P1267 Negative baseline diagnostic imaging does not exclude pulmonary embolism in patients with reccurrent syncope

INTRODUCTION

In patients who are admitted to a hospital due to episode of syncope, acute pulmonary embolism (PE) is rarely considered as a possible cause. This report presents two cases illustrating PE as a cause of syncope with elevated cardiac troponin (cTn) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels despite normal echocardiographic examination and negative Doppler ultrasound imaging.

Case 1: An 83-year-old woman admitted to the ER due to episodes of recurrent syncopes. According to her anamnesis, she had four episodes of syncopes during last three weeks without chest pain, dyspnea, palpitation or hemoptysis. ECG revealed a normal sinus rhythm with a heart rate of 70 bpm without ischemic changes. Laboratory tests revealed raised levels of cTn and NT-proBNP. Transthoracic echocardiography (TTE) demonstrated preserved left and right ventricular systolic functions without

any cardiac chamber enlargement and mild tricuspid regurgitation with a PAP of 35 mmHg. Patient’s pre-test probability for pulmonary embolism was low (Wells’ score < 2) but D-dimer level was elevated. Doppler imaging for detection of deep vein thrombosis was negative. Computed tomography pulmonary angiography (CTPA) showed filling defects in the pulmonary arteries consistent with pulmonary embolism (Panel A). The patient was discharged with rivaroxaban therapy without any complication.

Case 2: A 69- year-old woman presented to ER with symptoms of chest pain and recurrent episodes of syncope for the last 2 days. Her medical history revealed hypertension and hyperlipidemia. On admission ECG showed a normal sinus rhythm with a heart rate of 105 bpm and T-wave inversions in inferior leads. Laboratory tests showed elevated levels of cTn and NT-proBNP. TTE demonstrated normal left ventricular systolic function with an ejection fraction of 55% and normal right ventricular function and chamber size with a tricuspid annular plane systolic excursion of 22 mm. Diagnostic coronary angiography was performed to exclude acute ischemia revealed non-significant coronary artery stenosis. Doppler ultrasound imaging for detection of deep vein thrombosis was negative. CTPA showed filling defects in the bilateral main pulmonary arteries consistent with acute bilateral pulmonary embolism (Panel B-C). The patient was discharged with rivaroxaban therapy after four days of hospitalization period without any complication.

CONCLUSION

Elevated cTn and NT-proBNP leves on admission strongly suggest transient hemodynamic impairment causing cardiac injury and syncope. Normal admission ECG and TTE can exclude most possible acute cardiac causes of syncope. Although acute right ventricular dsyfunction is the most frequent finding of acute massive PE causing hemodymanic impairment resulting with syncope, diagnosis of acute PE should only be excluded with CTPA in patients with similar clinical characteristics despite normal TTE and negative venous Doppler ultrasound imaging.

Abstract P1267 Figure

Type A intramural hematoma in a patient with acute coronary syndrome mimicking acute Type A aortic dissection

Intramural hematoma (IMH) of ascending aorta is a rare but potentially lethal form of acute aortic syndrome (AAS). It is characterized by a hematoma within the media layer of the aorta secondary to rupture of the vasa vasorum in the absence of an intimal tear. However, the theory of "micro-tear" which cannot be easily detected has been raised. It may stabilize, regress, or progress to rupture or dissection. Similar to Type A aortic dissection (AD), patients with IMH of ascending aorta, as well as patients with persistent pain, are treated urgent surgery. We report a case of an ascending aorta IMH in a patient admitted to hospital with epigastric and chest pain with ST-elevation myocardial infarction in inferior leads. Coronary angiography (CAG) was performed and contrast injection from the right coronary artery (RCA) ostium showed marked contrast enhancement of the aortic wall. The CAG was terminated with a suspicion of Type A AD. The diagnosis of IMH starting just above RCA ostium with a thickness of 18 mm was made with computed tomographic angiography. An emergent surgical repair of the aorta and one-vessel coronary artery bypass graft surgery was performed successfully in our patient.

Bone Mineral Density in Patients on Maintenance Hemodialysis and Effect of Chronic Hepatitis C Virus Infection

OBJECTIVE

To determine the prevalence of osteopenia and osteoporosis in HD patients at our center; to investigate whether HCV infection affects BMD in hemodialysis patients; to test for correlations between bone mineral density (BMD) and clinical and laboratory parameters in this population.

