JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
disease. A 2D TTE demonstrated moderate mitral regurgitation withnormal left ventricular function. In right heart catheterization, large v waves were noted and 2D TEE also revealed severe mitral regurgitation. On 2D TEE, the mitral valve annuloplasty ring was visible above the native anterior mitral valve leaflet. Color Doppler flow estimated the effective regurgitation orifice area of 0.4cm2 using the proximal isovelocity surface area method and regurgitant volume of 58 cc, consistent with severe mitral regurgitation. A “floating mitral ring” and dehiscence measuring 1 cm in diameter were seen on high resolution three-dimensional reconstruction resulting fromthe detachment of the ring fromthe weakened posterior annulus. Based on these findings patient was referred to cardiothoracic surgeon for re-do mitral valve surgery. Discussion: This was a perplexing case as the patient’s dyspnea could be explained by many disease processes including atrial fibrillation, mitral regurgitation and chronic obstructive lung disease. The standard imaging modalities did not help us to formulate a diagnosis. 3D TEE provided invaluable and unparalleled information of mitral valve pathology. Annuloplasty ring dehiscence is a well described complication of mitral valve repair and should always be considered in symptomatic patients. AUTOIMMUNE DIABETES PRESENTEDWITH DIABETIC KETOACIDOSIS INDUCED BY IMMUNOTHERAPY IN AN ADULT WITH MELANOMA A.A. Alzenaidi, MD; J. Dendy, MD; L. Rejjal, MD Department of Internal Medicine, Ochsner Medical Center, New Orleans, LA Introduction: Immunotherapy has been approved for treatment of melanoma. Autoimmune endocrinopathies have been reported in trials involving immunotherapy but autoimmune diabetes has not been definitively linked to them. Here we describe a case of autoimmune diabetes presenting with DKA after receiving combined immunotherapy with anti-CTLA4 and anti-PD1 monoclonal antibodies. Case: A 47year old gentleman with metastatic melanoma presented to our institution with confusion, abdominal pain and decreased oral intake. The patient had a history of diabetes on metforminwhichwas discontinued two years prior. Hewas started on Novilumab/Iplimumab for metastatic melanoma. He had received two cycles of immunotherapy and treatment was initially well tolerated. However, eight days after the second cycle the patient developed lethargy, confusion, vomiting and abdominal pain. CT of the head was negative for intracranial abnormalities and without evidence of brain metastasis. His laboratory results included: serum sodium 126 mmol/L, potassium 6.7 mmol/L, BUN 55 mg/dL, creatinine 3.5, bicarbonate 5 mmol/L, chloride 94 mmol/L, albumin 3.2 g/dL. Serum beta-hydroxybuterate was elevated (4.7 mmol/L, N: 0.0-0.5 mmol/L) and the calculated anion gap was 43 mmol/L. Serum lipase elevated (535 u/L, N: 4-60 u/L). The diagnosis of diabetic ketoacidosis was made and he was started on intravenous fluids and insulin therapy. Given his history of metastaticmelanoma, his DKAwas initially thought to be secondary to pancreatic metastasis especially considering
the elevated lipase level. A non-contrast CT of the abdomen showed no evidence of pancreatic metastasis. Interestingly, further investigation identified high serum titers of anti-glutamic acid decarboxylase (anti-GAD) antibodies (0.43 nmol/L, N: <0.02 nmol/L), a low C-peptide level (0.2 ng/ml, N: 0.9-5.5 ng/ml), supporting an autoimmune etiology of the diabetes. Other islet autoantibodies were not elevated and his Hemoglobin A1C was 8.0%. Discussion: There are few case reports about diabetes and immunotherapy. Autoimmunemechanismwas suggested as the culprit, although not all cases reported with positive antibodies. Moreover, it is unlikely that patient developed latent autoimmune diabetes (LADA) and not related to immunotherapy due to the course of LADA is quite more gradual and our patient presented with acute DKA few days post the second cycle. Physicians and patients should be aware that autoimmune disorder such as DKA may be a rare but important immunotherapy related adverse events. SECOND REPORTED CASE OF CANDIDA CATENULATA FUNGEMIA
G. Garmon, MD¹; M. Hughes, MD¹; R. Arora, MD¹; V. Mekala, MD²; R. Washburn, MD²
1. LSUHSC Shreveport Department of Internal Medicine; 2. Overton Brooks VA Section of Infectious Disease
J La State Med Soc VOL 169 MARCH/APRIL 2017 49 Case: A 57 year-oldwhitemanwith a history of alcoholic cirrhosis, recurrent pancreatitis and pseudocysts, intra-abdominal abscess and prior partial small bowel obstruction, and prior extended courses of IV antibiotic therapy presented to the emergency department with fevers, malaise, and abdominal pain. The patient was initially admitted to the intensive care unit because of sepsis, placedonbroad spectrumantibiotics, and received image-guided drainage of the largest abscesses. His course was complicated by recurrent small bowel obstruction attributed to one abscess that was not amenable to drainage. The patient had poor oral intake, only liquids includingmilk. He eventually requiredPICCplacement for TPN. He subsequently experienced fever and altered mental status. Preliminary blood cultures from the PICC and periphery indicated“budding yeast species”. Micafunginwas added and the catheterwas removed. Blood cultures fromthe PICCandperiphery grew C. catenulata, while vancomycin-resistant Enterococcus grew only from the PICC line cultures. The patient improved, and follow-up cultures remained negative. The patient completed a two week course of micafungin and was eventually discharged to a long-term acute care facility for completion of antimicrobial therapy. 6 Introduction: There are over 20 species of Candida yeasts that can cause infection in humans, themost common of which is Candida albicans. This is the second reported case of Candida catenulata fungemia. Candida catenulata is not usually associated with invasive infection in humans. The previously reported case was in a patient with gastric cancer. Candida catenulata is a natural contaminant of dairy products. Cases of candidaemia with this species are uncommon.
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