fossa, popliteal area of left leg and lower right calf. Because of painful ambulation, he had been using crutches for days prior. He was admitted to the hospital. Workup revealed elevated partial thromboplastin time (PTT) of 75.6 seconds (N= 24.7-35.5 seconds), normal prothombin time (PT), and international normalized ratio (INR). Mixing studies yielded an uncorrected and prolonged activated PTT of 63.6 seconds after two hours. Measurement of Factor VIII inhibitor yielded an elevated 432 Bethesda units/ml (refer- ence range: <1.0 U/ml). Factor VIII activity was decreased to <0.6% (reference range of 50-100%). AHAwas diagnosed. However, lupus anticoagulant was positive. Patient was im- mediately started on treatment with prednisone and rituxan followed by cytoxan. PTT after treatment decreased to 28.5 seconds. The patient had no further episodes of extremity bleeding or swelling. Discussion: AHA is a rare and life-threatening bleeding disorder caused by auto-antibodies against Factor VIII. It most commonly occurs in patients more than 65. Although it may be associated with autoimmune disorders, malig- nancies, and medications, half of reported cases remain idiopathic. This patient with a relatively mild presentation of AHA had a positive coexisting lupus anticoagulant and Factor VIII inhibitor. The presence of both simultaneously is exceedingly rare andmay denote a protective mechanism in a grave bleeding disease. Chylous Ascites in Kaposi Sarcoma: A Case Report P. Johnson, E. Chang, E. Smith, and B. Lo LSU-Health Sciences Center, New Orleans Introduction: Chylous ascites is a known complication associated with Kaposi sarcoma (KS). There are only three reported cases of chylous ascites in patients with KS. Case: A 26-year-old Caucasian male with a history of AIDS (CD4-123), KS, pleural effusion, and pulmonary em- boli was admitted for diffuse abdominal pain and scrotal edema. Physical exam was notable for tachycardia, pallor, decreased basilar breath sounds, diffuse abdominal pain with distention, positive fluid wave and shifting dullness without rebound or guarding, tender scrotal edema, ingui- nal adenopathy, and purple lesions on his upper palate and torso consistent with KS. A prior EGD and colonoscopy showed Kaposi’s lesions throughout the GI tract. An ab- dominal CT revealed diffuse adenopathy. A paracentesis was performed and 1,510 mL of milky, turbid, blood-tinged fluid was removed. Fluid analysis was negative for malig- nancy but demonstrated 36,300; RBCs and triglycerides concentration of 740 mg/dL. The patient was started on liposomal doxorubicin for his KS during his hospitalization and finally achieved adequate pain control and improve- ment of his ascites and scrotal edema after three rounds of treatment as an outpatient. Discussion: Chylous ascites is an uncommon find- ing that is caused by the presence of intestinal or thoracic lymph in the peritoneal cavity. Chylous ascites is diagnosed by milky ascitic fluid with a triglyceride content typically
greater than 200 mg/dL. Causes of chylous ascites include: malignancy, trauma, chronic liver disease, inflammation, and infection. Disruption of the lymphatic system from obstruction or traumatic injury is the underlyingmechanism for the formation of chylous ascites. While the exact cell of origin for KS remains unclear, the current opinion is that KS tumor cells are derived from lymphatic endothelium. Hence, the development of chylous ascites may possibly be due to in-situ KS in that region rather than metastasis to the thoracic duct as once thought. Chemotherapy for KS can often improve symptoms (response rate 60-90%) as was seen in our patient.
Treatment of Cutaneous Neoplasm With Spray Cryotherapy J. Minadeo, R.E. Cuenca, and D.A. Jansen LSU-Health Sciences Center, Shreveport
Introduction: Cutaneous neoplasms are a therapeutic challenge and produce a significant burden on the healthcare system, particularly in the elderly population. Treatments producing significant eradication rates with acceptable cos- mesis at a low cost are needed. High energy transfer (25-W) spray cryotherapy technology using a unique liquid nitrogen (LN2)-based catheter delivery system successfully treats and eradicates neoplastic tissue and is FDA approved. We report the initial safety and feasibility results of 23 patients, 53 lesions, treated at various sites including head, neck, trunk, and extremities. Methods: Spray cryotherapy is a rapid energy transfer technology employing liquid nitrogen sprayed through a long catheter at -196 o C. Twenty-three patients with biopsy- proven skin neoplasia were treated under local anesthesia in an outpatient setting. Treatment parameters included duration of spray and the number of freeze and thaw cycles. Lesions were re-examined for clinical response, cosmesis, and the need for re-treatment at 1, 4, 8, and 12 weeks. Results: Spray cryotherapy was easily delivered and covered all visible lesions with minimal bystander side effect. Visual re-examination demonstrated complete clinical responses in 21/23 patients and 51/53 lesions. Mean follow-up is nine months. Two patients had lesions with partial responses, which were excised. Minimal pain, good wound healing, and no adverse effects occurred. The desired clinical was achieved within 30 days. Side-effects included one patient with edema at the treatment site. A superficial distant injury inadvertently occurred during readying of the catheter. Discussion: Current therapeutic modalities include surgery and radiation; both efficacious but costly, painful, and often complex with variable cosmetic outcomes. Spray cryotherapy offers a low complexity, relatively low-cost therapeutic option for these neoplasms. These results sug- gest that this technique is safe, effective, and successful for tumor eradication and reduction. Our initial findings war- rant a multi-center prospective trial.
J La State Med Soc VOL 166 March/April 2014 89
Made with FlippingBook - Online catalogs