A Case of Mineralocorticoid Induced Hypertension Secondary to Cushing's Syndrome

We present a case of mineralocorticoid induced hypertension secondary to Cushing's syndrome in a hospitalized patient with uncontrolled hypertension and hypokalemia.A 78-year-old female with hypertension, hypothyroidism, and known pituitary (1.6 cm) and left-sided adrenal mass (2.9 cm) since 2012, presented to the hospital with altered mental status and rectal bleeding with hemoglobin of 5.8 g/dL. On arrival, she was afebrile, blood pressure 87/51 mm Hg, pulse 95 bpm, and saturating at 97% on room air. The patient was altered and had bloody stool positive for fecal occult blood test, with the rest of the examination being normal. Her hospital course was complicated by uncontrolled hypertension (on lisinopril and amlodipine) and severe hypokalemia. During her hospital stay, her potassium ranged 2-2.5 mEq/L (3.5-5.1) and she had persistent metabolic alkalosis. Aldosterone <1 ng/dL, plasma renin activity (PRA) 0.38 ng/mL/hr and aldosterone/PRA ratio 2.6 (0.9-28.9). Thyroid function: TSH 0.709 uIU/mL (0.30-5.00), free T4 1.4 ng/dL (0.7-1.7). Catecholamines were not significantly elevated: free metanephrines <25 pg/mL (<57), normetanephrines 158 pg/mL (<148). Further investigation revealed severe hypercortisolism: 24-hour urinary free cortisol 422 mcg/24 hours, cortisol AM 29.2 mcg/dL (3.7-19.4), and cortisol 31 mcg/dL with 1 mg dexamethasone suppression test. Late-night salivary cortisol was not obtained. ACTH was 138 pg/mL (9-46) and cortisol level after 8 mg dexamethasone suppression test was elevated at 17.2 ug/dL. MRI brain showed a pituitary macroadenoma sized 1.6×1.4×1.1 cm, stable since 2012. CT abdomen showed a left adrenal nodule measuring 2.3×3.3×2.8 cm. Further workup revealed free testosterone 10.6 pg/mL(0.2-3.7), total testosterone 22 ng/dL (2-45), DHEA-Sulfate 533 mcg/dL (45-430), IGF-1 81 ng/mL(34-245), Human growth hormone 0.2 ng/mL (<10), FSH 0.3 mIU/mL, LH 0.1 mIU/mL, prolactin 18.9 ng/mL(0-29), and deoxycorticosterone <16 ng/dL (<16). Given the patient's clinical presentation (rectal bleeding, altered mental status) with associated laboratory abnormalities, the plausible explanation for her hypertension and hypokalemia was ACTH-mediated hypercortisolism resulting in increased mineralocorticoid activity. Other possible etiologies considered were syndrome of apparent mineralocorticoid excess, Liddle's syndrome, deoxycorticosterone tumors, and exogenous intake of steroids. The patient was started on spironolactone and amiloride, both blood pressure and potassium levels improved. A decision was made to proceed with inferior petrosal sinus sampling, to determine the exact source of ACTH, however, prior to completion patient developed COVID pneumonia and expired.Our case highlights the importance of considering hypercortisolism in patients presenting with hypertension, hypokalemia, and metabolic alkalosis with suppressed aldosterone and renin levels. Furthermore, Cushing's syndrome should be a consideration even in the absence of classic cushingoid features as in this patient.Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Point of care ultrasonography (POCUS) uses an ultrasound technique that helps physicians augment physical examination findings and guide clinical decision-making at the bedside. We present a case that became a watershed moment for internal medicine residents at Abington Jefferson Hospital to use POCUS for every patient with atrial flutter/fibrillation with RVR prior to initiating diltiazem drip. CASE PRESENTATION: A 73-year-old male presented to the emergency department with complaints of palpitations. He was tachycardic with a heart rate in the 150s, and his rhythm was irregular. His basic labs were normal;an electrocardiogram investigation showed that he was experiencing an atrial flutter with 2:1 and 3:1 blocks. Chest X-ray was clear. He was given IV metoprolol 10 mg twice without achieving rate control and then started on a diltiazem drip, which initially improved his heart rate to 70s with rhythm changing to atrial flutter with 4:1 block. However, he started to become hypoxic, requiring intubation and then hemodynamically unstable, requiring initiation of pressors. Postintubation CXR indicated bilateral diffuse pulmonary edema and vascular congestion. Subsequently, he had Pulseless electrical activity (PEA) arrest. Return of spontaneous circulation (ROSC) was achieved after 3 minutes of chest compression and one round of epinephrine injection. Transthoracic echocardiogram showed an ejection fraction of 10%. He had a right heart catheterization which showed a CI of 1.7 and elevated PCWP and RVP. He was started on milrinone for ionotropic support and needed norepinephrine, vasopressin and phenylephrine to sustain his blood pressure. DISCUSSION: Atrial flutter and fibrillation are routinely seen arrhythmias in hospital settings. Patients with irregular rhythm who are in rapid ventricular rate and normotensive are often given IV metoprolol few times and then started on a diltiazem drip if RVR continues. Diltiazem not only decreases heart rate (negative chronotropic) but also decreases ventricular squeeze (negative ionotropic). It is contraindicated in patients with reduced ejection fraction. Patients’ ejection fraction values are not always known, especially if they have never had a transthoracic echocardiogram in the past or prior records are not available. POCUS helps physicians and residents to access and estimate LV function quickly and augments clinical decision making at the bedside. CONCLUSIONS: Internal Medicine Residents at Abington Hospital have made it a part of their protocol to always perform bedside ultrasonography in patients with atrial flutter/fibrillation with rapid ventricular rate before initiating diltiazem drip to prevent further avoidable cardiogenic shocks. Reference #1: Fey H, Jost M, Geise AT, Bertsch T, Christ M. Kardiogener Schock nach bradykardisierender Therapie bei tachykardem Vorhofflimmern : Fallvorstellung einer 89-jährigen Patientin [Cardiogenic shock after drug therapy for atrial fibrillation with tachycardia : Case report of an 89-year-old woman]. Med Klin Intensivmed Notfmed. 2016 Jun;111(5):458-62. German. doi: 10.1007/s00063-015-0089-9. Epub 2015 Oct 6. PMID: 26440099. Reference #2: Bitar ZI, Shamsah M, Bamasood OM, Maadarani OS, Alfoudri H. Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU. J Cardiovasc Imaging. 2021 Jan;29(1):60-68. doi: 10.4250/jcvi.2020.0138. PMID: 33511802;PMCID: PMC7847790. Reference #3: Murray A, Hutchison H, Popil M, Krebs W. The Use of Point-of-Care Ultrasound to Accurately Measure Cardiac Output in Flight. Air Med J. 2020 May-Jun;39(3):218-220. doi: 10.1016/j.amj.2019.12.008. Epub 2020 Jan 14. PMID: 32540116. DISCLOSURES: No relevant relationships by Fnu Aisha No relevant relationships by Lucy Checchio No relevant relationships by Ans Dastgir No relevant relationships by Shravya Ginnaram No relevant relationships by Syeda Hassan No relevant relationships by Chaitra Janga No relev nt relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Binod Poudel No relevant relationships by Shreeja Shah