SUBJECTS AND METHODS

The study involved 76 end-stage renal disease patients. Forty-three (56.6%) patients were tested negative for anti-HCV antibodies and HCV-RNA. Thirty-three (43.4%) of them had positivity of anti-HCV antibodies and permanent or intermittent HCV-RNA positivity at least for two years. Mean HD duration was 86.4 months. Patients completed a standard questionnaire that listed age, sex, occupation, education level; cause of renal failure, smoking history, dialysis duration, and sports activities engaged in during life, and pathologic bone fractures. The women answered additional items about age at menarche, number of pregnancies and menopausal status. Each subject underwent a baseline physical examination, including measurement of body weight and height for calculation of body mass index. The results of laboratory tests that had been done at monthly visits in the previous year were retrospectively evaluated, and mean levels for the year were used for correlation testing. Bone mineral density was measured in the spine, femoral neck and forearm. Relationships between BMD values and chronic HCV infection, laboratory results and clinical parameters were analyzed.

RESULTS

In the 43 patients who were negative for anti-HCV antibodies and HCV-RNA, spine BMD testing showed osteopenia in 16 (37.2%) cases and osteoporosis in 7 (16.3%) cases. The corresponding values for the neck of the femur were 14 (32.6%) and 6 (14.0%), and for the forearm were 19 (44.2%) and 15 (34.9%). In the 33 anti-HCV antibodies and HCV-RNA positive patients; spine BMD testing showed osteopenia in 10 (30.3%) cases and osteoporosis in 7 (21.2%) cases. The corresponding values for the neck of the femur were 17 (51.5%) and 4 (12.1%), and for the forearm were 4 (12.1%) and 25 (75.8%). Bone mineral density decreased as dialysis duration increased (p<0.05). There was no statistical difference between BMD measurements of chronic HCV infection positive and negative group.

CONCLUSION

However the mean BMD values for all three sites in the 76 HD patients were low HCV infection may not be a risk factor for low BMD in this population.

Prognostic value of the PAI-1 4G/5G polymorphism in invasive ductal carcinoma of the breast

The study group was derived from the archive materials of 55 invasive ductal breast cancer (IDC) patients who had undergone breast-preserving surgery (partial mastectomy/ axillary dissection). All patients included in the study had clinically T(1)-2, N0-M0 invasive ductal carcinoma. Genomic DNA species were extracted from paraffin-embedded blocks, and plasminogen activator inhibitor type-1 (PAI-1) gene 4G/5G genotyping was done by polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP). Patient demographics, axillary metastasis status, metastatic lymph nodi/total dissected lymph nodes from axilla, histopathologic characteristics of tumors, local recurrences, and survival ratio were assessed. PAI-1 4G/5G genotype frequencies were 4G/4G (64%), 4G/5G (31%), and 5G/5G (5%) in the patient group. According to the results based on frequencies, the demographics were not different. Five-year local recurrence rate of 4G/5G patients was the lowest (2/17, 12%) (P = 0.02). Also five-year distant metastases ratio of 4G/5G patients was the highest (18%) (P = 0.01). Five- and 10-year disease-free survival rates for the 4G/4G, 4G/5G, and 5G/5G groups were 97% and 94%, 82% and 77%, and 100% and 94%, respectively (P = 0.004). The results of this study indicate that the 4G allele in the PAI 1 gene had a negative impact on local recurrence and disease-free survival of patients with clinical T(1)-2N0M0 IDC.

Localized fluid collections after liver transplantation

BACKGROUND

Liver transplantation is an accepted effective therapy for patients with diseases that lead to hepatic failure. In addition to vascular, rejection-related, biliary, and lymphoproliferative complications, posttransplantation fluid collections, such as hematomas, seromas, bilomas, localized ascites, and abscesses can affect graft survival. In this study, we have presented, ultrasonography and computed tomography images as well as reviewed the literature.

METHODS

Between December 1988 and March 2005, 138 patients (94 men [68.11%], 44 women [31.89%] of mean age, 26.77 years (range, 1 to 64) underwent liver transplantation in our institution from living-related donors in 85 and deceased donors in 53 recipients. This retrospective study analyzed the fluid collections diagnosed after liver transplantation.

RESULTS

Among 138 liver transplants we identified 56 localized intra-abdominal fluid collections, including 46 hematomas, 4 bilomas, and 6 abscesses. Fluid collections were noticed between 0 and 1095 days (mean = 13.50 +/- 152.82 days). Thirty-three collections were identified in living-related, and 23 in deceased donor recipients. The collections showed an average volume of 375 cm3, with a range of 1 to 4368 cm3. Two cases of bilomas were related to hepatic arterial insufficiency, one from a hepatic artery occlusion and the other from a significant stenosis.

