Probiotics and Gut Microbiota in Obesity: Myths and Realities of a New Health Revolution

Obesity and its comorbidities are humans’ most prevalent cardio-metabolic diseases worldwide. Recent evidence has shown that chronic low-grade inflammation is a common feature in all highly prevalent chronic degenerative diseases. In this sense, the gut microbiota is a complete ecosystem involved in different processes like vitamin synthesis, metabolism regulation, and both appetite and immune system control. Thus, dysbiosis has been recognised as one of the many factors associated with obesity due to a predominance of Firmicutes, a decrease in Bifidobacterium in the gut, and a consequent short-chain fatty acids (SCFA) synthesis reduction leading to a reduction in incretins action and intestinal permeability increase. In this context, bacteria, bacterial endotoxins, and toxic bacterial by-products are translocated to the bloodstream, leading to systemic inflammation. This review focuses on gut microbiota composition and its role in obesity, as well as probiotics and prebiotics benefits in obesity.

Metabolic Syndrome: Is It Time to Add the Central Nervous System?

Metabolic syndrome (MS) is a set of cardio-metabolic risk factors that includes central obesity, hyperglycemia, hypertension, and dyslipidemias. The syndrome affects 25% of adults worldwide. The definition of MS has evolved over the last 80 years, with various classification systems and criteria, whose limitations and benefits are currently the subject of some controversy. Likewise, hypotheses regarding the etiology of MS add more confusion from clinical and epidemiological points of view. The leading suggestion for the pathophysiology of MS is insulin resistance (IR). IR can affect multiple tissues and organs, from the classic “triumvirate” (myocyte, adipocyte, and hepatocyte) to possible effects on organs considered more recently, such as the central nervous system (CNS). Mild cognitive impairment (MCI) and Alzheimer’s disease (AD) may be clinical expressions of CNS involvement. However, the association between MCI and MS is not understood. The bidirectional relationship that seems to exist between these factors raises the questions of which phenomenon occurs first and whether MCI can be a precursor of MS. This review explores shared pathophysiological mechanisms between MCI and MS and establishes a hypothesis of a possible MCI role in the development of IR and the appearance of MS.

Phytotherapy for Cardiovascular Disease: A Bench-to-Bedside Approach

At present, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide, and global trends suggest that this panorama will persist or worsen in the near future. Thus, optimization of treatment strategies and the introduction of novel therapeutic alternatives for CVD represent key objectives in contemporary biomedical research. In recent years, phytotherapy-defined as the therapeutic use of whole or minimally modified plant components-has ignited large scientific interest, with a resurgence of abundant investigation on a wide array of medicinal herbs (MH) for CVD and other conditions. Numerous MH have been observed to intervene in the pathophysiology of CVD via a myriad of molecular mechanisms, including antiinflammatory, anti-oxidant, and other beneficial properties, which translate into the amelioration of three essential aspects of the pathogenesis of CVD: Dyslipidemia, atherosclerosis, and hypertension. Although the preclinical data in this scenario is very rich, the true clinical impact of MH and their purported mechanisms of action is less clear, as large-scale robust research in this regard is in relatively early stages and faces important methodological challenges. This review offers a comprehensive look at the most prominent preclinical and clinical evidence currently available concerning the use of MH in the treatment of CVD from a bench-to-bedside approach.

Exploring Phytotherapeutic Alternatives for Obesity, Insulin Resistance and Diabetes Mellitus

At present, the pathologic spectrum of obesity-insulin resistance (IR)-diabetes mellitus (DM) represents not only a pressing matter in public health but also a paramount object of study in biomedical research, as they constitute major risk factors for cardiovascular disease (CVD), and other chronic non-communicable diseases (NCD). Phytotherapy, the use of medicinal herbs (MH) with treatment purposes, offers a wide array of opportunities for innovation in the management of these disorders; mainly as pharmacological research on small molecules accumulates. Several MH has displayed varied mechanisms of action relevant to the pathogenesis of obesity, IR and DM, including immunological and endocrine modulation, reduction of inflammation and oxidative stress (OS), regulation of appetite, thermogenesis and energy homeostasis, sensitisation to insulin function and potentiation of insulin release, among many others. However, the clinical correlates of these molecular phenomena remain relatively uncertain, with only a handful of MH boasting convincing clinical evidence in this regard. This review comprises an exploration of currently available preclinical and clinical research on the role of MH in the management of obesity, IR, and DM.