COVID-19 outbreak: challenges and opportunities towards agriculture sector

This study underscores the impact of the Covid-19 outbreak on the agriculture sector and highlights some sound practices to promote agriculture growth, which is essential amid Covid-19. The primary aim of this research is to add the knowledge already available on the topic and sustain the agriculture growth amid of Covid-19 outbreak. The study revolves around its twin research question;what are the challenges to the agriculture sector amid Covid-19 and how challenges may transmute into opportunities? The qualitative methodology is used with content analysis technique to collect the data collection. Content available in diverse formats related to neighbouring characteristics of the impact of the Covid-19 outbreak on agriculture. The results of this document enable us to wrap up the purpose of the research. There is a need to improve, promote and digitalize the agriculture sector in all dimensions, that can face and overcome the challenges, which are profound due to enforcement of lockdown after the Covid-19 outbreak. Government policy/role is an important factor to develop any type of strategy or development in this sector, especially in the value addition process. The local government can sustain local food commodities in domestic markets that will directly motivate farmers to focus on their production. No doubt, Covid-19 ascertains so many challenges for every business but the right strategy at right time transform challenges into opportunities. Strategy refers to some interests and priorities from the government side to promote the agriculture sector. This is the need of the time and essential for agriculturalists to stay in business.

Relationship between outcomes of covid19, its susceptibility and blood groups

COVID-19, a viral infection spread across the world affecting many people around the world. In ABO blood type, certain types are more prone to infections and causes severe symptoms. Relationship between ABO blood type and COVID-19 still needs to be found out. A prospective cohort study was conducted to evaluate a relationship between ABO blood type and COVID-19. Data was collected from 148 patients who presented for COVID testing through PCR or nasal swab tests. COVID positive patient’s blood test was performed to find out ABO blood group/type and their symptoms with which they presented. The blood group distributions, age and gender of these patients were recorded. It was seen that there is a statistically significant association between COVID and blood group A+, A-, B+ with p-value of 0.01, 0.03 and 0.01 respectively and no statistical significance was found between B-, O+, O-, AB+ and AB-with P-value of 0.06, 0.1, 0.9, 0.7 and 0.8 respectively. Multi variate analysis performed showed age, blood group and ICU stay to be significantly associated with COVID with p-value of <0.01, 0.05, <0.01 and gender to be non-significantly associated with COVID with p-value of 0.7. Blood group A+, A-and B+ are more prone to contract COVID virus with more severe symptoms. Fever and cough have been to be positively associated with COVID cases and found to be affecting patient’s health. Age is also found be affecting patient’s life, with a higher chance of contracting COVID-19 as the increases.