribute to pneumonia that is parent infiltrate from the ct chest so that was still compatible now we are stuck with three is it sepsis with hypothetia is it sle with hyper feminine or is it uh he tried to look at whether we can make sense out of it by looking at pc3 c4 levels and what we learned from this was that this pattern is not like sepsis where you would have either see both c3 c4 would be low but this differential c4 being very low and c3 being just low that is not like sepsis so this was more in terms of a non-effective thing like sle where c4 is very very low and c3 is just so this fitted in most with the sle or an autoimmune phenomenon rather than sepsis so then we were still left out what happens with c3c4 in visa we have again a systematic review and meta-analysis which showed us that c3 c4 levels drop in both severe poverty and in visa and the pattern is very similar to what we would see in an autoimmune phenomenon so the complement the the analysis of the complement level c3 c4 is also compatible with both sl now this was just vaccination she did not have kovid or contact with kobe which forms the the when you look at the criteria it says that either cohere or contact with phone so she did not have either it was just vaccination so can we actually label this and disturb when it is just vaccination and doesn't satisfy those three these two major criterias so again this is the systematic review published just this year 2022 addressing the majority of the cases and published worldwide and 2.5 of these cases which is published and reported in the systematic review was post vaccination no known disease no known expression only vaccination so i will not go through this because of lack of time i'll just skip to this part which is probably which will open for the discussion and debate so i tried to look at the pros and cons for each of this and each of these had their pros and cons so synthesis leukocytosis with very high crpn flu calcium in consolidation reported in the ct chest this was infected pneumonia negative cultures serology is heritage of more than 50 000 yes hyper fertility is possible but more than 50 is actually limited to one two three four conditions not sepsis is not known because that high values c3 c4 profiles are not compatible sle it fits in the criteria of clinical sle and c3c for profile also matches as i showed you in the algorithm but leukocytosis in sle is not common and usually even with hlh they have leukopenia so that was a bit uncommon for that we saw many clinical parameters and lab parameters are comparable with vissa the only thing was it is odd and very rare not to have evidence of core infection only vaccination causing this so about five to six days from outside and another four to five days within the hospital she had already completed 10 days of this antibiotics the inflammatory markers are settled the steroids during this time were escalated to methylprednisolone because once the non-infected viscera came into consideration we moved from hydrocortisone without prednisone this case was later transferred under rheumatology ozone discharged was on immunomodulators for about six weeks the decision was whether to consider sle and continue for law or to consider visa and stop at six weeks which is the median duration which we treat misa so this is the repeat imaging which you see after two weeks of the steroids and obviously the initial couple of days of antibiotic completely resolved on follow for nearly a year now she has been asymptomatic of all the immunomodulators sorry so this is my parting slide all lung infiltrates with fever need not be immune or infected initiation of steroids or immuno modulators in these sepsis mimics can save life when they already have multiple dysfunction and you consider immunomodulators after five days seven days a week they are too far gone so applause especially with bonds adult transistors these toxic shocks and robeson or these you should consider upfront when you have this criteria etc clinical lab criteria has to be closely reviewed even though serological markers and microbiological diagnosis can be inconclusive delayed or may be negative complement level estimation somewhat helped us here at least to take out the sepsis from the major differential come down in sle and the associated this is the open question whether it was attributed to vaccination or was the vaccine just an incident thank you for that excellent presentation just gives you the challenges that you get when you get mixed medical pictures the floor is open to questions and dr santa if there is anybody in the in your audience who is wanting to ask a question we can have we have five minutes for that the interval between vaccination and onset of fever was two weeks and there was no rash in this patient could i ask a question gnr uh doctor i know that is a nice presentation i just would be interested in knowing how do you see the the natural history unfolding do we have any data at all what happens now six weeks the patient is much better the lung insulators have disappeared what next sir i have a follow-up of a year now this was somewhere in 2020 during the delta time and all so we have a follow-up of nearly a year so she is not on immuno modulators after six weeks and she's doing fine it's absolutely fine thank you excellent case this is just my my question because as the problem is we see a lot of patients the fact that uh at the end of six weeks he's your father for one year did the protein area also discipline so that would make me feel that it's probably not excellent the first week after vaccination people coming in actual collaboration would be incidental could be otherwise i could see that the paper was from juvederm hospital also the office were from department of cardioid so that inflammatory syndrome precipitating atherosclerotic events also were happening post-vaccination so does it all fit into this one thing i always wanted to study on acs after execution but you never got to doing that thank you we go on to the next case this is being presented by dr panna mother from the department of emergency medicine and dr johnson will be