1 SOCIETA' SCIENTIFICA DI MEDICINA INTERNA FEDERAZIONE DELLE ASSOCIAZIONI DEI DIRIGENTI OSPEDALIERI INTERNISTI TOSCANA Arezzo Firenze Grosseto LivornoLucca XIII Congresso Regionale FADOI Toscana Firenze Hilton Florence Metropole Ottobre 2014 IX Congresso Regionale ANÍMO Toscana Firenze Hilton Florence Metropole 24 Ottobre 2014 Massa-Carrara Pistoia PisaPrato Siena
2 ELENCO ABSTRACT MEDICI Redatto da Simone Meini Congresso Regionale FADOI Toscana Firenze Ottobre A CASE OF ACUTE FORM OF SARCOIDOSIS, THE LOFGREN SYNDROME. Antonielli E. Crociani A. Vannucchi V. Ciervo D. Mannoni A. Fedeli L. Fintoni T. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 2 A CASE OF ACUTE HAEMORRHAGIC ALVEOLITIS CAUSED BY INTRAVESICAL BACILLUS CALMETTE-GUÉRIN INSTILLATION. Antonielli E. Vannucchi V. Crociani A. Ciervo D. Degl'Innocenti G. Turchi V. Mancini A. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi, Firenze 3 A CASE OF DEADLY ACUTE LIVER FAILURE DUE TO DEATH CAP. Antonielli E. Crociani A. Vannucchi V. Ciervo D. Degl'Innocenti G. Fedeli L. Fintoni T. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 4 A CASE REPORT OF ACQUIRED HEMOPHILIA A Manetti S. Cappelli F. Rosi C. Stanganini S. Santoro E. AUSL8 Arezzo Bibbiena 5 A DANGEROUS POLYARTHRITIS Vannucchi V. Ciervo D. Degl'Innocenti G. Antonielli E. Crociani A. Rocchi F. Fintoni T. Fedeli L. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 6 A DILEMMA IN DIAGNOSIS: PRIMARY HEPATIC LYMPHOMA Degl'Innocenti G. Ciervo D. Vannucchi V. Crociani A. Rocchi F. Bacci F. Biagioni M.C. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze
3 7 A RARE CAUSE OF HYPERCALCEMIA IN A YOUNG WOMAN: THE PRIMARY LYMPHOMA OF THE BONE. Para O. Crociani A. Antonielli E. Panigada G. Fintoni T. Fedeli L. Biagioni MC. Manni M. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 8 A STRANGE CASE OF ANCA-ASSOCIATED VASCULITIS: CAN MYCOBACTERIAL INFECTION DELAY THE DIAGNOSIS? Ciervo D. Antonielli E. Vannucchi V. Crociani A. Casati C. Mancini A. Innocenti R. Para O. Degl'Innocenti G. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 9 ACCURACY OF NURSE-PERFORMED LUNG ULTRASOUND IN PATIENTS WITH DYSPNEA: A SINGLE-CENTRE PROSPECTIVE OBSERVATIONAL STUDY Masi L. Cresci A. Basile V. Sabatini S. Cei M. Bianchi L. Mazzi V. Mumoli N UO Medicina 1 - Ospedale di Livorno 10 ACUTE INTERMITTENT PORPHYRIA Basile V. Brondi B. Cresci A. Mumoli N UO Medicina 1 - Ospedale Livorno 11 AUDIT CLINICO COME STRUMENTO EFFICACE NEL MIGLIORAMENTO DELLA DIMISSIONE DEL PAZIENTE DIABETICO DALLE UO DI MEDICINA INTERNA Montagnani A. in rappresentanza del Gruppo DDIMA U.O. Medicina Interna, Ospedale Misericordia USL 9 Grosseto 12 CARCINOSI PERITONEALE: UNA SORPRESA DIAGNOSTICA ALLA BIOPSIA PERITONEALE Burberi L. Casati C. Fabbri M. Mannini D. Corradi F. Morettini A. Medicina interna OACA 1 Firenze 13 CARDIAC COMPLICATIONS IN PATIENTS HOSPITALIZED FOR COMMUNITY ACQUIRED PNEUMONIA IN A INTERNAL MEDICINE WARD. Vannucchi V. Ricci E. Silverii MV. Ciervo D. Antonielli E. Degl'Innocenti G. Crociani A. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 14 CASO NEUROLOGICO DI PERTINENZA INTERNISTICA Rossi F. Montagnani A. Galassi L. Randisi P. Lenzi A. Verdiani V. UO Medicina Interna Ospedale Misericordia USL 9 Grosseto
4 15 CLASSIFICAZIONE E SIGNIFICATO PROGNOSTICO DELL IPERGLICEMIA NEL PAZIENTE RICOVERATO: RISULTATI DI UNO STUDIO PROSPETTICO OSSERVAZIONALE CONDOTTO IN TRE UNITA DI MEDICINA INTERNA DELLA A.O.U. CAREGGI. Bazzini C. Casati C. Fabbri A. Crociani A. Pieralli F. Corradi F. Pignone A. Morettini A. Nozzoli C. A.O.U. Careggi Firenze 16 COLITE MICROSCOPICA: UN CASO DI DIARREA IATROGENA Seghieri M. Lodato M. Taddei M. Scuola di Specializzazione Medicina Interna. Pisa 17 CYTOMEGALOVIRUS PANCREATITIS: A RARE MANIFESTATION IN IMMUNOSUPPRESSED PATIENT WITH NEW DIAGNOSIS OF SYSTEMIC SCLEROSIS. Ciervo D. Vannucchi V. Antonielli E. Bacci F. Rocchi F. Degl'Innocenti G. Mancini