Authors' Affiliations

Sagar Nagpal, MD, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Sindhu C. Pokhriyal, MD, Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY Vaishnavi Theegala, MD, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Dipsa Shastri, MD, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Rami Dalbah, MD, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Abhijith Paladagula, MD, Department of Internal Medicine, East Tennessee State University, Johnson City, TN

Location

Culp Center Ballroom

Start Date

4-25-2023 9:00 AM

End Date

4-25-2023 11:00 AM

Poster Number

82

Faculty Sponsor’s Department

Internal Medicine

Name of Project's Faculty Sponsor

Rupal Shah

Classification of First Author

Medical Resident or Clinical Fellow

Competition Type

Competitive

Type

Poster Presentation

Project's Category

Cardiovascular System, Nervous System, Neurological Disorders

Abstract or Artist's Statement

Introduction - Pure autonomic failure is a rare disorder characterized by orthostatic hypotension, absence of a compensatory rise in heart rate, and abnormal autonomic functions. In most cases, supine hypertension is seen coupled with orthostatic hypotension, making the management of these patients a big challenge.

We present the case of a 74-year-old gentleman, who presented to the ED with altered mental status for a day; weakness, and falls for 3 weeks. The patient had a past medical history of Hypertension, alcoholism, and REM sleep disorder. He was being treated for erectile dysfunction for the last 10 years and had a family history of Parkinson's disease in his mother and sister. The patient was compliant with Lisinopril 40 mg, Amlodipine, and Rosuvastatin, Tamsulosin 0.4 mg. His blood pressure(BP) on presentation was ranging between 109/74-194/76 mm of Hg. Systolic BP dropped by 30mmHg after tilting the angle of the bed to 45 degrees for 1 minute with no change in HR and the patient became symptomatic in this position. Orthostatic vitals showed a dramatic drop in Systolic BP of >80mmHg with no change in heart rate. MRA and MRI showed chronic microvascular changes. The Echocardiogram, Cortisol, and TSH levels were all normal. All anti-hypertensives were discontinued and supportive treatment was started with Midodrine, Droxidopa, and Pyridostigmine, thigh-high TED hose and abdominal binders at bedtime, and Nitroglycerin patch at night for hypertension. The patient was started on fludrocortisone as he continued to drop his BP by 80 mmHg on standing. The use of TED stockings and bed tilting improved the issue of uncontrolled supine hypertension at night.

Conclusion- Treatment of autonomic dysfunction continues to be challenging. There are no definitive guidelines and management is largely individualized. Both pharmacological and non-pharmacological measures are used.

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A Path Difficult to Tread.pptx (112 kB)
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Apr 25th, 9:00 AM Apr 25th, 11:00 AM

A Path Difficult to Tread: Pure Autonomic Failure, A Case Report

Culp Center Ballroom

Introduction - Pure autonomic failure is a rare disorder characterized by orthostatic hypotension, absence of a compensatory rise in heart rate, and abnormal autonomic functions. In most cases, supine hypertension is seen coupled with orthostatic hypotension, making the management of these patients a big challenge.

We present the case of a 74-year-old gentleman, who presented to the ED with altered mental status for a day; weakness, and falls for 3 weeks. The patient had a past medical history of Hypertension, alcoholism, and REM sleep disorder. He was being treated for erectile dysfunction for the last 10 years and had a family history of Parkinson's disease in his mother and sister. The patient was compliant with Lisinopril 40 mg, Amlodipine, and Rosuvastatin, Tamsulosin 0.4 mg. His blood pressure(BP) on presentation was ranging between 109/74-194/76 mm of Hg. Systolic BP dropped by 30mmHg after tilting the angle of the bed to 45 degrees for 1 minute with no change in HR and the patient became symptomatic in this position. Orthostatic vitals showed a dramatic drop in Systolic BP of >80mmHg with no change in heart rate. MRA and MRI showed chronic microvascular changes. The Echocardiogram, Cortisol, and TSH levels were all normal. All anti-hypertensives were discontinued and supportive treatment was started with Midodrine, Droxidopa, and Pyridostigmine, thigh-high TED hose and abdominal binders at bedtime, and Nitroglycerin patch at night for hypertension. The patient was started on fludrocortisone as he continued to drop his BP by 80 mmHg on standing. The use of TED stockings and bed tilting improved the issue of uncontrolled supine hypertension at night.

Conclusion- Treatment of autonomic dysfunction continues to be challenging. There are no definitive guidelines and management is largely individualized. Both pharmacological and non-pharmacological measures are used.