hypercalcemic crisis (>50%) are markedly higher in mediastinal PCs compared to parathyroid adenomas. Conducting appropriate preoperative localization
studies is crucial to effective management. The precision of CT and MRI imaging in detecting PC are 90–100% and 100% respectively.
BRASH SYNDROME: A CLOSE “BRASH” WITH DEATH? Fernanda Correa, David Beyer, Supraja Sridhar, Munraj Singh, Jasmine Nikdast, Kristi Boudreaux, Lee Engel; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: BRASH Syndrome is an underrecognized entity defined by bradycardia, renal failure, atrioventricular nodal blockade, shock and hyperkalemia. This constellation may occur when hyperkalemia and AV nodal blockade combine to produce a vicious cycle of shock, renal failure and resistant hyperkalemia that can be life-threatening and requires urgent provider recognition. Case: An 87-year-old woman with decompensated cirrhosis due to untreated hepatitis B & C on nadolol and spironolactone and CKD3 presented with progressive encephalopathy and decreased oral intake over three weeks accompanied by increasing dyspnea and a fall. Upon presentation, the patient was bradycardic (HR 30), hypotensive, and hypoxic with bilateral crackles on auscultation and pitting edema in her lower extremities. Initial laboratory evaluation showed hyperkalemia with an acute kidney injury. Her bradycardia did not improve after atropine administration. She was admitted to the ICU and placed on non-invasive positive pressure ventilation and continuous infusion of epinephrine to maintain adequate end-organ
perfusion. The patient underwent diuresis and frequent potassium shifting over the course of her admission. Hemodialysis was offered but due to chronic comorbidities and declining functional status, her family decided to defer dialysis and enter the patient into inpatient hospice care. Supportive care continued until the day of transfer when she was found to be euvolemic without pressor requirement or supplemental oxygen and a normal potassium level. She was able to be discharged home with home hospice with family support. Discussion: BRASH syndrome is an important and underrecognized entity in critical care medicine that requires urgent recognition. This constellation of symptoms may be difficult to differentiate between pure hyperkalemia and pure AV nodal blockade. The differences in these syndromes relate to the degree of hyperkalemia and the use of prescribed medications, respectively. Treatment involves addressing each component simultaneously, including immediate treatment of hyperkalemia, adequate resuscitation for hypotension or shock, and vasopressors to address AV nodal blockade & improve renal perfusion.
PNEUMONITIS PRESENTING AS LATE-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS Ishrat Gillani, Adrianne Melanthiou, Jasleen Hora; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease with significant heterogeneity on presentation. SLE occurs primarily in young women of childbearing age with clinical features ranging from mild joint and skin involvement to life-threatening kidney, hematologic and/or central nervous system involvement. Early detection and treatment is important as Lupus Nephritis is a major cause of morbidity and mortality in patients with SLE. Case: A 43 year-old female with hypertension, hyperlipidemia, and hypothyroidism presented with complaints of progressively worsening shortness of breath over two months with pain on
inspiration, increased dyspnea on exertion, bilateral lower extremity swelling, productive cough and fevers. Of note, the patient had multiple ED visits for polyarthralgias and recurrent URI’s over the past 2 years. The patient reported having worked in a shipyard and endorsed several pets at home including dogs, cats, and birds. The patient was a former smoker and had quit smoking one month prior to the current presentation. On arrival to the ED, the patient afebrile, tachycardic, tachypneic, and hypoxic requiring 4L supplemental oxygen. Admit labs with leukopenia, anemia, elevated ESR/CRP, and elevated IgE levels. CXR is notable for cardiomegaly. D-Dimer elevated, and CTA negative for pulmonary 11
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