Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine

ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20

Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine To cite this article: (2014) Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine, Acta Clinica Belgica, 69:sup3, S4-S26, DOI: 10.1179/0001551214Z.000000000149 To link to this article: http://dx.doi.org/10.1179/0001551214Z.000000000149

Published online: 25 Nov 2014.

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Date: 21 March 2016, At: 20:45

Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine 12-13 December 2014 – Auditorium Brouwer, Medical Campus Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels

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Oral Presentations O19 Impact of hyponatremia on muscular strength and on the Timed-Up-and-Go test Yannick Gombeir, Fre´de´ric Vandergheynst, Guy Decaux

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O08 The influence of chronic kidney disease on gut microbial metabolism Ruben Poesen, Karen Windey, Pieter Evenepoel, Vicky De Preter, Kristin Verbeke, Bjo¨rn Meijers

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O21 Intravascular lymphoma: A retrospective monocentric observational analysis and review of literature Dorothee Gullentops, Steven Vanderschueren, Olivier Gheysens, Thomas Tousseyn, Gregor Verhoef, Daan Dierickx S5 O35 The implementation of latent tuberculosis screening in Belgium’s AIDS reference centers: a questionnairebased survey Chloe´ Wyndham-Thomas, Kinda Schepers, Violette Dirix, Jean-Christophe Goffard, Franc¸oise Mascart, Jean-Paul Van Vooren S5 Poster Presentations P01 Splenic Infarction: a retrospective study on a forgotten organ Xavier Vandemergel

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P02 Osteonecrosis of the jaw in a patient on Denosumab. A case report. Celine Cornil, Dragos Ilisei, Sophia Abdel Kafi, Xavier Vandemergel

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P03 A potentially fatal phosphate diabetes induced by Ferrum Carboxymaltose administration. A case report. Franc¸ois Simon, Dragos Ilisei, Sophia Abdel Kafi, Xavier Vandemergel S7 P04 Chronic fatigue syndrome. Look at the phosphate! Franc¸ois Simon, Xavier Vandemergel

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P05 PI3-kinase inhibition does not affect human plasmacytoid dendritic cell activation by low molecular weight ligands of toll like receptor 7 Julie Callenaere, Stanislas Goriely, Se´verine Thomas, Fabienne Willems S8 P06 Severe hyperthermia after Intravenous Ferric Carboxymaltose (InjectaferH ) administration Claudia Motosan, Myriam El amine, Pierre Mols, Ahmed S. E. Ramadan

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P07 Prevalence of hyperlipidaemia in HIV-infected patients on Protease Inhibitors at selected HIV- clinics in the Cape Metropole region Pierre Mugabo S8 P09 Smoking cessation can kill Emmanuelle Alaluf, Rene´ Colassin, Michel Vanhaeverbeek

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P10 Fever of unknown origin (FUO) in an elderly patient: a case of lymphatic tuberculosis Johan Clukers, Greta Moorkens, Erik Van Bouwel, Jos Callens, Jan Teuwen

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ß Acta Clinica Belgica 2014

Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine

P11 An innocent kiss Katrien Clotman, Anke Verlinden, Alain Gadisseur, Philippe Jorens, Greta Moorkens

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P12 Dyspnea and non-productive cough in a patient with rheumatoid arthritis Els Gielis, Jan Van Offel, Greta Moorkens, Luc De Clerck

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P13 Effectiveness of Telemedicine-guided home blood pressure and 24h-ambulatory monitoring in assessing blood pressure and blood pressure control Xavier Galloo, Patricia Van der Niepen S10 P14 Anemia and Aortis stenosis. Don’t forget the Heyde’s Syndrome Celine Cornil, Xavier Vandemergel, Sophia Abdel Kafi, Dragos Ilisei

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P15 Fever of unknown origin in the HIV-infected patient Lynn Gers, Luc Colemont, Robert Rutsaert

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P16 Infections complicating treatment in Goodpasture’s disease: a case report Tim De Weerdt, Mark Helbert, Johan Verhelst, Greta Moorkens

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P17 Acute renal failure in light-chain myeloma Katrien Leyssens, Kalung Wu, Greta Moorkens, Tom De Beukelaar

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P18 Complications after endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): an illustrated case of a broncho-mediastinal fistula. Miche`le Compagnie, Jacques Lecomte, Alain Van Meerhaeghe S13 P20 From diarrhea to dyspnea Annemie Jacobs, Walter Droogne, Hans Jacobs, Paul Herijgers

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P22 Lower limb swelling after a tropical stay Lukas Van Duffel, Jan Van Offel, Greta Moorkens, Luc De Clerck

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P23 Characteristics, treatment and prognosis of primary central nervous system lymphoma: a single center retrospective study Anke Van Mellaert, Liesbeth Smets, Philippe Demaerel, Gregor Verhoef, Paul Clement, Daan Dierickx S14 P24 Uncommon gastrointestinal manifestations of long-term cannabis use Gae¨lle Leemans, Ellie Senesael, Rembert Mertens, Sabine Allard, Patrick Lacor

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P25 Liver abscess caused by Klebsiella pneumoniae: a distinct clinical entity to be considered in diabetic patients presenting with fever and gastro-intestinal complaints. Esther Scheirlynck, Rembert Mertens, Lucie Seyler, Sabine Allard, Patrick Lacor S15 P26 Leptospirosis: an Atypical Presentation C. B. A. Seghers, E. Vlieghe, V. Siozopoulou, J. L. Bosmans

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P27 Sarcoidosis: three different stories Yentl De Roeck, Inge Hantson, Sebastien Anguille, Greta Moorkens, Robert Rutsaert

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P28 Vogt-koyanagi-harada syndrome: literature review and presentation in a university hospital. Liza Sels, Liesbet Henckaerts

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P29 De novo thrombotic microangiopathy after non-renal solid organ transplantation Annelies Verbiest, Jacques Pirenne, Daan Dierickx

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P30 5-Oxoproline-induced high anion gap metabolic acidosis: case report Jaderi Zahra, Johan Flamaing

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P31 Cardiotoxicity after radiation therapy Thalia Bekelaar, Anne Vorlat, Greta Moorkens, Christiaan Vrints

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P32 Black pleural effusion Virginie Mercier, George Tragas, Rudy Peche, Olivier Gilbert, Alain Van Meerhaeghe

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P33 Metastatic malignant melanoma: don’t forget the surgeon! Felix De Bie`vre, Pol Specenier P34 Metastatic Renal Cell Carcinoma: don’t forget surgery Elisa Cassiers, Pol Specenier P36 Wasting away Sam Proesmans, Christiane Brands, Hans Slabbynck, Jan Nagler, Joannes Holvoet

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P37 Legionella pneumophila pneumonia followed by Hemophagocytic Lymphohistiocytosis: a case report Michael Janssens, Sebastien Anguille, Sofie Rosier S20 P38 Cowden Syndrome: a novel PTEN mutation description and how to recognize a not-so-rare Hereditary Cancer Syndrome Pauline Delannoy, Guillaume Franc¸ois Debray, Albert Beckers, Hernan Valdes-Socin S21 P39 Tissue is the issue Elien Dewaele, Jan Van den Brande, Pol Specenier

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P40 Overwhelming pneumococcal infection in a previously healthy adult: the fatal case of a missing organ. Joke Cuypers, Liesbet Henckaerts S22 P41 A Case of von Meyenburg complex-associated cholangitis Kirsten Saevels, Luisa Vonghia, Michae¨l Torfs, Ann Driessen, Greta Moorkens

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P42 Adrenocortical Carcinoma Presenting with full blown Cushing Niels Bochanen, Marcel Twickler, Luc Van Gaal

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P43 An unusual cause of perimyocarditis Gaelle Vermeersch, Paul Vermeersch, Greta Moorkens, Hans Slabbynck

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P44 Cardiovascular risk evaluation of HIV-infected patients in a case-control study: comparison of the D:A:D and Framingham equations Samuel Markowicz, Marc Delforge, Coca Necsoi, Ste´phane De Wit S23 P45 Hypercalcemia in an old man Sofie Geth, Vanessa Helsen, Rozette Verbiest, Jef Schurmans

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P46 Infectious mononucleosis, a common disease with uncommon complications Pieter-Jan Van Gaal, Louis Verbist

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P47 Clinical evaluation of patients with apparently idiopathic SIADH A. Soupart, G. Decaux, M. Coffernils, I. Nyenyeli, F. Gankam, B. Couturier, F. Vandergheynst, D. Franc¸ois S25 P48 Association of absolute lymphocyte count, neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios with mortality in chronic hemodialysis patients: a retrospective single-center cohort study Elikyah Esther Kayembe, Dieter De Clerck, Christian Tielemans, Patricia Van der Niepen, Jacques Sennesael, Dirk Van Ingelgem, Rene Scheepmans, Karl Martin Wissing S25 P49 Familial hypercholesterolemia: among patients with a very high cholesterol level, does the presence of a genetic mutation lead to an extra cardiovascular risk? Justine Vereeke, Olivier S. Descamps S26

Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine

Oral Presentations

O19 Impact of hyponatremia on muscular strength and on the Timed-Up-and-Go test Yannick Gombeir1, Fre´de´ric Vandergheynst1, Guy Decaux1 1



Hopital Erasme, Bruxelles, Belgium

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Introduction: Hyponatremia is the most common electrolyte disorder encountered both in hospitalized and ambulatory patients. It is associated with an increased risk of gait disorders, fall and fracture. This study aims to evaluate the impact of hyponatremia on muscular strength and on the Timed-Up-and-Go test which is used to evaluate the risk of fall in geriatric patients. Methods: 10 patients (66.6621.8 years) were recruited in this prospective study. All of them presented an asymptomatic chronic hyponatremia due to SIADH (127.762.7 meq/L). Three tests were performed in hyponatremia and after correction of the electrolyte disorder. The tests measured the hand’s strength with the Grip test (N59), the quadriceps’ strength (N55) and the Timed-Up-and-Go test (N510). Results: With regard to evalution of muscular strength, we did not observe any significant difference for the Grip test (19.7168.90 kg in hyponatremia vs 19.7969.47 kg in normonatremia; p50.906) as well as for the quadriceps’ strength (67,72638,92 N in hyponatremia vs 68,5640,45 N in normonatremia, p50,723). Conversely, for the Timed-Up-and-Go test there is a significant reduction of the time needed to perform the test after correction of hyponatremia (14.3064.81 seconds in hyponatremia vs 12.1264.56 seconds, in normonatremia; p50.006). Conclusion: Whereas there is no impact of hyponatremia on muscular strength, we observed for the first time a reversible perturbation of an easy-to-do, fall risk predicting test in chronic asymptomatic hyponatremic patients. We believe that this finding is a of clinical relevance and represents an another argument to treat moderate asymptomatic hyponatremia.

O08 The influence of chronic kidney disease on gut microbial metabolism Ruben Poesen1, Karen Windey1, Pieter Evenepoel1, Vicky De Preter1, Kristin Verbeke1, Bjo¨rn Meijers1 1

University Hospitals Leuven, Leuven, Belgium

Introduction: The gut microbial metabolism contributes substantially to the human metabolome and is a well-known source of so-called uremic retention solutes. Mounting evidence indicates that the gut microbial metabolism can be disease-specific. Whether chronic kidney disease is associated with a distinct gut microbial metabolism has not been studied to date. Methods: Fecal samples of 20 hemodialysis patients were collected. We included 2 control groups composed of 20 unrelated healthy controls, as well as 20 household contacts on the same diet. Untargeted fecal metabolic fingerprinting with characterization of individual volatile organic compounds was performed with a dedicated GC-MS method. Differences in fecal metabolite profiles were examined with partial least square discriminant analysis and Wilcoxon rank-sum test. Results: Partial least square discriminant analysis demonstrated a clear distinction between fecal metabolite profiles of hemodialysis patients and healthy controls with a total of 92 volatile organic compounds being significantly different between both groups. In contrast, discrimination between hemodialysis patients and their household contacts on the same diet was less pronounced. Conclusions: The renal phenotype is associated with a distinct gut microbial metabolism. While there is a clear impact of dietary and other chronic kidney disease related factors on gut microbial metabolism, the influence of renal function loss per se is less pronounced. The potential beneficial effect of therapeutics targeting gut microbiota in patients with renal disease has to be awaited.

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O21 Intravascular lymphoma: A retrospective monocentric observational analysis and review of literature Dorothee Gullentops1, Steven Vanderschueren1, Olivier Gheysens1, Thomas Tousseyn1, Gregor Verhoef1, Daan Dierickx1 1

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University Hospitals Leuven, Leuven, Belgium

Background: Intravascular lymphoma (IVL) is a rare subtype of extranodal non-Hodgkin lymphoma, characterised by proliferation of large B-cell lymphoma cells only within the lumina of small vessels. The disease is underdiagnosed because a myriad of symptoms may be present and it has an aggressive clinical course. Aims: We undertook a retrospective observational analysis of all patients diagnosed with IVL between January 1995 and December 2013 at the University Hospitals of UZ Leuven, aiming to obtain information on incidence, disease characteristics, treatment and outcome. Our data were compared with the largest retrospective study of IVL reported so far. Methods: Medical records of all patients were used to collect baseline patient characteristics (age, gender, history), IVL related characteristics (both biochemical and clinical), type of treatment and response to treatment (initial response, final outcome, cause of death). Results: Nine patients were included in this analysis. The median age at diagnosis was 64 years (range 41–72), with a female predominance (67%). The majority of the patients presented with fever of unknown origin (67%) and 78% of the patients had at least one B-symptom at presentation. Eastern Cooperative Oncology Group (ECOG) performance state was one or more in eight (89%) patients. Eight (89%) patients presented with advanced stage (Ann Arbor stage IV). LDH elevation was observed in nine (100%) of the patients; anaemia and thrombocytopenia in six (67%) and leukopenia in eight (89%) patients, respectively. The average time to diagnose was 115 days (range 10-506). One to five biopsies were needed to diagnose IVL and one patient was only diagnosed post-mortem. Central nervous system, bone marrow, skin, kidney, renal and uterus involvement were reported in 33, 33, 22, 11 and 11% respectively. Initial treatment consisted of BVAM (22%), CHOP (22%), R-CVP (11%), R-CHOP (11%) and hyperCVAD (11%). At follow-up three year overall survival was 22%. Conclusions: The results of our study showed that most patients have advanced, disseminated stage at the time of diagnosis and had a poor outcome. The study illustrates how difficult it is to diagnose the disease, with one diagnosis even post-mortem. Central nervous system, skin and bone marrow were involved in the majority of the cases, which is compatible with literature. Different chemotherapy regimens are used and only two patients (22%), both young females, were alive at three year follow-up period. More studies are needed to evaluate if these are significant prognostic factors.

