PREECLAMPSIA AND PSEUDO POSTPARTUM CARDIOMYOPATHY. H. Zakariya 1 , R.D. Hobbs 1 ; 1 Oakwood Healthcare System, Dearborn, MI (Tracking ID #76568) LEARNING OBJECTIVES: To recognize that volume overload in the preeclamptic patient can lead to pulmonary edema and the misdiagnosis of postpartum cardiomyopathy. CASE INFORMATION: A 29 year-old, G5P3AB2 woman presented with severe dyspnea, orthopnea and peripheral edema five days after delivering a baby. Her pregnancy had been complicated by preeclampsia but managed without difficulty. Vital signs were: BP 157/96, P 110, R 22, T afebrile. Oxygen saturation was 94% on 100% O2. Bilateral rales, jugular venous distention, an S3 and S4 with 3+ pitting edema and a mitral regurgitation murmur were noted on physical examination. Cardiac enzymes were normal. Hgb was 9.7 g/dl. An EKG showed sinus tachycardia. Spiral CT was negative for pulmonary embolus. She was admitted with a diagnosis of postpartum cardiomyopathy. An echocardiogram showed severe mitral regurgitation, trivial tricuspid regurgitation, a small pericardial effusion and an ejection fraction of 50-55%. She was treated with furosemide and rapidly improved. Repeat echocardiography, done two weeks later when she was asymptomatic and off medications, showed that the mitral regurgitation had cleared, there was no pericardial effusion and her ejection fraction was unchanged. Further history revealed that in the last months of pregnancy and immediately postpartum she had been advised to``drink a lot of fluids.'' IMPLICATIONS/DISCUSSION: In preeclampsia the expected fall in colloid oncotic pressure is greater than that seen in normal pregnancies. Cardiac output increases 40% during normal pregnancy and extravascular volume is expanded. Following delivery, significant amounts of extravascular fluid move into the intravascular space and are cleared. In our patient, increased fluid intake led to over expansion of the extravascular volume with pulmonary edema occurring as the fluid was mobilized. Notably, this is not a case of postpartum cardiomyopathy. Her ejection fraction was normal on both initial and repeat echocardiograms and does not show primary muscular dysfunction. The mitral regurgitation cleared with diuretics and is not suggestive of a structural lesion. Small pericardial effusions may occur as a normal variant during pregnancy. Instead, her condition is explained by extreme fluid shifts in a preeclamptic woman. Diagnostic confusion occurs if the physician interprets the findings in terms of the non-pregnant state. year old female with no PMH except appendectomy, admitted with a five days of abdominal pain. It began as``indigestion'' in the epigastrum for several days but progressed to a sharp, constant, right-sided abdominal pain. Associated symptoms included anorexia, three days of constipation, with no bowel movement but some flaitus. She had no dysuria, normal menses, and no bloody bowel movements. She had one episode of``sweats'' and chills two days prior. On exam, she was afebrile and in moderate distress. Her vital signs were normal and abomen was soft with hypoactive bowel sounds and voluntary guarding in the right mid abdomen. Rectal exam was guiac negative. The remainder of the exam was normal. UA, CBC, LFTS, amylase, and lipase were normal. CT of the abdomen revealed a 5.3 cm mass( with a small air pocket) adjacent to the hepatic flexure with mesenteric stranding and sigmoid diverticulosis. Bowel rest and ampicillin -sulbactam were implemented. By the third day, her exam markedly improved. She was discharged on amoxicillin-clavulanate with follow up colectomy planned. IMPLICATIONS/DISCUSSION: The frequency of diverticulosis in younger patients is thought to be increasing. Most people will be asymptomatic. Overall, 15% will be right sided in western countries. Symptoms include bloating and abnormal bowel habits. About 20% develop clinical diverticulitis and of those, 10 to 20% will require surgery. Complications of diverticula include simple inflammation, abscess, bleeding, and fistula formation. Abscess may cause abdominal pain for several days duration, nausea, constipation and fever. WBC can be normal in up to 45% of patients. Treatment of complicated diverticulitis often requires combined medical and surgical approach. Evidence suggests more virulent disease in young people. Often these patients are treated with early colectomy. They have a higher incidence of right sided disease that can be mistaken for appendicitis. Longer lifespans lead to increased potential for morbidity. With CT guided drainage, the two part surgeries (with colostomy and then take down) decreased dramatically. Contained perforation is managed with antibiotics followed by partial colectomy. Offering colectomy after the second attack of uncomplicated diverticulitis has recently been challenged. Conservative treatment after the second attack is now considered a reasonable option in older patients. However, for younger individuals, with no medical comorbidities, early surgery may be the preferred option. The patient is a 33 year old female, gravida two para one, at eight weeks gestation who presents to the office. Her first pregnancy was complicated by a deep venous thrombosis at fifteen weeks gestation. At that time hypercoaguability work up was performed due to a positive family history. The patient had elevated protein C resistance and she was placed on full dose heparin through the duration of her pregnancy. Her third trimester she developed hypertension. She delivered at thirty-five weeks and remained on anticoagulation six weeks following delivery. Factor V leiden mutation was confirmed by gene testing following