cheering she is the main resident in that department this heart skips a beat not just because of a lover's eyebrow it skips leads because of other things too and she will tell you how to get around it thank you sir so today the topic uh which the case which we will be discussing is uh ischemic live wires shockingly hyperactive heart as sir said uh we'll see what this case is all about so uh one fine morning we had a 55 year old gentleman uh visiting the emergency department uh he had he came with complaints of left sided chest pain associated with diaphoresis and the pain was radiating to his left shoulder and he gives a history that started around three and a half hours before he arrived into the emergency so as emergency physicians always our prime importance is to rule out the immediate life-threatening causes so we went about we do this by evaluating the abcds uh here the airway he it was patent he was talking in full sentences uh breathing wise uh breathing and ventilation his air entry was bilaterally equal but he had a respiratory rate of 34 per minute so he was a little bit tachyc and he had a saturation of 95 percentage which was maintained on boom on further hospitalization uh we were able to illustrate basic repetitions also circulation wise all the peripheral pulses were equal and bilaterally heart rate was 113 per minute a bit of tachycardia tachycardia was present uh the blood pressure was 113 over 90 in mercury and the capillary refill time was normal less than three seconds disability-wise he was conscious oriented people's equal reaction his sugars were 277 a bit on the higher side but he was a diabetic patient uh and exposure-wise uh a febrile he was a bit diaphoretic otherwise uh a febrile there was no sign for pale edema or no other abnormalities were so after uh completing the primary survey we went ahead and planned we went ahead and administered four liters of oxygen to the patient by a face mask and uh iv candidation was done and blood samples were connected we also planned to get ecg website echo as well as a portable chest a quick uh history is was obtained we go through about it using a mnemonic called the samples history where s stands for the signs and symptoms here a higher 55 year old gentleman as we discussed uh left side chest pain with diaphoresis radiation of pain to the left shoulder uh the pain was the side of the pain was over the left precordium and the character was for heaviness or a timing sensation uh over the left recording he did not have any associated disney even though he was a bit tachypnic on the monitors he did not have any disney assets there was no history of syncopal episodes and no other gi symptoms vomiting allergies there were no allergies and medications and past medical surgical history he was on only hydrolyzing some years and as well as antihypertensive medication for systemic high dimension another history is that he had a reason for a category b 19 infection that was around two months back he had his breakfast in the morning and after which he started having pain and he's a non-alcoholic and a non-smoker now after this we went into a detailed secondary survey that includes a head-to-toe examination uh here the uh heat examination that is the head head eyes ears nose uh a normal teeth and all the cavity are normal the neck and chest examination uh there were no distended brains there were no masses or there were no keratin it was absent cardiovascular system was also normal hearthstones were heard no cardiac murmurs were audible respiratory system examination revealed bilateral basal gravitation both in the auxiliary regions intrascapular in the scapular regions bilaterally cavitation fine gravitational forward and red zones were equal but abdomen was soft non-tender bowel sounds were normal and central our system also he was alert uh he had high higher mental functions were normal neurological we went ahead and got a 12-lead ecg here this is the ecg is the first ecg that we got uh it's it has a rate of 110 the rhythm is normal the normal axis and there are std changes uh in leads beta tree androsceptic st depression was seen with reciprocal chains after this we went ahead with a screening point of care echo which revealed a poor lb function an rwma elicited in the anterior and septal walls which was uh correlating with the ecg that we uh saw and the ibc was plethoric and he had bilateral d lines on uh over the long fields suggesting of an early pulmonary the chest ray also show the portable chest x-ray showed features of early pulmonary area uh in view of this early pulmonary edema the uh hysterectomy at the saturations we started him on a bipap ventilation as his permanent radio was seen to be progressing slowly uh he was being observed in the department afterwards so this is the x-ray that we uh the initial x-ray portable chest x-ray which showed early intending pulmonary features uh so he was uh in our department around 40 minutes or half an hour to 40 minutes later we started having we suddenly started having a chest pain central chest feet and we saw that he was having a ventricular tachycardia on the monitors according to the american heart association arrhythmia it was deemed to be unstable because he had the signs of heart failure and he had chest pain uh he was immediately connected to the crash cart to the defibrillator since he was alert and away we had we considered sedating him with injection meter zola and also got a concern from his guys to a synchronized electrical cardiac after this yeah after the initial cardioversion he was reverted to sinus rhythm very [Music] followed by an inclusion as an idea [Music] [Music] thank you so during the registration phase we started with the injection ammunition 150 milligram standards was given and followed by infusion as an anti-arrhythmic medication and he was going into shock he was going into hypertension and for which an isotropic support with noradrenaline infusion was also initiated in view in view of all his this clinical scenario he was electively intubated from the emergency and he was other drugs administered during this period was i programmed as a beta blocker