O35 The implementation of latent tuberculosis screening in Belgium’s AIDS reference centers: a questionnairebased survey Chloe´ Wyndham-Thomas1, Kinda Schepers1, Violette Dirix2, Jean-Christophe Goffard1, Franc¸oise Mascart2,3, Jean-Paul Van Vooren1 1

Unite´ de traitements des immunode´ficiences, Hopital Erasme, Bruxelles, Belgium, 2Laboratoire de Vaccinologie et Immunologie Mucosale, ‘

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ULB, Bruxelles, Belgium, Laboratoire d’Immunobiologie, Hopital Erasme, Bruxelles, Belgium

Introduction: Persons infected with HIV have a 20–30% higher risk of developing tuberculosis (TB), and HIV-associated TB remains a major cause of death. Screening for latent tuberculosis infection (LTBI), the asymptomatic phase that frequently precedes TB, is a recommended prevention strategy. The aim of this questionnaire-based study is to assess the implementation of LTBI screening in the various HIV care centers across Belgium. Methods: A multiple-choice questionnaire was sent by mail to 55 infectious disease specialists working in a Belgian AIDS reference center or satellite clinic. Questions focused on the experience of the physicians in the field, size of and TB incidence in their practices, use of LTBI screening and treatment, opinions concerning systematic screening of all patients and barriers to its implementation. Results: Response rate reached 62% (34 physicians). Close to 80% were in favor of selective LTBI screening targeting HIV-infected patients at highest risk of TB rather than systematic screening of all patients. Notable variability in screening methods used was observed. The main barriers to the implementation of LTBI screening and treatment identified were lack of sensitivity of screening tools, risk associated to polypharmacy and toxicity of treatment. Discussion: In low TB-incidence countries, who, when and how to screen for LTBI in HIV-infected patients remains unclear. Studies in Belgium or in epidemiologically comparable populations as well as national guidelines are lacking and urgently needed. Future studies should evaluate risk assessment scores that identify HIV-infected patients at highest risk of progression to TB and therefore the best candidates for LTBI screening.

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Poster Presentations

P01 Splenic Infarction: a retrospective study on a forgotten organ Xavier Vandemergel1 1

Centres Hospitaliers Jolimont, Nivelles, Belgium

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Introduction: Predominant causes of splenic infarction are thought to be bacterial endocarditis, sickle cell disease and hematologic malignancy. Although a few series have been published, only one focus on clinical presentation.1 Methods: We conducted a restrospective chart review of all cases of splenic infarction diagnosed in our institution between 2000 and 2010 (600 beds). Results: 22 cases were included (14 men and 8 women) with mean age of 53 years (16–90). Fever was present in 27% and shivering in 22% of cases. Nausea and vomiting were present respectively in 18% and 22% of cases. LDH were elevated in 60% of cases (4256206 U/l) and Leucocytosis was high in 57% (1782363057/mm3). Blood cultures were positive in 25% of cases. Mean CRP was 9.8mg/dl65.7. At admission, 60% of patients had abdominal pain predominantly in left region. Splenomegaly was clinicaly found in 4 cases and 4 patients were in shock. In all cases, diagnosis was performed with the use CT scan and/or echography. Etiology was ischemic in 5 cases, infectious diseases in 4 cases (meningococcemia 1 case, E coli septicemia 2 cases, Streptococcus endocarditis one case). 3 patients had hematologic malignancies and 3 patients had splenic infarction following pancreatitis. In the other cases, the causes were traumatic or without clear etiology. Evolution was always good except for patients with haematologic diseases, all 3 died within a few months. Conclusions: Splenic infarction remains a challenge for the clinician. We focus on clinical presentation and review different etiologies.

References 1 Splenic infarction: An update on William Osler’s Observations. IMAJ 2010;362.

P02 Osteonecrosis of the jaw in a patient on Denosumab. A case report. Celine Cornil1, Dragos Ilisei1, Sophia Abdel Kafi1, Xavier Vandemergel1 1

Centres Hospitaliers Jolimont, Nivelles, Belgium

Introduction: Osteonecrosis of the jaw (OSJ) is a classical but rare complication of biphosphonates. Denosumab (ProliaH or XgevaH), a human RANKL monoclonal antibody is a novel bone antiresorptive drug. In clinical trials, Denosumab causes rapid, profound, and prolonged decreases in bone turnover markers without a change in bone formation. In large trial.1,2 We report the case of a patient developping OSJ after administration of Denosumab. Case Report: A 65 year-old woman presented to emergency room with inappetence, gingival pain and swelling of the left cheek. Her medical history was significant for hypertension, ethylo-tabagism, asthma, vertebral osteoporotic fractures, treated for three years with zoledronic acid. End of 2013, the patient fell and suffered a hip fracture. She was also followed by a dentist for dental extractions and prothesis. After that, she received Denosumab (60 mg). The admission CT-scan showed a osteonecrosis of the upper left jaw, associated with fracture and severe abcess extending to maxillar sinus and submaxillar gland. We started antibiotherapy for 14 days by amoxyclav with clinical improvement. Unfortunately, at the end of treatment she presented recidivant pain, swelling and fever. The second CT-scan showed progression of the abcess. We started antibiotherapy again, by clindamycin and programmed a surgical management. Conclusion: We reported the case of a patient presenting stage 4 OSJ after administration of Denosumab. Clinicians must remember the gravity of this side-effect regarding potential advantages of the drugs.

References 1 Denosumab for prevention of fractures in postmenopausal women with osteoporosis. R.Cummings et al. New Eng J Med 2009;361:756– 65. 2 Denosumab in men receiving androgen-deprivation therapy for prostate cancer. M.R Smith et al. New Eng J Med 2009;361:745–55. 3 Osteonecrosis of the jaw in a patient on Denosumab. T.L. Aghallo et al. J Oral Maxillofac Surg. 2010;68:959–963.

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P03 A potentially fatal phosphate diabetes induced by Ferrum Carboxymaltose administration. A case report. Franc¸ois Simon1, Dragos Ilisei1, Sophia Abdel Kafi1, Xavier Vandemergel1 1

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Centres Hospitaliers Jolimont, Nivelles, Belgium

Introduction: Phosphate diabetes is defined by phosphate clearance . 15 ml/’ with a proximal tubular reabsortion rate (PTR,85%). A plasma level of phosporus ,1 mg/dl can be fatal. Ferrum carboxymaltose (FCM) is frequently used for its facility. Hypophosphatemia is frequently found after administration but a level ,1 mg/dl was described in only one case. Case report: A 45 year-old woman has iron deficiency since 4 years due to to heavy menstrual bleeding. Past medical history included tuberculosis in 1985. Gastroscopy was normal. She complained of fatigue and headache. She took oral iron supplementation but developed side-effects that led to the discontinuation of treatment. In 2011 she received 2 administrations of iron sucrose (IS)(total dose: 200 mg) without repercussion on phosphate level (PP) (2.7 mg/dl after second administration). In 2012, laboratory findings were: Hb: 9.9 gr/l, serum ferritin (SF) 6 mg/l (nl 13–150) and serum iron saturation (IS) 6.7% (nl 15–50). She received 3 infusion of IS (total dose: 300 mg) with a slight reduction of PP (2.1 mg/dl) but without symptoms. In 2014, her Hb was 9.8 gr/dl with IS of 6% and SF of 13 mg/l, PP before injection of FCM was 2.5 mg/dl with a PTR of 89%. This moderate elevation of phosphate clearance was probably due to 25-OH D carence and secondary hyperparathyroidism (PTH: 147.2 ng/l (nl 15–65)) (25OHD3: 9ng/ml, nl.30). She received then two administration of FCM (InjectaferH, Vifor Pharma) (one week interval). 10 days after the second infusion, she complained of intense fatigue. Blood analysis show then a PP at 0.93 mg/dl with TPR at 77%. She received phosphate oral supplementation with amelioration of fatigue and one month later, phosphate level was 1.2 mg/dl with TPR at 71%. Two months after the first administration, PP returned to normal value at 2.34 mg/dl with TPR at 13%. Conclusion: We report the case of a woman presenting reversible phosphate diabetes and profound hypophosphoremia after administration of FCM. Surveillance of PP is important during treatment and this potential side-effect must be keep in mind.

References 1 FDA Advisory Commitee Briefing Document. Feb 2008.

P04 Chronic fatigue syndrome. Look at the phosphate! Franc¸ois Simon1, Xavier Vandemergel1 1

Centres Hospitaliers Jolimont, Nivelles, Belgium

Introduction: Chronic fatigue syndrome (CFS) is a disabling illness of unknown cause, mainly characterised by unexplained, disabling fatigue lasting more than six months, myalgia, and neuropsychological symptoms. Phosphate diabetes defined by a phophate clearance .15 ml/min and a tubular proximal phosphorus reabsorption rate (TPR) ,85% is associated with neuromuscular dysfonction, fatigue and mild depression, symptoms which may mimic CFS. Case report: A 48 year-old patient was seen in the outpatient clinic because of fatigue lasting for 2 years. Exhaustive work-up was done by another clinician who made the diagnosis of CFS. The fatigue was present in the morning and lasting all the day, every day. The sleep was normal. The mood was good. He took no drugs and didn’t smoke. Physical examination was normal. A biology performed two years earlier show hypophosphoremia (1.8 mg/dl), the rest of the biology was normal including calcium and parathyroid hormone. A new dosage showed hypophosphoremia (1.7 mg/dl) with phosphaturia (56 mg/dl). TPR was 80% (nl .85%) and the clairance of phosphate was 20 ml/min confirming the phosphate diabetes. He was treated with dipyridamole and phosphate supplement with improvement of fatigue but he refused to underwent further evalution. Conclusion: Phosphate diabetes must be excluded in patient suspected of CFS. In a previously study, De Lorenzo et al found that 10% of patients fullfilled criteria of CFS have phosphate diabetes.

References 1 Phosphate diabetes in patients with chronic fatigue syndrome. F.De Lorenzo et al. Postgrad Med J 1998;74:229–232.

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P05 PI3-kinase inhibition does not affect human plasmacytoid dendritic cell activation by low molecular weight ligands of toll like receptor 7 Julie Callenaere1,2, Stanislas Goriely1, Se´verine Thomas1, Fabienne Willems1 1

Institute for Medical Immunology, Universite´ Libre de Bruxelles (ULB), Gosselies, Belgium, 2Departement of General Internal Medicine, Eramse Hospital, Universite´ Libre de Bruxelles (ULB), Brussels, Belgium

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Phosphatidylinositol 3-kinase (PI3K) plays a key role in numerous cell processes, like proliferation, growth and regulation of inflammatory responses. This makes PI3K a promising target of pharmacologic therapy in cancer and inflammatory diseases and inhibitors are currently being tested in a large number of clinical trials. In plasmacytoid dendritic cells (pDCs), PI3K is required for type I interferon (IFN) production induced by Toll-like Receptor 9 (TLR9) ligands but its impact on TLR7 signaling remains to be clarified. Here, we studied the influence of PI3K inhibition on TLR7-mediated activation of pDCs, as imidazoquinolines (low molecular weight ligands (LMW) of TLR7, like imiquimod and R848) are widely used since many years in both the clinical (as antiviral and anticancer compounds) and experimental setting. First, we studied the effect of PI3K inhibition by LY294002 on the synthesis of IFN-a and TNF-a in human pDCs from whole blood by intracellular detection of cytokines by flow cytometry. PI3K inhibition did not modify this synthesis in response to LMW TLR7 ligands, while it down-regulated this production elicited by single strand RNA (a TLR7 ligand mimicking viruses), and the TLR9 ligands CpG A and B. Next, we examined the transcription of type I IFN and NF-kB-dependent pro-inflammatory cytokines and chemokines by PCR. We show that it was inhibited by LY294002 in CpG A-stimulated pDCs, whereas it remained unaffected in R848-stimulated cells. Finally, we demonstrated by intracellular detection of phosphorylated protein by flow cytometry that the activation of NF-kB in response to CpG A was downregulated by LY294002, while it was unaltered in R848-stimulated cells. These results indicate a differential involvement of PI3K in the activation of human pDCs, according to the nature of the TLR7 ligand. In particular, low molecular weight TLR7 agonists, like the one used in the clinical setting, were able to stimulate these cells to produce type I IFN and pro-inflammatory NFkB-dependent cytokines and chemokines in a PI3K-independent manner. Besides offering new insight into the complex regulation of TLR responses, this opens new possibilities for the development of novel antiviral and anticancer pharmacologic strategies in patients treated with PI3K-inhibitors.

P06 Severe hyperthermia after Intravenous Ferric Carboxymaltose (InjectaferH) administration Claudia Motosan1, Myriam El amine1, Pierre Mols1, Ahmed S. E. Ramadan1 1

CHU Saint Pierre, Brussels, Belgium

Intravenous Ferric Carboxymaltose (IFC) InjectaferH is a relatively stable iron substitute. Its structure allows an easily and fast administration of large amounts of iron up to 1000 mg. It is known to be a fairly safe molecule whose prevalence of side effects is of the order of 1%. However, an injection of 1000mg InjectaferH in a young patient of 23 years old with iron deficiency anaemia without another notorious history developed a severe hyperthermia above 40uC in day 4 post injection. No infectious outbreaks have been highlighted. This pyrexia was controlled by body cooling and the addition of non-steroidal anti-inflammatory drugs (NSAIDs). Within four days, hyperthermia was resolved and consequently, iron deficiency anaemia was corrected gradually with the improvement of its symptoms. Apart from any other explanatory cause, severe hyperthermia reported in the case of our patient is due to the administration of InjectaferH injection. This situation has fortunately not complicated by multiple organ failure.