A. Baroncelli S. Pieralli F. Nozzoli C Medicina Interna e d'urgenza AOU Careggi Firenze 18 DELIRIUM COME MARKER PRECOCE DI INTOSSICAZIONE DIGITALICA NEL GRANDE ANZIANO UN CASO CLINICO Boncinelli M. Pozzi C. Barghini E. Ambrosio ML. Gabbani L. Geriatria per la Complessità Assistenziale AOU Careggi Firenze 19 DIFFERENZE DI GENERE E RISCHIO CARDIOVASCOLARE Straniti M. Teghini L. Giovannetti R. Raimondi L. Pierotello R. Pugliese N. Panigada G. ASL3 Ospedale di Pescia 20 EFFECTS OF ENDOGENOUS SEX HORMONES IN MEN WITH DEEP VEIN THROMBOSIS Mazzi V. Masi L. Cei M. Mumoli N Ospedale Civile - UO Medicina 1 Livorno 21 ELEVATI VALORI DI CA72-4: DAL CASO CLINICO A REVIEW DELLA LETTERATURA Fabbri M. Casati C. Torrigiani A. Di Marzi G. Burberi L. Corradi F. Morettini A. Medicina Interna Firenze
5 22 FOURNIER S SYNDROME: A RARE COMPLICATION OF OFFICE BASED HEMORROIDAL PROCEDURE Crociani A. Antonielli E. Vannucchi V. Ciervo D. Degl'innocenti G. Mancini A. Luise F. Sammicheli L. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 23 IL DELIRIO NEL PAZIENTE CRITICO: PREVENZIONE, DIAGNOSI E TRATTAMENTO. Tanzi M.T. Cammelli R. Marini F. Sarti A. ASF Firenze 24 IL PERCORSO GESTIONALE DELLA PANCREATITE ACUTA NELL OSPEDALE DEL 3 MILLENNIO TRA INTENSITÀ DI CURA E ORGANIZZAZIONE DELLA RETE TERRITORIALE: SPUNTI DI RIFLESSIONE DA UN CASO CLINICO. Chiti I. Squillante R. Giovannetti R. Pantone C. Pierotello R. Pugliese N. Panigada G. ASL 3 Ospedale Pescia 25 IL SETTING ALTA COMPLESSITA AD EMPOLI: UNA REALTA INTERMEDIA TRA UNA SUBINTENSIVA E UNA DEGENZA ORDINARIA MA COMUNQUE UNA RISORSA PER L OSPEDALE. Chiarugi L. Manzi S. Lavecchia R. Dacomo D. Cinotti S. Lombardo G. U.O.C. Medicina Interna Empoli Setting Alta Complessità Empoli 26 IL TRATTAMENTO CON COLECALCIFEROLO È IN GRADO DI INIBIRE IL SISTEMA RENINA ANGIOTENSINA E MIGLIORARE LA FUNZIONE ENDOTELIALE IN PAZIENTE AFFETTI DA IPERTENSIONE ESSENZIALE ED IPOVITAMINOSI D Carrara D. Bruno R. M. Ghiadoni L. Gervasi F. Duranti E. Bacca A. Barzacchi M. Taddei S. Bernini G. Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa 27 IMPIEGO DELLA "MINI TROMBOLISI" NEL TRATTAMENTO DELL'EMBOLIA POLMONARE A RISCHIO INTERMEDIO Fabiani P. Anelli S. Bassi P. Caniggia D. Iurato A. Montorzi G. Querci F. Villani G. Ospedale di Portoferraio (LI) 28 INAPPROPRIATEZZA PRESCRITTIVA DI PPI IN MEDICINA: REVISIONE DELLA LETTERATURA E DATI PERSONALI Straniti M. Teghini L., Giovannetti R., Raimondi L. Pierotello R., Pugliese N., Panigada G. ASL3, ospedale di Pescia
6 29 INFEZIONE DA C. DIFFICILE CON RETTORRAGIA E MARCATA LEUCOCITOSI: DESCRIZIONE DI UN CASO CLINICO Vazzana N. Beltrame C. Taccetti G. Scarti L. Fortini A. SOC Medicina Interna, Ospedale S. Giovanni di Dio, Azienda Sanitaria Firenze 30 LA SORVEGLIANZA E IL CONTROLLO DEI MICRORGANISMI MULTIFARMACO RESISTENTI NELL'AZIENDA SANITARIA DI FIRENZE. Faraone A. Bartoli D. Brugnoli S. Picca F. Serpietri L. Vazzana N. Fortini A. SOC Medicina Interna, Ospedale S. Giovanni di Dio, Azienda Sanitaria Firenze 31 MI HA CHIAMATO SOLO ORA!!! Bertoni M. Giani A. Calabrese E. Siclari O. Di Natale M.E. U.O. Medicina Interna II. ASL 4 di Prato 32 MOSCHOWITZ STRIKES BACK Crociani A. Antonielli E. Vannucchi V. Ciervo D. Degl'innocenti G. Baroncelli S. Para O. Bacci F. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 33 NAO NEL PAZIENTE NEOPLASTICO? UN CASO CLINICO Lamanna D. de Palma A. Palma E. Cati G. Mazzi A. Quattrucci L. Alessandri M. UO Medicina Interna PO Massa Marittima 34 NEW ORAL ANTICOAGULANTS VERSUS WARFARIN FOR THE PREVENTION OF PERIPHERAL SYSTEMIC EMBOLISM IN ATRIAL FIBRILLATION: SYSTEMATIC REVIEW AND META-ANALYSIS Mumoli N. Mazzi V. Masi L. Sabatini S. Basile V. Cei M UO Medicina 1 - Ospedale di Livorno 35 OUTCOMES A LUNGO TERMINE DEL PAZIENTE CON ISCHEMIA CRITICA DEGLI ARTI INFERIORI: ILOPROST MIGLIORA LA SOPRAVVIVENZA E IL TASSO DI AMPUTAZIONE Meini S1. Melillo E2. Laureano R1. Panigada G3. 1 SOC Medicina Interna OSMA Firenze 2 UO Angiologia Università degli studi di Pisa 3 SOC Medicina Interna Ospedale di Pescia
