Intern Report Pearls 12/6/17 – HTG-induced acute pancreatitis

Thank you, Claire, for presenting a case of a young man who presented with acute abdominal pain found to have appendicitis and DKA from profound hypertriglyceridemia!

Key Pearls:

  1. The differential diagnosis for labs that cannot be calculated include substances in the blood that are interfering with tests, commonly fats, proteins, and bilirubin.
  2. The management of hypertriglyceridemia induced acute pancreatitis (HTG-AP) includes: IVF, bowel rest, insulin, pain control, electrolyte management and, in extreme circumstances, plasmapheresis!
  3. In patients with an underlying metabolic defect, the common triggers that can result in profound hypertriglyceridemia (and resultant complications) include development of glucose intolerance, alcohol use, and thyroid dysfunction.

Check out this awesome post from Anna Parks also about hypertriglyceridemia and pancreatitis!  She reviews the many causes of endogenous and exogenous substances that can cause lab interference, genetic causes of hypertriglyceridemia, and treatment.


More on plasmapheresis for treatment of HTG-AP

In this systemic review of HTG-AP, the authors found 8 studies that evaluated plasmapheresis as a specific treatment for HTG-AP. All 8 studies concluded that plasmapheresis is an effective treatment for reducing serum triglyceride concentration. Two studies found that symptoms of acute pancreatitis, particulary abdominal pain, were also improved. In patients with chronically elevated triglycerides, 2 studies found that long-term, routing plasmapheresis decreased recurrence of HTG-AP. In summary, the authors concluded that the treatment does not seem to decrease the morbidity and mortality of HTG-AP. However, prospective, randomized trials are needed!

This treatment seemed to work magic for Claire’s patient! Here’s a photo of the fat that was apheresed from her patient’s blood.

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Evernote: https://www.evernote.com/shard/s462/sh/ccfe021d-5fc1-4b9b-812b-c3d33b1d970c/a62db18c4134b53d38c3a8285edfc764

 


Filed under: Morning Report

Moffitt Cardiology Pearls 12.5.17 – Sinus Exit Block and Endocarditis

Thank you Nadia (my co-fellow to be next year!!) for presenting an amazing cardiology case with Anne Thorson. She presented the case of a man w/ hx of crack cocaine use and recent strep pneumo meningitis p/w acute SOB found to have a diastolic murmur, PR prolongation, sinus exit block and an perivalvular abscess!! The patient was found to have severe chronic AI and was being evaluated by CT surgery for definitive management while on IV abx. Keep us updated!!

Key Pearls

  1. ECG conduction changes, from first degree AV block to complete heart block, are associated with increased mortality in patients with known endocarditis (Am Heart J 2001;142:280-5.)
  2. See this study in the American Heart Journal for more information about conduction abnormalities and endocarditis (remember that these will occur at the level of AV node).
  3. See Figure below for more information on sinus exit block.

For more information see – https://lifeinthefastlane.com/ecg-library/sa-exit-block/

 


Filed under: Cardiovascular Medicine, Infectious Disease, Morning Report