Renal infarction in a patient with thyrotoxicosis-induced atrial fibrillation treated successfully with dabigatran, a case report and literature review

Renal infarction is an underdiagnosed condition with multiple possible causes, including atrial fibrillation. The treatment approach includes percutaneous endovascular therapy (PET) to restore blood flow, antiplatelet therapy, anticoagulation, or combination therapy, depending on the patient's status and available modalities. Warfarin is the standard anticoagulation therapy, although direct oral anticoagulation (DOAC) therapy is getting more popular. Here, we present a 60-year-old male patient with hyperthyroidism complicated by acute renal infarction, which was successfully treated with dabigatran, evident by non-recurrence and restoration of blood flow in a follow-up CT angiogram. This case report may open the door for the use of DOAC in acute renal infarction though more studies are needed to prove the efficacy.

Ankylosis of the Shoulder After Traumatic Head Injury: A Late Presentation

Heterotopic ossification (HO) is the formation of bone in surrounding soft tissue. In the literature, several causes for this phenomenon were mentioned, trauma - including surgery, burns, and traumatic brain injury. HO in a shoulder is not frequently seen after traumatic brain injury (TBI). This relationship between TBI and HO can be explained in many ways. Surgical treatment entails many complications and important anatomical structures are at risk (e.g., axillary nerve). Surgeon must weigh both, risks and benefits and counsel the patient before taking a decision of surgical excision. We present a rare case of ankylosis of the shoulder following a traumatic brain injury.

192. Epidemiology, Microbiological Characteristics and Clinical Outcomes of Invasive Blood Stream Infections of Group B Streptococcal Isolates From Qatar

Background

Group B Streptococci (GBS) or Streptococcus agalactiae colonize humans genitourinary and gastrointestinal tracts particularly of females. The pathogen is capable of causing invasive disease primarily in infants, pregnant and postpartum women as well as the elderly and patients with comorbidities. There is paucity of studies of the disease with regional differences in prevalence and presentation of invasive blood stream infection (BSI). In this study, we aim to assess prevalence, microbiological characteristics as well as clinical outcomes of invasive GBS disease from all ages groups at Hamad Medical Corporation (HMC), Qatar.

Methods

A retrospective study was conducted on all patients with microbiologically confirmed GBS bacteraemia between January 2015–March 2019. Demographic, microbiological characteristics as well as clinical data were extracted from hospital information system.

Results

Out of 196 confirmed cases of GBS blood stream infection, 63.7 % were females (125/196) of whom 44.8 % were pregnant (56/125), 53.6 % (30/56) were colonized while 36.3 % (71/196) were males. There were three distinct age group populations, paediatric less than 4 years of age at 35.7 %, young adults 25-34 (20.9 %) and the elderly > 65 year (17.4 %). Presenting symptoms were mild with fever recognised in only 53 % of cases (104/196) while 89% of cases had low Pitt bactermia score of 0-2. Microbiological characteristic using disc diffusion tests demonstrated all isolates were universally sensitive to penicillin (100%, 196/196) with significant resistance to clindamycin at 28.6 % (56/196) and erythromycin at 49 % (96/196) of which 34.4 % (33/96) had inducible clindamycin resistance. Clinical outcome showed high cure rate of 87.25% (171/196) with low complications at 8.76 % (17/196) and 4% (8/196) 30-day mortality.

Antibiotic sensitivity profile for GBS isolates

Conclusion

Streptococcus agalactiae blood stream infection in Qatar is common in females, affects the very young, young adults and the elderly. Almost half of affected pregnant women are colonized. The organism remains universality sensitive to pencilling with significant resistance to clindamycin and erythromycin. Patients presents with mild symptoms with high cure rates, low complications and safe outcome for the majority of cases.