7 36 PERCEZIONE E CONOSCENZA DEL PROBLEMA IPERTENSIONE ARTERIOSA Turchi G1 Faetti L1. Vagli E1. Mercantini F1. Burello E2. 1 Università degli studi di Siena 2 Università degli studi di Napoli 37 PERICARDIAL EFFUSION AND ANTILAMIN ANTINUCLEAR ANTIBODIES: AN UNUSUAL ASSOCIATION Mazzi V. Mumoli N. Mandolesi M.C. Occhipinti G. Cei M. Presidio Ospedaliero di Livorno 38 POLMONITE GRAVE ACQUISITA IN COMUNITÀ: OUTCOME ED INDICATORI PROGNOSTICI NEL PAZIENTE SOTTOPOSTO A VENTILAZIONE NON INVASIVA VERSUS TERAPIA CONVENZIONALE. Para O. Manni M. Mancini A. Pieralli F. Vannucchi V. Ciervo D. Crociani A. Degl'innocenti G. Antonielli E. Nozzoli C. Medicina Interna e D'Urgenza AOU Careggi Firenze 39 SIAMO SICURI DI CONOSCERE TUTTE LE CAUSE DI ANEMIA EMOLITICA? UN CASO NON COMUNE DI INFEZIONE DA CMV Chiti I. Alessandrì A., Checchi M., Squillante R. Raimondi L., Birindelli A, Pugliese N., Panigada G ASL 3 Ospedale Pescia 40 SINDROME DI GUILLAN-BARRÈ E RABDOMIOLISI: UNA CURIOSA ASSOCIAZIONE Seghieri M. Lodato M. Taddei M. Scuola di Specializzazione Medicina Interna Università di Pisa 41 STATINS DO NOT INCREASE BLEEDING RISK DURING VITAMIN K ANTAGONISTS TREATMENT FOR VENOUS THROMBOEMBOLISM: A RETROSPECTIVE COHORT STUDY Sabatini S. Riva N. Di Minno MND. Pomero F. Mumoli N. Ageno W. Dentali F UO Medicina 1 - Ospedale di Livorno 42 SUCCESSFUL TREATMENT OF A KLEBSIELLA PNEUMONIAE CARBAPENEMASE- PRODUCING SEPSIS WITH A DOUBLE-CARBAPENEM REGIMEN IN A VERY OLD MAN Mazzi V. Pardelli R. Mumoli N. Cei M. Presidio Ospedaliero di Livorno
8 43 UN CASO CLINICO COMPLESSO CARATTERIZZATO DA ESTESE E PROFONDE ULCERE CUTANEE LOCALIZZATE LI ARTI INFERIORI. Degl'innocenti D. 1^ U.O. Medicina Ospedale Prato 44 UN CASO DI COAGULAZIONE INTRAVASCOLARE DISSEMINATA ASSOCIATA ALL'USO DI SORAFENIB IN UNA DONNA AFFETTA DA EPATOCARCINOMA MULTIFOCALE IN CIRROSI EPATICA HCV CORRELATA. Lorenzini G. Spolveri S. Ospedale del Mugello Borgo San Lorenzo 45 UN CASO DI EMOFILIA ACQUISITA A COME MANIFESTAZIONE DI GVHD CRONICA IN UN PAZIENTE SOTTOPOSTO A TRAPIANTO DI CELLULE STAMINALI EMATOPOIETICHE CORDONALI TRATTATO CON RITUXIMAB. Bazzini C. Angarano R. Donnini I. Nozzoli C. Linari S. Crociani A. Rocchi F. Bacci F. Pieralli F. Guidi S. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze 46 UN CASO DI EMOFILIA ACQUISITA A IN UN PAZIENTE CON ARTRITE REUMATOIDE IN TRATTAMENTO CON ADALIMUMAB. Bazzini C. Galassi L. Agostino G. Lenzi A. Randisi P. Vagheggini F. Verdiani V. U.O. Medicina Interna, Ospedale Della Misericordia Grosseto 47 UN CASO DI LEISHMANIOSI VISCERALE. Tavernese G. Fortini A. Colasanti L. Fabbroni A. Contri S. Bribani A. SOS Medicina - Ospedale Serristori Figline V.no 48 UN CASO DI NEUROLUE ESORDITO CON DISTURBI PSICHICI. Lavecchia R.mChiarugi L. Schipani E. Lombardo G. U.O.C. Medicina Generale A.S.L. 11 Empoli 49 UN CASO DI PORPORA TROMBOTICA TROMBOCITOPENICA INDOTTA DA TICLOPIDINA Vazzana N. Taccetti G. Beltrame C. Scarti C. Calacoci L. Di Pietro G. Fortini A. SOC Medicina Interna, Ospedale S. Giovanni di Dio, Azienda Sanitaria Firenze 50 UN CASO PARTICOLARE DI GRAVE NEUTROPENIA. Chiarugi L1. Filippelli M1. Lavecchia R1. Tedici M2 Bartalucci P3. Lombardo G1. 1 U.O.C. Medicina Interna A.S.L U.O.C. Farmacotossicodipendenza A.S.L.11 3 U.O.C. Pronto Soccorso A.S.L.11
