The Harms of Unnecessary CT Pulmonary Angiography: A Case Report and Literature Review.

Pulmonary embolism (PE) poses a significant health risk in the United States, with high mortality rates. Clinicians maintain a low threshold for suspecting PE, potentially leading to deviation from guideline-recommended algorithms and unnecessary computed tomography pulmonary angiography (CTPA). This case discusses a 46-year-old woman who presented with symptoms suggestive of PE following a prolonged road trip. Despite a low Wells score and negative D-dimer results, she underwent CTPA, resulting in an unnecessary and harmful interventional radiology-guided thrombectomy. This highlights the importance of adhering to guidelines in PE diagnosis to mitigate potential harms associated with the overuse of available medical tools.

Survival Against the Odds-Hemophagocytic Lymphohistiocytosis Amidst the Shadows of Disseminated Histoplasmosis: A Case Report and Literature Review.

Hemophagocytic lymphohistiocytosis (HLH) secondary to Histoplasma capsulatum is rare, impacting <1% globally, with a mortality rate of up to 31%. Herein, we present a rare case of HLH secondary to H capsulatum, affecting a 57-year-old female with rheumatoid arthritis. Extensive investigations were unrevealing and despite broad-spectrum antibiotics, her condition worsened, leading to respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support, shock requiring multiple vasopressors, and acute kidney injury (AKI) requiring hemodialysis. Diagnosis confirmed disseminated histoplasmosis (DHP), prompting Amphotericin B and methylprednisolone treatment, resulting in significant improvement and discharge with posaconazole therapy. Secondary HLH, primarily arising from severe infections like DHP, is discussed. Limited research exists on this condition in human immunodeficiency virus (HIV)-seronegative individuals. Diagnosis involves HLH-2004 and HScore criteria. Managing histoplasmosis-associated HLH remains challenging due to multiorgan failure risks and treatment complexities and needs further research.

A Neurocritical Case Study of Intracerebral Hemorrhage Unveiling Multiple Myeloma Through the Lens of Hickam's Dictum.

Multiple myeloma (MM) is a hematologic malignancy characterized by clonal proliferation of plasma cells in the bone marrow, often leading to various end-organ damages. Here, we report the case of a 73-year-old previously healthy woman who was initially diagnosed with an intracerebral hemorrhage secondary to a potential hypertensive emergency. However, further evaluation revealed a diagnosis of MM. This case points out the importance of comprehensive evaluations in neurocritical care and challenges the notion of simplistic diagnostic explanations, illustrating the relevance of Hickam's dictum in clinical practice. It highlights the need for clinicians to consider a broad range of potential etiologies in similar cases, ultimately leading to tailored management strategies and improved patient outcomes.

A Case Report of Pulmonary Vein Stenosis Within the Labyrinth of Fibrosing Mediastinitis.

This case centers on a 76-year-old male experiencing exertional dyspnea and hemoptysis, with a medical history marked by recurrent pulmonary embolism and chronic obstructive pulmonary disease (COPD). Notably, he resides in a histoplasmosis-endemic area. A computed tomography (CT) pulmonary embolism scan revealed notable findings, including an enlarged right lower pulmonary artery, vascular congestion, atelectasis, and a mass exerting pressure on the right lower pulmonary vein. Biopsy results identified the mass as fibrosing mediastinitis, likely attributed to histoplasmosis. A transthoracic echocardiogram indicated right ventricular dilatation, impaired function, and a right ventricular systolic pressure of 63 mm Hg. During right heart catheterization, the patient displayed disparate pulmonary artery wedge pressures (PAWPs) between the right and left sides. This discrepancy was linked to a blunted back wave from the left atrium to the catheter, induced by pulmonary vein compression. Although an infrequent phenomenon, the recorded asymmetry in PAWPs played a crucial role in guiding accurate patient management. The absence of subsequent evaluation of PAWP on the left side could have altered the treatment plan, potentially delaying appropriate patient care. This case emphasizes the necessity of thorough exploration with right heart catheterization when clinical symptoms warrant, highlighting the importance of standardized practices in such procedures.