MON-383 Sporadic Bilateral Pheochromocytoma with Renal Pelvis Paraganglioma: A Rare Coexisting Occurrence

Pheochromocytomas (PHEO) and paragangliomas (PGL) are rare neuroendocrine catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla and the extra-adrenal autonomic paraglanglia respectively. The natural course of this disease increases morbidity and mortality. Most cases are sporadic, unicentric and unilateral and occur in the 4^th and 5^th decade of life. Hereditary disease typically presents at a younger age and are likely to be bilateral and linked to germline genetic mutations. This is the case of a 26 year-old lady with history of early onset high blood pressure (HTN) in the setting of bilateral (B/L) adrenal masses. At 21 years old, she was diagnosed with HTN accompanied with symptoms of depression, cry spells, anxiety, tachycardia and episodes of chest pain that warranted frequent ER visits. She was started on labetalol, lisinopril and hydrochlorothiazide. The work-up for early onset HTN prompted urine fractionated catecholamine collection that revealed normal metanephrines but elevated normetanephrines more than 10 times above the upper limit of normal. SPECT CT abdomen and pelvis showed a 3 cm left adrenal mass lesion compatible with a pheochromocytoma and a 4.5cm complex but dominantly low right adrenal mass with no significant uptake suggestive of a benign adenoma. Dexamethasone suppression test, 24-hour urine free cortisol, aldosterone, plasma renin activity, calcitonin, calcium and PTH levels were within normal limits. Repeated testing showed urine norepinephrine 793 mcg/24h (normal 15-100), urine dopamine 641mcg/24h (normal 52-480), normal urine epinephrine, plasma normetanephrines 2383pg/ml (normal <148) and normal plasma metanephrines. With the diagnosis of Normetanephrine secreting PHEO, She was alpha blocked to undergo left adrenalectomy. Final pathology confirmed left PHEO. After surgery lisinopril was restarted due to HTN, and cathecholamines mildly improved but remained elevated. 7 month later CT abdomen w/wo contrast plus PET CT described status post left adrenalectomy; interval decrease in size of the right adrenal mass now avidly positive reflecting an additional PHEO and an enhancing mass in the left renal pelvis and left renal calyx consistent with a PGL, retrospectively also present in prior imaging. Interestingly no germline mutation was identified in genetic analysis. Simultaneous PGL and PHEO is rare with an incidence of 0.3 and 1 per 100000. Our detailed literature review found only two cases with bilateral PHEO and PGL. Less than 17 cases with renal PGL have been published. Our case is the first sporadic B/L PHEO with renal PGL ever reported. Although no specific genetic mutation was found in our patient, we propose close monitoring with imaging and to be continued in patients with a hereditary pattern. As genetic technology continues to evolve we will be able to identify a clear mutation in this type of patients.

MON-359 Primary Adrenal Insufficiency Secondary to Chronic Use of Posoconazole: A Case Report