9 51 UN'IPOGLICEMIA COMPLICATA de Palma A. Lamanna D. Quattrucci L. Palma E. Cati G. Mazzi A. Alessandri M. UO Medicina Interna PO Massa Marittima 52 UNA CAUSA INUSUALE DI COMA : INFARTO TALAMICO BILATERALE Baruffi M.C. Nenci G. Amati R. Rosso A. Fortini A. SOC Medicina Interna, Ospedale S. Giovanni di Dio, Azienda Sanitaria Firenze 53 UNA DIFFICILE DIAGNOSI DI IPERTENSIONE ARTERIOSA. Fabiani P. Anelli S. Bassi P. Caniggia D. De Napoli V. Iurato A. Montorzi G. Querci F. Villani G. Ospedale di Portoferraio (LI) 54 UNA MIOSITE TUTTA DA INDAGARE. Cappelli F. Manetti S. Pascarella L. Rosi C. Stanganini S. Lombardini F. Santoro E. UOC Medicina Ospedale Casentino. Bibbiena 55 UNA SPADA DI DAMOCLE DEI NOSTRI GIORNI: LA REINTRODUZIONE DELLA TERAPIA ANTICOAGULANTE NEI PAZIENTI CON EMORRAGIA CEREBRALE SPONTANEA Chiti I. Bassu R. Raimondi L. Squillante R. Lucchesi I. Pugliese N. Panigada G. ASL3, Ospedale di Pescia 56 UNA STRANA DISFAGIA. Bazzini C. Romagnoli A.M. Scarpignato E. Rossi F. Panichi O. Camarda M. Verdiani V. U.O. Medicina Interna, Ospedale Della Misericordia Grosseto 57 UNO STRANO DOLORE DA ANALGESICO. Di Stasi V. Ferracane S. Casati C. Fabbri M. Cosentino E. Mannini D. Morettini A. Corradi F. Medicina Interna OACA 1 AOU Careggi Firenze 58 THE REVOLVING DOOR SYNDROME IN INTERNAL MEDICINE: A STUDY ON SUBJECTS DISCHARGED FROM ALL INTERNAL MEDICINE DEPARTMENTS OF TUSCANY WITH DIAGNOSIS OF HEART FAILURE AND PNEUMONIA. Tellini M. Petrioli A. Forni S. Fruttuoso S. Bernardini M. Morettini A. Medicina Interna OACA 1 AOU Careggi Firenze
10 1 A CASE OF ACUTE FORM OF SARCOIDOSIS, THE LOFGREN SYNDROME. Antonielli E. Crociani A. Vannucchi V. Ciervo D. Mannoni A. Fedeli L. Fintoni T. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze A 49 years old men was admitted to our hospital for fever associated with hands, wrists and ankles joints arthralgia present for about 15 days. He had no respiratory symptoms. On physical examination showed mild swelling and tenderness in both ankle, tender red bumps was noted over bilateral lower limbs. Body weight loss around 7 kg was noted in the last month. Laboratory studies included a complete blood count, plasma levels of creatinine, nitrogen, electrolytes, calcium, liver enzyme, tumor markers were within normal limits. Serum angiotensin converting enzyme and chitotriosidasis were within the normal range. He was negative for rheumatoid factor, anti-cyclic citrullinated peptide and antinuclear antibodies. A chest radiograph showed bilateral hilar mass lesion. A chest TC scan revealed bilateral hilar and multiple mediastinal lymphadenopathy. On abdomen TC scan spleen is enlarged. A bronchoscopy with endobronchial transbronchial needle aspirate (TBNA) of the hilar lymph nodes was performed with sampling for bacterial culture and cytology resulting negative. A fluorodeoxyglucose-positron emission tomography showed hypermatabolic lesions at the upper lung lobe, at the level of paratracheal, mediastinal and hilar lymphnodes. An excisional lymphonode biopsy was performed and the results of histology demonstrated a non caseating granuloma wich suggested a diagnosis of Lofgren s Syndrome. Oral administration of prednisolone was initiated and symptoms gradually subsided. Sarcoidosis is a chronic multisystem inflammatory granulomatous disease with unknown etiology characterized by the presence of non caseating granulomas in affected organs. Lofgren s syndrome is a benigne, acute, self limiting form of sarcoidosis characterized by the association of erythema nodosum or polyarthralgia or polyarthritis and bilateral hilar lymphadenopathy. Sarcoidosis can be difficult to diagnose because the disease produces few signs and symptoms in early stage and when they occur, they can mimic those of other diorders, expecially lymphoproliferative disorders. Serum ACE levels as a diagnostic test is limited (sensitivity 60%, specificity 70%). In literature is reported higher sensitivity (88%) and specificity (92%)of chitotriosidase as a marker of active sarcoidosis, although in our case the results were not significant. The chest radiographic findings has various diagnostic reliability (accuracy of 98% in stage I, 89% in stage II, low in other stage). Chest TC scan has very high sensitivity, but low specificity for detecting sarcoidosis. In conclusion, a biopsy with histopatological exam is essential to confirm a diagnosis of Lofgren syndrome and rule out other causes of bilateral hilar lumphadenopathy.
