Autoimmune Implications in a Patient with Graves' Hyperthyroidism, Pre-eclampsia with Severe Features, and Primary Aldosteronism

Background and Objectives: Graves' disease (GD) and primary aldosteronism (PA) are two pathologies that can cause significant morbidity and mortality. GD is mediated by autoantibodies, and recent studies have shown autoantibody involvement in the pathophysiology behind both PA and pre-eclampsia. The coexistence of GD and PA, however, is reportedly rare. This report describes a unique case of Graves' hyperthyroidism and concomitant PA in a patient with a history of pre-eclampsia with severe features. Case Presentation: The patient presented at 17 weeks pregnancy with mild hyperthyroidism, negative TSH receptor antibodies, and a low level of thyroid-stimulating immunoglobulins (TSI). Her TSH became detectable with normal thyroid hormone levels, and therefore, no anti-thyroid medication was administered. At 34 weeks she developed pre-eclampsia with severe features, and a healthy child was delivered; her TSH returned to normal. Seven months after delivery, she presented emergently with severe hyperthyroidism, hypertensive crisis, and a serum potassium of 2.5 mmol/L. Her hypertension was uncontrolled on multiple anti-hypertensives. Both TSI and TSH receptor antibodies were negative. The aldosterone(ng/dL)/renin(ng/mL/h ratio was (13/0.06) = 216.7, and abdominal CT imaging demonstrated normal adrenal glands; thus, a diagnosis of PA was made. Her blood pressure was subsequently controlled with only spironolactone at 50 mg 2xday. Methimazole was started but discontinued because of an allergic reaction. Consequently, a thyroidectomy was performed, and pathology revealed Graves' disease. The patient remained well on levothyroxine at 125 mcg/day and spironolactone at 50 mg 2xday three months after the thyroidectomy. Conclusions: This patient manifested severe GD with antibodies undetectable by conventional TSI and TSH receptor assays and accelerated hypertension from PA simultaneously. These conditions were successfully treated separately by spironolactone and thyroidectomy. Autoimmune PA was considered likely given the clinical picture. The diagnosis of PA should be considered in hypertension with GD.

Delayed Right Diaphragmatic Hernia With Chilaiditi Syndrome: A Case Report

Diaphragmatic hernias can be congenital or acquired and manifest as a defect thus allowing abdominal contents to protrude into the thorax through the defect. Common presentations and symptoms can include shortness of breath, nausea, vomiting, and abdominal pain. Rarely colon or small bowel is interposed between the liver and the diaphragm, Chilaiditi sign. When the Chilaiditi sign is accompanied by symptoms it is termed Chilaiditi syndrome. We present a case of a 41-year-old male who was involved in a motor vehicle accident 12 years prior and presented with a right diaphragmatic hernia and Chilaiditi syndrome. The patient presented with a 21-hour history of abdominal pain, nausea, and vomiting. A computed tomography scan of the chest and abdomen revealed the presence of Chilaiditi sign, wherein the large bowel was positioned above the liver, having herniated through a diaphragmatic defect. The patient subsequently underwent an exploratory laparotomy which confirmed an 8 x 4 cm right diaphragmatic defect. Primary repair was completed with intraperitoneal mesh. Diaphragmatic hernias pose diagnostic challenges due to their variable symptomatology and possible delayed onset. Consequently, the importance of including diaphragmatic hernia as part of the differential diagnoses for patients experiencing abdominal pain and/or difficulty breathing is highlighted by this case, especially for individuals with a distant record of trauma.

Necrotizing Fasciitis of the Abdominal Wall Secondary to Complicated Appendicitis: A Case Report

Acute appendicitis is one of the most common surgical emergencies worldwide. Many complications can occur secondary to complicated appendicitis including abscess formation, gangrene, sepsis, and perforation, rarely, leading to abdominal wall necrotizing fasciitis. The incidence of necrotizing fasciitis as a complication of ruptured appendicitis is extremely uncommon. The formation of an enterocutaneous fistula leading to this complication further emphasizes the rarity of such occurrence with few cases reported in the literature. Herein, we present a case of abdominal wall necrotizing fasciitis in a 72-year-old female presenting to the local emergency room with complaints of severe suprapubic abdominal pain associated with abdominal distension and acute onset foul-smelling drainage. Physical exam was significant for suprapubic and right lower quadrant abdominal tenderness with associated large indurated tender lesion and purulent weeping with large ecchymosis. Abdominal computed tomography (CT) revealed extensive subcutaneous emphysema, a large cavity with layering fluid extending into the peritoneal space, and a possible fistula formation between the intra-abdominal cavity and subcutaneous tissue. Following the diagnosis of probable necrotizing fasciitis secondary to fistula formation, the patient underwent emergent exploratory laparotomy and extensive debridement of necrotic tissue. In this report, we take the opportunity to highlight the importance of promptly recognizing and treating this uncommon complication and maintaining a high level of suspicion to prevent life-threatening consequences.

