were assessed and were negative. Thyroid imaging identified a 3.2 cm left lower thyroid nodule, and a sestamibi scan showed tracer uptake in that region. ENT performed a left inferior parathyroidectomy with removal of the mass. Pathology showed hypercellular tissue consistent with an adenoma. Post-operatively she received calcium, magnesium and vitamin D supplementation to minimize risk of the “Hungry Bone Syndrome”. Her calcium normalized, her AKI resolved and her PTH trended down to 74 approaching the normal range. Discussion: Proper management and diagnostic evaluation in a hypercalcemic crisis is critical to treating this life-threatening condition. These
patients are extremely intravascularly volume deplete, and at high risk for surgical complications (hematoma, recurrent laryngeal nerve injury) and symptomatic hypocalcemia/hypophosphatemia/ hypomagnesemia. Her calcium above 20 necessitated searching for other causes like parathyroid carcinoma, myeloma, humoral hypercalcemia of malignancy, vitamin D toxicity, lymphoma and sarcoidosis. Fortunately she was found to just have a strikingly severe case of primary hyperparathyroidism from a benign adenoma. Prompt stabilization on admission, thoughtful diagnostic work-up, surgical consultation and careful post-operative monitoring helped save this patient’s life.
A RARE CASE OF REVERSE TAKUTSUBO IN AN ELDERLY MAN WHO PRESENTED WITH NEW ACUTE ONSET HEART FAILURE AND AFIB WITH RVR Wafah Kadhim, Gerald O’Bryan; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Takotsubo or stress-induced cardiomyopathy is a condition characterized by transient regional systolic dysfunction, mainly of the left ventricle, mimicking myocardial infarction without the evidence of angiographic obstructive CAD or plaque rupture. Reverse takotsubo is a variant of Takotsubo that is characterized by basal akinesis or hypokinesis with apical hyperkinesis that resolves spontaneously. The incidence of Takotsubo is estimated to be 2% of all troponin positive patients with suspected ACS, and reverse Takotsubo is even rare, estimated to be 1-23% of all cases of Takotsubo. It is significantly more common in younger and postmenopausal women than men. Symptoms at presentation are usually similar to ACS with chest pain, dyspnea or syncope, ischemic ST changes or unstable angina, and some patients have signs of heart failure and arrythmias. Onset usually triggered by emotional or physical stress. Case: A 69-year-old male with suspected reverse takotsubo cardiomyopathy presents with acute onset combined systolic and diastolic heart failure (HF), as well as atrial fibrillation with RVR. The presentation consisted of features typical of acute onset HF of SOB, DOE, PND, orthopnea, cough and
LE edema. Troponins were modestly elevated and eventually plateaued. The EKG was without acute ischemic changes and patient denied chest pain. Patient was started on full dose anticoagulation and diuresis via IV Lasix. Once euvolemic, patient had an echo, which revealed a LV EF 25-30%, grade II LV diastolic dysfunction. Other than apical segments, remaining LV segments were hypokinetic, a finding suggestive of reverse takotsubo. Patient with history of daily alcohol and methamphetamine use which likely contributed to his presentation. Patient was started on GDMT, digoxin for rate control and referred for angiogram for further ischemic workup which is pending. Patient reported significant improvement in symptoms with treatment. Discussion: The mechanism of reverse Takotsubo is not well understood, however, theories include catecholamine cardiotoxicity, low estrogen level and coronary artery spasms, some of which may be relevant in this patient with history of substance use. This cardiomyopathy should be considered in a wider range of demographic, in the absence of acute emotional stress and in the setting of sympathomimetics abuse.
NON-TRAUMATIC HEMOTHORAX IN A 43-YEAR-OLD WOMAN Christopher VanDreumel, Hunter Hall, Camille Prejean, Seema Walvekar; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
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