P07 Prevalence of hyperlipidaemia in HIV-infected patients on Protease Inhibitors at selected HIV- clinics in the Cape Metropole region Pierre Mugabo1 1

School of Pharmacy, University of the Western Cape, Cape Town, South Africa

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine Antiretroviral therapy has improved the clinical status of patients with HIV infection. However, concerns have arisen that treatment may have side effects. Specifically protease inhibitors have harmful effects on lipid metabolism, glucose control and body fat distribution. The purpose of this study was to determine whether protease inhibitors therapy affects lipid levels in HIV infected patients in selected HIV clinics in the Cape Metropole region. The study was designed as a retrospective study comparing baseline and follow up total serum cholesterol and triglycerides in male and female HIV infected patient 0 to 65 years of age on protease inhibitors. Paediatrics patients were initiated on protease inhibitors. Adults and adolescents started protease inhibitors treatment after failing first line treatment. Serum total cholesterol, triglycerides, CD4 cell count, viral load, age and gender were determined at baseline and 3 months, 1 year and 2 years after the start of protease inhibitors. Data was collected from patient folders meeting the study criteria and analyzed using appropriate statistical methods. All information recorded was handled with strict confidentiality. The study was approved by the University of Western Cape ethics committee. The results indicated a significant increase in the serum total cholesterol and triglycerides after exposure to protease inhibitors. This increase is associated with the duration of protease inhibitor therapy, an increase in the CD4 cell count and a decrease in viral load. In conclusion protease inhibitors do induce hyperlipidaemia in the patients involved in this study. Further research is needed to evaluate the impact of first line antiretroviral therapy on lipid levels.

P09 Smoking cessation can kill Emmanuelle Alaluf1, Rene´ Colassin1, Michel Vanhaeverbeek1 1

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Hoˆpital A. Vesale, Montigny-le-Tilleul, Belgium

A 46-year-old woman was referred to our hospital for uncontrolled hypertension that was poorly responsive to standard antihypertensive therapy. She has been smoking one cigarette packet per day for 30 years but had just stopped tobacco about two months before consulting. She was complaining about headache, dizziness, asthenia and had also polyuria, dry mouth, polydipsia, and periods of hand tetany. The blood tests showed severe hypokalemia and metabolic alkalosis. We started directly further investigations that revealed hypoaldosteronism and reduced renin plasmatic level. We then made several additional exams to determine the etiology of this hypertension. We finally asked our patient further about her lifestyle including dietary habits. We then understood she eats a lot of liquorice daily since her smoking cessation two months ago. It is important to note that a complete anamnesis at first would have allowed us to find faster and easier the right diagnostic hypothesis. We should keep in mind that many investigations lead not only to heavy burden on the health care system with a big financial impact for all the society, but also to anxiety among patients and families and can even be harmful for our patients. Initial clinical judgment acquired with a complete anamnesis and examination remains nowadays the essential initial approach.

P10 Fever of unknown origin (FUO) in an elderly patient: a case of lymphatic tuberculosis Johan Clukers1,2, Greta Moorkens1,2, Erik Van Bouwel3, Jos Callens3, Jan Teuwen3 1

UA, Antwerp, Belgium, 2UZA, Antwerp, Belgium, 3AZ KLINA, Antwerp, Belgium

Background: Fever of unknown origin (FUO) in the elderly is most frequently caused by non-infectious disease (malignancy and inflammatory disease). Tuberculosis is the most common infectious disease associated with FUO in older patients. In many cases, FUO is due to atypical presentations of a common disease. In the elderly (especially those aged .80 years), oral temperatures of >38.3uC will more likely be associated with serious bacterial or viral infections. Because of the high frequency of tuberculosis and arteritis temporalis in this age group, temporal artery biopsy and repeated sampling for acid-fast bacilli, should be considered in the routine diagnostic approach. Case presentation: A 72-year-old male presented, in the emergency department after syncope, confusion and slurred speech. His past medical history consisted of an ischemic CVA and partial gastrectomy (recurrent peptic ulcers). Complete cardiologic and neurologic work-up was negative and the patient was discharged. 3 weeks later the patient was readmitted with the same symptoms. Observation showed a high fever predominantly during the night. There were no diagnostic clues with regard to the fever in this patient’s history or on clinical examination. Inflammatory markers were slightly elevated. During the episodes of fever the patient was delirious. Multiple blood and urine cultures revealed no infective organisms. Chest X-ray and an abdominal CT scan showed no abnormalities. Because of diarrhoea, routine stool cultures and colonoscopy were performed who returned negative. The patient lost .10 kg during his hospital stay. Further exploration was done by FDG-PET scintigraphy. Metabolic activity was noted in mediastinal lymph nodes. A tuberculin skin test showed a strong positive result. The clinical diagnosis of tuberculosis was confirmed by: caseation necrosis (granulomas) on mediastinal lymph node biopsy and a positive PCR result for Mycobacterium tuberculosis. Prompt treatment with quadruple tuberculostatic therapy was initiated. Definitive culture results showed no resistance pattern. Triple therapy (isoniazid-rifampicin-pyrazinamide) was thus continued for a total of 1 year. The later clinical course was complicated by prolonged hospitalisation because of persistent fever during two months, on going episodes of confusion (negative dementia work-up) and renal insufficiency (glomerular haematuria). A diagnosis of tuberculous glomerulonephritis was added (in absence of auto-immune markers). Finally he was admitted to a geriatric ward because of persisting cognitive problems. Conclusion: Intensive evaluation of FUO in the elderly is necessary as those persons are vulnerable to irreversible changes as in functional and cognitive deterioration. A ‘whole body inflammation scintigraphy’ could sometimes proof useful in cases were potentially no diagnostic clues are present.

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P11 An innocent kiss Katrien Clotman1, Anke Verlinden1, Alain Gadisseur1, Philippe Jorens1, Greta Moorkens1 1

UZA, Antwerpen, Belgium

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Background: The hemophagocytic syndrome(HLH) is a rare condition in which hyperinflammation results in an ineffective uncontrolled immune respons. Familial HLH was first described by Farquhar and Claireaux in 1952. Case report: We describe a 17-year old women who presented at the emergency ward with persistent tardiness, icteric sclerae en a fulminant rash after a period of Epstein Barr infection a month earlier. Clinical examination revealed a critically ill young women with high fever, low blood pressure, tachycardia, a severe morbilliform rash, swollen lymph nodes in the neck and a hepato- and splenomegaly. Laboratory results revealed a pancytopenia with impaired clotting parameters, renal insufficiency and liver failure. High levels of ferritine and triglycerides were measured. Chest X-ray was normal and the ECG showed a sinustachycardia. Viral serology revealed a high titer of IgM antibodies against the Epstein Barr virus. An urgent bone marrow puncture showed a reactive marrow with pronounced hemophagocytic features. The diagnosis of haemophagocytic syndrome was made and she was started on the HLH-2004 protocol with Etopuside, corticosteroids and Rituximab. After abdominal and infectious life-threatening complications, the clinical situation of the patient improved and after 10 months she could leave the hospital. Conclusion: Haemophagocytic syndrome is a life- threatening condition. It can be genetic or secondary due to an infection or malignancy and the diagnosis is based on the HLH criteria of the Histiocyte society in 2004. The disease has a high mortality and is treated with corticosteroids and chemotherapy (etopuside and cyclosporine). In this case a common’ young adult infection’ induced the overwhelming activation of normal T-lymphocytes and macrophages invariably leading to clinical and hematological alterations.

P12 Dyspnea and non-productive cough in a patient with rheumatoid arthritis Els Gielis1, Jan Van Offel1, Greta Moorkens1, Luc De Clerck1 1

Antwerp University Hospital, Antwerp, Belgium

Background: The development of dyspnea and a non-productive cough in patients with rheumatoid arthritis (RA) is a diagnostic challenge. Case report: A 75-year old woman, diagnosed with RA three months earlier and treated with Methotrexate (MTX 10 mg/week) and Prednisolone (5 mg/ day), presented with a two week-history of progressive dyspnea and a non-productive cough. No articular complaints were mentioned on admission. There was no history of smoking or occupational exposure to hazardous substances. Clinical examination showed absence of fever, presence of a moderate tachypnea and tachycardia and bibasilar inspiratory rales on pulmonary auscultation. Pulse oximeter saturation was 96%. Blood tests showed a normal white cell count and a CRP of 4.1 mg/dl. Partial oxygen pressure on arterial blood gas was low (68.1 mmHg) and pulmonary function tests showed a TLC of 82% and a decrease in diffusion capacity compared to previous reports (DLCO/VA 81%). Chest X-ray showed a diffuse reticulonodular infiltrate at the bases of the lungs and thoracic CT revealed an interstitial pneumonia with the appearance of bilateral ground-glass opacities without signs of pulmonary fibrosis. To exclude any infection, a bronchoscopy was performed. A poor growth of S. aureus in the bronchus aspirate was seen, BAL analysis showed an increase in lymphocytes (22.5%), neutrophils (9%) and eosinophils (16.5%), culture was negative for Pneumocystis Jiroveci, bacteria and viruses. Initial treatment with antibiotics, was unsuccessful and the patient developed further respiratory insufficiency with a high need of oxygen. The diagnosis of a MTX- induced interstitial lung disease was made and after discontinuation of methotrexate and a treatment with high doses of corticosteroids, the patient fully recovered. Conclusion: Drug-induced lung toxicity can be serious, and is usually effectively treated by recognizing the disorder. The presence of a pronounced cough, with an acute onset after the initiation of methotrexate, without any signs of pulmonary infection, suggests the presence of a methotrexate-induced pneumonitis. This drug adverse event is treated with high doses of corticosteroids and a life-long discontinuation of the responsible drug is recommended.

P13 Effectiveness of Telemedicine-guided home blood pressure and 24h-ambulatory monitoring in assessing blood pressure and blood pressure control Xavier Galloo1,2, Patricia Van der Niepen1,2 1

Universitair Ziekenhuis Brussel, Brussels, Belgium, 2Vrije Universiteit Brussel, Brussels, Belgium

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine Aim: To evaluate the effectiveness of telemedicine-guided home blood pressure (tele-HBPM) compared to 24h ambulatory blood pressure monitoring (ABPM) in assessing BP and BP control, as only few direct comparative studies are available. Methods: We therefore conducted a prospective clinical trial in normal volunteers (15) and patients with treated arterial hypertension, with (21) and without (10) chronic kidney disease. All subjects underwent with a 1-month interval twice one-week of BP monitoring with office BP (3 measurements at 2 visits), 24h-ABPM and tele-HBPM during 7 consecutive days. Results: Mean BP levels were 129/77 mmHg and 127/76 mmHg for tele-HBPM, 130/77 mmHg and 128/75 mmHg for daytime-ABPM, and 134/76 mmHg and 130/73 mmHg for office BP, all respectively at the first and the second visit periods. No significant difference in BP between the three techniques was found. Blood pressure control was comparable between the different monitoring techniques. Following the Bland-Altman method, a good agreement between the two out-of-office techniques was found. Patients with HT and suffering CKD stage 5 are a class apart. Their systolic and diastolic BP turns out to be higher than that of the other patients, irrespectively of the used technique. Moreover the results show lower reproducibility. Conclusion: Both out-of-office techniques (24h-ABPM and tele-HBPM) showed good agreement for systolic as well as diastolic BP, and are equally effective in assessing BP and BP control (during daytime). The evaluation of the true blood pressure and of blood pressure control in patients with HT and CKD stage 5 is more difficult than in other patients.

P14 Anemia and Aortis stenosis. Don’t forget the Heyde’s Syndrome Downloaded by [Gazi University] at 20:45 21 March 2016

Celine Cornil1, Xavier Vandemergel1, Sophia Abdel Kafi1, Dragos Ilisei1 1

Centres Hospitaliers Jolimont, Nivelles, Belgium

Introduction: Heyde’s syndrome is defined by the association of bleeding from angiodysplasia and aortic stenosis.1 Angiodysplasia is classically discribed in the colon, but it also can be identified in any parts, or multiple parts, of gastrointestinal tract. One of the possible mechanism of Heyde’s syndrome is the development of an aquired form of von Willeband disease by mechanical disruption of the von Willebrand multimers during turbulent passage through the narrowed valve, and from a von Willebrand factor interaction with platelets that triggers platelet clearance.2,3 Case Report: A 82 year-old women presented to emergency room with pallor, dyspnea NYHA IV, confusion and myocardial infarction. Her medical history was significant for hypertension, type 2 diabetes, chronic renal failure, dyslipidemia and a severe aortic stenosis (AS) known for more than five years (SVAo-0,6 cm2). Blood results showed an iron deficiency anemia (Hb-6,2 g/dl). Gastroscopy, colonoscopy and 3D-colonoscopy revealed no acute or chronic gastrointestinal bleeding. Wireless video capsule endoscopy revealed positive for gastro-duodenal micro-angioma. Conclusion: We reported the case of a patient known for more than five years with a severe AS whom developed an angiodysplasia, being a classical example of Heyde’s syndrome. The peculiarity of the case lies in the importance of the silent anemia and given the severity of the AS, playing a role in the development of myocardial infarction.

References 1 Heyde EC. Gastrointestinal bleeding in aortic stenosis (letter). N Engl J Med 1958; 259:196. 2 Vincentelli A, Susen S, Le Tourneau T, et al. Acquired von Willebrand syndrome in aortic stenosis. N Engl J Med 2003; 349:343. 3 Pareti FI, Lattuada A, Bressi C, et al. Proteolysis of von Willebrand factor and shear stress-induced platelet aggregation in patients with aortic valve stenosis. Circulation 2000; 102:1290. 4 O’Brien JR, Etherington MD, Brant J, Watkins J. Decreased platelet function in aortic valve stenosis: high shear platelet activation then inactivation. Br Heart J 1995; 74:641.

P15 Fever of unknown origin in the HIV-infected patient Lynn Gers1,2, Luc Colemont1, Robert Rutsaert1 1

GasthuisZusters Antwerpen, Antwerpen, Belgium, 2Universiteit Antwerpen, Antwerpen, Belgium

A 30-year-old man, HIV-positive since four years, presented at the emergency room with fever since 3 weeks, diffuse abdominal pain, diarrhea and weight loss (20kg in 2 months). He did not take any antiviral therapy, because his CD4z counts was 500/ml at the consultation with his treating physician in Bulgaria a few months earlier. Physical examination revealed high grade fever (40uC) and tenderness in the right upper quadrant. Blood examination returned an elevated CRP and abnormal liver function tests. A chest X-ray and urine sediment were negative. Blood cultures, thick smear and stool cultures remained negative. The CD4z count on flow cytometry was 204/ml. An ultrasound examination of the abdomen showed splenomegaly with a diffuse inhomogenous parenchyma, and a focal lesion in the right liver lobe, that was confirmed by CT-scan. Laparascopic biopsies were taken from the liver lesion and the free fluid in the Douglas space was sampled. Pathological examination revealed granulomata and on immunohistochemical staining acid fast bacilli were seen. A subsequent CT-scan of the thorax demonstrated increased interstitial markings. Sputum cultures showed the presence of

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine acid fast bacilli. In conclusion, this HIV-patient was diagnosed with pulmonary and extrapulmonary tuberculosis. A tuberculosis treatment program was started and antiviral therapy was initiated. HIV-related fever of unknown origin (FUO) is defined as a temperature . 38.3uC during .4 weeks (ambulatory) or .3 days (hospitalized) with negative cultures after two days of incubation. In the general population, FUO is caused by infections (30%), malignancies (18%), auto-immune diseases (12%) and various other causes including drug fever (14%). Twenty-six percent of the cases remain idiopathic. Regarding HIV-related FUO, 70% is caused by infections, with mycobacteria being responsible for the majority of the cases. Mycobacterial infection should be high on the list of differential diagnoses in the HIV-infected patient with FUO, and standard investigations should include Ziehl-Neelsen staining, mycobacterial PCR and culture on every sample taken.

