the pancreas. Throughout the workup, he was prescribed cornstarch and diazoxide, but he was nonadherent with cornstarch and developed pancreatitis, which was suspected to be from diazoxide. Surgical resection of the splenic region of the pancreas was recommended, but he was lost to follow-up. He eventually elected for definitive surgical treatment after experiencing more hypoglycemic episodes. He was transferred to a facility with Surgical Oncology services and underwent an exploratory laparotomy with subtotal distal pancreatectomy and splenectomy. After surgery, the patient maintained euglycemia. On post- op day 5, he developed bradycardia, transitioned to ventricular tachycardia, and went into asystole.
Advanced resuscitation was performed, but patient was unable to be resuscitated and expired.
Discussion: Inappropriate endogenous insulin secretion includes insulinomas, which generally results in fasting hypoglycemia, and NIPHS, which typically results in post-prandial hypoglycemia. Since these etiologies are relatively rare, these conditions can pose certain challenges to clinicians. This case report demonstrates the importance of history-taking as timing of hypoglycemia is helpful in differentiating insulinomas versus NIPHS. Furthermore, SACST remains valuable for localization when other imaging studies are negative, allowing surgical intervention to be pursued for definitive therapy.
INFECTIVE ENDOCARDITIS: RELYING ON A CLINICAL DIAGNOSIS Calvin Rome, Rebecca L. Prechter, Jasmine M. Weber, Murtuza J. Ali; Louisiana State University, New Orleans, LA.
Introduction: Infective endocarditis (IE) is clinically challenging due to its high mortality rate and devastating complications. Early diagnosis is often difficult due to varying symptoms and inconclusive imaging. In recent years, transcutaneous aortic valve replacement (TAVR) has become more prevalent and IE in these patients is often complex. Case: An 80-year-old man with a history of severe aortic stenosis status-post transcatheter aortic valve replacement (TAVR) presented with acute encephalopathy. He was septic and febrile to 103.6 °F on arrival. A lumbar puncture showed 3767 white blood cells /mm3 (95% neutrophils) and he was treated empirically for meningitis. Cardiology was consulted for non-ST elevation myocardial infarction with a high sensitivity troponin of 5392 ng/mL and an electrocardiogram showing non-specific T-wave inversions in the precordial leads. Blood cultures grew Group C β-hemolytic Streptococci, raising concern for IE. Initial transthoracic echocardiogram (TTE) showed no signs of IE. Prior to transesophageal echocardiogram (TEE), he developed Osler’s Nodes. No vegetations or abscesses were identified on TEE.
Even with a lack of echocardiographic findings, this patient was diagnosed with and treated for IE based on the Duke criteria. He was considered to definitively have IE given his 1 major and 3 minor criteria. Given the overwhelming evidence for IE, the patient was treated with a 6-week course of antibiotics. Discussion: Although a rare complication of a TAVR, the mortality associated with IE in TAVR patients is exceedingly high. Retrospective analysis indicates 30-day mortality of greater than 18%. One study reports a staggering one-year mortality of 45.6%. Clinicians must evolve their thinking as the presentation in these patients is more non-specific than native valve IE. TTE and TEE have a lower sensitivity and specificity for diagnosing IE in TAVR. Therefore, utilization of tools such as Duke criteria is paramount for accurate diagnosis and treatment as demonstrated by this case. Duke criteria are the gold standard for diagnosing IE and recent updates have increased sensitivity and specificity to 84% and 94% respectively. Prompt and accurate diagnosis is key to improving outcomes of IE in TAVR patients. Clinical criteria are essential in this endeavor.
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