and iv magnesium sulfate ong was also given as it was a polymorphic ventricular tachycardia he was uh electively intubated and he was admitted to the cardiac care unit so initially what we saw as a normal non st elevation anterior wall myocardial infarction we were suspecting an n stable uh and study without impending pulmonary edema which progressed very quickly into an electrical star electrical storm is which is defined as three or more sustained episodes of ventricular tachycardia fibrillation or appropriate shocks from an implantable cardioverter defibrillator within a time period of 24 hours here in this case we have to shock him over 10 times in the first one hour itself so electrical storm ethiologies include uh most commonly being ishkeemia other structural heart diseases uh long duty syndromes etcetera are includes the etiology of an electrical stop here our patient he was admitted to the cardiac unit and he was uh other uh speaking about the lab values he had an initial profile was elevated because he was having an hdv and only all the other including serum electrolytes uh all the other parameters were with the normal even the thyroid functions were done that was with the normal limbs all the other parameters were normal only the tropic was initial topic was elevated and the second topic after the um uh the electrical strong was definitely more than 30 000 uh he was admitted and he was uh electively went into uh uh angiogram uh cardiac angiogram was done which showed a proximal led occlusion uh suggesting that ishpedia so the management of uh in general of the electrical storm includes the uh acls protocol acls protocol in general uh then antiarrhythmic medications beta blockers device programming is uh has to be done if it is in case in cases with patients who are having an icd's incident neuraxial modulation such as ganglion blockade can be used for immediate management and later on a sympathetic deniation can be [Music] an foreign storm uh other methods include catheter ablation and treating the underlying costs although also also important for management of this electrical stock thank you what happens is the important thing is identifying this electrical storm and that goes with the definition uh not only going the other important thing is that you can use beta blockers but because there's a certain surge in adrenergic activity in the patient so usage of beta flocker is also an important considering beta blocker income differently with the cardiologist is another important uh medication that you can use to bring down this energy surge so uh early diagnosis and early identification considering that the possibility of an electrical song which goes by the definition saying that if the patient has it goes into rectangular within five minutes of the last termination of the last last week and uh or within 24 hours if there are recurrent episodes of bt then you have to consider this electrical the other thing is uh treating the underlying cause that is could be thyrotoxicosis or it could be a worsening binary edema it could be a acute ischemic attack mi a new mi so there are also answering those and reading early the underlying cause is also an important concept open to questions thank you dr johnson and dr panna welcome we have one minute what's happened to the patient now now how is the patient what is the uh natural course of a hospital course with the patient recovery yeah uh he was admitted here his opposite hospital was five days included and uh during that period he was stable he did not have any more episodes of uh vp or uh uh he was normal during that time he was treated with uh iv heparin and blockers amir drawn exit and other conservative medications after which he was discharged and electively a caging was done after a few days which showed this uh proximal alias after which the patient is fine enough you mentioned about samples what are the full form of samples because you i thought symptom signs is okay allergy you mentioned but then after that i did not get the for the benefit of the residents okay s4 signs and symptoms a for allergies m4 medications t for past medical and surgical histories l for last meal or lmp in case of females e4 events that led to the current situation and last ss social social history thank you johnson says that's the protocol they follow the emergency in specialities and super specialities we have the comfort of knowing telescopic degree of knowledge it's all inspiring to know that in emergency medicine and in critical care medicine you have to know hell of a lot about health a lot otherwise you won't be pulling out patients like this thank you congratulations we go on to the next case uh straight away this is uh will be presented by dr josh lynn maria shady she is uh our mrcp student she's i've had she's had the we've had the pleasure of having her with us and tanil will be sharing the session good evening everyone today i'll be presenting an interesting case which involves a fall a crash and a savage a 72 year old lady a known diabetic with past history of varicose veins presented to us with an unleashed history of slip and fall and she had and she complained of pain of the right hip we did an x-ray of the right hip which showed basic cervical fracture of the right neck of silva she was posted for bipolar hemiarthroplasty of the right hip now considering her age and her risk factors we went and we got a cardiology fitness and her echo was done which was normal and she was given a shot of low molecular it happened on the day of procedure soon after positioning her for spine anesthesia she had hypotension and bradycardia and she was gasping and ancestoring she was immediately intubated and resuscitated ionotropes and iv fluids were started started to sustain her beauty an urgent echo was done which showed hugely dilated immobile right atrium and right ventricular with elevated uh pa pressures consider with the onset of new echo findings we suspected and obtured pulmonary embolism and we did an immediate thrombolysis before her with connectives this is the ech of the patient which shows sinus tachycardia classical finding of subject