P16 Infections complicating treatment in Goodpasture’s disease: a case report Tim De Weerdt1,2, Mark Helbert1,2, Johan Verhelst1, Greta Moorkens2 1

ZNA middelheim, Antwerp, Belgium, 2University hospital Antwerp, Antwerp, Belgium

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Introduction: Goodpasture’s disease is an antibody mediated disorder, with antibodies directed against glomerular and alveolar membranes, that causes pulmonary-renal syndrome. Case report: an 18 year-old man was admitted to the hospital with fatigue, malaise, nausea and abdominal pain since ten days and with diarrhoea, dry cough, and moderate dyspnoea since five days. Medical history showed symptomatic nephrolithiasis treated with (ESWL) On admission (D0) blood pressure was 170/100 mmHg, pulse 126bpm, temperature 37,9uC. Physical examination was normal except for minimal epigastric pain. Blood tests revealed anaemia (Hb 7,7 g/dl), increased WBC count (14,60E9/L), increased CRP (146,6 mg/L) and severe renal failure (eGFR 6 ml/min/1,73m2). Arterial blood gas analysis indicated hypoxemia and hyperventilation. Urine analysis showed severe haematuria (2385 RBC/ml) and proteinuria (10g/g creatinine). A chest X-ray showed consolidation of the right lung. Hydronephrosis was excluded through abdominal ultrasound. A pulmonary CT scan and bronchoscopy were performed and revealed dispersed alveolar bleeding. Renal biopsy showed extracapillary proliferative (’crescentic’) glomerulonephritis in more than 90% of glomeruli, with a linear immunofluorescence pattern for both IgG and C3, thus pathognomonic for anti-GBM (Goodpasture’s) disease, indicating acute but typically irreversible renal failure. A very high anti-GBM antibody titer (1131 IU/ml) was measured. ANF and ANCA were absent. The patient developed alveolar consolidations leading to acute respiratory failure, necessitating endotracheal intubation and mechanical ventilation. On day 2 ‘induction’ immunosuppressive therapy was started: pulse steroids (3x1000mg IV), plasmapheresis (3– 4x weekly), cyclophosphamide (2mg/kg PO) and TMP/SMX (PO) was added to prevent pneumocystis jirovecii pneumonia. Intermittent haemodialysis (with ultrafiltration) was started. Induction therapy was complicated bij transient leukopenia and by multiple infections: Day 13 – E. Coli VAP; Day 14 – CNS catheter-related-septicaemia; Day 20 – (1) systemic CMV-infection/CMV pneumonia (R/valgancyclovir and anti-CMV-enriched-gammaglobulins because of pulmonary deterioration and increasing CMV-PCR values despite valgancyclovir therapy); (2) herpes simplex type I-pneumonia (R/valgancyclovir); (3) metapneumoviruspneumonia (no specific therapy); Day 26 – brevibacterium pneumonia and Day 35 – pseudomonas aeruginosa pneumonia. Immunosuppressive therapy was tailored to the patients’ clinical (infectious), cytological and renal condition. The patient was discharged from ICU on day 53 and recovered clinically except for renal function. He was discharged from hospital on day 59, with further need of hemodialysis. Conclusion: goodpasture’s disease is a very severe disease with fulminant course and ominous prognosis if untreated. Treatment however compromises the immune system and can lead to several infectious complications. Often, Goodpasture’s syndrome will result in end stage renal failure despite treatment, however most often it is a ‘one-shot’ disease. Hence, following remission, patients can typically be transplanted without risk for relaps.

P17 Acute renal failure in light-chain myeloma Katrien Leyssens1, Kalung Wu2, Greta Moorkens3, Tom De Beukelaar1 1

Jan Palfijn ziekenhuis, Merksem, Belgium, 2Stuivenberg ziekenhuis, Antwerpen, Belgium, 3Universitair ziekenhuis, Antwerpen, Belgium

Background: Multiple myeloma accounts for 10% of all hematologic malignancies. The clinical symptoms are caused by skeletal destruction, renal failure and plasma cell infiltration of the bone marrow, which results in a compromised normal hematopoiesis. Case report: A 62-year old man with a medical history of diabetes mellitus, hypertension and atrial fibrillation was admitted with shoulder pain since 8 months without history of trauma or physical overload. His general practitioner already performed a chest X-ray, ultrasound of the left shoulder and a chest CAT-scan (with contrast), which revealed multiple osteolytic lesions of the clavicle, scapula, ribs and thoracic vertebrae. Clinical examination was normal except for tenderness of the ribs, shoulder, clavicle and back. Venous blood analysis revealed acute renal failure with elevated creatinine (12.6 mg/dl), hyperkalemia (5.9 meq/l), and normal calcium. Serum electrophoresis and immunofixation showed increased serum free kappa light chains (17100 mg/L) with normal serum free lambda light chains. Bone marrow examination revealed increased plasma cells (19%) with a monoclonal phenotype. The diagnosis of multiple myeloma, light-chain kappa was made. The patient was treated with Bortezomib and dexamethasone. Also hemodialysis was initiated using a high-cut-off protein-permeable membrane (HCO 1100) which is particularly effective in the removal of the nephrotoxic serum free light chains. Conclusion: Kidney disease can occur in up to 50% of patients with multiple myeloma. A major cause is the light chain cast nephropathy (myeloma kidney) which causes tubular dysfunction. This can be triggered by dehydration, hypercalcemia, infections, contrast medium, NSAIDs, diuretics, ACEi and ARBs. Patients with acute kidney injury are more likely to experience early mortality and have worse overall survival. Prognosis can be improved with new therapeutic therapies such as bortezomib in combination with high doses of steroids and hemodiafiltration/hemodialysis (with a high-cut-off

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine protein-permeable membrane). One of these membranes is the Gambra HCO 1100 which gives excellent clearance rates for both kappa and lambda light chains, with a reported mean reduce of light chains by 35–75%. In this patient we observed an almost 100% kappa light chains reduction with a complete normalization of kidney function. Authors: Dr. K. Leyssens, algemeen inwendige, Jan Palfijn Ziekenhuis Merksem; Dr. K. Wu, hematologie, Stuivenberg ziekenhuis Antwerpen; Dr. G. Moorkens, algemeen inwendige, Universitair ziekenhuis Antwerpen; Dr. T. De Beukelaar, pneumologie, Jan Palfijn ziekenhuis Merksem.

P18 Complications after endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): an illustrated case of a broncho-mediastinal fistula. Miche`le Compagnie1, Jacques Lecomte2, Alain Van Meerhaeghe2 ULB, Bruxelles, Belgium, 2Hopital Ve´sale, Montigny-le-Tilleul, Belgium

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EBUS-TBNA has become the preferred technique in the etiological diagnosis of mediastinal lymphadenopathies and lung nodules. Although defined as a noninvasive technique, some complications begin to be described. A recent systematic review on 16,181 patients reported a serious complication rate of 0.14%. 52% of these were of infectious nature, followed by perforations, respiratory insufficiencies, pneumothorax and hemorrhages. We report the case of a 58 year-old patient who developed a broncho-mediastinal fistula and bronchopneumonia post-EBUS TBNA. One year earlier a NSCLC was diagnosed and treated by thoracoscopic middle lobectomy and radical mediastinal lymphadenectomy. A recent thoracic CT scan showed a suspicious lesion of the right upper lobe with a moderately hypermetabolic lymphadenopathy in the seventh lymph node area on PET-CT. Therefore, an EBUS-TBNA was performed in this area. At the time of the puncture, the patient reported a sudden retro-sternal pain that persisted for a few days. Seven days after the procedure, he consulted for episodes of pyrexia with chills, cough and purulent expectorations. A quinolone antibiotherapy given during 10 days did not improve the situation and he was admitted to our hospital. A thoracic CT scan highlighted a bronchopneumonia in the right segment 6 and a broncho-mediastinal fistula with air collection under the carina. Afterwards, it appeared that a chest radiograph performed 7 days after the procedure already revealed the presence of a fistula. The patient’s health improved after IV broad spectrum antibiotherapy. No specific germs were identified. Ganglion puncture did not reveal any neoplastic cell. Learning points

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First-choice technique but not devoid of complications, mainly of infectious kinds. Importance of the follow-up after the procedure. Need for evaluation and oversight of new diagnostic techniques, including the collection of possible adverse events.

P20 From diarrhea to dyspnea Annemie Jacobs1, Walter Droogne2, Hans Jacobs2, Paul Herijgers1,2 1

KU Leuven, Leuven, Belgium, 2UZ Leuven, Leuven, Belgium

Introduction: Intestinal neuroendocrine tumours, also known as carcinoid tumours, are rare and are characterized by a high potential to metastasize. We present a case of carcinoid heart disease. Case report: A 67-year-old woman with a medical history of coronary bypass graft surgery was referred to a university hospital with severe diarrhea (6 stools a day) since 6 months and loss of appetite. Weight loss was insignificant. She didn’t mention any abdominal pain or nausea. Facial flushing, especially when drinking alcohol, was present since many years. In the past 2 months, progressive dyspnea was marked, mostly when doing exercise. Clinical examination revealed hepatomegaly and a systolic murmur (2/6). The patient didn’t have any malleolar edema. The laboratory results showed increased levels of liver enzymes (gamma glutamyltransferase 221 U/L, alkaline phosphatase 169 U/L, ASAT 45 U/L, ALAT 50 U/L). Chromogranine level was elevated to 10040 mcg/L. Abdominal computed tomography showed a mass in the ileum and several metastases in the liver. A positron emission tomography scan revealed images of neuroendocrine carcinoid tumour. Histopathologic examination of the liver biopsy material was receptor positive for synaptofysine, chromogranine and CD56. Serum levels of 5-hydroxyindoleacetic acid (5-HIAA) were firmly elevated. Both transthoracal and transesophageal cardiac ultrasound showed a mobile structure in the right atrium, which suggested a tumoral thrombus. Severe tricuspid insufficiency, pulmonary insufficiency and mild pulmonary hypertension were noticed, and the diagnosis of carcinoid heart disease was made. The patient was treated with long-acting somatostatine analogue and underwent cardiac surgery with implantation of a bioprosthetic tricuspid and pulmonary valve. Conclusion: Carcinoid heart disease (Hedinger syndrome) is a major cause of morbidity and mortality in patients with metastatic neuroendocrine tumours. The cornerstone of therapy is medical treatment with somatostatin analogues (such as octreotide and lanreotide), as well as standard heart failure therapy. However, valve replacement surgery is the only definitive treatment option which can possibly contribute to improved outcomes in patients with severe cardiac involvement and well-controlled systemic disease. Acta Clinica Belgica

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P22 Lower limb swelling after a tropical stay Lukas Van Duffel1, Jan Van Offel1, Greta Moorkens1, Luc De Clerck1 1

Antwerp University Hospital, Antwerp, Belgium

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Background: Eosinophilic fasciitis (EF) is a connective tissue disorder of unknown etiology which is characterised by painful, symmetrical upper and/or lower limb or trunk oedema and thickening of skin, subcutis and fascia. Case report: A 65-year old male patient was referred to the department of rheumatology, several months after acute onset of a persistent painful, bilateral swelling of the lower extremities. The symptoms started shortly before returning from a journey to South-East Asia. There were also a foursome of morphea-like skin lesions, with concordant findings on skin biopsy. Clinical examination showed the presence of the so-called ‘groove sign’, a depressed aspect of superficial veins, which is suggestive of a subcutaneous fibrotic process. Laboratory investigations showed an increased sedimentation rate and C-reactive protein level, and a peripheral eosinophilia without leucocytosis. Serological testing revealed the presence of Toxocara IgG antibodies, without signs of ocular larva migrans on ophthalmoscopy. There were no signs of venous thrombosis or cardiac failure on doppler ultrasonography and echocardiography respectively. Full body magnetic resonance imaging revealed perifascicular and fascicular swelling at the level of the lower back musculature and the upper and lower leg muscles. Marked oedema of fascia and a cellular infiltration with B- and T-cell lymphocytes and macrophages were seen on muscle biopsy. The patient was treated with a high dose of corticosteroids, resulting in a good clinical and biochemical response. An antihelminthic treatment regimen with Albendazole was added, as a concomitant infection with Toxocara as the cause of the eosinophilia could not be excluded. Discussion: EF or Shulman’s syndrome is a rare cause of pitting oedema and thickening of skin and fascia of the limbs. It is an inflammatory disorder which is mostly accompanied by a peripheral eosinophilia. Morphea occurs in about one third of cases. The diagnosis is based on muscle biopsy, and can be supported by magnetic resonance imaging. Occurrence of the symptoms after a tropical journey, and the positive Toxocara serology made the diagnosis more complicated in this case. EF has been associated with strenuous exercise, hematologic disorders and solid tumours. Regarding infectious associations, only cases with borreliosis and Mycoplasma arginini have been described.

