of HPS with improved oxygenation and shunt in the majority (about 80 percent) of patients within 6 to 12 months. Given the nature of rapid progression and
poor prognosis, it is crucial to have a high suspicion for HPS in a patient with liver disease and hypoxia for prompt referral for liver transplant evaluation.
HIDDEN IN PLAIN SIGHT: A DECADE-LONG UNDETECTED PACEMAKER LEAD MISPLACEMENT Arpita Pawa, Joel Joseph, Kathryn Gayle; Willis-Knighton Medical Center, Shreveport, LA.
Introduction: The risk of stroke with transvenous permanent pacemakers is between 4 to 5% and studies have not recommended routine use of anticoagulation or antiplatelet agents.
especially given her atrial fibrillation history. Due to pacemaker dependency, she underwent lead extraction via sternotomy, placement of RV and LV epicardial leads, closure of the interatrial defect, and left atrial appendage amputation. Discussion: Permanent pacemakers (PPM) are associated with a higher incidence of subclinical AF, increasing stroke risk. Studies suggest that pre- PPM placement screening for patent foramen ovale (PFO) may reduce stroke risk. Our patient, with AF and frequent falls, was not on anticoagulation and did not undergo PFO screening, potentially leading to her presentation. Typically, PPM leads are placed in the right atrium and RV, resulting in a left bundle branch block (LBBB) on EKG. However, this patient’s baseline RBBB indicated lead misplacement, which routine transthoracic echocardiogram failed to detect. Lead extraction and repositioning is the definitive treatment for misplacement. Most cases are detected early, but this patient’s lead misplacement went undiagnosed for 11 years, making it unique.
Case: A 76-year-old female with dementia, paroxysmal atrial fibrillation (AF), sick sinus
syndrome with a dual chamber pacemaker was admitted with slurred speech and word finding difficulty for 1 hour. Initial vitals, CT of the head, CT angiogram perfusion scans were normal with an NIH score of 6. An electrocardiogram (EKG) showed ventricular paced rhythm with a right bundle branch block (RBBB). Thrombolysis was deferred due to her dementia and history of falls. An MRI showed no ischemic changes. Workup with an echocardiogram raised concern for misplaced right ventricular (RV) pacemaker lead crossing into left ventricle (LV) via a defect, which was reiterated by a CT of the chest. Device interrogation showed pacemaker dependency. Concern arose for the lead being a potential source of thromboembolism,
HYPERINSULINEMIC HYPOGLYCEMIA, THE ANTITHESIS OF DIABETES MELLITUS Hardy Hang, Daniel G. Stout; Louisiana State University, Lafayette, LA.
Introduction: Hypoglycemia is a condition in which a person’s blood glucose levels fall below physiologic levels, which may lead to diaphoresis, lightheadedness, weakness, tremors, visual disturbances, seizures, altered mental status, and/or death. There are multiple causes of hypoglycemia, some of which are mediated by inappropriate endogenous insulin secretion (hyperinsulinemic hypoglycemia), such as an insulinomas. Case: A 53-year-old male presented with recurrent weakness, tremors, and lightheadedness. His symptoms mostly occurred in the mornings, and they did not worsen post-prandially. The patient
was evaluated with laboratory findings significant for elevated insulin, proinsulin, and C-peptide paired with glucoses less than 50 mg/dL, but cortisol and sulfonylurea screening were negative. Differential diagnoses included insulinoma versus non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) during that time. Radiologic evaluations, including nuclear medicine octreotide scan, abdominal MRI, CT of the abdomen and pelvis, DOTA-TATE (for neuroendocrine evaluation) scan, and endoscopic ultrasound, were all negative for any discrete lesions. However, a selective arterial calcium stimulation test (SACST) revealed insulin hypersecretion in the proximal splenic region of 35
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