Cortisol attenuates inflammatory responses, contributes with glucose homeostasis, and enhances vascular smooth muscle tone augmenting blood pressure among other functions. The symptoms and signs of adrenal insufficiency (AI) depend upon acuity and degree of loss of the adrenal function, including whether mineralocorticoid production is preserved or not. A 65 years-old male with past medical history of mixed connective tissue disease developed 2 weeks of fever and was diagnosed with hemophagocytic lymphohistiocytosis for which he was placed on HLH-94 protocol (ectoposite and high dose pulse steroids). He was also found to have invasive murcomycosis initially treated with amphotericin and posacolonazole(PSO). Given the culture results, amphotericin was stopped and PSO 500mg daily was continued. The patient had a complicated hospital course and was discharged on 2mg of dexamethasone with a pertinent taper. He developed weakness and failure to thrive. His dexamethasone was increased to 3mg daily by his oncologist, and his PSO and chemotherapy was continued. Due to worsen fatigue and deconditioning the patient was brought to the Emergency Room. Upon arrival he was noticed to have persistent orthostatic hypotension despite intravenous fluids, hyponatremia and hyperkalemia (what is the potassium) suggestive of mineralocorticoid deficiency. Further endocrinology workup revealed plasma renin activity of 16.7ng/ml/hr (0.167-5.380) with a low aldosterone level of 1.6ng/dl (0.0-30). CT abdomen imaging showed intact adrenal glands bilaterally. Patient was diagnosed with PSO induced primary AI, he was placed on fludrocortisone with significant symptoms improvement and normalization of electrolytes and blood pressure. After a thorough literature review we found two case reports of iatrogenic Cushing in patients using Fluticasone and PSO, three cases of steroid induced secondary AI in patients treated with inhaled budesonide and PSO; and two cases of primary adrenal insufficiency in patients using PSO without steroids. PSO effects in the adrenal axis are rare, clinicians should be aware of their potential effects on the hypothalamic-pituitary-adrenal axis and pharmacologic interactions with steroids.

SUN-411 Isolated Central Diabetes Insipidus Due to Astrocytoma: A Case Report

Central diabetes insipidus (CDI) is characterized by a decreased release of antidiuretic hormone (ADH) resulting in a variable degree of polyuria. Patients with central nervous system lesions an impaired thirst mechanism can lead to moderate to severe hypernatremia can develop. Here we report a case of CDI cause by an astrocytoma tumor. This is a 64 year-old female who was found to have multiple cerebellar lesions in MRI as part of dizziness work up. She was admitted to undergo brain biopsy. She became polyuric during the procedure and the immediate post-operative time. Her thirst mechanism was impaired by the anesthesia. Serum sodium increased from 142 to 166 mmol/L (135-146) with a serum osmolality 326 mOsm/kg (275-295), urine specific gravity 1.002 and urine osmolality 131mOsm/kg consistent with diabetes insipidus (DI). The patient received 1mcg of demopressin with resolution of polyuria, polydipsia as well as hypernatremia confirming CDI. Further assessment of the anterior pituitary axis was within normal limits. In the light of the clinical findings, a second review of the imaging confirmed the presence of a pituitary stalk with mild diffuse thickening without nodularity. She eventually recovered her thirst mechanism and her urine output was adequate despite not receiving desmopressin for more than 48 hours. Final pathology revealed Brain astrocytoma, for which she was started on temozolamide. Patient was readmitted a month later with altered mental status, she was found to have an urinary track infection and hypernatremia due to worsening CDI requiring demopressin on the clock. Repeating imaging revealed significant parenchymal disease and leptomenigeal disease affecting the sella, stalk and hypothalamic regions. A wide range of lesions can present as isolated thickening of the pituitary stalk. We could only find 5 other cases of patients with astrocytoma who debuted with isolated CDI. Interestingly we found that Temozolamide has been reported as a rare cause of CDI with only 3 cases reported in the literature, but in our patient CDI was confirmed prior to initiation of chemotherapy.