P23 Characteristics, treatment and prognosis of primary central nervous system lymphoma: a single center retrospective study Anke Van Mellaert1, Liesbeth Smets1, Philippe Demaerel1, Gregor Verhoef1, Paul Clement1, Daan Dierickx1 1

University Hospitals Leuven, Leuven, Belgium

Background: The poor prognosis of primary central nervous system lymphoma (PCNSL) has improved since the introduction of methotrexate as cornerstone of the treatment. Methotrexate (MTX) is given in monotherapy or in combination with other chemotherapeutic agents, radiotherapy or rituximab. However, many questions about prognostic factors and optimal treatment protocol for PCNSL remain unanswered. Material and methods: This retrospective study includes 81 patients with PCNSL, treated in the University Hospital of Leuven between 1991 and 2014. We collected information on treatment and on patient related and tumor related characteristics in their medical files. Influence of these different factors on overall and relapse free survival and on total and complete remission rate, was examined. Results: Median survival after diagnosis was 8.4 months, median relapse free survival was 10.1 years. Patients who were able to achieve an initial complete response had a better prognosis. Negative prognostic factors were decreased renal function (eGFR ,60 ml/min) and age older than 60 years. MTX in monotherapy gives a higher chance of complete response in comparison to treatment without methotrexate. We observed a positive effect on survival when patients treated with MTX get additional treatment with cytarabine, radiotherapy or both. The addition of intrathecal chemotherapy also has a positive effect on survival. Conclusion: MTX remains an important cornerstone in the treatment of PCNSL. We observed an additional role for cytarabine, radiotherapy and intrathecal chemotherapy. Further prospective trials remain necessary to determine the value of prognostic factors and the optimal treatment for PCNSL.

P24 Uncommon gastrointestinal manifestations of longterm cannabis use Gae¨lle Leemans1, Ellie Senesael2, Rembert Mertens2, Sabine Allard2, Patrick Lacor2 1

Medical School, Vrije Universiteit Brussel, Brussels, Belgium, 2Department of Internal Medicine, UZ Brussel, Brussels, Belgium

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine Background: Cannabis is the most commonly used illicit drug in the world with an average use of approximate 4% of the entire population. The seeked short term effects comprise euphoria, relaxation or disinhibition. The drug is nowadays also used for medical purposes, e.g. in patients with cancer or other chronic dseases, because of its well known antiemetic and analgesic properties. Less well-recognized however is the paradoxical potential of certain chronic users to develop clinical conditions such as acute abdominal pain and/or hyperemesis. Case reports: Two cases of cannabis-related acute gastrointestinal conditions are described. The first case concerns a 30-year-old woman who who was admitted with a fourth episode of acute vomiting and epigastric colicky pain in two days. Work-up at the emergency department showed mild inflammatory signs on blood analysis, a negative pregnancy test and a normal abdominal X-ray. A therapy with intravenous antiemetics and fluids was installed. During her stay in the hospital she developed the need to take hot showers up to five times a day to control her symptoms. This observation led to the presumptive diagnosis of cannabis hyperemesis syndrome. New medical history taking revealed chronic cannabis use. The second case concerns a 25-year-old man with a clinical history of GERD who came to the emergency department because of epigastric pain with nausea and vomiting since four days. Blood analysis did not show any signs of inflammation, abdominal X-ray and gastroscopy were not contributive. Shortly after admission, he developed an acute urinary retention and an elevated lipase level. Abdominal ultrasound and CT-scan showed a normal appearance of liver and pancreas, and absence of cholelithiasis. The symptoms of nausea and pain disappeared on symptomatic treatment, and the lipase levels decreased spontaneously. Anamnesis pointed to chronic cannabis use as the probable cause of his condition. Discussion: As a result of today’s increasing rate of chronic cannabis consumption among young people, two new but still not widely known clinical conditions have been recognized in recent years. The ‘cannabinoid hyperemesis syndrome’ is characterized by cyclic nausea and vomiting, abdominal colicky pain and an unusual impulsive need to take hot showers. This strange phenomenon is not yet completely understood. One hypothesis is that of stimulation of cannabinoid receptors (CB1) on the splanchnic leading to vasodilation. Contact of the skin with hot water causes cutaneous vasodilation so that blood is derived from the gastrointestinal circulation whereby the symptoms disappear. This is also known as the ‘cutaneous steal syndrome’. The second hypothesis relates to the thermoregulatory function of the hypothalamus. Chronic cannabis use leads to dysregulation of the temperature homeostasis as cannabinoidreceptors located in the hypothalamus are stimulated. The change in hypothamalic function can possibly be counteracted by exposure to hot water, with consecutive release of the symptoms. Cannabis-induced pancreatitis presents clinically with the classical symptoms of abdominal pain in combination with elevated pancreatic enzymes. A possible explanation for a causal relation with cannabis lies in the presence of cannabinoid receptors in the pancreas. In normal conditions these receptors may contribute to lowering of insulin resistance and regulation of appetite, but when they become activated by exogenous cannabinoids, there might be an interaction with production of pancreatic hormones resulting in dysfunction and inflammation of the pancreas.

P25 Liver abscess caused by Klebsiella pneumoniae: a distinct clinical entity to be considered in diabetic patients presenting with fever and gastro-intestinal complaints. Esther Scheirlynck1, Rembert Mertens2, Lucie Seyler2, Sabine Allard2, Patrick Lacor2 1

Medical School, Vrije Universiteit Brussel, Brussels, Belgium, 2Department of Internal Medicine, UZ Brussel, Brussels, Belgium

Background: In the past two decades Klebsiella pneumoniae has been increasingly recognized as a possible cause of pyogenic liver abscess, first predominantly in Asia, but later on in Europe as well. Liver abscess caused by K. pneumoniae is mostly cryptogenic, but underlying diabetes mellitus is frequently associated. The clinical manifestations are nonspecific and often consist of fever with chills, sometimes in association with gastro-intestinal complaints. Treatment is mostly based on antibiotherapy combined with percutaneous or surgical drainage. Case report: A 47-year-old male presented with malaise, fever, headache, otalgia and nausea since a few days. He also complained of hyperglycaemiarelated symptoms, namely polyuria, nycturia and polydipsia. His medical history revealed diabetes mellitus, treated with metformine but with poor therapeutic compliance. Blood analysis confirmed hyperglycaemia, as well as inflammatory signs and elevated liver enzymes. Abdominal ultrasound and CT scan showed the presence of three liver abscesses. Empirical antibiotherapy (with cefuroxime and metronidazole) was instituted. As inflammatory signs persisted, a transcutaneous drainage of one of the abscesses was performed, showing growth of K. pneumoniae on culture of collected pus. On the basis of the antibiogram, antibiotherapy was switched to amoxicillin-clavulanate IV, followed by oral treatment. The clinical evolution was favorable, apart from a hydropneumothorax (treated with temporary drainage) as a complication of transcutaneous liver punction. Discussion: As the clinical presentation of K. pneumoniae liver abscess is often not specific, it is important to consider this diagnosis when a patient presents gastro-intestinal complaints, biologic signs of inflammation and elevated liver enzymes, especially when there is underlying diabetes mellitus.

P26 Leptospirosis: an Atypical Presentation C. B. A. Seghers1, E. Vlieghe1, V. Siozopoulou1, J. L. Bosmans1 1

Antwerp University Hospital, Antwerp, Belgium

Background: Leptospirosis is a zoonosis with a variable presentation caused by pathogenic spirochetes of the genus Leptospira. It occurs worldwide, but is far more common in tropical climates. Anicteric leptospirosis is usually a self-limited flu-like disease, whereas the icteric form is a severe illness characterized by multiple organ involvement and even failure. We report an unusual case of anicteric leptospirosis associated with rapidly progressive

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P27 Sarcoidosis: three different stories Yentl De Roeck1, Inge Hantson2, Sebastien Anguille2, Greta Moorkens1, Robert Rutsaert2 Antwerp University Hospital, Edegem, Belgium, 2St. Vincentius Hospital, Antwerp, Belgium

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Sarcoidosis is a multisystem inflammatory granulomatous disease of unknown etiology that predominantly affects the lungs and intrathoracic lymph nodes. It has diverse clinical manifestations, most frequently including pulmonary disorders. We present three recent cases. The first case is about a 21-year old man with no medical history who was admitted to the hospital with a progressive non-productive cough and pain in the left hemithorax since two weeks, accompanied by sweating, anorexia and dyspnea on exertion. He had lost 10kg of weight in 12 months. Physical examination showed a facial erythema and multiple little inguinal lymph nodes. Chest X-ray revealed pronounced bilateral hilar lymphadenopathy. A PETCT-scan showed large irregular hilar and mediastinal FDG-avid lymph nodes with flaky infiltrates in both lungs. A biopsy obtained from an endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of multiple hilar lymph nodes showed non-caseating granulomas, compatible with sarcoidosis stage 2. Further investigations showed no organ damage so no specific treatment was associated. The second case is about a 72-year old man who was treated for sarcoidosis during two years. Six months after stopping the steroid therapy with prednisolone he developed fever, myalgia and dysgeusia. He reported a weight loss of 10kg over the past six months. We found no focus of infection. A PET-scan revealed a FDG-avid infiltrate in the right lung and mediastinal, hilar and aortopulmonary lymphadenopathy. A biopsy confirmed a recurrence of sarcoidosis. In the last case a 30-year old male patient presented with chronic myalgia since two years. He was recently diagnosed with fibromyalgia and wanted a second opinion. Because of the persistent clinic we made a PET-scan that revealed hypermetabolic hilar and mediastinal lymph nodes. An EBUS confirmed the diagnosis of sarcoidosis stage 1. Symptomatic treatment with NSAID was started. Sarcoidosis is a diagnosis of exclusion established by clinical manifestations, radiologic findings, and histologic evidence of non-caseating epithelioidcell granulomas in .1 organ. Most patients do not require therapy and their conditions spontaneously improve.

P28 Vogt-koyanagi-harada syndrome: literature review and presentation in a university hospital. Liza Sels1, Liesbet Henckaerts1 1

UZ Leuven, Leuven, Belgium

Purpose: To evaluate the clinical presentation of Vogt-Koyanagi-Harada syndrome in Belgian patients in comparison with the literature. Methods: A retrospective case series of 12 patients diagnosed and treated in a university hospital. The 12 patient files were checked for gender, age, ethnicity, duration of follow-up, stage of disease, ocular and extraocular manifestations, presence of symptomatic lymphocytic meningitis, differential diagnosis, treatment and side effects, number of recurrences, complications and time to complete remission. Results: Besides ocular manifestations all 12 patients had also neurological manifestations with headache (100%) and lymphocytic meningitis (75%) as main findings. The primary auditory (67%) and dermatological (33%) manifestations were respectively tinnitus (50%) and vitiligo (33%). Recurrent uveitis occurred in the majority (64%) with an average of 2.1 times per patient and a mean time to recurrence of 5.7 months. An ophthalmologic complete remission was achieved in 7 (58%) patients after a mean period of 14 months (ranging from 2 to 42 months). There is a favourable prognosis with normal visual acuity in 92% of patients at the end of the follow-up. Conclusion: Vogt-Koyanagi-Harada syndrome is a rare disorder that is little known in general medicine. The main problem is that this disorder affects multiple systems and patients are not always seen first by an ophthalmologist. That’s why every internist should keep this syndrome in mind when examining a patient with visual complaints associated with general symptoms such as headache, general malaise, fever and nausea. Those general symptoms may not simply be attributed to the uveitis, but their presence should be an argument to do a lumbar puncture to rule out underlying lymphocytic meningitis. Contrariwise there has to be an ophthalmologic examination in each patient with unexplained general symptoms to rule out Vogt-Koyanagi-Harada syndrome.

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P29 De novo thrombotic microangiopathy after non-renal solid organ transplantation Annelies Verbiest1, Jacques Pirenne1, Daan Dierickx1 1

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UZ Leuven, Leuven, Belgium

Thrombotic microangiopathies (TMAs) are best known for their presentations as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome. Yet a multitude of secondary forms of the disease exists. TMA also presents as a rare but serious complication of organ transplantation, on which much knowledge remains hypothetical. Although TMA after hematopoietic stem cell and kidney transplantation has been described extensively in literature, little information is available on TMA following non-renal solid organ transplantation. We present a literature review of TMA after non-renal solid organ transplantation which answers many pending questions. Many factors contribute to its pathogenesis, especially ischemia-reperfusion, immunosuppressive drugs, acute disease and even a relative deficiency of the von Willebrand factor (vWF) cleaving protease (ADAMTS13). The mean incidence rate (0–4%) and time of onset (2 weeks – 2 years) are different according to the type of transplantation, differences we will try to explain. The three month survival rate is about 70%. An elevated vWF/ADAMTS13 ratio promises to become a useful diagnostic tool in TMA early after liver transplantation. The most important therapeutic intervention is withdrawal of calcineurin inhibitors. After resolution patients may be rechallenged with calcineurin inhibitors. Plasma exchange therapy has historically grown as a standard of care but its value remains controversial. We will however defend its use in TMA early after liver transplantation.