pulmonary embolism along with s s in lead one and uh prominent u wave and lead three t wave inversion and v three and a right one branch of the antidepressant binary embolism is the obstruction of pulmonary artery or one of its branches by material either thrombus tumor air of fat that originated elsewhere in the body patients can present as acute subacute or chronic in our case a patient's presentation was absorbed now further evaluation and management of acute pulmonary embolism depends on the hemodynamic status of the patient usually massive or high-risk pulmonary embolism the patients present with hypotension which is non-responsive to uh fluid therapy and those calculations be categorized as unstable and submassive or intermediate higher this pulmonary embolism patients present with moderate borderline hypotension which is responsive to uh uh fluid therapy and these patients might have obvious function or echo now pulmonary embolism causes increased increased pulmonary vascular pressure which causes an increased rv overload this can uh contribute to two mechanisms the main mechanism is where there will be high rv uh right ventricular dilatation and hypokinesis which reduces the right ventricular output and also simultaneously causes intervention receptor deviation towards the left ventricle thereby reducing the uh left ventricular preload and causing systemic arterial hypertension by decreasing the cardiac output another mechanism is by increasing the right ventricular wall tension which increases the myocardial oxygen denmark which control which causes right ventricular ischemia refraction and radius which reduces the permeability perfusion thereby causes systemic arterial hypertension now in a suspected high-risk pulmonary embolism with shock or hypertension presenting with shock or hypotension further management is based on the patient's status if the patient is hemodynamically unstable uh as as seen in our case where the patient was had a cardiac arrest on people we did not have any other imaging modality available so we go in for an echocardiogram if the echocardiogram shows a right ventricular overload uh we can directly go in for repercussion either by thrombosis or endonectomy if there is no rv overload we need to go and we need to search for other causes if the patient is stable then we can go in for a ct pulmonary angiogram if positive we can go in for re-perfusion if negative we need to go in for we need to search for other causes this is the classical science seen on echocardiogram for acute pulmonary embolism which shows classical echo finding uh is the mid right ventricular free wall will be hypokinetic or internet and the effects will be hyperkinetic uh our patient was clear she clinically improved she was excavated after thrombolysis she was continued on low molecular weight apparent uh and we also did a lower limb venus doppler which was normal ah this is a ctp of the patient which is the gold standard and diagnosis of ugly pendulum which shows the main pulmonary artery you can see the thrombus uh extending into the right and the left pulmonary arteries with filling defects as well after this our main concern was on our weird challenge was on how to get a patient through her surgery so to rule out any uh cardiac event or a cardiac process we did a coronary angiogram an mdd was held involving the international radiology orthopedic and anesthesia team uh the patients bystanders will explain the risk of recurrence of pulmonary embolism when on on temporary cessation of anticoagulation for surgery and with this perspective it was decided to proceed with the surgery only after uh placement of ivc filter so this is the image showing the ivc filter usually venu cover filters are not routinely recommended the specific indications involve recurrent embolism while on adequate anticoagulation significant bleeding complications during anticoagulation in acute phase it is usually inserted by the jugular or the femoral wheel and placed in the infrared portion of the vehicle the filter institute temporary idc filters are preferred over permanent and temporary ivc filters are removed within the first few months our patient she underwent by a successfully underwent bipolar hemiacoplasty of the right hip under spinal anesthesia after stopping anticoagulation for 12 hours perioperative and post-operative period was uneventful she was mobilized post-operatively and was discharged with an oral department she is on regular follow-up with her she's doing well and ivc filter remover is planned towards the end of this month take home message is that the pulmonary thromboembolism should be prevented at all costs with appropriate prophylactic antibody regimen immediate thrombolysis salvage this patient from near fatal pulmonary impulsion and a multidisciplinary approach and use of appropriate therapeutic measures can ensure good outcomes even in such difficult clinical scenarios thank you very dramatic case where i was called from the outpatient for an arrest in the theater and this patient the benefit was of the intraoperative inside the theater and echocardiography was immediately done by the anesthesia chief and we detected that prompted us to give the thrombolysis within the theater and that was what salvaged this patient but that was not the end of it this patient wanted to walk back considering the risk we were we were telling the team the relatives there's a big team of almost 20 people that we want this patient to walk home but we want 100 how do we give 100 guarantees can she have a coronary next time that's why we ended up doing economy angiography disease and then getting the interventional radiologist coming and putting an ivc filter and with the ivc filter she went in for the surgery and it was a comfortable sailing through the surgery and the patient walked by the third or fourth day and she's coming for regular follow-up so permanent pressure has come down and dr rohit our interventional radiologist is planning at ivc filter removal in a week or two now the question is and according to the current esc 2019 guidelines if it's a reversible major cost even it's enough to give up to