Thyroid Abscess: Challenges in Diagnosis and Management

Thyroid abscess is an uncommon infectious pathology. The thyroid is highly resistant to infection due to high iodine content, capsular encasement, and rich vascularity. Acute suppurative thyroiditis represents <1% of thyroid diseases that could potentially become a life-threatening endocrine emergency. A 48-year-old woman with AIDS presented with 3 days of fever, tender neck swelling, and methicillin-resistant Staphylococcus aureus bacteremia. Apart from leukocytosis, initial laboratory values including thyroid function tests were normal. The initial plain computed tomography scan of the neck and ultrasound scan of the neck were inconclusive as well. By day 4, she worsened, and on repeat computed tomography scan of the neck with contrast, multiloculated abscesses in the thyroid and retro pharynx were seen, which needed emergent drainage. Acute suppurative thyroiditis, a rare disease, occurs in patients with either preexisting disorders of the thyroid or in the immunocompromised. The most common pathogen is Staphylococcus aureus. In our case, we highlight the fact that initial imaging may be negative in the early stages of acute suppurative thyroiditis and lead to an erroneous diagnosis of subacute thyroiditis. There are less than 5 cases of methicillin-resistant Staphylococcus aureus suppurative thyroiditis reported.

Fatal Pulmonary Embolism in the Setting of Immune Reconstitution Inflammatory Syndrome Attributed to Ovarian Tuberculosis

In developed countries, tuberculosis remains a health care challenge due to human immunodeficiency virus (HIV) and immigration from endemic regions. The Centers for Disease Control and Prevention reported 9557 new cases in 2015, with extrapulmonary involvement in 20.2% of the cases. We present a 33-year-old woman from Cape Town, South Africa, who developed abdominal pain and fever while working on a cruise ship. She sought medical where she underwent computed tomography of her chest, abdomen, and pelvis with findings suggestive of pulmonary tuberculosis and an 8.9-cm pelvic mass. HIV testing was positive and the patient was started on antiretroviral therapy. Bronchoscopy confirmed the presence of acid-fast bacilli, and she was started on rifampin, isoniazid, pyrazinamide, and ethambutol. She remained persistently febrile, raising suspicion for immune reconstitution inflammatory syndrome. However, despite empiric antibiotics, the patient remained persistently febrile, tachycardic, and on day 10 of admission she went into ventricular fibrillation and expired. Autopsy revealed an occlusive thrombus in the left main pulmonary artery in addition to necrotizing granulomata in multiple organs and bilateral tubo-ovarian abscesses. Postmortem cultures for were positive for Mycobacterium tuberculosis, all consistent with disseminated Mycobacterium tuberculosis. Although previous reports underscore the association between tuberculosis and hypercoagulability, the exact mechanism remains unknown. In this article, we report a case of disseminated tuberculosis complicated by bilateral tubo-ovarian abscesses with fatal pulmonary thrombus formation.

In utero virilization secondary to a maternal Krukenberg tumor: case report and review of literature

BACKGROUND

Krukenberg tumors are ovarian metastatic adenocarcinomas with a primary origin usually located in the stomach, colon, gallbladder, pancreas, or breast. Occasionally, these tumors produce virilization in the affected individual due to androgen production by luteinization of the tumoral stroma. It is believed that during pregnancy these tumors are more likely to increase androgen production due to the elevated levels of human chorionic gonadotropin (hCG). High maternal androgens can cross the placenta producing virilization of the female fetus.

CASE PRESENTATION

A 46,XX newborn female, whose mother was diagnosed with a metastatic ovarian tumor during her second trimester of gestation associated with worsening hirsutism and acne, was found to have ambiguous genitalia at birth. Testosterone levels in both the mother and infant were elevated. Follow-up laboratory tests showed progressive normalization of circulating androgens after delivery.

CONCLUSIONS

Krukenberg tumors are rare and may produce virilization of the mother and the female fetus when present during pregnancy.

Left Atrial Size and Heart Failure Hospitalization in Patients with Diastolic Dysfunction and Preserved Ejection Fraction

Context:

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome associated with diastolic function abnormalities. It remains unclear which factors, if any, can predict the transition from asymptomatic diastolic dysfunction to an overt symptomatic phase.