P30 5-Oxoproline-induced high anion gap metabolic acidosis: case report Jaderi Zahra1, Johan Flamaing2 1

UZ Antwerpen, Antwerpen, Belgium, 2Department of Geriatric Medicine, UZ Leuven, Department of Clinical and Experimental Research, KU

Leuven, Belgium Abstract: Metabolic acidosis occurs commonly in hospitalized patients and can be subcategorized in non-anion gap and high-anion gap acidosis.The majority of high-anion gap acidosis include lactic acidosis, ketoacidosis, acidosis that results from the ingestion of toxic substances such as methanol, ethylene glycol or paraldehyde and a component of the acidosis of kidney failure. There are rarer causes of high-anion gap metabolic acidosis however, one of which is the accumulation of 5-oxoproline.We present a case report of 5-oxaloproline acidosis as we intend to alert clinicians to the condition. Case report: An 82-year-old woman was admitted to receive prosthesis of the right shoulder due to an intra-articular fracture for which she received Paracetamol (acetaminophen) systematically. A few days after the surgery the patient developed a septic arthritis and was started on Flucoxacilline IV 4x2g/d in combination with Acetaminophen 4g/d to relieve the pain. The shoulder was recovering from pain and immobility after a few days of treatment when the patient developed shortness of breath without signs of infection (respiratory rate up to 30 breaths per minute) and suddenly developed a diminished level of consciousness. Her vitals were stable. An arterial blood gas revealed a metabolic acidosis with a pH of 7.20, a pC02 of 18 mmHg, a PO2 of 175 mmHg, a bicarbonate of 5.9 mmol/l and a base excess of 230. The anion gap was 29.55 mEq/l (corrected for serum albumin of 29 g/l). The serum lactate was measured 3 times and showed a normal count each time (1.0–1.7 mmol/l). The urine was also examined but showed no sings of ketones. The use of methanol and ethylene glycol was considered unlikely in this patient. The blood results showed a serum creatinine of 1,50 mg/dL (Cockcroft-Gault clearance of 65 ml/min). The cholestatic liver enzymes though were elevated (ALP 323 U/l, cGT 370 u/l). We noted a therapeutic Acetaminophen level in the blood. (3.2 mg/l). Since we were able to dismiss the major causes of metabolic acidosis, we asked one of our specialists in electrolyte disturbances to guide us through this particular case. He suggested a measurement of 5-oxaloproline in the urine and serum as the accumulation of it may be a rare cause of metabolic acidosis. The results of the tests showed a 5-oxoproline of 16,623 mmol/mmol creatinine (normal ,100 mmol/mmol creatinine) in the urine and plasma level of 6573 mmol/l (normal 15 mmol/l) which confirmed the diagnosis of pyroglutamic acidosis as the cause of the metabolic acidosis. The patient was malnourished due to her illness and that in combination with the ingestion of Acetaminophen and Flucloxacillin led to the acidosis. Flucloxacillin was immediately replaced by Clindamycin and Paracetamol was stopped. The patient was treated with bicarbonate and Acetylcysteine. After four days of treatment the patient was recovered and the arterial blood gas was normalized. Pyroglutamic metabolic acidosis can be caused by chronic Paracetamol ingestion, anorexia or alcohol abuse. High levels of 5-oxoproline occurs as a result of overproduction of polyglutamic acid due to deficiency of glutathione synthetase (GS). GS and c-glutamyl cysteine synthetase produce glutathione. Depletion of glutathione levels due to malnutrition, Acethaminophen use and severe sepsis activates the enzyme in producing c-glutamyl cysteine (c-GS) out of cysteine and glutamate. c-GS can be converted to glutathione by GS. With a high level of c-GS, c-glutamyl cyclotransferase converts it directly to 5-oxoproline. Accumulation of 5-oxoproline occurs in the blood which causes acidosis. Oxoproline aciduria and 5-oxoprolinaemia has been described in patients who use Paracetamol, Vigabatrin and the antibiotics Flucloxacillin and Netilmicin due to inhibition of oxidation of 5oxoproline. The possibility of 5-oxoproline must therefore be considered in cases of unexplained high anion-gap in patient with the above risk factors. Conclusion: 5-oxoproline-associated high anion-gap metabolic acidosis should be considered when the cause of high anion gap metabolic acidosis remains poorly defined and the above-mentioned risk factors like renal insufficiency, malnutrition in combination with the use of the drugs such as Paracetamol, Flucloxacillin and Netilmicin is present. Though considered rare, it may be more common than expected and physicians can help patients quickly recover from this type of acidosis with accurate diagnosis and treatment.

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P31 Cardiotoxicity after radiation therapy Thalia Bekelaar1, Anne Vorlat2, Greta Moorkens2, Christiaan Vrints2 1

University of Antwerp, Antwerp, Belgium, 2UZA, Edegem, Belgium

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Background: Cardiac complications after mediastinal radiation therapy occur in 10 to 40 % of the patients and typically present 10 to 15 years after treatment. We present a case report of a middle-aged woman with cardiogenic shock due to valvular insufficiency after mediastinal chemoradiation therapy for non-Hodgkin lymphoma. Case report: A 42-year-old woman presented with an episode of acute respiratory distress, desaturation, tachycardia and hypotension. Medical history revealed a diffuse large B-cell non-Hodgkin lymphoma at the age of 32, for which she received 6 cycles of chemotherapy with R-CHOP 21 and additional 40 Gy of involved field radiation therapy. Laboratory tests showed inflammation and abnormal liver function tests. X-ray imaging and cardiac ultrasound showed pulmonary oedema and reduced myocardial contractility. Diagnosis of cardiogenic shock was made. Oxygen, inotropy, antibiotics and diuretic therapy were started. Further investigation after clinical stabilisation showed a hypokinetic left ventricle and a massive mitral valve insufficiency. There was also an important aortic valve insufficiency. Coronary angiography was normal. Anatomopathological investigation of the pleural puncture fluid was suspected to be nonHodgkin lymphoma, but additional investigation with PET-CT scan showed no relapse of non-Hodgkin lymphoma. Based on this findings, diagnosis of cardiogenic shock due to valvular insufficiency and heart failure was made. This cardiac complications are due to cardiotoxicity as sequel of the chemoradiation therapy 10 years earlier. Medication for cardiac failure was started and both the mitral and aortic valve were replaced by a mechanical heart valve prosthesis. Conclusion: Cardiotoxicity after mediastinal radiation therapy involves coronary artery disease, valvular disease, arrhythmias and cardiac failure. The severity of this complications depends on the radiation dose and surface, concomitant use of antracyclines, age when treated and presence of cardiac risk factors. The risk of cardiac mortality is elevated by 2 to 7 times. At present, there are no evidence based guidelines with regard to follow-up of patients after chemoradiation therapy to the mediastinum. However routine cardiac check-up (including ECG, echocardiography and early cardiac risk factor control) on a regular basis might be able to detect and postpone cardiac complications, especially in young patients.

P32 Black pleural effusion Virginie Mercier1, George Tragas1, Rudy Peche1, Olivier Gilbert1, Alain Van Meerhaeghe1 1

CHU, Charleroi, Belgium

A 86-year-old man was admitted in July 2014 for poor general condition, loss of appetite and increasing dyspnea. Two years earlier, he was diagnosed with a low-grade fibromyxoid sarcoma invading the right side of the chest wall with the presence of a pleural effusion. He underwent a resection of the lesion and a concomitant thoracocentesis revealed the presence of neoplastic cells in the pleural fluid. He was treated since 2013 by pazopanid (VEGF Tyrosine Kinase Inhibitor) following the detection of metastases to the mediastinal lymph nodes. He also took rivaroxaban 15 mg/day for atrial fibrillation. On physical examination, he presented dullness to percussion and decreased breath sounds on the right side of the thorax. A chest radiograph was consistent with a large pleural effusion. Subsequent thoracocentesis yielded a black fluid which appeared to be an exudate: pleural protein 3190 mg/dL and a high LDH value of 414 U/l. Pleural fluid glucose concentration was measured at 50 mg/dL and amylase at 39 U/L.Cytologic examination revealed many red blood cells but no malignant cells. Cultures for bacteria, fungi and mycobacteria were negative. Black pleural effusions are extremely rare. The black color is related to liquefaction of old blood or to necrotic debris.4 Potential causes involve fungal infections by Aspergillus species (Aspergillus niger) or Zygomycoses (Rhizopus oryzae). Transplant patients and patients with cancer, diabetic ketoacidosis, extensive burns or trauma, intravenous drug abusers are prone to develop these fungal infections. Metastatic melanoma involving the pleural space might be associated with black pleural effusions. A charcoal-containing empyema complicating a treatment for alcohol and drug overdose has been reported.1,4,5 Black pleural effusions may also be the result of crack cocaine inhalation with intracellular or extracellular carbon pigment transport across the visceral pleura.6 In the present case, the neoplastic hypothesis could not be rejected, given the patient’s history and the low sensitivity of the cytologic examination of malignant pleural effusion (60%). Side effects of VEGF-targeted agents should also be considered since they have been associated with an increased risk of hemorrhage. Also the Xa factor inhibitor (rivaroxaban), administered in this patient for atrial fibrillation may result in pleural hemorrhagical effusion.

References 1 Black pleural effusion in melanoma, Wei-Chih Liao MD, Chia-Hung Chen MD, Chih-Yen Tu MD. CMAJ 2010 May 18–182(8) 2 Diagnostic tools of pleural effusion, Moon Jun Na. Tuberc Respir Dis (Seoul) 2014 May; 76(5): 199–210. Published online 2014 May 29. 3 Pleural fluid analysis: stanstill or awork in progress? T.Hassan,M.Al-Alawi, S. H. Chotirmall, and N. G. McElvaney- Respiratory Research Division, Educationand Research Center, Royal College of Surgeons in Ireland, Beaumont Hospital,Beaumont Road, Dublin 9, Ireland 4 Lai CC1, Liaw SJ, Hsiao YC, Chiu YS, Laio WY, Lee LN, Hsueh PR. Empyema thoracis due to Rhizpus oryzae in an allogenic bone marrow transplant recipient. Med Mycol. 2006 Feb;44(1):75–8.

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5 Black pleural effusion. Takeshi Saraya, Richard W Light, Hajime Takizawa, Hajime Goto. The American journal of medicine Jul; 126 (7):641.e1–6. Doi: 10.1016/j.amjmed.2012.11.017. Epub 2013 Apr 13. 6 Black pleural effusion. Randolph P. Cole, MD. The American journal of medicine. Letter to the Editor. Doi: 10.1016/j. amjmed.2013.07.034

P33 Metastatic malignant melanoma: don’t forget the surgeon! Felix De Bie`vre1, Pol Specenier1,2 Antwerp University Hospital, Edegem, Belgium, 2Antwerp University, Wilrijk, Belgium

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Introduction: Systemic treatment of metastatic melanoma is rapidly evolving with multiple new options. However, in some cases, surgical resection of metastases can be associated with a prolonged survival. Case presentation: A nodular melanoma (Breslow 1.9 mm, Clark 4) located at the right arm in a 44-year old Caucasion male was resected in November 2006. No sentinel lymph node procedure was performed. In June 2008, a large single axillary lymph node was removed. No further metastases were detected in the other lymph nodes at completion lymphadenectomy. Our patient subsequently received adjuvant high-dose interferon for 1 year. On 18FDG-PET-CT-scan at the end of the adjuvant treatment, lesions with high metabolic activity were detected at the ileum and at the musculus sartorius (see image). Patient was free of symptoms. In December 2009, patient underwent a laparoscopic partial resection of the small bowel and of the right musculus sartorius. In the resection specimen, we found a metastasis of melanoma with a diameter of 4.5 cm in the bowel wall, invading the serosa and the mesenterial fat, and a metastasis in the musculus sartorius (diameter 2.5 cm). Patient received no further therapy and has been free of symptoms and free of tumor ever since. PET-CAT was performed yearly and remained negative (latest PET-CAT March 2014).

Discussion: Our case illustrates that, even in the era of active targeted agents and immunotherapy, surgical resection of oligo-metastases of melanoma should be considered. Prolonged disease-free survival can be occasionally observed.

P34 Metastatic Renal Cell Carcinoma: don’t forget surgery Elisa Cassiers1, Pol Specenier1,2 1

Antwerp University, Wilrijk, Belgium, 2Antwerp University Hospital, Edegem, Belgium

Mutiple new targeted agents are currently available for the treatment of metastatic renal cell carcinoma. Median survival of patients treated with these new agents now exceeds 2 years. However, surgical removal of metastases should not be dismissed, as illustrated by the following patient case. A 46-year old Dutch male was diagnosed with a clear cell carcinoma of the right kidney in February 2005 for which the right kidney was surgically removed. His subsequent surgical history is summarized in the table. Metastases in brain or lungs were resected at 6 occasions. In November 2013, PET scan showed a new solitary metastasis in the right upper lung lobe. Residual function of the left lung prohibited a right pneumonectomy. No treatment was started as the patient was asymptomatic. In April 2014, clear tumor progression was observed and sunitinib 50 mg/day 4 weeks on, 2 weeks off, was started. The treatment was poorly tolerated (loss of taste, loss of energy, hand-foot syndrome). Disease progression was documented at reevaluation in August 2014. At reevaluation in August 2014, tumor progression in the lungs and lymph nodes was documented. MRI of the brain showed a solitary metastasis with

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Date

Surgery

Findings

September 2005 March 2007 June 2007 August 2008 November 2010 July 2013

median sternotomy lobectomy left superior lobe metastasectomy right lung metastasectomy right lung complete resection metastasectomy right lung

bilateral lung metastases lung metastases multiple metastases 4 metastatases solitary metastasis right frontal lobe 2 metastases

P36 Wasting away Sam Proesmans1,2, Christiane Brands1, Hans Slabbynck1, Jan Nagler1, Joannes Holvoet1 1

ZNA Middelheim, Antwerp, Belgium, 2University of Antwerp, Antwerp, Belgium

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Background: HIV has become a chronic disease, since therapy has greatly improved over the past few years. A rising incidence of immune-mediated diseases, such as sarcoidosis is observed in HIV patients. Similarities between the population at risk for sarcoidosis and those who are HIV positive are noticed: they are young and black. Sarcoidosis has a peak incidence between age 20 and 40, concurrent with the peak sexual transmission of HIV. Furthermore sarcoidosis is three times more frequent in black Africans/Afro-Americans than in Caucasians. Case-report: We present a 45 year old black women, HIV-positive for over 20 years and well controlled under highly active retroviral therapy HAART (efavirenz/emtricitabine/tenofovir). Her CD4-count hardly ever went below 500/mm3 and recent viral load count showed undetectable. On the follow-up consultation she reported unintentional weight loss of 8 kilograms over the last months, periodically fever and a profound fatigue. A routine blood sample showed a disturbed liver function, with a cholestatic pattern. Alkaline phosphatase and gamma-glutamyltransferase reached values of 30 times the upper limit of normal. To further investigate this cholestasis, a liver ultrasound was performed, which showed hyperreflective lesions throughout the entire liver. An abdominal CT-scan showed diffusely hypodense lesions in the liver and the the spleen. Positron emission tomography (PET) confirmed these lesions in both liver and spleen, together with two mediastinal adenopathies. A liver biopsy revealed a non-caseating granulomatous hepatitis. Given the radiological features, the pathological diagnosis, the clinical presentation and evolution, and after exclusion of tuberculosis and other infections through culture, T-spot and various serology, the diagnosis of sarcoidosis was made. Therapy with high dose corticosteroids was started: the fever subsided, the patient gained weight, and liver function improved. Discussion: Lesions in both liver and spleen are seldom a sign of malignancy. We should consider sarcoidosis as a possible diagnosis in all HIV-positive patients, under (long standing) HAART. Furthermore, we want to emphasize the increasing incidence of sarcoidosis and the severity of the disease, especially in blacks, who have a mortality rate as high as 17 times the rate in white individuals. Hence proper diagnosis and appropriate care are mandatory.

