ATYPICAL PRESENTATION OF SARCOIDOSIS: UNILATERAL
RARE CASE OF ACUTE ESOPHAGEAL NECROSIS SECONDARY TO DIABETIC KETOACIDOSIS GURVITS SYNDROME T. Joshi; R. Gioe; J. Evans; D. Raines Department of Internal Medicine, LSU Health Sciences Center - New Orleans *Presented as a mystery case Introduction: Acute esophageal necrosis is a life-threatening condition. It is a rare disease with an incidence ranging from 0.01% to 0.28% of all upper GI endoscopies. Upon review of the English literature, only 14 cases of AEN associated with DKA have been published over the past 50 years. We present a case of AEN associated with DKA. Case: A 61 year old man with a history of hypertension, hyperlipidemia, type 2 diabetes, peptic ulcer disease, tobacco use, alcohol abuse, and obesity presented to the hospital with severe shortness of breath, worsening back pain and acid reflux symptoms. His vitals on admission were 97.8 F, blood pressure 183/85, heart rate 141 beats per minute, respiratory rate 31/min, and oxygen saturation at 99% on room air. On physical examination he had dry mucous membranes and tachycardia. His laboratory findings showed blood glucose of 833 mg/dL. ABG showed pH of 7.164, pCO2 of 11.1 mmHg, HCO3 of 4 mEq/L, and PO2 of 128 mmHg with an anion gap of 25. Serum Beta- Hydroxybutyrate of 4.9 mmol/L, 2+ urine ketones, (WBC) of 30.2 K/uL, Hb 13.5, potassium of 5.8, BUN 31 with Creatinine of 2.7. CXR was unremarkable and patient was started on an insulin drip. On day 2, he developed hematemesis without melena or hematochezia. On day 3, he continued having hematemesis and dysphagia. The next day Hb decreased from 12.8 to 10.7 g/dL and he had chest discomfort. Endoscopic evaluation revealed severe necrotic esophagitis along the entire esophagus with gastric and duodenal mucosa. Patient was started on oral (PPI) therapy and oral sucralfate therapy. The patient’s DKA resolved and he was discharged on 6 weeks of oral PPI and sucralfate therapy with plans for repeat EGD outpatient. Discussion: It is important to diagnose AEN in the settingof DKA as it is associated with increased disease-specific
based on the clinical presentation and demonstration of non caseating granulomas in the lymph nodes. This case highlights the presentation of sarcoidosis with supraclavicular lymphadenopathy and the possible environmental and occupational risk factors for sarcoidosis. Prompt recognition and management of anterior uveitis is important to prevent long term complications of uveitis.
SUPRACLAVICULAR LYMPHADENOPATHY
N. Patel; R. Singh; A. DeWitt; V. Tati Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge *Presented as a mystery case Introduction: Sarcoidosis is a systemic granulomatous disease of unknown etiology that can affect any organ system. Hilar and mediastinal lymphadenopathy is a common manifestation, however other causes of lymphadenopathy must be ruled out in a stepwise approach. Case: A 34 year old male quarry worker with significant exposure to granite for 15 years presented with a palpable non- tender mass on the left side of his neck for 2 months. During this time, he also had subjective fevers, drenching night sweats and a 30 lb. unintentional weight loss. The patientdenieddysphagia, dyspnea, cough or other upper respiratory symptoms. He endorsed occasional marijuana use and had tested negative for HIV within the past 2 years. He also reported intermittent redness and burning sensation in his eyes for the past 1 year. He stated that he used a surgical mask at work, but did not use a respirator. Physical examination revealed a mobile, non-tender, rubbery mass on the left side of his neck extending from the midclavicular line to the sternocleidomastoid muscle. Electrolytes and CBC were unremarkable, HIV and Quantiferon Gold were negative. His ACE level was elevated. Neck CT showed cervical, left supraclavicular and mediastinal lymphadenopathy with a mass effect on the left subclavian vein and numerous collaterals in the left neck and shoulder. It also showed bilateral ground glass nodular infiltrates. Excisional biopsy of the left cervical lymph node demonstrated noncaseating granulomas.
Discussion: inflammatory
Sarcoidosis
is
an
systemic
disease
characterized noncaseating granulomas. Cervical lymphadenopathy as the initial presentation of sarcoidosis is rare, adding to the difficulty in diagnosis. Furthermore, our patient presented with B symptoms increasing the possibility of malignancy. Sarcoidosis was diagnosed by
18 J LA MED SOC | VOL 171 | NO. 1
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