Materials and Methods:

Patients hospitalized with suspected heart failure between January 2012 and November 2014 with a transthoracic echocardiogram demonstrating preserved systolic function were screened (n = 425). Patients meeting the American College of Cardiology Foundation/American Heart Association definition for HFpEF (n = 40) were matched in a 1:1 fashion to individuals admitted for hypertensive urgency with diastolic dysfunction and neither pulmonary edema nor history of heart failure (n = 40). The clinical records and echocardiograms of all eighty patients included in this retrospective study were reviewed.

Results:

Patients with HFpEF had higher body mass index (BMI), creatinine, beta-blocker use, and Grade 2 diastolic dysfunction when compared to the hypertensive control population. Echocardiographic analysis demonstrated higher right ventricular systolic pressures, left ventricular mass index, E/A, and E/e’ in patients with HFpEF. Similarly, differences were observed in most left atrial (LA) parameters including larger LA maximum and minimum volume indices, as well as smaller LA-emptying fractions in the heart failure group. Multivariate logistic regression analysis revealed LA minimum volume index (odds ratio [OR]: 1.23 [1.09–1.38], P = 0.001) to have the strongest association with heart failure hospitalization after adjustment for creatinine (OR: 7.09 [1.43–35.07], P = 0.016) and BMI (OR: 1.11 [0.99–1.25], P = 0.074).

Conclusion:

LA minimum volume index best correlated with HFpEF in this patient cohort with diastolic dysfunction.

An Occult Malignancy Behind a Demyelinating Disease: POEMS Syndrome

We report a case of a 38-year-old man presenting with bilateral lower extremity weakness and paresthesias that progressed during a 4-month period to severe polyneuropathy forcing the patient to be bed bound. Throughout his multiple hospitalizations, he was treated erroneously for chronic inflammatory demyelinating polyneuropathy, without significant improvement in his symptoms. In addition, he developed hepatosplenomegaly (organomegaly); endocrinopathies such as diabetes mellitus, central hypogonadism, and hypothyroidism; monoclonal spike evidenced in the serum electrophoresis; and hyperpigmentation of skin, altogether consistent with POEMS syndrome. During his last hospitalization he developed excruciating pain on his left hip, and imaging revealed the presence of a 9 × 6 cm osteolytic mass with sclerotic rim in the left acetabulum. Biopsy of the mass confirmed an isolated IgG lambda plasmacytoma. The patient received radiation to his left acetabular lesion followed by left hip replacement. Subsequently, the patient underwent autologous bone marrow transplant. Eighteen months after his initial presentation, he had satisfactory clinical response and is functional without significant limitations. POEMS syndrome is a rare paraneoplastic syndrome secondary to an underlying plasma cell disorder, which can oftentimes be overlooked and misdiagnosed. The median age of presentation is 51 years, and only 31% of the cases occur in fairly young patients under the age of 45 as evidenced in this case. As clinicians, we should be aware of the constellation of features associated with POEMS syndrome and be able to recognize them promptly.

[Estimations of the prevalence of attention deficit hyperactivity disorder in Marabino children]

AIMS

This study reports the findings of research aimed at determining the rate of prevalence of attention deficit hyperactivity disorder (ADHD) in children of school age.

SUBJECTS AND METHOD

The epidemiological study was conducted using a community sample extracted by means of multi stage stratified sampling according to socio economic level and schooling and consisted in 1,141 children of both sexes of school age from the city of Maracaibo. The revised Conners scales were used to collect data.

RESULTS

The estimated prevalence of ADHD was 7.19% and we also obtained 0.35% for the hyperactive type, 1.14% for the disattentional subtype, and 5.70% for the combined type. Contrary to what was expected, prevalence was higher for females. It was found that 7.45% of the general sample scored higher on the academic problems scales, whereas for the sample identified as having ADHD, academic problems were 50% and the comorbidity between ADHD and academic problems was confirmed.

CONCLUSIONS

The estimates for prevalence found in this study are consistent with those reported in the literature, which suggests that ADHD is a valid diagnosis for Marabino children.