delivery. She had a seizure disorder as a child and took dilantin and multivitamin prior to pregnancy. Her father had a pulmonary embolus and has antithrombin III deficiency. She is a pharmacist and does not smoke or drink alcohol. Comprehensive physical exam is normal. The patient was placed on continuous subcutaneous infusion of heparin because she declined lovenox therapy. IMPLICATIONS/DISCUSSION: Factor V Leiden is the leading cause of thomboembolism in pregnancy (44%). Pulmonary embolus contributes greatly to maternal mortality rates. Venous thromboembolism occurs in one in 1500 pregnancies. The most prothrombotic time is immediately post partum. In addition factor V Leiden has been associated with HELLP, intrauterine growth retardation, miscarriage, and pregnancy induced hypertension. The activated protein C resistance test may be falsely positive because of changes that take place in the coagulation system during pregnancy. Diagnosis must be confirmed with gene testing. If factor V positive, patients have a three to five times greater risk of stillbirth. Factor V Leiden is present in 20±40% of abruptions. There have been no randomized control trials to demonstrate that full dose anticoagulation will reduce the risk of any of these complications. Treatment is based on extrapolation of data from nonpregnant patients. There is controversy over treatment of pregnant patients with factor V and a prior DVT. At present, patients are offered prophylactic dose heparin or full dose heparin or lovenox based on individual risk stratification (i.e homozygous vs. heterozygous). For individuals with factor V but no prior event, a variety of options exist: prophylactic subcutaneous heparin throughout the pregnancy with full dose anticoagulation postpartum for six weeks versus postpartum treatment only versus clinical surveillance alone. Lovenox will likely replace heparin because of its favorable side effect profile. Risks include a 2% major bleeding risk, heparin induced thrombocytopenia, and osteoporosis. (2) To review the presentation, treatment, and prognosis of CMV colitis among immunocompetent adults. CASE INFORMATION: A 17-year-old female was admitted to the hospital for a complaint of bloody diarrhea. She had been in good health until 4 months earlier when she noted intermittent passage of bright red blood and reddish tissue with her stool. Ten days before admission, she developed cramping periumbilical pain, soon followed by fever and watery diarrhea with hematochezia. Pertinent findings on examination included a temperature of 100.4 F, slightly pale conjunctivae, a soft abdomen with normoactive bowel sounds and minimal tenderness periumbilically, and bright red blood on digital rectal exam. Her white cell count was 8,200/mm3 with 37% neutrophils and 55% lymphocytes. Atypical lymphocytes were present. Stool samples were negative for ova, parasites, C. difficile toxin, and other bacterial enteropathogens. An abdominal CT scan showed thickening of the wall of the entire large bowel. On colonoscopy, there were diffuse inflammation in the colon, mucosal nodularities, and diminished haustral markings. Colonic biopsies demonstrated active colitis with CMV infection, but no architectural distortion to suggest an underlying chronic inflammatory bowel disease (IBD). A CMV antigenemia test came back positive, and anti-CMV IgM and IgG titers were both elevated. HIV serology, however, was negative and CD4 count was 354. Markers for IBD, including p-ANCA and ASCA, were likewise negative. The patient was treated with valganciclovir for 21 days. ABSTRACTS   Clinical Vignettes  LEARNING OBJECTIVES: 1) Raise index of suspicion for severe metabolic derangement in elderly patients. 2) Recognize clinical signs of hypernatremia. 3) Recognize limitations of using concentrated supplements as meal replacement. CASE INFORMATION: A 79 year old woman with advanced Alzheimer's disease was brought to the E.D. due to a 4-week progressive decline in her overall level of function. She had been hospitalized 8 weeks prior for an aspiration pneumonia. Her daily fluid intake since that time consisted of six 8oz cans of a``balanced nutrition shake'', along with some soup. 4 days prior she was given antibiotics by her primary physician. She showed no improvement and developed diarrhea. Physical exam revealed an obtunded woman. Her pulse was 120bpm and rectal temperature was 38.9 Celsius. She was normotensive. She had dry oral mucosa and skin tenting. Her neurological exam was nonfocal. Lab studies were significant for sodium of 185mEq/L, chloride of 148mEq/L, BUN of 124mg/dL and a creatinine of 3.0mg/dL. Urine osmolality was 819mOsmol per kg with urine sodium of 22mMol/L. Her WBC was 13K. Labs from her prior admission revealed sodium of 143mEq/L; chloride of 106mEq/L; BUN and creatinine were 7mg/dL and .7mg/dL respectively. Her free water deficit was calculated at 9 liters, and she was placed on D5W1/2NS at 150cc/hr. Her tachycardia and fever resolved. She began keeping her eyes open and speaking some words. On the sixth hospital day serum sodium was 146 with normal BUN and creatinine. The patient was discharged on a diet of purees and thickened liquids. DISCUSSION: Patients with dementia are at a risk for hypernatremia due to their inability to verbalize a need for water or to obtain it for themselves. Hypernatremic dehydration can lead to mental status changes that are easily missed in a severely demented patient. While canned high calorie shakes are an attractive supplement for patients with poor oral intake, they are highly concentrated and contain little water. This renders them a poor substitute for total meal replacement.