CONCLUSIONS

Localized intra-abdominal fluid collections were commonly seen after liver transplantations, diminished in size without treatment, but required aspiration or drainage in some patients.

Venous complications after orthotopic liver transplantation

We report venous complications, including portal vein and hepatic vein stenoses, that required interventional radiological treatment in three pediatric and two adult living related liver transplant recipients. Between April 2001 and April 2005, 81 liver transplantations were performed at our hospital. Sixty-two grafts were from living donors. During follow-up, three portal vein stenoses were identified in three pediatric recipients, and two hepatic vein stenoses in two adult patients. In the children, two had received left lateral segment grafts, and one had received a right lobe graft from two mothers and one father, respectively. The etiologies of liver failure were Alagille syndrome, biliary atresia, and fulminant Wilson's disease. Portal vein stenoses were identified at 8, 11, and 12 months after transplantation; all three patients underwent percutaneous transhepatic portal venous angioplasty with a success rate of 100%. The mean follow-up was 102 days; no recurrence has occurred. In contrast, hepatic venous stenoses were diagnosed in two adult recipients. One of them was a 24-year-old woman with autoimmune hepatitis and the other a 43-year-old man with cryptogenic cirrhosis. Hepatic vein stenoses were diagnosed at 3 and 4 months after transplantation. Both hepatic vein stenoses were dilated with balloon angioplasties via the transjugular route. Venous complications identified by Doppler ultrasonography were confirmed by computerized tomographic angiography. Angioplasty represents an effective and safe alternative to reconstructive surgery in the treatment of venous complications after liver transplantation.

Relationship between leptin and bone mineral density in renal transplant recipients

INTRODUCTION

Leptin plays an important role in regulating appetite and energy expenditure and also functions in the neuroendocrine, hematopoietic, and immune systems, among others. Leptin may be involved in modulating bone mineralization. The relationship between leptin and bone mineral density (BMD) is not clear. This study examined the relationship between BMD and serum leptin levels in renal transplant recipients.

MATERIALS AND METHODS

Forty-one patients (28 men and 13 women; age 16 to 55 years) were grouped according to percentile of serum leptin level hypoleptinemic (<5th percentile, n = 14), normoleptinemic (between the 5th and 95th percentiles, n = 19), or hyperleptinemic (>95th percentile, n = 8). The patients also were grouped according to lumbar z score) and total femur z scores (>-2 vs <-2 for both).

RESULTS

The groups with different leptin statuses were compared with respect to age, sex distribution, and body mass index. Mean lumbar z score and mean lumbar BMD were higher in the hyperleptinemic group than in the normo- and hypoleptinemic groups (P < .05 for all). Considering the 42 patients overall, those with lumbar z scores >-2 had higher mean serum leptin/BMI than those with lumbar z scores <-2 (0.55 +/- 0.65 vs 0.18 +/- 0.23, respectively, P < .05). Serum leptin/BMI ratio was correlated with lumbar z score (r = .38, P < .05) and lumbar BMD (r = .32, P < .05).

CONCLUSION

In conclusion, the data indicate that elevated leptin level is associated with increased bone mass at lumbar sites in renal transplant recipients. This suggest that increased leptin has a bone-sparing effect, especially in the lumbar region, in this patient group.

Osteoarthritis in hemodialysis patients: relationships with bone mineral density and other clinical and laboratory parameters

OBJECTIVE

The aim of this study was to determine the role that hemodialysis (HD) plays in radiologically assessed osteoarthritis (OA) of the hand, knee, and hip.

MATERIALS AND METHODS

Eighty patients who had been on regular HD for at least 2 years were included. Anterior-posterior radiographs of the pelvis, weight-bearing knees, and hands and wrists of each patient were examined. Bone mineral density (BMD) of spine, femur, and forearm was measured.

RESULTS

Radiologic assessment of the 80 patients' hands showed that 41 individuals had osteopenia, 12 had midphalangeal subperiosteal resorption, 11 had cystic bone lesions, eight had bone erosion, four had osteophytic lesions, and three had subchondral sclerosis. Bone erosion in the hands was significantly associated with HD duration, forearm T score, and serum parathyroid hormone level. Radiologically, OA was demonstrated in eight knee and ten hip joints. Minimum joint space in the tibiofemoral compartment correlated with body mass index, and minimum joint space in the hip correlated with age. The mean BMD measurements at all three sites studied in the HD patients were low. Only the duration of HD significantly correlated with forearm BMD.