Landiolol for Treating Arrhythmias: A State-of-The-Art Review.

This article provides a state-of-the-art review on landiolol, a medication that was recently submitted for 7 approvals. Focusing on its pharmacology, pharmacokinetics, and pharmacodynamics, the analysis underscores landiolol's unique attributes compared to conventional beta-blockers, particularly esmolol. As a sympatholytic agent, landiolol exhibits a short half-life, high cardioselectivity, and minimal impact on blood pressure, setting it apart in the realm of arrhythmia treatment. The review explores landiolol's potential applications, emphasizing scenarios where other beta-blockers may be limited. A detailed examination of its efficacy in preventing postoperative atrial fibrillation reveals promising results from clinical trials, suggesting its utility in diverse surgical settings. Additionally, the article delves into landiolol's role in rate control for atrial fibrillation/flutter, treatment of ventricular tachycardia/fibrillation, and its use in managing sepsis-related tachyarrhythmias. The evolving landscape of landiolol's applications extends beyond cardiac care, including potential anti-inflammatory, antioxidative, analgesic, and anticancer effects. While the outcomes from various studies are promising, challenges persist, requiring further research to optimize dosing strategies, identify optimal patient populations, and elucidate mechanisms underlying its diverse effects. The potential expansion of landiolol's applications highlights the importance of ongoing clinical investigation, offering a promising avenue for enhancing arrhythmia management and addressing broader medical needs.

Relation between non-alcoholic fatty liver disease and carotid artery intimal media thickness as a surrogate for atherosclerosis: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Non-alcoholic fatty liver disease (NAFLD), characterized by hepatic steatosis without heavy alcohol consumption or other chronic conditions, encompasses a spectrum from non-alcoholic fatty liver to non-alcoholic steatohepatitis leading to cirrhosis. This analysis aimed to investigate the correlation between NAFLD and carotid intimal media thickness (C-IMT), a non-invasive surrogate for atherosclerosis. METHODOLOGY: Database searches, including PubMed, EMBASE and Cochrane Library, yielded studies up to April 2023. Included were studies exploring the NAFLD-C-IMT relationship in populations aged >18 years. Exclusions comprised non-English papers, those involving animals or pediatric populations and studies lacking control groups. RESULTS: No statistical significance was noted between mild and moderate NAFLD compared to the control group regarding C-IMT [95% confidence intervals (CI): -0.03, 0.12] and (95% CI: -0.03, 0.21), respectively. There was a statistically significant difference only in the Severe NAFLD group ( P value 0.03). NAFLD with and without metabolic syndrome showed statistically significant differences compared to control regarding C-IMT (95% CI: 0.04, 0.12) and (95% CI: 0.01, 0.07), respectively. Fifty-nine studies were mentioned without classification of NAFLD severity and revealed a high statistically significant difference between NAFLD and controls regarding C-IMT with (95% CI: 0.09, 0.12, P < 0.00001). Stratified analysis according to sex was done in two studies and revealed statistical differences between NAFLD and control regarding C-IMT in both groups. CONCLUSION: This meta-analysis underscores a significant association between NAFLD and increased C-IMT, emphasizing the importance of assessing C-IMT in NAFLD patients to identify cardiovascular risk and tailor therapeutic interventions for improved patient outcomes.

Assessing and improving radiation safety in cardiac catheterization: a study from Cairo University Hospital.