Disclosures

All Authors: No reported disclosures

Late-Onset Euglycemic Diabetic Ketoacidosis in a Patient With Massive Stroke Requiring Decompressive Craniectomy: A Case Report

Euglycemic diabetic ketoacidosis (DKA) is a well-recognized adverse effect associated with the use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. Early recognition of this medical emergency and timely intervention can prevent the notorious consequences of this serious complication. However, this form of DKA can easily be masqueraded by normal serum glucose levels. This article describes a 49-year-old man diagnosed with type 2 diabetes mellitus (DM) on dapagliflozin who presented with a large right-sided middle cerebral artery (MCA) stroke complicated by euglycemic DKA, developed 72 hours after stopping the drug. This case is unique considering that dapagliflozin's half-life is only 12.9 hours, and the body completely eliminates it within 72 hours. But our patient developed DKA features after the elimination window. Hence, this case highlights the importance to consider euglycemic DKA in the presence of ketonemia and metabolic acidosis in a patient who is a chronic SGLT-2 inhibitor user even if the drug was discontinued several days before the patient's presentation.

Abstract P257: Refractory Hypertension Partially Improved With Anxiolytics

Background: Resistant hypertension is a BP that is not controlled by three or more anti-hypertensive medications of different classes, including diuretics. Refractory hypertension is an evolving term reflecting a BP that is not controlled with five agents or more of different anti-hypertensive classes, including diuretics. Patient with refractory HTn has to have secondary hypertension workup.

Case: A 45-year-old lady with a known past medical history of obesity, HTN, and DM-II. She was admitted as she had generalized fatiguability and vague chest pain. The ECG, and the TTE showed hypertensive heart disease. She had normal cardiac enzymes. Initial BP was recorded to be 185/127 mmHg. Consequently, she was commenced on anti-HTN medications. Her BP was difficult to control with the maximum doses of six anti-HTH medications (amlodipine, valsartan, hydralazine, indapamide, labetalol, spironolactone)(Fig 1).

Decision-making: All the secondary causes of HTN were excluded; normal renin-aldosterone ratio, normal US doppler for the renal arteries, normal sleep study, normal CT chest and abdomen looking for masses, normal dotatate scan, and negative pheochromocytoma work-up. Because she had social stress, she was commenced on anxiolytics (alprazolam). Subsequently, the BP reading improved by around 10-20 SBP; however, her average reading continued to be around 160/90 mmHg.

Conclusion: Refractory hypertension is a management dilemma, especially when the causes of secondary hypertension are excluded. Benzodiazepines can be a reasonable option in certain situations where the refractory hypertension is believed to be stress-induced.

Osmolar-gap in the setting of metformin-associated lactic acidosis: Case report and a literature review highlighting an apparently unusual association

RATIONALE

Metformin-associated lactic acidosis (MALA) is a rare adverse effect that has significant morbidity and mortality. MALA is a high anion gap (AG), nonosmolar acidosis. Associated osmolar-gap (OG) is rarely reported, so finding an OG may make the diagnosis of MALA challenging.

PATIENT CONCERNS

Forty-five years' old type II diabetic patient on metformin presented to emergency with a two-day history of vomiting, watery diarrhea, and mild abdominal discomfort. On examinations, he looked dehydrated. Investigation revealed acute kidney injury (AKI) with a high lactic acid (LA) level of 24 mmol/L, pH of 6.8, AG of 40, and an OG of 20 mOsm/kg DIAGNOSES:: The presence of an OG made the diagnosis challenging; the history was negative for alcohol, osmolar substance, or illicit drug ingestion or use. The toxicology screen was negative. After ruling out plausible causes of AG and OG, MALA was deemed the likely reason for his presentation likely precipitated by dehydration and AKI.

INTERVENTIONS

He underwent two sessions of hemodialysis, afterward managed with fluid hydration.

OUTCOMES

On day 3, he was in the polyuric phase suggestive of acute tubular necrosis. His serum creatinine improved afterward with improved acidosis; after 8 days, he was discharged in stable condition.

LESSONS

MALA is a rare side effect of metformin therapy. Acute kidney injury is a known precipitant of MALA. In our review, we highlight the association of MALA and the presence of an OG. We believe that treating physicians should be aware of this relationship to avoid delaying or overlooking such an important diagnosis.