P37 Legionella pneumophila pneumonia followed by Hemophagocytic Lymphohistiocytosis: a case report Michael Janssens1, Sebastien Anguille1, Sofie Rosier1 1

AZ middelheim, Antwerpen, Belgium

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare and potential life threatening auto-immune disease. It can be triggered by various events of which infection is one of the most frequent. A 77-year old man was admitted to the emergency department because of a progressive decrease of consciousness since 2 days. The patient’s family reported the presence of fever one day before admission. Clinical investigation showed a mentally confused patient with difficulties to speak . Heart rate was 110/min and irregular; blood pressure was 100/70 mmHg; oxygen saturation was 94%; capillary refill time was .5 sec and temperature was 37.2uC. Lung and heart auscultation were normal. Neurological investigation showed symmetrically and light-responsive pupils. There was no muscular weakness of the limbs. Tendon reflexes in the lower limbs were absent. ECG showed an atrial flutter. Arterial blood gas revealed a pO2 of 62.9 mmHg, pCO2 of 18.2 mmHg, pH of 7.32, HCO3 of 9.2 mmol/L and lactate of 8.7 mmol/L. Lab tests showed leukocytosis of 22610ˆ9/L(90% neutrophils), Creatinine of 4.69 mg/dl ( 0,66–1,25); LDH of 1806 U/L ( 313–618); AST of 284 (17–59); ALT of 99 U/L( ,49); D-dimers of 8.33 mg/ml(,0.5) and C-reactive protein of 377 mg/L (,10). Chest X ray showed a small infiltrate in the right lower lobe. CAT scan of the brain was normal. The patient was transferred to the ICU with the presumptive diagnosis of sepsis caused by pulmonary infection . Broad spectrum antibiotics were started . The next day legionella antigen urine test showed positive and the diagnosis of legionella pneumonia was made. Routine laboratory analysis revealed an extreme high ferritin level of 25700 ng/mL ( 18–464) leading to the diagnosis of a HLH, probably provoked by the legionella infection. Antibiotic therapy was continued and administration of dexamethasone was started as treatment for the HLH, after bone marrow punction was performed. The patient responded well to both therapies and recovered.

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine Conclusion: Hemophagocytic lymphohistiocytosis is a rare and potentially lethal disease which is often provoked by infectious. Prompt and correct diagnosis is of vital importance to start initial treatment as quick as possible end therefore reduce mortality. The diagnosis is made on the HLH 2004 trial criteria.

P38 Cowden Syndrome: a novel PTEN mutation description and how to recognize a not-so-rare Hereditary Cancer Syndrome Pauline Delannoy1, Guillaume Franc¸ois Debray1, Albert Beckers1, Hernan Valdes-Socin1 1

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Introduction: The PTEN hamartoma tumor syndrome (PHTS) includes Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome (BRRS), PTENrelated Proteus syndrome (PS), and Proteus-like syndrome. Cowden syndrome is a dominantly inherited multi-system disorder causing increased risks for benign and malignant neoplasias. An early recognition allows early screening and other preventive measures prior to a patient enduring multiple cancer diagnoses. Case Report: A 20-year-old woman presents with a thyroid nodule. Family history is not contributory. The clinical examination demonstrates hamartomas of the palate and mouth as well as a nodular papilloma at the end of the little finger of the right hand. She had multiple nævi and an atypical melanocytoma was resected in 2011. Thyroid exploration highlighted a nodular goitre essentially developed at the expense of the right thyroid lobe. This lobe had one macronodule clinical and by ultrasound means suspect. Thyroid scintigraphy confirmed this was a ‘cold’ nodule. Thyroid cytoponction showed an atypical cytology with Hurtle cells. The risk of malignancy was estimated at 20–30 %. Surgery was recommended. Anatomopathology identified a benign adenoma of 6.3cm diameter. Because of a high suspicion of Cowden syndrome, a genetic exploration was undertaken. This one showed the presence of a novel heterozygous mutation t c.445C . T (p. Gln149 *) at the level of PTEN gene, confirming the diagnosis of CS. Conclusions: Patients with CS have an increased risk for breast, thyroid, renal, uterine, and other cancers as well as benign neoplasias and neurodevelopmental problems. It is important for clinicians to recognize these patients and refer them for cancer genetics consultation. The lifetime risk for thyroid cancer (usually follicular, rarely papillary, but never medullary thyroid cancer) is approximately 35%, so thyroid surgery is recommended when thyroid nodular pathology is present.

P39 Tissue is the issue Elien Dewaele1,2, Jan Van den Brande1,2, Pol Specenier1,2 1

Antwerp University Hospital, Edegem, Belgium, 2Antwerp University, Edegem, Belgium

Introduction: Metastases are not always confirmed by microscopy before treatment. This can lead to unpleasant surprises. Case report: A 50-year old female patient underwent a resection of a myxofibrosarcoma grade 2 in October 2010. Section margins were free and adjuvant radiotherapy was administered. A routine FDG PET in November 2013 showed a mass with high metabolic activity at the caecum and a second small focus of metabolic activity at the hepatic flexure of the colon. Increased FDG activity was also present at the right atrium. During colonoscopy, a polypoid lesion in the ascending colon was observed. Biopsies showed a adenoma with low grade dysplasia. A right hemicolectomy was performed in January 2014. No malignant tumor was found and the diagnosis of a large adenoma was confirmed. Echocardiography showed a mass in the right atrium which was resected in February 2014. Microscopy showed a dedifferentiated high grade myxofibrosarcoma. No adjuvant chemotherapy was administered. In June 2014, a follow-up PET-CAT was performed. Multiple hypermetabolic lesions were present in both lungs and at the pericard. The lesions at the pericard were hypodense on CAT. The lung lesions were nodular with spicular borders and had a diameter of less than 1 cm. The conclusion of the radiologist and nuclear medicine specialist was ‘image of lung and pericardial metastases’. As the images were extremely suggestive for metastases and as the occurrence of metastases in this patient was extremely plausible, no histological confirmation of metastasis was obtained, as this required an invasive procedure with non-negligible risks. Chemotherapy with ifosfamide and doxorubicine was scheduled but had to be postponed due to an intercurring hemorrhage of the spleen. A new ‘baseline’ PET scan before the rescheduled start of chemotherapy showed a decreased volume and metabolic activity of the lesions in the lungs and at the pericard, suggesting a nonmalignant underlying cause. Of course chemotherapy was cancelled. Images will be presented at the meeting. Conclusion: The presence of metastases should be confirmed histologically whenever possible. Tissue is still the issue.

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P40 Overwhelming pneumococcal infection in a previously healthy adult: the fatal case of a missing organ Joke Cuypers1, Liesbet Henckaerts1 1

UZ Leuven, Leuven, Belgium

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Case report: A 42-year old Caucasian male was admitted with diarrhea, muscle weakness and fever. His medical history was unremarkable. In the last months, he had traveled to rural India, Tel Aviv and Moscow and he had had several unsafe homosexual contacts. On admission, clinical examination only showed mild hypotension and oliguria but no other anomalies. Blood tests showed acute renal impairment (creatinine 1.94 mg/dL), mild rhabdomyolysis (creatinine kinase 200 U/L), elevated C-reactive protein (CRP, 218 mg/L) and moderate liver function abnormalities (2*ULN); the haemogram was normal. A tentative diagnosis of acute viral gastroenteritis was made, and the patient was started on intravenous fluid resuscitation. Thirty-six hours after admission, however, the patient showed neurological decline (Glasgow coma scale 6), as well as progressive signs of distributive shock. There was no clear infectious focus and no clinical signs of meningitis. The patient was intubated, and broad-spectrum antibiotics were started, taking the travel history into account. Blood tests revealed progressive inflammation (CRP 420 mg/L), leukopenia (2.1 10ˆ9) and thrombopenia (30 000), deterioration of liver function (liver function tests 5* ULN) and rhabdomyolysis (CK 10 000 U/L). HIV test was negative. Blood smear showed the presence of acanthocyts, echinocyts and Howell-Joly bodies, consistent with asplenia, which was confirmed on abdominal ultrasound. Computed tomography of the brain showed cerebral edema, probably due to intracranial infection. Despite aggressive treatment, based on continuation of broad spectrum antibiotics, vasopressor support and intracranial pressure measurement, the patient died of transforaminal herniation only 24 hours after onset of sepsis. Post factum, Streptococcus pneumonia was isolated from admission blood cultures. Postmortem examination confirmed hyposplenia. Discussion: Isolated congenital asplenia is a rare condition, usually diagnosed in childhood. Very few cases are described in adults. In contrast with patients with acquired asplenia, these patients and their treating physicians are unaware of their condition and the associated risk of untreated bacterial infection, the need for prophylactic or early empiric antibiotic therapy and vaccination. Mortality of infections is high when the initiation of antibiotics is delayed, and, as in our patient, mainly due to encapsulated bacteria.

P41 A Case of von Meyenburg complex-associated cholangitis Kirsten Saevels1, Luisa Vonghia1, Michae¨l Torfs1, Ann Driessen1, Greta Moorkens1 1

UZA, Edegem, Belgium

Introduction: Von Meyenburg Complexes (VMCs), also called bile duct hamartomas are a rare clinicopathologic entity, consisting of small (,1.5 cm), usually multiple and nodular cystic lesions of the liver. They originate from embryonic bile ducts that fail to involute. Case Report: A 54 year old man with a medical history of Hashimoto thyroiditis and penicillin allergy was admitted to the Department of Internal Medicine because of fever of unknown primary focus. Since a month he started feeling ill with as major complaints tiredness and myalgia. Since two weeks there was a concurrent fever. The fever was not responding to antipyretics (paracetamol). Laboratory results on admission showed leucocytosis, an elevated C-reactive protein and disturbed liver-tests. Urine cultures and blood cultures were negative. X-ray of the chest didn’t reveal infiltrations. An abdominal ultrasound was negative. Also a transoesophageal cardiac ultrasound and eyefundus-examination were negative. Since the patient clinically deteriorated, empiric therapy with ceftriaxone was started. On abdominal Computed Tomography-scan we visualized several millimetric hypodense liverlesions without hypercaptation on Positron Emission Tomography. Magnetic resonance cholangiopancreatography (MRCP) showed multiple subcentimeter liver nodules, without communication with the biliary tree. There were no abnormalities of the biliary tree. The morphology, diffusion pattern and absence of pathological contrast captation were all characteristic for the presence of von Meyenburg complexes. Biopsy showed the presence of active cholangitis. Cultures of the biopsy –specimen remained negative. Final diagnosis was von meyenburg complexes associated cholangitis. There was a good clinical and biochemical evolution under treatment with ceftriaxone. Conclusion: VMCs are generally asymptomatic and thus in most instances they are diagnosed incidentally. We report a rare case of cholangitis in a patient affected by VMCs. In literature, only a few case reports describe this association. Cholangitis would be a result of biliary obstruction, supposedly due to excess mucus secretion, and has generally a favorable outcome.

P42 Adrenocortical Carcinoma Presenting with full blown Cushing Niels Bochanen1, Marcel Twickler1, Luc Van Gaal1 1

Department of Endocrinology, Diabetes and Metabolic Disease, Antwerp University Hospital, Edegem, Belgium

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Background: Cushing’s syndrome is described in 1910 by Harvey Cushing (1869 – 1939) characterized by hypertension, amenorrhea, hirsutism, truncal obesity, abdominal striae, oedema, glucosuria and osteoporosis. Different causes have been described. Adrenocortical carcinoma (ACC) is a rare endocrine tumour (with a prevalence of 0.7–2.0 cases per 1 million population per year) with a poor prognosis, responsible for only a minority of cushing’s syndrome . Due to its high mortality a fast diagnosis is warranted. Case report: A 63-year-old female with no significant medical history presents with a 20 kg weight gain in the past 8 weeks, most distinctly at face and abdomen . She had a regular period, no hair loss, no thoracic of gastro-intestinal complaints. Physical performance was not impaired (maximal Karnofsky score). Clinical examination showed a blood pressure of 160/99 mmHg, a buffalo hump, Moon face, pronounced truncal obesity and striae and peripheral pitting oedema. Increased diurnal cortisol levels were present without physiologically variation; increased 24 hour urinary cortisol excretion and a failure to suppress cortical secretion after administering 1 mg dexamethasone. Moreover the DHEA-S levels were significantly elevated suggesting the presence of adrenal carcinoma MRI scanning revealed a large mass in the adrenal region with extension to the liver. PET-CT confirms the extent of this mass, without arguments for other metastasis at distance. The patient underwent surgery: resection of the adrenal gland, nefrectomy and atypical hepatectomy segment 7. The pathological examination confirmed the clinical suspicion of a primary adrenal carcinoma. After surgical resection, hydrocortisone was started (substation dose). In addition to surgery, patient was treated with mitotane; a compound that inhibits steroid synthesis with the aim to control remnant tumour mass. After a 18 months follow up, the patient is in good clinical condition under treatment with mitotane and there is no evidence for tumour recurrence. Conclusion: In this abstract we report a case of a 63-year-old female with a adrenocortical carcinoma which presents as a Cushing’s syndrome. Adrenal carcinoma is a rare disease with a high mortality. Against that background it is preferred to have the Doctor’s and patient’s delay as short as possible. In our case, clinical signs existed for only eight weeks before referral. As presented in this case, additional treatment with mitotane, after optimal debulking of the adrenal mass by the surgeon, is considered. Such strategy gives most beneficial effect in patients with a adrenocortical carcinoma.

P43 An unusual cause of perimyocarditis Gaelle Vermeersch1, Paul Vermeersch1, Greta Moorkens2, Hans Slabbynck1 1

ZNA middelheim, Antwerpen, Belgium, 2Universitair ziekenhuis Antwerpen, Antwerpen, Belgium

Introduction: In western societies the most common cause of acute perimyocarditis is idiopathic (presumably viral). However less prevalent causes can occur and the clinician should be aware of that. Case report: Recently we saw a 19-year-old man with acute onset severe chestpain suggestive for perimyocarditis: pericardial rub on clinical investigation and pericardial effusion and slightly depressed left ventricular function on cardiac ultrasound. He was symptomatically treated with high dose salicylates. However a routine peripheral blood smear showed an abnormal elevation of eosinophils (5,570 10ˆ9/L; 40,1 %). Clinical history revealed that this previously healthy young man suffered from several exacerbations of asthma, diagnosed 6 months earlier with spirometry, chronic sinusitis, fatigue and weight loss up to 5kg. The triad of hypereosinophilia, asthma and sinusitis next to the cardiac involvement made the presence of Churg Strauss syndrome (CSS) or Eosinophilic granulomatosis with polyangiitis(EGPA) very likely. Although a histological confirmation is required by the different diagnostic criteria for CSS (Lanham’s criteria, ACR classification criteria and Chapel Hill criteria), we decided to refrain from a myocardial biopsy since there is a small risk for serious complications. A cardiac MRI was done to confirm the presence of myocardial involvement and showed discrete patchy myocardial (delayed) enhancement. Perinuclear ANCA’s were negative, as expected since ANCA-negative patients with CSS more commonly present with cardiac manifestations. The patient was treated with high doses of corticosteroids. He fully recovered clinically, eosinophilia normalized, and so did his cardiac MRI after 1 month of follow-up. After discontinuing his corticosteroids the patient relapsed immediately. Corticoids were resumed and the association of cyclofosfamide needs to be discussed. Conclusion: Churg Strauss syndrome (CSS) or Eosinophilic granulomatosis with polyangiitis(EGPA) is a multisystem disorder classified as an antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis of the small and medium sized arteries and is characterized by asthma, allergic rhinitis and prominent peripheral blood eosinophilia. The epidemiology remains unclear because of the uncertainties related to diagnosis. It is important to check for cardiac involvement since it negatively affects the prognosis. The golden standard for diagnosis is confirmation by biopsy. Treatment consists of high doses of corticosteroids and may need the association of cyclofosfamide. Although perimyocarditis is often benign and self-limiting, the clinician needs to be aware that rare causes exist.