11 2 A CASE OF ACUTE HAEMORRHAGIC ALVEOLITIS CAUSED BY INTRAVESICAL BACILLUS CALMETTE-GUÉRIN INSTILLATION. Antonielli E. Vannucchi V. Crociani A. Ciervo D. Degl'Innocenti G. Turchi V. Mancini A. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi, Firenze We report a case of a 80-year-old man who presented to our emergency department for high fever (39 C), hematuria and dyspnea four hours after intravesical administration of Calmette-Guérin bacille (BCG) for a superficial bladder cancer. The patient already underwent two cycles of instillation. He developed hypoxemic respiratory failure with diffuse alveolitis at chest CT scan. Leukocyte count was 5.06 X 10^9/L, liver function test revealed aspartate aminotransferase 189U/L (15-37 U/L) and alanine aminotransferase 113 U/L (30-65 U/L). Search for Legionella and pneumococcal urinary antigen and sputum staining for Mycobacterium Tubercolosis were negative. A bronchoscopy revealed diffuse alveolar hemorrhage. The analysis of the bronchoalveolar lavage (BAL) fluid was negative for Mycobacterial species, pneumocystis jirovecii, and other bacterial and viral infection. The nasopharingeal swab for H1N1 was negative as well as results of galactomannan in serum and BAL. Empiric antibiotic treatment was started with no benefits. There was a rapid and significant clinical and radiological improvement with pulsed bolus of steroids and i.v. Immunoglobulins. A control of the computed tomography of the chest revealed multiple ground-glass opacities on both lung fields. Search for autoantibodies (i.e. ANCA, GBM) turned negative as well as BAL cytology. We supposed that a diagnosis of hypersensitivity interstitial pneumonitis with hemorrhagic alveolitis was the most fitting with the clinical picture. In literature there are few reports on hypersensitivity pneumonitis (HP) following intravesical instillation of BCG and none with hemorrhagic alveolitis. HP is explained by a hypersensitivity phenomenon following, usually, traumatic instillation of BCG. Hypersensitivity pneumonitis (HP) is a rare immunologically mediated lung disease caused by repeated exposition of organic antigens and should be considered in patients with acute respiratory symptoms with onset soon after immunotherapy with BCG.
12 3 A CASE OF DEADLY ACUTE LIVER FAILURE DUE TO DEATH CAP. Antonielli E. Crociani A. Vannucchi V. Ciervo D. Degl'Innocenti G. Fedeli L. Fintoni T. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze On august 8th a 74-year-old female was admitted to the emergency room with nausea, vomiting, and diarrhea. She reported ingesting non commercially sold mushrooms with other members of the same family, at a common Sunday lunch nearly 96 hours earlier. No other member reported GE symptoms. Her past medical history was relevant only for hypertension. She lived alone and she did not consume alcohol, and she did not use any medication. On admission vital signs were normal, her physical examination was unremarkable except for dehydration. Arterial blood gas analysis was normal. There were laboratory signs of hepatitis. After starting fuid replacement she was admitted to our Internal Medicine Unit. On the next morning hepatitis B surface antigen, hepatitis B core antibody, immunoglobulin M, and antihepatitis C antibody were found to be nonreactive. A hepatitis B virus DNA analysis was performed using the polymerase chain reaction and was negative. After carefully reviewing her history appeared evident that, on Sunday dinner, she alone ate mushrooms deemed to be amanita cesarea ( Cesar s mushroom ), but advised with caution from the mushroom picker to throw it away. On the second day amanituria turned positive. Along with lab signs of worsening hepatic failure, she developed hypotension and confusion. The regional referral center for liver transplantation was consulted, but unfortunately for her advanced age, despite a good performance status previous to admission and the low index of comorbidity, the patient was deemed unsuitable for the procedure. She was then transferred to Intensive Care Unit where she was intubated and supported in vital functions, as well as started venousvenous hemofiltration with MARS filters and plasma exchange. After 7 days of hospital admission she died. Mushroom poisoning is a relatively rare cause of acute liver failure. Amanita phalloides (death cap) is the most common and fatal cause of mushroom poisoning. Many illustrious deaths in the history are attributed to this mushroom commonly named death cap. One of the most popular is the death (or assassination?) of the Holy Roman Emperor Charles VI; as stated by the french illuminist Voltaire as dish of mushrooms changed the destiny of Europe." Death cap, that can be confused with Cesar s mushrooms, contains amanitins, which are powerful hepatotoxins that inhibit RNA polymerase II in liver. This process is characterized by an asymptomatic incubation period followed by the gastrointestinal and hepatotoxic phases which rapidly progress to multiorgan failure and eventually death in most cases. One option of effective treatment is plasmafiltration with dedicated filters (i.e. Molecular Adsorbents Recirculating System MARS). It is a procedure that offers some advantage when started soon after toxic mushrooms ingestion in order to avoid or as a bridge to liver transplantation. This case is relevant since it points out two special aspects of acute liver failure due to Amanita phalloides ingestion. One is the needing of a repeated careful history taking; the second one is the needing of a basic medical culture on edible mushroom micology.
13 4 A CASE REPORT OF ACQUIRED HEMOPHILIA A Manetti S. Cappelli F. Rosi C. Stanganini S. Santoro E. AUSL8 Arezzo Bibbiena Background: acquired hemophilia A (AHA) is a rare autoimmune disorder, caused by circulating auto-antibodies against factor VIII (FVIII), that results in inhibition of FVIII coagulant activity. The incidence is approximately 1 per million/year and related mortality rate is more than 20%. In 50% of cases it happens in patients with medical conditions such as postpartum, autoimmune disorders, underlying hematologic or solid cancers, infections, vaccination and use of medications. Two primary goals are: emergency management with bleeding control and inhibitor elimination, as long term therapy. Case Report: we admitted a 58 years old woman, with history of multiple sclerosis, with severe anemia caused by multiple hematomas and bruising after minor trauma; about 6 months before, she had needed hospitalization in other hospital for severe abdomen hemorrhage during heparin prophylaxis, requiring embolization of her right internal iliac artery. In the Emergency Department her blood tests revealed hemoglobin of 6,4 g/dl and prolongation of PTT (56 sec). After 3 packed red blood cell replacement and plasma infusion, hemoglobin value was 9.0 g/dl and there wasn t any improvement in PTT (58 sec). The history of new-onset bleeding diathesis with PTT prolongation, without correction with plasma replacement and history of autoimmune disease put clinical suspicion of acquired hemophilia. Laboratory tests confirmed low FVIII levels (1,2%) and presence of antibodies against factor VIII (FVIII) with low titer (3,5 U/mL Bethesda). Clinical picture showed stability therefore it was not necessary to use specific haemostatic agents such as bypassing agents (recombinant factor VIIa and activated prothrombin complex concentrates), usually useful for patient with high titer of inhibitors, or administration of FVIII concentrates, usually required for patients with low titer of inhibitors, to control bleeding. After consultation of the main Center of Tuscany (Careggi Hospital), we started prednisone therapy 1 mg/kg/die and we observed a progressive reduction of PTT and after a week PPT was normalized (33 sec), FVIII was 15,9% and inhibitors titer decreased to 1,7 U/mL. Conclusion: acquired hemophilia A is an uncommon cause of bleeding diathesis but prompt diagnosis is necessary to treat specifically life-threatening bleeding and to begin immunosuppressive therapy to eradicate FVIII inhibitors.