three months away earlier we used to give six months or one year but if this patient had a major reversible cost she was immobilized and she had a fracture that's a major risk factor so we can even stop the anticoagulation after three months if we cannot identify a cause in a given patient and has a major parametrism might even be lifelong if you have an antiphospholipid antibody syndrome and equivalence is lifelong otherwise you will have to have a hematological worker try and identify process or if it's only a minor risk factor also you need to give long term because you do not know when the next statement is very important even today in our emergency we have a permanent policy in a 17-week pregnancy so it is a very common thing i remember our seniors usually tell us was not an indian phenomenon but we have learned it the bad way that it can occur and we need to be ready to treat it and in this situation the multidisciplinary management was the beauty of the treatment in this given question thank you fact that this patient has survived such a critical phase and comes who successfully speaks volumes for the quality of care you and your team gave money any questions from the audience dr assanta from the group you have virtually go on to this case this is from the department of gastroenterology and will be presented by dr sharing thomas she is the resident in gastroenterology and dr jeffery will share this thank you my name is dr sharon tess thomas and i am a junior resident here in the medical gastroenterology department and i'm here with my consultant dr jeffy john who's also the moderator for this presentation so the case presentation we have for you today is titled a deadly disguise and delving into the history of the patient we have a 44 year old gentleman with no known commodities who had initially presented to our obd with complaints of diffuse abdominal discomfort postprandial loose tools and generalized tyrants for about two months there's no history of fever abdominal distension of blood and stools and no history suggested with actress there's no history of alcohol consumption conservative alternative medicine intake or high-risk behavior we had even ruled out a history of tuberculosis in this patient so routine blood investigations which were sent on an op basis which included cbc crp lfd and triable were all noted to be normal however this is still occult blood tests have turned out to be positive so this obviously warranted an endoscopic evaluation from our team and we went ahead with ogd spoke which was done on the 30th of november last year which revealed a diffused gastritis and a natural biopsy which showed mild chronic active gastrointestinal fibrosis a colonoscopic evaluation was also done on the same day which showed a colitis picture and sigma advice biopsy had revealed a focal mild active inflammation so he was continued on symptomatic management but the plan for further evaluation including a cect have the symptoms not relieved however the patient was lost to a follow-up after this visit and he had resorted to taking homeopathy medication since he had not gotten any symptomatic beliefs and a month after his last visit he had been admitted under our care with two episodes of hemitamises and persistent this epic symptoms so an initial evaluation he was notably conscious and oriented his vitals was stable and he was aphid right there was no power it just peel edema or lymphadenopathy and his oral cavity was notatively normal but abdominal examination was also soft and there was no organometallic other systemic examinations were also grossly normal and lab investigations which were done for the patient initially showed a cdc which showed mild leukocytosis with the raised esr of 46 millimeters in the first arm and three admin values at 2.57 milligrams per deciliter this peripheral smear was noted to be normal however his urine routine analysis had shown nephrotic range protein area of three plus we obviously got the nephrology team involved as well at this point and we had gotten a non-contrast ct abdomen in view of its raised reaction levels and this was done to rule out any obstructive renal pathology the scan obviously showed a mild hepatomegaly with my bilateral renal enlargement and it was suggested by the team that we go ahead with calculating the urinary algorithms and the random urine argument and 24-hour urinary levels were assessed which is in the rates of thousand and three thousand respectively a serum protein electrophoresis initially done showed a micro uh hypoalgamine picture with a deposition of beta to microglobulin and no m band in the gamma region however a serum protein electrophoresis repeated after a few weeks did show a small m in the gamma region with so a renal biopsy was suggested by the nephrology team in buff has raised creatinine levels is protein urea as well as a short history of presentation and we see here that the specimens from the renal biopsy shows amorphous material elasmophilic material which has been deposited and this is the amyloid deposition that you see marked in red arrows and this on staining with congo red did show an aperture by refrigerants under polarized light this is the gold standard for diagnosing amyloidosis mr pathologically and keeping this in mind we did a retrospective re-evaluation of the gastric um mucosal slides that we had obtained during by ogd smokey and this showed uh deposition of extracellular eosinophilic nature again confirming our diagnosis of the mitosis as well as the congo red staining with the gene by refrigerants under polarized light a copper positivity was also seen on isc of the gastric mucosa and it was noted to be weakly past positive to see and evaluate the involvement of the other organs because in america in this case we have gone ahead with a pet ct which showed diffuse heterogeneously at pg avid bone marrow of the axial as well as the appendicular skeleton and these are images from the patient's pelvic right here we got the hemato oncology team involved as well at this point and we had gone ahead with the sleek serum free light chain assay which revealed increased copper light rain