An Unusual Presentation of Cecal Volvulus With Internal Herniation Through the Foramen of Winslow

Internal hernias through the Foramen of Winslow account for 0.1% of abdominal hernias and 8% of internal hernias, with a mortality rate of 36%-49%. Cecal volvulus accounts for only 1%-1.5% of all intestinal obstructions with a mortality rate of up to 48%. We present a case of a 56-year-old female evaluated for lower abdominal pain and nausea who received a right hemicolectomy after reduction of a cecal volvulus with internal herniation through the Foramen of Winslow. The ambiguous presentation can complicate initial management, but early detection is essential for quick operative repair and prevention of onset or progression of bowel ischemia and necrosis.

Gabapentin as a Symptomatic Modifier in Median Arcuate Ligament Syndrome: A Case Report and Assessment of Treatment Modalities

Median arcuate ligament syndrome (MALS) is a rare constellation of neurogenic gastrointestinal (GI) symptoms resulting from compression of the celiac trunk and celiac plexus by the median arcuate ligament. MALS is characterized by nonspecific symptoms including nausea, vomiting, diarrhea, bloating, unintentional weight loss due to food aversion, and postprandial epigastric abdominal pain. We present a case of atypical, chronic MALS that confounded clinicians for over a decade and led to various misdiagnoses, including early-onset Parkinson’s disease. Of the constellation of symptoms that MALS may present with, postprandial epigastric pain is a classic symptom and increases the index of suspicion for the diagnosis; however, the absence of the classic symptom of postprandial epigastric pain and the predomination of nonspecific GI symptoms and syncope in our patient further clouded clinicians’ ability to diagnose MALS. Upon further investigation, we elucidated a link between gabapentin, which our patient was chronically prescribed, and its efficacy in decreasing neurogenic hypersensitivity in the GI tract. Our case and the implications of gabapentin use to decrease neurogenic pain from MALS represents a novel addition to the literature on MALS treatment modalities and elucidates new avenues for continued research in the use of gabapentin as a symptom-modifying agent in the nonoperative and preoperative treatment of MALS.

Ruptured Hepatic Hemangioma in the Third Trimester of Pregnancy: A Rare Case Report

Hepatic hemangiomas are considered the most common benign mesenchymal hepatic tumors. Most cases are asymptomatic. However, giant hemangiomas can present with a variety of clinical presentations, with a rupture being the most catastrophic outcome. Only a few cases of ruptured perinatal hepatic hemangiomas have been reported. Accelerated growth of hepatic hemangiomas caused by increased estrogen in pregnancy, increased intra-abdominal pressure, and direct contact with a gravid uterus are possible mechanisms for increased risk of rupture during pregnancy. The safety of either non-operative or surgical treatment of symptomatic giant hemangioma during pregnancy has not been adequately investigated. We present a rare case of a 28-year-old G1P0 female at 33 weeks gestation that presented with a ruptured hepatic hemangioma treated with damage control surgery followed by nonanatomic surgical resection.

Giant Proximal Right Colon Submucosal Hematoma Leading to a Large Bowel Obstruction

A 41-year-old female with a previous history of chronic obstructive pulmonary disease (COPD) and polycythemia presented to the emergency department with worsening shortness of breath and cough which progressed to respiratory distress requiring mechanical ventilation. During her hospital stay, she developed abdominal distention followed by a fever and a four-point decrease in hemoglobin. A non-contrasted abdominopelvic CT scan was ordered which showed a very large retroperitoneal hematoma adjacent to the right colon with subtle active bleeding. Selective angioembolization of a distal segment of the right colic artery was performed by Interventional Radiology (IR) to achieve hemostasis and hemodynamic stability. Due to the persistent and worsening abdominal distention, a CT scan with contrast was ordered which clearly showed a submucosal hematoma in the region of the right colon extending from the hepatic flexure to the cecum. The hematoma was completely obstructing the proximal and mid ascending colon leading to a large bowel obstruction. Exploration of the abdomen showed severe bowel dilation, and frank ischemia of the hepatic flexure of the colon. Right hemicolectomy with primary ileocolonic anastomosis to evacuate the right retroperitoneal hematoma was subsequently performed. The patient was discharged on post-operative day 16 with no major complications.

