Journal of the Louisiana State Medical Society
finding on a surveillance CT involving the small bowel. The patient underwent CT enterography and was found to have a partially obstructing mass located on the mesenteric side of the small bowel. Laparoscopic exploration of his abdomen was performed with resection of the mass and re- anastamosis of the small bowel; no signs of other masses or metastatic deposits were evident. Gross pathology revealed an 8 cm lesion fixed on the mesenteric side of the bowel se- rosa eroding into the bowel lumen, which was determined to be a poorly differentiated carcinoma invading through both the mucosal and serosal surfaces. Immunostaining of the sample revealed CK-7 and TTF-1 staining characteristics in line with the biopsy from the patient’s primary lesion in the lung, and a diagnosis of NSCLC metastatic to the early ileumwas made. The patient was considered to have a soli- tarymetastatic event to the small bowel andwas discharged with plans to undergo salvage therapy. Several weeks later, the patient returned to the emergency room with nausea, weight loss, melena, and decreased appetite. On CT scan- ning, he was found to have widespread carcinomatosis with implants throughout his large and small bowel, along with nodules in his liver, adrenal glands, and kidneys. Discussion: While an extremely rare location for iso- latedmetastasis in patients with NSCLC, metastatic disease to the small bowel may be associated with mild and non- specific symptoms that may not be immediately recognized as metastatic disease. While these lesions generally portray a very poor prognosis, early and aggressive therapy may improve time to further relapse and quality of life.
derwent left adrenalectomy with removal of a 1.8 x 1 x 1 cm mass. Histopathology was consistent with pheochromocy- toma with focal invasion of the periadrenal fat. The patient remained normotensive intraoperatively and post-surgery. All laboratory abnormalities subsequently normalized. Discussion: Pheochromocytomas usually cause sus- tained hypertension or adrenergic spells but occasionally present with few symptoms, especially if small. The Mike Tyson Challenge: An Extreme Case of Rhabdomyolysis A. Wright and J. Spiegel LSU-Health Sciences Center, New Orleans Introduction: There are many causes of rhabdoymy- olysis, including excessive exercise. One of the most serious complications of rhabdoymyolysis remains acute kidney injury (AKI), which is caused by non-protein heme pigment that is released frommyoglobin. Furthermore, inflammation of the muscle can compress structures in the same fascial compartment, resulting in compartment syndrome. Case: A 24-year-old inmate was brought to the emer- gency department with severe thigh pain and dark-colored urine after participating in “The Mike Tyson Challenge.” During this challenge, he performed 372 squats over a 45-minute time interval. The thigh pain began the next morn- ing followed by “Coca-Cola”-colored urine. On physical exam, his thighs were extremely tense, and he underwent emergent bilateral fasciotomy for compartment syndrome. He was found to have a creatinine kinase of 401,880 U/L, BUN of 45 mg/dl, serum creatinine 7.21 mg/dl, and potas- sium of 6.3 mmol/l. Urinalysis revealed 250 blood/ul but only 3 to 5 red blood cells/HPF. He received insulin, sodium polystyrene sulfonate, IV fluid hydration, and hemodialysis. He slowly improved while receiving three weeks of hemo- dialysis and physical therapy in the hospital. Discussion: In his prime, “Iron” Mike Tyson was the self-proclaimed “baddest man on the planet.” A workout based on his physical training was developed and named the “Mike Tyson Beast Workout” or “Challenge.” Some rules of the “Beast Workout” are as follows: 1) The workout must be performed in no more than one hour; 2) The aim is to perform dead lifts, bench press, squats, chest press, and dumbbell curls throughout the hour. Our patient barely survived the squats. Fortunately, aggressive surgical in- tervention, fluid hydration, and hemodialysis were able to reverse the damage caused by the release of myoglobin from injured muscle.
A Case of “Normotensive” Pheochormocytoma R. Nair and J.D. Maier LSU-Health Sciences Center, Shreveport
Introduction: Pheochromocytoma is a rare cause of hypertension but is potentially lethal and should be con- sidered in patients with suspected secondary hypertension. Although presence of a pheochromocytoma is less likely in the absence of typical symptoms and findings, atypical presentations do occur, and laboratory and imaging studies become more important for diagnosis. Case: A 60-year-oldmale with history of asthma, recent- onset mild hypertension treated with low-dose amlodipine, and no significant family medical history was noted to have an incidental 2 cm left adrenal nodule - hyperintense on T2 MRI images of the lumbar spine - which was obtained for evaluation of back pain. The patient had no symptoms of adrenergic spells except for occasional mild night sweats. Physical exam was unremarkable with blood pressure 136/80mmHg. Laboratory evaluation disclosed persistently elevated plasma metanephrines, 24-hour urine epinephrine, and urine metanephrines two to four times the upper limit of normal. Serum and 24-hour urine cortisol were within normal limits. A dedicated CT of the adrenals showed a 2.1 cm adrenal nodule with precontrast attenuation of >10 HU and essentially no contrast washout on delayed post-contrast phase, suggestive of pheochromocytoma. The patient un-
82 J La State Med Soc VOL 166 March/April 2014
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