deposition of about 546 milligrams per liter with a copper to lambda ratio of 19.9 inches again significantly elevated here the renal biopsy immunofluorescence done in the same renal biopsy specimen showed that there is a monoclonal immunoglobulin deposition with glomeruli showing a copper light chain restriction bone marrow studies were done thereafter and the bone marrow aspirate in traffic biopsy showed a cellular marrow with atypical plasmocytosis approximately 15 percent of copper light chain restriction and to keep uh just to make a note the the cutoff for diagnosing multiple myeloma is 10 percent of this patients obviously crossed that there was also amorphous extracellular eosinophilic material again and thickened blood vessels which on converted staining again through the vocal tree by refrigerants under polarized light cytogenics was done for protestation of this patient and the fish panel showed a deletion of 17p which carries a grave prognosis as well as additional copies of chromosome 17 a cardiac involvement was established with the help of biochemical markers where elevated drop by and bnp levels were not so with this we came to the final diagnosis for our patient which was a light chain aka a l omega secondary to multiple myeloma with the involvement of the gut kidneys and the heart further management and follow-up of the patient was done by the hampton oncology team who had advised chemotherapy for the patient and after discussing with the family of the patient as well we had gone ahead with uh the cyber decks protocol and the first dose was given to the patient two weeks after he was admitted formal doses of the same were given to the patient before their atomic which is a monoclonal chemotherapy agent used in multiple myeloma started as well eventually however the patient did develop a septic shock with blood cultures revealing eclectic pneumonia growth and he had gone into multi-organ dysfunction syndrome as well and finally his account took his illness on the 17th of march 2022 two and a half months after being diagnosed so just a few pointers on amyloidosis that i would like to share with you coming to the pathogenesis wherein we classify the type of proteins which are being deposited if they are normal proteins which are produced in abnormal numbers you can have two types which is either a l protein or a a protein al protein is an acquired mutation which is usually seen with plasma cell discretions like our patient caviar and chronic inflammation which causes increased saa protein which leads to aa amyloidosis also known as secondary myobitrosis the third kind is production of normal amounts would have mutant proteins for example transparatin and this leads to deposition of attr protein which results in habitary amylosis these are three infographics that i have picked up from the amyloidosis foundation's official website which shows general signs and symptoms that patients with amino acids do present now if you do look at these images you can see that there are a lot of overlapping features and symptoms like protein in the urine fatigue patients complaining of diarrhea constipation and a generalized feeling of weakness so these are also complaints that our patient initially presented with so keeping this in mind they take home message from our presentation would be that gastrointestinal symptoms as the presenting manifestation of light chain of myelosis is rare and this is in the range of three to five person and on top of that the usual presentation age for amyloidosis is gi amirosis is in the sixth and the sorry is in the seventh and the eighth decade but unfortunately a patient developed the disease in his fifth decade and due to the non-specific gi symptoms and the endoscopic findings associated with gi americorps the diagnosis can often be delayed or may even be ignored and the next point we have to keep in mind is that gastric amyroverosis is an excellent mythical inflammatory bowel disease this was a differential diagnosis we had kept in mind initially when we saw the patient on an op basis as well and the usual time frame from symptom onset to diagnosis in various studies is anywhere between seven to 24 months the gastric amyloidosis usually carries a very dismal prognosis especially in our patient who had a deletion of 17p where the prognosis is extremely well so with that i will be concluding this presentation thank you all for this opportunity as well as for your attention thank you so uh this case is uh important for two aspects one this was actually a 44 year old me you did not suspect amyloid in 44 year old me for the usual use of presentation is anywhere between seven to eight decade and secondly the patient presented with hematimesis so uh gi symptoms as a percentage manifestation of america is again prayer so this was a diagnostic difficulty we had encountered because the first diagnosis which we had kept was obviously inflammatory bone disease and the patient does not did not have any respite following the initial treatment when he resorted to alternative medicines and uh when he presented a month later then that was a time you know what we did was we re-took the history we re-examined the patient but there were no obvious signs except for the labs which showed uh uh elevatedly added that was actually one of the pointers to diagnosis and we even rated the serum electrophoresis which initially was negative but on the second goal you know we picked above impact and we also sat with the pathologist to re-evaluate the slides uh which obviously through light on gastric um so whenever you are in fix it's always better that we go back to your old school of medicine like you know have a chat with the patient again redo the history re-examine the patient rerun the investigations and probably you know the diagnosis license all these things and we had excellent inputs from different departments to name from nephrology and hematology and obviously pathology the progress in this patient obviously decides on the systematic involvement we had involvement of the heart the cut as well as the kidneys and according to the different prognostic models whenever you