CONCLUSION

Osteoarticular complications are common in HD patients.

Joint pain and arthritis in renal transplant recipients and correlation with cyclosporine therapy

OBJECTIVE

The aim of this study was to determine the prevalence of joint pain and arthritis in renal transplant recipients and to investigate relationships with various laboratory and clinical parameters.

METHODS

Eighty-two patients who underwent renal transplantation (RT) had joint examinations and reported by questionnaire on levels of joint pain and arthritis. Each individual was then followed by the rheumatology department for 1 year, with joint examination and laboratory tests every 3 months.

RESULTS

Thirty-one of 82 patients (37.8%) complained of joint pain before RT, of whom seven reported pain continuing after the operation. Seventeen of the 82 (20.7%) began to suffer joint pain after RT. Six (7.3%) and three (3.7%) of the 82 patients, respectively, developed arthritis before and after transplantation.

CONCLUSION

The study showed that joint pain is common before and after RT. In renal transplant recipients, joint pain significantly correlated with serum cyclosporine levels higher than 200 ng/ml.

The effect of cisapride on gallbladder contractility in type II diabetic patients

BACKGROUND/AIMS

To investigate whether diabetics have altered gallbladder motility, and whether cisapride has any effect on gallbladder motility in these patients. The factors associated with abnormal gallbladder contractility, and with the effects of cisapride on gallbladder contractility in diabetics were also evaluated.

METHODOLOGY

The gallbladder contractility parameters of 20 diabetics and 20 controls were assessed by real time ultrasonography. The same measurements were made after cisapride treatment in diabetics.

RESULTS

Fasting gallbladder volume and residual gallbladder volume were statistically higher in the diabetic group than in the controls (P = 0.018 and P = 0.022, respectively). Multivariate analysis also showed a significant association between fasting gallbladder volume and existing diabetes (P = 0.0002). There was a significant positive correlation between level of hemoglobin A1c and fasting gallbladder volume (r = 0.48, P = 0.031). Responders to cisapride treatment had significantly higher hemoglobin A1c levels than nonresponders (6.6 +/- 1.3 vs. 9.1 +/- 1.8, respectively; P = 0.004). Logistic multiple regression analysis revealed that hemoglobin A1c level was the only independent factor that was predictive for efficacy of cisapride treatment.

CONCLUSIONS

This study demonstrates that diabetics have impaired gallbladder contractility, and that control of diabetes is predictive for gallbladder contractility and response to cisapride therapy in these patients.

From donor to recipient. Doppler US, power US and scintigraphy of kidney perfusion before and after transplantation

PURPOSE

To follow kidneys from the donor to the recipient by assessing whether perfusion changes occur by using duplex Doppler US, power Doppler US and scintigraphy.

MATERIAL AND METHODS

The prospective study included 12 donors and their corresponding 12 recipients. For each donor, both donor kidneys were evaluated by duplex Doppler US, power Doppler US and scintigraphy 1 day before surgery. The same procedure was carried out on the renal allografts at days 1, 3, 5 and months 1 and 3 post-transplantation. Power Doppler findings were classified according to a grading system of 1 to 4. Resistive indices (RIs) were determined based on interlobar and segmental arterial flow. Peak systolic velocity and RIs of the main renal artery were also measured. A perfusion parameter named the peak-to-plateau ratio was calculated. Statistical analysis was performed using the paired-samples t-test.

RESULTS

Intrarenal RI elevation and decreased renal artery peak systolic velocity was observed in normally functioning recipient kidneys.

CONCLUSION

Duplex Doppler sonography demonstrated that transplanted kidneys had an increase in intrarenal vascular resistance at 1 month and a decrease in renal artery peak systolic velocity at 3 months post-transplantation. Scintigraphy and power Doppler US did not reveal any statistically significant perfusion change in normally functioning kidneys from donor to recipient.

Hepatic alveolar echinococcosis. A case report

Alveolar echinococcosis is a rare parasitic disease caused by Echinococcus multilocularis and most commonly involves the liver. Early diagnosis and precise evaluation of the localisation and the extent of the lesions are essential for treatment. In this report, we present US and CT findings in a patient with hepatic alveolar echinococcosis.