Significance of Lung Weight in Cellular Ex Vivo Lung Perfusion

BACKGROUND

Currently, pulmonary edema is evaluated via surgical inspection and palpation in donor lungs, and there is no quantitative standard diagnostic tool for evaluating pulmonary edema in donor procurement and ex vivo lung perfusion (EVLP). The purpose of this study was to investigate the significance of lung weight at the donor hospital and lung weight during EVLP as a complementary parameter of transplant suitability in EVLP.

MATERIALS AND METHODS

Twenty-one of rejected human lungs were perfused in cellular EVLP. Transplant suitability was evaluated at 2 h as per standard criteria of Lund-protocol EVLP.

RESULTS

Lung weight at donor hospital was significantly correlated with PaO₂/FiO₂ (P/F) ratio in EVLP (r = -0.44). There was a significant difference in lung weight at donor hospital between suitable cases (n = 13) and nonsuitable cases (n = 8). Light lung group (lung weight at donor hospital < 1280 g; n = 17) was suitable for transplant in 76%, whereas none of heavy lung group (lung weight at donor hospital ≥ 1280 g; n = 4) was suitable (P < 0.05). Lung weight at 2 h and lung weight change during EVLP were significantly associated with P/F ratio at 2 h and transplant suitability (P < 0.05, each).

CONCLUSIONS

Our findings demonstrate that lung weight at donor hospital, lung weight change, and lung weight at 2 h of EVLP might be a predictor of P/F ratio and transplant suitability in cellular EVLP.

Ex Situ Liver Machine Perfusion: The Impact of Fresh Frozen Plasma

The primary aim of this single-center, phase 1 exploratory study was to investigate the safety, feasibility, and impact on intrahepatic hemodynamics of a fresh frozen plasma (FFP)-based perfusate in ex situ liver normothermic machine perfusion (NMP) preservation. Using an institutionally developed perfusion device, 21 livers (13 donations after brain death and 8 donations after circulatory death) were perfused for 3 hours 21 minutes to 7 hours 52 minutes and successfully transplanted. Outcomes were compared in a 1:4 ratio to historical control patients matched according to donor and recipient characteristics and preservation time. Perfused livers presented a very low resistance state with high flow during ex situ perfusion (arterial and portal flows 340 ± 150 and 890 ± 70 mL/minute/kg liver, respectively). This hemodynamic state was maintained even after reperfusion as demonstrated by higher arterial flow observed in the NMP group compared with control patients (220 ± 120 versus 160 ± 80 mL/minute/kg liver, P = 0.03). The early allograft dysfunction (EAD) rate, peak alanine aminotransferase (ALT), and peak aspartate aminotransferase (AST) levels within 7 days after transplantation were lower in the NMP group compared with the control patients (EAD 19% versus 46%, P = 0.02; peak ALT 363 ± 318 versus 1021 ± 999 U/L, P = 0.001; peak AST 1357 ± 1492 versus 2615 ± 2541 U/L, P = 0.001 of the NMP and control groups, respectively). No patient developed ischemic type biliary stricture. One patient died, and all other patients are alive and well at a follow-up of 12-35 months. No device-related adverse events were recorded. In conclusion, with this study, we showed that ex situ NMP of human livers can be performed safely and effectively using a noncommercial device and an FFP-based preservation solution. Future studies should further investigate the impact of an FFP-based perfusion solution on liver hemodynamics during ex situ normothermic machine preservation.

Lipid metabolism and functional assessment of discarded human livers with steatosis undergoing 24 hours of normothermic machine perfusion

Normothermic machine perfusion (NMP) is an emerging technology to preserve liver allografts more effectively than cold storage (CS). However, little is known about the effect of NMP on steatosis and the markers indicative of hepatic quality during NMP. To address these points, we perfused 10 discarded human livers with oxygenated NMP for 24 hours after 4-6 hours of CS. All livers had a variable degree of steatosis at baseline. The perfusate consisted of packed red blood cells and fresh frozen plasma. Perfusate analysis showed an increase in triglyceride levels from the 1st hour (median, 127 mg/dL; interquartile range [IQR], 95-149 mg/dL) to 24th hour of perfusion (median, 203 mg/dL; IQR, 171-304 mg/dL; P = 0.004), but tissue steatosis did not decrease. Five livers produced a significant amount of bile (≥5 mL/hour) consistently throughout 24 hours of NMP. Lactate in the perfusate cleared to <3 mmol/L in most livers within 4-8 hours of NMP, which was independent of bile production rate. This is the first study to characterize the lipid profile and functional assessment of discarded human livers at 24 hours of NMP. Liver Transplantation 24 233-245 2018 AASLD.

