Long distance of spontaneous coronary artery dissection involving LMT in a middle-aged man - Complete rapid healing and clinical usefulness of CABG as a temporizing strategy.

Spontaneous coronary artery dissection (SCAD) usually occurs in women, which can result in significant morbidities. A 38 year-old obese man who is currently smoking was referred to our hospital with chest pain. His electrocardiography and echocardiography suggested myocardial infarction in proximal region of left coronary artery. Emergent coronary angiography revealed 99% stenosis at mid portion of LAD and diffuse 50% stenosis from LMT to LAD. Intravascular ultrasound identified intramural hematoma severely compressing the true lumen which extended from mid LAD to LMT suggesting SCAD. After failed fenestration of the false lumen with balloon angioplasty, emergent coronary artery bypass graft using right internal thoracic artery and saphenous vein graft was performed. Two weeks after the surgery, follow-up CAG found completely healed native coronary artery which resulted in occlusion of RITA-LAD graft. This case raises two clinical important issues. First, SCAD can be seen in middle-aged men who are likely to have atherosclerosis. Secondly, CABG is useful as temporizing strategy for unstable SCAD involving LMT. The rapid healing and temporal lifesaving CABG contributed to avoidance of lifelong antiplatelet therapy. Although SCAD is relatively uncommon manifestation of acute coronary syndrome, optimal diagnosis and treatment for each patient need to be considered. .

A case of cardiac sarcoidosis mimicking cardiac amyloidosis on cardiovascular magnetic resonance.

A 52-year-old male visited our hospital with abnormal electrocardiogram and exertional fatigue. The electrocardiogram showed first-degree atrioventricular block, complete right bundle branch block, and inverted T waves in Leads II, III, aVF, V3, and V4. Echocardiography showed biventricular wall thickening involving granular sparkling of the interventricular septum. Late gadolinium enhancement on cardiovascular magnetic resonance (CMR) was found at the circumferential right ventricular wall and patchy regions of the left ventricle. Although these findings strongly suggested cardiac amyloidosis, he was finally diagnosed with systemic sarcoidosis due to the following. First, endomyocardial biopsy revealed non-caseating epithelioid granuloma with giant cells. Second, 18 F-fluorodeoxyglucose positron emission tomography showed uptake in bilateral hilar lymph nodes, para-aortic lymph nodes, and the biventricular wall of the heart. Although echocardiography and CMR are very useful tools for diagnosis of cardiomyopathies, their specificity and accuracy need to be considered.

Trichosporon asteroides Isolated from Cutaneous Lesions of a Suspected Case of "paracoccidioidomycosis ceti" in a Bottlenose Dolphin (Tursiops truncatus).

"Paracoccidioidomycosis ceti" is a rare zoonotic fungal infection affecting dolphins and is endemic worldwide. The causative agents are Paracoccidioides species; however, it is impossible to isolate the fungal species. We isolated Trichosporon asteroides from multifocal, irregularly raised skin lesions on a female bottlenose dolphin (Tursiops truncatus) captured off coast of Japan, which was suspected to have "paracoccidioidomycosis ceti." An abundance of round, yeast-like cells was detected in a potassium hydroxide direct-mount specimen of the skin samples; however, nested PCR targeting the partial sequence of 43-kDa glycoprotein-coding gene correspondent to Paracoccidioides sp. was negative. Biopsied tissue samples were cultured on brain heart infusion agar plates supplemented with chloramphenicol, 1% yeast extract, and 4% sodium chloride (4% NaCl-BHI), on Mycosel agar with 4% sodium chloride (4% NaCl-Mycosel), and on potato dextrose agar supplemented with chloramphenicol (CPDA) at 35 °C for 4 weeks. Cream-colored and wrinkled colonies consisting of hyphae and arthroconidia grew on 4% NaCl-BHI and CPDA, while film-like colonies composed of arthroconidia and round yeast-like cells developed on 4% NaCl-Mycosel. Although these primary cultures resembled fresh isolates of P. brasiliensis, they were identified as Trichosporon asteroides based on routine mycological studies and the internal transcribed spacer regions of ribosomal RNA sequences. The results suggested that trichosporonosis caused by T. asteroides might remain latent among cases of "paracoccidioidomycosis ceti" diagnosed without cultures and molecular biological analysis.