14 5 A DANGEROUS POLYARTHRITIS Vannucchi V. Ciervo D. Degl'Innocenti G. Antonielli E. Crociani A. Rocchi F. Fintoni T. Fedeli L. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze Venous thromboembolism represents a complication of systemic inflammatory diseases. Acute rheumatic disease (ARF) is a severe and sometimes overlooked disease involving heart, joints, skin and central nervous system. We report a rare case of pulmonary embolism in a patient with ARF. A 45 year-old italian man was admitted in our ward for sudden onset dyspnea, fever and painful migrant polyarthritis, involving hands, wrists and knees joints. He referred recurrent pharingitis over the last 2 months treated with extendedspectrum antibiotic therapy. On examination he was tachypnoic with bibasilar crackles and severe hypoxic-hypocapnic respiratory failure; joints of wrists and knees appeared swelling and warmth with a severe limitation of motion. A CTscan revealed a sub-massive pulmonary embolism. An anticoagulant treatment was started. Considering the severe joint involvment an extended blood test panel was performed revealing elevated levels of C-reactive protein and erythrocyte sedimentation rate associated with high-titer of antistreptolysin-o antibodies and cryoglobulines. Throat culture was negative for streptococcal infection. Lupus anticoagulant (LA) was positive but antiphospholipid antibodies were negative as well as the research for congenital thrombophilic mutations. The echocardiogram exam excluded a cardiac involvement, showing a normal left ventricular systolic function and absence of valvular defects. According with Jones criteria a diagnosis of ARF was performed and an appropriate antibiotic therapy was started with a rapid improvement of polyarthritis. Pulmonary embolism represents a rare complication associated with ARF. Systemic flogosis, cryoglobulines and LA positivity seem to be the major risk factors in this case.
15 6 A DILEMMA IN DIAGNOSIS: PRIMARY HEPATIC LYMPHOMA Degl'Innocenti G. Ciervo D. Vannucchi V. Crociani A. Rocchi F. Bacci F. Biagioni M.C. Para O. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze Primary hepatic lymphoma (PHL) is an extremely rare malignancy, accounting for less than 0.4% of extranodal non- Hodgking lymphomas and 0.016% of all non-hodgking lymphomas. The majority of PHL case originate from B cells while T-cell lymphoma is less common. The etiology of PHL is unknown and although the liver contains lymphoid tissue, host factors seem to make the liver a poor environment for the development of malignant lymphoma. We report a case of a 70-year old woman with a history of previous (5 years ago) latero-cervical lymphoma with negative follow-up. 1 month before admission she had taken nimesulide for several days for low back pain. Ten days later she was admitted to the emergency room for jaundice: abdomen Doppler ultrasound and abdomen computed tomography (CT) resulted negatives and liver damage was attributed to drugs (nimesulide); so she was discharged. For the persistent of icterus and further increase of bilirubin levels (predominantly direct share) she was admitted to our department. She had also increased level of cholestasis indices and serology for human immunodeficiency (HIV), Hepatitis C (HCV), and hepatitis B (HBV), Ebstein Barr virus (EBV) and Citomegalo-virus (CMV) resulted negatives. Tumor markers and autoantibodies specific for the liver and bile ducts resulted negatives. A supplemental colangio-mri showed mild enlargement of the main bile duct. It was performed hepatic biopsy that resulted positive for hepatic lymphoma originate from B cells and, after haematologist evaluation, she began chemotherapy.