Comparison of normothermic and hypothermic perfusion in porcine kidneys donated after cardiac death

BACKGROUND

Normothermic machine perfusion (NMP) is an alternative strategy for preserving kidneys donated after cardiac death (DCD). The relative efficacy of prolonged NMP compared to hypothermic machine perfusion (HMP) in DCD kidneys with moderate ischemic injury is undetermined. This study compares NMP and HMP kidney preservation in a porcine DCD model.

METHODS

Ten porcine kidneys underwent NMP or HMP preservation following 45 minutes of warm ischemia and 5 hours of cold ischemia. After 8 hours of machine preservation, hemodynamic stability, renal function, perfusate biomarkers, and histologic integrity were assessed in a simulated reperfusion model.

RESULTS

During simulated reperfusion, no differences were observed in oxygen consumption, urine production, creatinine clearance, fractional excretion of sodium, proteinuria, and perfusate levels of lactate dehydrogenase and aspartate aminotransferase. Resistance was no different after 30 minutes of simulated reperfusion. Histologically, NMP kidneys demonstrated increased vacuolization after preservation and greater loss of tubular integrity after simulated reperfusion. Perfusate levels of alkaline phosphatase (AP) and gamma glutamyltransferase (GGT) were higher in NMP kidneys during preservation, but upon simulated reperfusion, AP and GGT levels were higher in HMP-preserved kidneys. Peak AP and GGT during simulated reperfusion of HMP kidneys were over 14 times higher than peak AP and GGT during preservation of NMP kidneys.

CONCLUSIONS

NMP provided comparable preservation of renal function as HMP and minimized AP and GGT release upon reperfusion.

Impact of Temperature on Porcine Liver Machine Perfusion From Donors After Cardiac Death

Normothermic machine perfusion (NMP) has been introduced as a promising technology to preserve and possibly repair marginal liver grafts. The aim of this study was to compare the effect of temperature on the preservation of donation after cardiac death (DCD) liver grafts in an ex vivo perfusion model after NMP (38.5°C) and subnormothermic machine perfusion (SNMP, 21°C) with a control group preserved by cold storage (CS, 4°C). Fifteen porcine livers with 60 min of warm ischemia were preserved for 10 h by NMP, SNMP or CS (n = 5/group). After the preservation phase all livers were reperfused for 24 h in an isolated perfusion system with whole blood at 38.5°C to simulate transplantation. At the end of transplant simulation, the NMP group showed significantly lower hepatocellular enzyme level (AST: 277 ± 69 U/L; ALT: 22 ± 2 U/L; P < 0.03) compared to both SNMP (AST: 3243 ± 1048 U/L; ALT: 127 ± 70 U/L) and CS (AST: 3150 ± 1546 U/L; ALT: 185 ± 97 U/L). There was no significant difference between SNMP and CS. Bile production was significantly higher in the NMP group (219 ± 43 mL; P < 0.01) compared to both SNMP (49 ± 84 mL) and CS (12 ± 16 mL) with no significant difference between the latter two groups. Histologically, the NMP livers showed preserved cellular architecture compared to the SNMP and CS groups. NMP was able to recover DCD livers showing superior hepatocellular integrity, biliary function, and microcirculation compared to SNMP and CS. SNMP showed some significant benefit over CS, yet has not shown any advantage over NMP.

Mosquito age as a factor influencing the transmission of Wuchereria bancrofti

Two mosquito species; Culex pipiens and Aedes caspius of different ages were experimentally infected with moderate microfilarial densities of Wuchereria bancrofti and examined for their vector potential to transmit this parasite. Tested age groups of Cx. pipiens supported the development of the infective stage of the parasite (L3) but those of Ae. caspius arrested its development especially aged mosquitoes. For Cx. pipiens, infection rates and the mean number of microfilaria (mf) were found decreased with insect age groups while their survival was not affected. Also, proportion of mosquitoes harbouring L3 of the parasite was quite similar for the examined age groups, however; the 4 days-old group was the highest. On the other hand, Ae. caspius capability to respond against W. bancrofti was decreased in older mosquitoes. The observed results may indicate certain influence of mosquito aging on the development of W. bancrofti which differ according to mosquito species.

Melanization response of two mosquito species against Wuchereria bancrofti

The melanization response of two mosquito against Wuchereria bancrofti was studied under different conditions of temperatures, adult age and feeding regimes. The two mosquito species were Culex pipiens, a susceptible species for W. bancrofti transmission and Aedes Caspius, a refractory one.