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6/5/23 NTC — Catecholamine Crisis 2/2 Paraganglioma

At noon teaching conference today, UCSD Endocrinologist and former chief resident Robert Thomas guided us through the case of a middle-aged man who initially presented to an OSH ED five years ago with abdominal pain and nausea/vomiting and was found on CT imaging to have a retroperitoneal mass. He was lost to follow-up, but returned to the OSH ED three years later with presyncope and weight loss and was found on imaging to have enlargement of the retroperitoneal mass. He was again lost to follow-up, but was seen four months later by UCSD Pulmonology for evaluation of an incidentally found lung nodule. On review of his OSH imaging, the Pulmonology team was more concerned by the retroperitoneal mass and placed a STAT referral to UCSD GI for EGD/EUS/FNA, which he underwent a week later and which showed pheochromocytoma/paraganglioma. He was referred to Endocrinology and underwent biochemical testing, which confirmed catecholamine hypersecretion. He was started on an alpha-blocker and was scheduled for surgical resection, but then declined surgery and was subsequently lost to follow-up.

The patient presented two years later to the UCSD ED with abdominal pain, nausea/vomiting, and unintentional weight loss, and was found to have uncontrolled hypertension, tachycardia, DKA, and multiorgan dysfunction, including AKI, rhabdomyolysis, NSTEMI, and new-onset HFrEF. CT imaging showed further enlargement of his paraganglioma. He was re-started on his alpha-blocker and his EF improved from 23% to 56%, consistent with catecholamine-induced cardiomyopathy.

We used the case to discuss the differential of retroperitoneal masses, risk factors for pheochromocytoma/paraganglioma (MEN 2A and 2B, neurofibromatosis type 1, Von Hippel Lindau syndrome, Carney-Stratakis dyad), its clinical presentations, its diagnosis (plasma and/or 24-hour urine metanephrines), and its treatment (alpha BEFORE beta blockade (!!!), pre-op volume resuscitation, surgical resection).

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6/5/23 Hillcrest NTC: peri-operative medicine

Today at Hillcrest noon teaching conference, we worked in small groups using MKSAP-style questions to review guidelines for pre-operative medical evaluation, which internists are often asked to do both in the inpatient and outpatient setting. Key takeaways include avoiding pre-op testing for low-risk ambulatory surgeries, thinking carefully about peri-operative medication management and which classes of medications to consider holding around the time of surgery, reviewing cardiac indications to postpone surgery and applying a screening algorithm using functional status (e.g. METS then peri-op risk calculators) for greater than low risk surgeries.

We concluded conference with some advice on residency financial wellness and the importance of true own-occupation disability insurance from one of our recommended resources (WCI). Thanks to our faculty members Dr. Farkhondehpour, Dr. Horman, Dr. Woodell, and Dr. Jassal for sharing clinical and career pearls!

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6/2/23 — Continuing Resident Meeting and Official Launch of Residency Houses!!!

On Friday, we had our annual Continuing Resident Meeting, where we received important program updates from Dr. Jassal! We also officially launched our Residency House program! The Houses sat together for lunch, met their new Chiefs, and competed in the first House Games, with Mission Bay House emerging victorious! Thank you to everyone for making the day a BLAST and to Matthew Tan for designing our House crests!

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HC NTC 6.1.23 – Treating Tetanus

Today, PGY-1 Dr. Tanner Long presented a case of a young patient who presented found down with opisthotonus, risus sardonicus, trismus, apnea/respiratory failure requiring emergent criothyroidotomy, cardiac arrest, and subsequent shock (likely septic and possible obstructive). Patient also had a history of injection drug use and had dirty wounds covered in necrosis with maggots and flies and was found in a riverbed. Given the risk factors and clinical picture, tetanus was high on the differential. We discussed empiric treatment of tetanus. Thank you to infectious disease expert, Dr. Morgan Birabaharan, for all the wonderful teaching!

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HC NTC 5.30.23 – Paraganglioma

Today, we discussed a case of a patient who with PMH of HTN and DM presented with acute nausea, vomiting, and abdominal pain. The patient was noted to be in DKA with concurrent lactic acidosis, respiratory acidosis, and metabolic alkalosis as well as acute hypoxemic respiratory failure with pulmonary edema and EF of 23% without WMAs. The patient was tachycardic, hypertensive, and had a Type 2 NSTEMI. On abdominal imaging, the patient had a large necrotic retroperitoneal mass consistent with paraganglioma (outside records confirmed elevated serum and urine metanephrines as well as biopsy). His clinical picture was consistent with catacholamine crisis and was started on alpha blockade and admitted to the ICU for management. Thank you to endrocrinology experts, Dr. Decamps and Dr. Ekanayake, for discussing this interesting and rare case with us!