16 7 A RARE CAUSE OF HYPERCALCEMIA IN A YOUNG WOMAN: THE PRIMARY LYMPHOMA OF THE BONE. Para O. Crociani A. Antonielli E. Panigada G. Fintoni T. Fedeli L. Biagioni MC. Manni M. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze Clinical case: a 26 years-old woman presented to our department to persistence by about 15 days of nausea, vomiting, epigastric discomfort and high fever. The patient had not relevant clinical history in the past. She had family history of primary hyperparathyroidism (mother affected by parathyroid adenoma). For about a month she referred lumbar pain in the absence of radiological changes treated with NSAIDs with little benefit. At admission to our department high values of serum calcium (14.5 mg / dl) with normal serum parathormone level were found in blood. An abdominal echography showed obstructive hydro-ureteralnephrosis. The physical examination didn t show hepato-splenomegaly or lymphadenopathy. A chest-abdominal CT scan showed diffuse osteolytic lesions in the spine, pelvis and femur. On blood tests microcytic anemia, ferritin values within the limits and high values of vitamin B12 were present. Absence of M component in serum or urine, protein electrophoresis, immunofixation, Bence-Jones proteinuria and free light chains value excluded a multiple mieloma. In view of the family history of parathyroid adenoma with hyperparathyroidism, we performed neck ultrasonography and parathyroid 99mTc-MIBI planar scintigraphy that resulted normal. The curve of PHT has however showed a trend within the physiological limits. Urinary electrolytes (calcium, magnesium, sodium, potassium) were normal. We found mild vitamin-d deficiency. Autoantibody were negative. Mammography and breast ultrasound didn t show pathological findings. Tumor biomarkers and immunophenotype examination were normal. A total-body PET revealed the presence of diffuse bone lesions with different degrees of metabolic activity in absence of extra-osseous sites of uptake. In the suspicion of Paget s disease were also assayed urinary pyridinoline that found within limits. Vertebral biopsy was unrevealing. During hospitalization hypercalcemia was resistant to medical treatment with marked neurological symptoms. In consideration of the persistent hyporigenerative microcytic anaemia in the absence of active bleeding (EGS negative, absence of macroscopic bleeding) we performed bone marrow biopsy that showed large B-cell lymphoma indicative of primary lymphoma of the bone (CD45 +, CD20 +, CD10 + weak, CD3-, CD5-, Tdt-, CD30-, ALK1-, CD56-). Serology for CMV, EBV, HIV and hepatitis viruses were negative. The patient was therefore transferred to the Hematology Department where she began chemotherapy (CHOP), which is currently in progress. Discussion: Primary lymphoma of the bone (PLB) primarily arising from the medullary cavity is an extremely rare entity, with only retrospective studies and sporadic cases reported in the literature. The cause of PLB is not well-known now, however, viral infection, immunodeficiency, organ transplantation, Paget s disease of the bone and inherited factors have been identified as possible causes in the process; although this has only been found in retrospective studies. The majority of PLB patients are >45 years of age and there is a slight male preponderance, with a male to female ratio of 1.2:1.8. Involvement of any region of the skeleton is possible, however, a trend exists in favor of the long bones with persistent bone marrow PLB has an improved prognosis compared with other bone malignant tumors, such as osteosarcoma or secondary lymphoma of the bone. A younger age has also been identified as an independent predictor of survival. PLB is a distinct clinicopathological entity with a relatively homogeneous morphology and clinical behavior, and is usually of B-cell type. PET-CT is of great importance in evaluating CR, and patients with PLB treated with combined modality therapy have been found to exhibit a superior outcome compared with those treated by single modality therapy.
17 8 A STRANGE CASE OF ANCA-ASSOCIATED VASCULITIS: CAN MYCOBACTERIAL INFECTION DELAY THE DIAGNOSIS? Ciervo D. Antonielli E. Vannucchi V. Crociani A. Casati C. Mancini A. Innocenti R. Para O. Degl'Innocenti G. Pieralli F. Nozzoli C. Medicina Interna e d'urgenza AOU Careggi Firenze According to Chapel Hill Consensus Conference, microscopic polyangiitis (MPA) is defined as a systemic, necrotizing, non granulomatous vasculitis with few or no immune deposits, affecting small vessels. It is an autoimmune disease in which antineutrophil cytoplasmic antibodies (ANCA) play an important pathogenetic role presenting in 95% of patient: 70% are directed against MPO and 30% against PR3. This kind of vasculitis affects renal and pulmonary small vessels even if other organs can be involved such as gastrointestinal tract and Central nervosu system. Recent studies showed P-ANCA positivity also in non vasculitic disease such as chronic infections especially in Mycobacterial ones. We present the case of E.M.P, a 53 years old peruvian woman, admitted to our general ward for frontal headache associated with vomit without neurogical difects. A CT brain scan showed frontal cerebral bleeding with subaracnoideal hemorrhage so we performed an angiografphic study that was negative for cerebral vascular malformations. Laboratory testing showed acute oliguric renale failure with serum creatinine 4,2 mg/dl (vs 1.7 mg/dl two months before), nefritic urinary deposit and non nefrosic proteinuria (2.132 mg/24h). In her past clinical history, patient referred a renal BK infection succesfully treated with left nefrectomy and antimicrobial therapy. So we performed microbiological test (colture, genic amplification for BK and Quantiferon) that were negative per BK infection and thoracic-abdominal CT that was negative for pulmonary or renal tubercolosis relapse. Because of the renal function rapid deterioration (Serum creatinine 5.65 mg/dl) we performed an ultrasound exam, negative for urinary obstruction and laboratory tests that showed ANCA positivity (MPO 431 UI/mmL). Renal biopsy was not possibile because of patient s clinical condition. An ANCA-associated vasculitis was susptected so we started specific therapy with plasmapheresis, high dose steroids and rituximab with gradual renale function improvement. Recent studies showed the P-ANCA positivity also in non vasculitis disease such infections especially in Mycobacterial ones. In patients affected by TB: above 52,4% had P-ANCA positivity; of theese 47,6% showed anti-mpo and 28,6% anti-pr3. The low specificity of P-ANCA autoantibodies in that contenxt suggests that treatment decision should be focused non only on the result of ANCA test but also on the clinical features and over all on hystological biopsy which is the gold standard for an appropriate diagnosis.
18 9 ACCURACY OF NURSE-PERFORMED LUNG ULTRASOUND IN PATIENTS WITH DYSPNEA: A SINGLE-CENTRE PROSPECTIVE OBSERVATIONAL STUDY Masi L. Cresci A. Basile V. Sabatini S. Cei M. Bianchi L. Mazzi V. Mumoli N UO Medicina 1 - Ospedale di Livorno Several studies have recently shown that lung ultrasound (LUS) hold a reliable and easy evaluation of pulmonary congestion by assessment of B-lines; the aim of this study was to assess the diagnostic accuracy of nurse-performed LUS in the differential diagnosis of dyspnea. We prospectively evaluated all consecutive inpatients referred for dyspnea from April 2014 to September All patients underwent LUS, first by trained nurses and then by physicians expert in chest ultrasonography, with every group blinded with respect to each other. Interobserver agreement and accuracy of nurse-performed LUS were calculated, considering the physician's final diagnosis as the reference test. 175 nurse-performed LUS were included in the study. Nurse-performed LUS demonstrated sensitivity of 93.7% (95% CI ) and specificity of 98.7% (CI ), a positive predictive value of 99.2% (CI ) and a negative predictive value of 97.3% ( ). Correlation with the physician was good (r = 0.89). This preliminary report demonstrates that nurse-performed LUS achieved similar accuracy to physician-performed LUS. This approach could resolve some shortage problems in geographical areas or in times of economical constraints, where the availability of a trained physician is limited. Moreover, it should therefore be considered for routine use as part of the nurse triage in the emergency department for patients admitted with respiratory symptoms. Prospective studies with greater patient numbers would be valuable.