have involvement with both heart and kidney the prognosis is as low as 4 months and this patient was quite unfortunate he fit into that thank you thank you sharon and dr jeffy for an excellent presentation the abdomen is indeed a pandora's box and when you open it you are subjected to the possibility of multiple multiple diagnosis when you finally end up with amyloidosis that itself is a spectrum which is so difficult to analyze and uh congratulations for a great case and good presentation any uh questions from the audience dr once again the invitation is open from the group gn [Music] [Music] becomes extremely poor and here i think in this patient was that you have no choice but to treat and the treatment of this amyloidosis will be treatment which was done unfortunately she developed a substance which and depending upon the categorization also the patient was intermediate higher students lower gi questions one of the great advantages of working in an institution like this is that you have such phenomenal inputs from excellent teams in each department and i always recommend this to our students that this is the opportunity where you will get to see top of the line cases top of the line inputs top of the line management that is where you are able to diagnose right to the top and get outcomes which cannot usually be got in many other places so once more take the opportunity and learn we go on to the final case the evening and that is from the department of critical care medicine dr lindsey rajan will be presenting the case she is the registered in doing her depending program in the critical care and this is the case is about circumventing a blocked system good evening everyone this is the story of how we supplemented a block system in our ic so she was a 35 year old lady with history of hypertension on medication she won fine morning on first of may she took 60 tablets of total i'm loading it 5 mg and initially at the hospital she was managed with uh iv fluids and anti-amethysts and they noted that her vp is coming down and she was referred to another center for further management and at the second hospital she was added up with vice president one by one noradrenaline and vassar proceed and document infusions and even with that she was having refractory hypertension and she also developed acute kidney injury and for further management she was referred to our center the next day so when she arrived in our hospital into the micu she was on multiple inclusions of calcium gluconate lipid emulsion sodium bicarbonate human extract or high dose along with other vasopressins so in initial examination she was found to be a bit drowsy and she was having that nausea feeling he was she was having a heart rate of 94 100 per minute she was a regular with skipped beats in between and her vp was around 60 to 40 millimeters of mercury and his respiratory rate was 16 with saturation maintaining in nowhere of 96 percent agent and even with the bp of 60 over 40 millimeters of mercury her peripheral puzzles were on and her temperature was also normal other systemic examinations was within normal limits and we did this training echo and it showed that her right aj and right clinical were dilated she had concentric lvh with the moderate will be systolic dysfunction and her ivc was congested also we did the lung ultrasound which was normal and uh initial investigation we did an abg at the yeah as possible and it showed the ph of salvo in one that there is a metabolic acidosis with a lattice of 4.6 and other investigation came as she had a total increased total count and rft was mostly and her potency was 2.2 magnesium was 1.28 at the lower range and her blood sugars was high with 3.3 milligram per deciliter also her initial ecg showed multiple indian so about the management we went ahead with the management that is initially uh a b c or where we have to consider and a and b we uh electively integrated so that the c that is the most difficult part circulatory part to manage within this kind of situation because all the beta receptors and calcium circles are blocked so we have to deal with the c part thoroughly so abc is separate along with the grps levels and also iv calcium blue plate were given as infusion and also liquid emulsion was started from the other hospital that which we were we continued it and iv glucomannan was given because even with those uh drugs muscle process and other drugs she was not maintaining uh her nemo dynamics so we went ahead with iv glucagon and uh we also corrected potassium and magnesium also her accounts were a bit high and we expected in this case but we started uh with antibiotics after sending proper cultures so we immediately consulted with the nephrologist and we put a line immediately and started with continuous amino amino sigma dia filtration with a charcoal chemo filter and the charcoal filter was removed after 12 hours and the crrt was continued again gradually by next morning her adrenaline and dopamine patients were able to temper down cardiology consultation was done and advised a conservative manager at that point of time but after some time she had worsening of hypertension with increasing lactate levels in serial abds so in view of refractive esophagea we thought of giving methylene blue 50 milligram we gave it 100 ml and an hour a period of 30 minutes and some sort of magic blood pressures uh were improving and the other cluster process we were able to taper off but that was only transient so again uh we thought of handing a female effort in future elements it is an alpha agonist so we started with female electron infusion aspect protocol and again the magic happened started uh it started showing improvement in hemodynamics and other versa presses were able to temper down and the crrt was continued her serial abg's improved urine output increased and after two days we took her off from crrt the fourth day we were able to extubate the patient and the fifth day last dialysis was done and the seventh day that is after one week we were able to shift that patient to room and uh she was discharged after the evaluation by a psychiatrist and followed bruce it came she