MULTIPLE MYELOMA MASQUERADING AS AN AKI
RARE CAUSE OF STEMI IN PROSTHETIC VALVE ENDOCARDITIS
replacement was indicated as early as possible. Embolization from aortic valve vegetation to the LAD is an extremely rare phenomenon; most emboli to the LAD arise from mitral valve vegetation. Early surgical intervention is vital in PVE associated with aortic root abscess as embolic events can become fatal complications.
S. Gavini; F. Shaikh; A. Ingraldi; J. Rosson Department of Internal Medicine, LSU Health Sciences Center - Lafayette valve endocarditis (PVE) is a condition with high risk of morbidity due to associated complications such as sepsis, perivalvular abscess, and peripheral embolism. We present here a case of left main coronary artery embolism due to PVE. Introduction: Prosthetic Case: A 35 year-old man with history of bioprosthetic aortic valve 8 months ago secondary to infective endocarditis presented with 1 day history of fever and malaise. Vitals on admission with tachycardia 111 beats/min, temp 101.8°F and 3/6 systolic murmur at aortic area with janeway lesions present on physical exam. Labs significant for lactic acid 2.8, troponin of 4.5 mg/dL and WBC 16. ECG with sinus tachycardia, premature atrial complexes, and right bundle branch block. Patient initiated on empiric antibiotics with blood cultures positive for methicillin sensitive staph aureus (MSSA). Transesophageal echo revealed vegetation on undersurface of bioprosthetic aortic valve with edema versus annular root abscess. Cardiothoracic surgery with evental plans for surgical repair, however on the following day, ECG revealed ST elevations in II, III, aVF, V1-V3 and troponin of 9.7ng/mL. Patient taken emergently for percutaneous coronary intervention (PCI) where the LAD had proximal embolic occlusion treated with drug-eluting stent and ejection fraction 20% with placement of intra-aortic balloon pump (IABP). A presumptive diagnosis of MSSA PVE with embolic myocardial infarction from vegetation was established. Patient became a poor surgical candidate with significant multisystem organ failure and soon decompensated secondary to his overall critical illness. Discussion: Staphylococcus aureus is the leading culprit in PVE and requires early surgical intervention when associated with aortic root abscess which can result in conduction abnormalities and embolic phenomenon presenting as a STEMI. PCI and IABP provided temporary stability however, revision of aortic valve
S. Khateeb; C. McIntyre Department of Internal Medicine, Ochsner Medical Center, New Orleans Case: A 70 year-old woman with normocytic anemia was transferred from an outside hospital with worsening renal function in the setting of an acute diarrheal illness despite supportive care with intravenous fluids. On admission, the patient complained of fatigue and decreased appetite in addition to her GI symptoms. Physical exam was noncontributory. Her creatinine was found to be 9.4, compared to 1.1 four months prior. BUN was 79 and bicarbonate was 18. A renal ultrasound revealed no signs of obstruction or hydronephrosis. Urine protein was found to be 1.4 g/day. Serum and urine electrophoresis immunofixation showed an IgA kappa paraprotein band. Her kappa/lambda light chain ratio was elevated to 313. A bone marrow biopsy was performed, which revealed plasma cell myeloma extensively involving a hypercellular bone marrow. The patient was diagnosed with multiple myeloma (MM). She underwent PLEX to clear the free light chains (LCs). Her renal function improved, and arrangements were made to begin outpatient chemotherapy with bortezomib, cyclophosphamide, and dexamethasone. Discussion: Acute kidney injury (AKI) is a problem frequently encountered by all hospitalists. Hospitalists are advised to consider myeloma cast nephropathy in the differential for AKI as up to 50% of MM patients will have an elevated creatinine level at diagnosis. A diagnosis of MM can be made when there is a myeloma- defining event (MDE) plus either marrow involvement of ≥10% clonal plasma cells or biopsy-proven plasmacytoma. MDEs include established CRAB criteria (hypercalcemia, renal failure, anemia, and bone lesions) and certain biomarkers, such as a kappa/lambda ratio ≥100 as seen in this case. MM is among the cancers with the highest rates of AKI, which can be due to damage to glomeruli or tubules fromparaprotein casts, volume depletion, hypercalcemia, or tumor lysis syndrome. LC cast nephropathy represents the most common renal manifestation of
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29 J LA MED SOC | VOL 171 | NO. 1
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