P44 Cardiovascular risk evaluation of HIV-infected patients in a case-control study: comparison of the D:A:D and Framingham equations Samuel Markowicz1, Marc Delforge1, Coca Necsoi1, Ste´phane De Wit1 1

CHU Saint-Pierre, Brussels, Belgium

Background: HIV-infected patients are at increased risk of developing cardiovascular disease (CVD). A cardiovascular risk-assessment model tailored to HIV population is essential for CVD prevention.

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine Methods: We conducted a retrospective case-control study within the HIV cohort of the Saint-Pierre Hospital, Brussels. Cases (n573) presented a first CVD (ischemic heart disease or stroke) between 2002 and 2012. Controls (n5142) were HIV patients without CVD matched for age, ethnicity and sex. We used Wilcoxon and Fischer tests to identify predictors of cardiovascular risk. Framingham and D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) equations were calculated and compared in patients at time of event, 2, 4 and 6 years before. We simulated the impact on D:A:D scores if different therapeutic interventions had been introduced when patient’s cardiovascular risk at 10 years exceeded 20%. Results: C-reactive protein (CRP) .3 mg/L (p50.01) and HIV viral load .50 copies/ml (p50.01) at time of event, as well as slower increase in CD4 cell count (p50.03) were more frequent in cases. D:A:D score in cases increased more and faster over time than the Framingham score. Simulation of therapeutic interventions led to a significant reduction of the D:A:D score in cases. Conclusions: Increased CRP levels, uncontrolled HIV viral load at time of event and slower immunological response were associated with increased CVD risk. D:A:D score seems to be more accurate than Framingham score in identifying HIV-infected patients at high risk of CVD. Aggressive management of CVD risk factors remains a priority in these patients.

P45 Hypercalcemia in an old man Sofie Geth1,2, Vanessa Helsen2, Rozette Verbiest2, Jef Schurmans2 1

Antwerp University Hospital, Edegem, Belgium, 2AZ Sint-Dimpna Geel, Geel, Belgium

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Background: Hypercalcemia is a common clinical problem. It is associated with a spectrum of clinical manifestations, independent of the etiology. We report a case of an old man with hypercalcemia, who was referred to the hospital with recurrent falling and aspecific symptoms. Case report: A 89-year-old man was referred to the emergency service with recurrent falling, unsteady gait and headaches. The patient mentioned anorexia, fatigue, dyspnea and urine-incontinence. Medical history revealed anemia, acute on chronic renal insufficiency, earlier suspicion of neurological disease and hypothyroidism. Clinical examination showed blood pressure of 151/86 mmHg, a systolic souffle, a hematoma in the right axilla, pressure pain at the right rib cage due to a fall and neurological signs of Parkinsonism. Laboratory findings showed hemoglobine 10.2 g/dL (12.0–16.0) with MCV101fL (78–102) CRP11.7 mg/L (,5), creatinine 1.74 mg/dL (0.72–1.25), calcium 2.95 mmol/L (2.20–2.50), PTH25.7 ng/L (15–65) and TSH7.2 mU/L(0.35–4.9) with normal fT3 and fT4. Lower body Parkinsonism was the initial diagnosis. Despite treatment with Prolopa, further clinical deterioration and rising of creatinine (4.49) and calcium (3.49) occurred. CT thorax showed diffuse bilateral adenopathies and biopsy showed a follicular lymphoma. The hypercalcemia was treated with fluid substitution, loop diuretics, pamidronate, calcitonine and steroids. Conclusion: Hypercalcemia can cause a range of aspecific symtomps including constipation, fatigue, depression, polyuria, polydipsia, dehydration, anorexia, nausea, muscle weakness and changes in sensorium. In more than 90 percent of the cases, the underlying disease is primary hyperparathyroidism or malignancy, but other causes should also be considered in the differential diagnosis. While mild hypercalcemia may not require immediate treatment, patients with severe hypercalcemia (.3.5 mmol/L) need more aggressive therapy with saline hydratation, calcitonine, pamidronate steroids or hemodialysis. The underlying disease should be treated.

P46 Infectious mononucleosis, a common disease with uncommon complications Pieter-Jan Van Gaal1,2, Louis Verbist2 1

UA, Antwerp, Belgium, 2ZNA Jan Palfijn, Antwerp, Belgium

Introduction: Infection with Epstein Barr Virus (EBV) is common in children and adolescents. Although generally mild and self-limiting, physicians should be aware of serious complications. Case Presentation: We present the case of a 19-year old women with no past medical history who presented with a 10 day history of abdominal pain, fever, diarrhea and vomiting. Intake withheld fatigue, pain on inspiration and marked anorexia and weight loss. Medication included oral contraceptives. She was diagnosed with acute hepatitis, and a subsequent abdominal CT scan revealed multiple splenic infarctions, and a venous thrombosis in the inferior vena cava. Pulmonary embolisms were detected on CT pulmonary angiography. Serologic testing withheld a positive EBV serology (PCR confirmed), and false positive IgM for H. simplex, M. pneumoniae and B. burgdorferi. Thrombophilia testing showed a low level of Protein C and a high level of Von Willebrand Factor (possibly due to acute thrombosis). Testing for lupus anticoagulant was positive. She was started on oral warfarin and supportive therapy was given. Discussion: Epstein Barr Virus is a common cause of flu-like disease in children and adolescents. Its clinical course is usually mild and self-limiting, although prolonged fatigue is common. In a minority of cases, EBV infection can lead to serious complications, such as hepatitis, myocarditis, meningitis/ encephalitis, acute acalculous cholecystitis and hemophagocytic lymphohistiocytosis (HLH). Our patient presented with extended venous thrombosis. EBV-associated thrombosis has been rarely reported in literature, most frequent accompanied by underlying thrombophilia. Although our patient had positive antiphospholipid antibodies, false-positive lupus anticoagulant has been described in 30–60% of patients with acute EBV-infection.

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P47 Clinical evaluation of patients with apparently idiopathic SIADH A. Soupart1,2, G. Decaux2, M. Coffernils1, I. Nyenyeli1, F. Gankam4, B. Couturier2, F. Vandergheynst2*, D. Franc¸ois3 Departments of Internal Medicine1 and Radiology3, Jolimont-Tubize Hospital and Departments of Internal Medicine2 and Nephrology4, Erasme University Hospital

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Idiopathic SIADH is a poorly studied disorder and its prognosis is uncertain. It refers to patients with hyponatremia and no obvious cause (6 30% of SIADH). The syndrome can be associated with numerous diseases and can predate their diagnosis for months (e.g. malignancy). The incidence of SIADH increases also with aging. Which diagnostic tests should be performed in these patients in search of occult diseases has not been defined. Patients and Methods: Between 2008 and 2014, 84 successive patients with SIADH lasting for at least 1 month and no obvious cause were enrolled in a prospective study. Inclusion criteria were: patients with no specific symptoms or signs and no biological abnormalities pointing toward a diagnosis and a normal X-ray of the chest. Further investigations consist for all the patients in a brain CT scan and a FDG-PET.

Means6SD

Total cases

Negative cases

Positive cases

N Age (range) Male sex SNa (mEq/l) Previous duration of Hyponatremia (months) Hyponatremia ,12 months Mortality

n584 70611 (28–99) n553 (63%) 12266 37638 n530 (35%) n520 (23%)

n558 (69%) 70614 (51–99) n532 (55%) 120615 41635 n516 (28%) n59 (15%)

n526 (31%) 66612 (28–84) n521 (80%)* 12266 30644 n514 (53%)* n511 (42%)*

*p,0.05 compared to negative cases Results: An underlying diseases reported to be associated with SIADH was found in 31% of the cases and were intrathoracic in 73% (10 malignancy, 7 infections, 3 bronchiectasis), cerebral in 19% (chronic subdural hematoma, normotensive hydrocephaly, intracranial cavernoma, empty sella syndrome, olfactive neuroblastoma), abdominal in 3%, ENT cancer in 3% and 1 NSIAD. Neoplasms were found in 50% of the patients with a high mortality rate (70%). Final diagnosis was made by chest CT scan in the majority (73%) of the cases. Old ischemic brain lesions were also found in 37% of the patients. Conclusions: In this first large prospective study we show that in asymptomatic patient with apparently idiopathic SIADH, additional investigations can lead to diagnosis of treatable diseases in a significant number of cases. This study shows also that extensive diagnostic procedures are unnecessary and the diagnostic work-up should include only a chest CT scan. In young patients with negative chest CT, brain CT scan can be done. The prognosis of positive cases is poor despite early care.

P48 Association of absolute lymphocyte count, neutrophilto-lymphocyte and platelet-to-lymphocyte ratios with mortality in chronic hemodialysis patients: a retrospective single-center cohort study Elikyah Esther Kayembe1, Dieter De Clerck1, Christian Tielemans1, Patricia Van Der Niepen1, Jacques Sennesael1, Dirk Van Ingelgem1, Rene Scheepmans1, Karl Martin Wissing1 1

Division of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium

Background: Classical cardiovascular risk factors are poor predictors of the high mortality in hemodialysis patients. The present study retrospectively investigated the association of three novel and readily available inflammatory markers (absolute lymphocyte count, neutrophil-to-lymphocyte and plateletto-lymphocyte ratios) on mortality in hemodialysis patients. Methods: Patient characteristics and monthly averages of laboratory data and treatment characteristics were retrieved from a prospectively collected database at the Universitair Ziekenhuis Brussel dialysis unit for 575 out of a total cohort of 686 patients who initiated maintenance hemodialysis between January 1rst 1998 to December 31rst 2011.These data were merged with outcome data (death as outcome of interest as well as renal transplantation, change of dialysis modality, change of dialysis center, recovery of renal function and loss to follow-up as censoring variables) obtained from the regional registry of dialysis patients in the Flanders region (NBVN). The effect of absolute lymphocyte count, neutrophil-to-lymphocyte and platelet-to-lymphocyte

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Abstracts presented at the 19th Annual Congress of the Belgian Society of Internal Medicine ratios as time-variant predictor variables for patient death was modelled by Cox proportional hazard regression with adjustment for potential confounding variables. Results: Absolute lymphopenia was an independent predictor for patient death with a hazard ratio (HR) of 1.56 (95%CI 1.12 to 2.18; P50.009) for the lowest as compared to the highest quartile after adjustment for age, gender, CRP and serum albumin. The highest quartile of the neutrophil-tolymphocyte were associated with a HR of 1.76 (95%CI 1.25 to 2.5; P50.001) as compared to the lowest quartile. An increase in the platelet-to-lymphocyte ratio was associated with an increased mortality in the univariate model but not after adjustment for other risk factors in the multivariate model. Age (HR 1.05 per year; P,0.0001), Male gender (HR 1.35; P50.015), Albumine (HR 0.25 per g/L; P,0.0001) and CRP (HR 1.01 per mg/L; P,0.0001) were the other independent variables associated with patient survival in the multivariate models. Conclusion: Lymphopenia and an increased neutrophil-to-lymphocyte ratio were strong and independent predictors of patient death in our single-center retrospective cohort study. These associations remained significant after adjustment for markers of inflammation and malnutrition such as CRP and albumin.

P49 Familial hypercholesterolemia: among patients with a very high cholesterol level, does the presence of a genetic mutation lead to an extra cardiovascular risk? Downloaded by [Gazi University] at 20:45 21 March 2016

Justine Vereeke1, Olivier S. Descamps2 1

De´partement de me´decine interne du Centre Hospitalier Jolimont-Lobbes, Haine St Paul, Belgium, 2Centre de recherche me´dicale de

Jolimont

Background: Familial hypercholesterolemia (FH) is a inherited disorders of LDL cholesterol metabolism, caused by mutation in the low-density lipoprotein receptor gene (LDLR), in the apolipoprotein B gene (APOB) or in the proprotein convertase subtilisin/kexin type 9 serine (PCSK9). It leads to a premature atherosclerosis and early cardiovascular disease (CVD). In this study in patients free of CVD at entry, we compared CVD incidence between patients genetically confirmed for FH and patients without mutation but with the same phenotypic characteristics (severe hypercholesterolemia and family history of early cardiovascular disease). Method: In our data bank of patients examined between 2002 and 2006 by genetic analysis for suspicion of FH (based on severe hypercholesterolemia and family history of early CVD), we selected the patients who were older than 40 years and free of CVD at entry (the moment of ADN analysis). Patients with too short follow-up (,2 years) or follow up outside our hospital were excluded. In the remaining, we collected through our hospital datafile or phone call (GP or patients), the most recent data regarding CV risk factors, lipid lowering treatment and occurrence of CVD since their entry. Results: From these 117 patients, 36 patients carried a FH mutation (‘FH patients’) and 36 patients did not carry a FH mutation (‘non FH patients’). At their last visit, there was no difference among the 2 groups in the average of LDL-cholesterol levels or in the distribution of the other cardiovascular risk factors (age, smoking, obesity, hypertension and diabetes). In FH patients, the treatment were however generally stronger (with higher dose or higher intensity of statins), and the mean calculated baseline LDL cholesterol levels were higher than in non FH patients. Kaplan Meier analysis of first CV event showed that, despite same LDL-C under treatment, the CV risk at ten years remained 30% higher in FH patients than in non FH patients. Conclusion: Among patients with severe hypercholesterolemia and family history of early cardiovascular disease, despite identical lipid phenotype on treatment, the presence of a genetic mutation is associated with more severe cardiovascular prognosis.

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Abstracts of the 19th Annual Congress of the Belgian Society of Internal Medicine, December 12-13, 2014, Brussels, Belgium.

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