was stable so a breed or a glance into the pharmacology and the rationale we have we have given multiple drugs in random and just rational behind all the drugs we gave so here the main systems are about beta receptor and the calcium channels are blocked so resulting in a state which with the heart which is not properly contracting and the peripheral vascular system which is fully dilated so it is very difficult situation to be uh to be taken away and also calcium channels will block the uh release of insulin secretion from the pancreas and it will lead to a hyperglycemic state and reduce cardiac glucose utilization so it is a very difficult scenario to deal with so initial management as always we have to take care of the abc that we taken care of let's see what's actually the difficult one initial uh time we can give the activated transfer and also can consider gastric lava so she was given the same from the outside hospital and hormone irrigation with polyethylene glycol in case of sustained relief preparation and i need fluids in these all cases of shock we used to give but here we have to give it consciously because these patients will be human and they can easily go into fluid already so and another drug hydrogen sulfate it is the first choice for symptomatic radicaria but this won't work wonder here so it has poor response with atropine surface other drugs we can give our genetic drugs another important therapy is high dose insulin uh you glycemic therapies well not therapy so the idea behind it is the healthy myocardium uses free fatty acid as a primary energy source but in shock state glucose is a proper energy substrate so what happened in calcium blocker there will be uh impairment of incident release from the beta cells and these would lead to a state in which uh glucose is there but there is no insulin to taken care of and so here we have to give high dose of insulin uh to be noted that in dk we used to give 0.1 units per kg of those but here we give 10 times the dose that is 1 units per kg bonus followed by 1 units per kg infusion and depending on the patient's response hypodermic response we will try to take those and if patient is not responding with a therapy it is that because this is not because of the cardiac area it is because of the vasodilatory part also so we have to take care of other uh measures also glucagon is another option it uh it works independent of beta adrenergic system causing ionotropic and dramatic effect and another therapy we gave was a liquid emotional therapy the idea behind this is intra lipid or liquid uh emulsion will absorb all the lipid soluble drugs and it is finely exerted to the hepatic system another uh modern treatment is giving supplemental calcium to make the calcium concentration two times ionized calcium so it increases the ionotropic another wonder drug we gave was the medallion it is the inhibiting limits nitric oxide cyclic gmb pathway scavenges nitric oxide inhibits nitric oxide synthesis nitric oxide is a peptide vasodilator so by inhibiting the nitric oxide we will be able to overcome this kind of situations and the dose is one to two milligram per kilogram at single intention another mod is by hemodialysis but unfortunately the two drug species of amlodipine and develop is uh of high protein bond but any more dialysis is useful in case of low separate soluble and low protein binding drugs so another option we have along with the nephrologist we went ahead with the hemodia filtration with chapter keyboard frustration and all together wonder happened with the patient so other therapies include sodium bicarbonate infusion to correct acidosis and other rusty therapies include transcutaneous so the take-home message is usual therapeutic manners to increase bp is ineffective as a media genetic system and calcium channels are blocked so these pathways have to be bypassed to increase the bp so those those moralities of treatment i uh told earlier will be coming in place and it should be chosen carefully depending on the hemodynamic response to each treatment so crt will check for hemoperfusion temporary facing and ecmo in selected cases can be used so always abc takes precedence over all other management thank you so much [Music] given but even with those drugs the bp was still 60 by 40 and the base was probably uh so so we had to apply a number of alternative agents to sort of bypass this blocked system and we were also not sure which of these engines would work so we had to try multiple we had to try multiple edges in this machine and luckily for the patient uh something worked and uh the fact that they've gone about it so scientifically is what has pulled this patient out great outcome when you feel that we've done something useful any questions from the [Music] something no no i would like to comment you on the excellent case presenter then we'll discuss congratulations thank you very much but uh we really wish you all back here because we could have had a more uh meaningful discussion dr uni and myself are saying that we should tell you all next time to come here uh many of our trainees are here you could have met with them it would have been a good interaction session also so we wish to thank everybody who was there so all those who presented your presentations were very good you spoke clearly nicely and we are really very proud of you so thank you must thank dr gita and the organizing team here for this opportunity to share this session thank you for the excellent participation of the fact that so many of you were here i'm sure that each one of you would have taken messages and learnt a lot you
Cochin Clinical Society - Aster Hospital
'Cochin Clinical Society' brings to you case discussions from 5 different specialties presented by the doctors of Aster Hospital: 1. To be or not to be- That is the question by Dr. Anup Warrier, 2. Ischemic liver wires - 'shockingly' hyperactive heart by Dr. Aparna Madhusudhanan, 3. A fall, a crash and the salvage by Dr. Joshlin Maria Shaji, 4. A deadly disguise by Dr. Sherin Tess Thomas and 5. Circumventing a Blocked System by Dr. Lincy Rajan.
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