Intracranial metastatic melanoma: correlation between MR imaging characteristics and melanin content

OBJECTIVE

Preliminary reports based on limited numbers of cases have proposed that specific MR imaging patterns may permit a distinction between melanotic and amelanotic brain metastases in melanoma patients. The purpose of this study was to test this hypothesis by categorizing MR images obtained from a large series of patients and correlating the results with the percentage of melanin-containing cells in surgically resected metastases.

SUBJECTS AND METHODS

The MR images of 30 patients with histologically proven intracerebral melanoma were reviewed retrospectively. Precontrast MR images were obtained with T1-weighted spin-echo sequences in axial and sagittal sections and with proton density-weighted and T2-weighted sequences in axial sections. After IV injection of gadopentetate dimeglumine (0.1 mmol/kg of body weight), T1-weighted images were obtained in axial and coronal sections. All patients had undergone gross total resection of the evaluated lesions. MR images of the metastases were reviewed and sorted into four groups on the basis of putative patterns: (1) melanotic pattern--hyperintense in relation to cortex on T1-weighted images, hypointense in relation to cortex on T2-weighted images, and isointense or hyperintense in relation to cortex on proton density-weighted images; (2) amelanotic pattern--hypointense or isointense in relation to cortex on T1-weighted images and hyperintense or isointense in relation to cortex on T2-weighted and proton density-weighted images; (3) indeterminate, or mixed, pattern--MR imaging characteristics that did not conform to those of one of the first two categories; and (4) hematoma pattern--MR imaging features that exhibited only hematoma characteristics. Tissue sections from all evaluated lesions were independently reviewed by a neuropathologist (G.N.F.), and the percentage of melanin-containing tumor cells in each resected metastatic lesion was estimated. The MR imaging data and histologic data were then compared to assess the predictive value of the MR imaging patterns.

RESULTS

Forty-two metastatic lesions were identified and categorized by MR imaging pattern as follows: 10 melanotic, 11 indeterminate (mixed), 16 amelanotic, and five hematoma. Correlation with histologic findings revealed that a majority (7/10) of lesions that exhibited a melanotic MR imaging pattern had more than 10% melanin-containing cells, over half (9/16) of lesions that exhibited an amelanotic MR imaging pattern contained histologically identifiable melanin (but always in less than 10% of cells), and lesions that exhibited a mixed MR imaging pattern were either amelanotic or contained less than 10% melanotic cells. Conversely, a majority of lesions containing more than 10% melanotic cells (7/8) demonstrated the typical melanotic MR imaging pattern, lesions with less than 10% melanin-containing cells exhibited a variety of MR imaging patterns, and only about half of patients with amelanotic lesions (6/13) showed the characteristic amelanotic MR imaging pattern. For five lesions, potentially informative imaging data on melanin content was obscured by histologically documented hematoma formation.

CONCLUSION

Only a minority of melanoma metastases have the anticipated MR imaging findings of melanotic melanoma, which consist of high signal intensity relative to that of cortex on T1-weighted images and low signal intensity relative to that of cortex on T2-weighted images. Of tumors that do exhibit this melanotic pattern, the majority have more than 10% melanin-containing cells. The putative MR imaging pattern for amelanotic melanoma is nonspecific, as over half of tumors with this pattern contain melanin.

Different biologic features of desmoid tumors in adult and juvenile patients: MR demonstration

OBJECTIVE

To demonstrate different biologic features of desmoid tumors on MRI between juvenile and adult patients.

MATERIALS AND METHODS

We have retrospectively analyzed clinical records and 121 MRI findings in 40 patients (8 juveniles and 32 adults) with proven desmoid tumors. The Fisher exact test and Kaplan-Meier curve were utilized for statistical analysis.

RESULTS

Recurrences in the juvenile patients were more multiple (50 vs 12%) and appeared significantly earlier than in the adult patients. Adult patients demonstrate a much greater recurrence-free rate (p = 0.0001). Infiltrative pattern was significantly predominant in the juvenile patients (63%) whereas the nodular pattern was more frequent in the adult patients (81%). Low-signal intensity zones on T1- and T2-weighted imaging as well as the type of contrast enhancement did not show any significant relationship with biological behavior. Four cases with no significant contrast enhancement showed low signal intensities on T2-weighted imaging.

CONCLUSION

Magnetic resonance demonstrates different biologic features between juvenile and adult patients with histologically same desmoid tumors. These differences may be useful in consideration of MRI follow-up studies.