19 10 ACUTE INTERMITTENT PORPHYRIA Basile V. Brondi B. Cresci A. Mumoli N UO Medicina 1 - Ospedale Livorno Introduction: Acute intermittent porphyria (AIP) is a hereditary disorder resulting from a partial deficiency of the heme biosynthetic pathway. Since biochemical measurements of patients and their healthy relatives overlap, the diagnosis of AIP may remain undetermined at the symptom-free phase. During an acute attack, which includes various neurovisceral symptoms, measurement of urinary porphobilinogen is a method of choice to confirm diagnosis. Clinical case: A 75-year-old woman with recent urinary infection presented with recurrent acute abdominal pain, vomiting, weakness and confusion. She also had orthostatic hypotension and bradycardia. Her medical and family history was unremarkable and she taking no medication. Physical examination showed no abnormalities except for moderate quadriparesis and abnormal behaviour with hallucinations. When a urinary catheter was placed, dark and reddish urine was drained and urinalysis showed no hematuria or pyuria. A diagnosis of AIP was confirmed by increased urinary excretion of porphobilinogen. She was treated with hematin and an adequate calorie intake and symptoms resolved in 2 days. Comments: AIC is a rare autosomal dominant metabolic disorder of the heme synthesis due to deficiency of porphobilinogen deaminase enzyme; it show low penetrance and thus might not appear in every generation. Clinical manifestations vary and consist of abdominal pain, peripheral neuropathy, orthostatic hypotension and mental disturbances and a high index of clinical suspicion is important to avoid delayed diagnosis. Drugs, alcohol, fasting, stress and infection are the most common precipitants of the acute attack.
20 11 AUDIT CLINICO COME STRUMENTO EFFICACE NEL MIGLIORAMENTO DELLA DIMISSIONE DEL PAZIENTE DIABETICO DALLE UO DI MEDICINA INTERNA Montagnani A. in rappresentanza del Gruppo DDIMA U.O. Medicina Interna, Ospedale Misericordia USL 9 Grosseto Il paziente diabetico rappresenta una significativa percentuale dei pazienti dimessi dalle Medicine Interne Ospedaliere ed il miglioramento della qualità delle cure offerte è un campo di sfida quotidiano. Lo scopo del presente studio è stato quello di condurre un Audit Clinico al fine di evidenziare le potenzialità di miglioramento ed implementare gli strumenti al fine di ottenere un progresso nella qualità assistenziale dei pazienti diabetici. L Audit Clinico è stato strutturato in 5 fasi: 1. Preparazione (selezione dei topic, definizione clinica delle domande, selezione dell evidenze, ecc ); 2. Definizione dei criteri, indicatori e standards; 3. Raccolta retrospettiva dei dati; 4. Analisi dei dati, identificazione dei maggiori discostamenti dagli standards; 5. Implementazione delle misure correttive; 6 raccolta dei dati post-implementazione. E stato condotto uno studio multicentrico, che ha coinvolto 20 Unità Operative di Medicina Interna nella I fase e 13 nella II fase, da almeno 10 Regioni Italiane. La documentazione clinica è stata raccolta retrospettivamente ottenendo informazioni da 1332 e 1052 dimissioni di pazienti diabetici, rispettivamente nella I e II fase del progetto. Risultati I fase vs II fase: Indicatore 1 (Ind1): N pazienti che ricevono informazioni sul controllo glicemico/pazienti dimessi (41,59 % vs 69,49 %; + 27,90 %) Indicatore 2 (Ind2): N Pazienti che ricevono istruzioni sul trattamento dell ipoglicemia/ pazienti dimessi (32,37 % vs 72,34 %; +39,97 %) Indicatore 3 (Ind3): N Pazienti che ricevono istruzioni sulle modalità di somministrazione sottocutanea dell insulina/ pazienti dimessi (60,42 % vs 80,50 %; +20,08 %) Indicatore 4 (Ind4): N Pazienti che ricevono uno schema o almeno consigli alimentari/pazienti dimessi (24,77 % vs 70,82 %; +46,04 %) Indicatore 5 (Ind5): N Pazienti con iperglicemia nota o nuova a cui viene dato un appuntamento ambulatoriale in lettera di dimissione/pazienti dimessi (60,66% vs 84,89%; +24,23%) Indicatore 6 (Ind6): N Pazienti con HbA1c riportata in lettera di dimissione/ pazienti dimessi (40,62 % vs 73,00 %; +32,39 %). L Audit Clinico, dopo aver consentito l identificazione delle carenze dei comportamenti clinici nella dimissione dei pazienti diabetici dalle UO di Medicina Interna italiane, ha permesso di ottenere i miglioramenti potenziali identificati dall elaborazione sistematica delle LG internazionali e nazionali. Al fine di stabilizzare questi significativi progressi dovrà seguire una continua azione di controllo e feedback standardizzando quei comportamenti che determinano una maggiore qualità di cura del paziente diabetico dimesso dall ospedale.
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