BACKGROUND: Catheter laboratories are high-radiation exposure environments, especially during X-ray procedures like percutaneous transluminal coronary angioplasty and electrophysiological studies. Radiation exposure poses risks of stochastic (e.g., cancer) and deterministic (e.g., skin changes) effects. This study assessed radiation safety and health practices in a cardiac catheterization unit to optimize radiation safety. A cross-sectional study in Cairo University Hospital (March-September 2019) evaluated 700 patients and healthcare workers. Real-time radiation measurements, educational lectures, and radiation protection measures were implemented in three phases. Data on radiation exposure, procedures, and compliance were collected and analyzed. RESULTS: The total procedure time and fluoroscopy time per cardiologist did not significantly differ between phases, but there was a statistically significant reduction in the mean total cumulative radiation doses between Phase I and Phase III for cardiologists (P = 0.013). Among nurses and technicians, there was no significant difference in radiation doses between the two phases. Significant correlations were found between operators' radiation doses, procedure time, and fluoroscopy time. Patients' radiation doses decreased significantly from Phase I to Phase III, with correlations between dose, procedure time, and gender. Compliance with radiation protection measures was suboptimal. CONCLUSIONS: Compliance with radiation safety standards in the cardiac catheterization unit at the Cairo University Hospital needs improvement. The study highlights the importance of adhering to radiation safety principles and optimizing protective measures to reduce radiation exposure for both patients and healthcare personnel. Despite low compliance, significant reductions in radiation doses were achieved with increased awareness and adherence to specific protection measures. Future efforts should focus on enhancing radiation safety protocols and organ-specific radiation impact assessments.

A Rare Case of Spontaneous Pneumothorax Leading to Cerebral Air Embolism.

Cerebral arterial air embolism (CAE), a rare subtype of air embolism, carries a 21% mortality rate. We present a unique case involving a 69-year-old female with a history of usual interstitial pneumonia (UIP) who suffered a transient ischemic attack (TIA) due to CAE. Unlike typical cases, CAE in this instance resulted from spontaneous pneumothorax, not the more common iatrogenic causes. Adding complexity, an unexpected discovery emerged during evaluation: a patent foramen ovale, contributing to paradoxical embolism. This underscores the vital need to consider CAE as a differential diagnosis in UIP patients with neurological symptoms, highlighting its rarity and diagnostic challenges.

Congenital Long QT Syndrome, Coinciding With Cavitary Mycobacterium avium Lung Infection, Led to Cardiac Arrest.

Congenital long QT syndrome is a cardiac disorder leading to arrhythmias and sudden cardiac death. We present a case of a 55-year-old woman with altered mental status experiencing cardiac arrest caused by congenital long QT syndrome, coincidentally found with Mycobacterium avium complex lung infection. Genetic testing identified a pathogenic mutation in the KCNH2 gene. (Level of Difficulty: Intermediate.).

Pharmacotherapy of refractory pulmonary arterial hypertension.

INTRODUCTION: Treatment of refractory pulmonary arterial hypertension (PAH) is challenging and rarely the focus of reviews. The purpose of this review is to discuss current treatment options of refractory PAH, along with the state of research of several new medications. AREAS COVERED: We conducted a comprehensive PubMed search on the relevant literature on treating PAH, with a focus on approved and investigational interventions for high-risk patients. Our strategy used keywords 'Treatment' AND 'Pulmonary Hypertension,' without date restrictions, ensuring a thorough survey of available literature for our review. EXPERT OPINION: By utilizing serial risk assessment to identify patients remaining intermediate or high-risk, more patients are likely to survive longer. This is done by earlier use of combination or triple therapy with prostacyclin drugs. Current medications for PAH are all essentially vasodilators that improve physiology, but do not truly modify the disease process. The potential application of new investigational medications is exciting as they work by novel pathways likely to change the landscape of refractory PAH treatment.

Unusual Presentation of Multiple Lung Nodules in a Patient With Supraglottic Squamous Cancer: A Rare Infectious Cause Revealed.

Pulmonary nodules are commonly encountered in medical practice, necessitating thorough evaluation due to their diverse etiologies. Identifying the underlying cause is of utmost importance, particularly in patients with a history of extrapulmonary cancer, to differentiate between metastasis and other etiologies. We present a rare case of a 24-year-old male with supraglottic squamous cancer who developed multiple pulmonary nodules, which surprisingly were caused by a rare infectious agent. The patient presented with bilateral infiltrates on imaging, raising strong suspicion of metastatic disease from primary cancer. However, bronchoscopy and biopsy revealed no malignancy but confirmed the presence of Corynebacterium amycolatum, leading to a change in the treatment approach from palliative to curative. This case highlights the importance of considering other etiologies, especially infections, in patients with cancer and pulmonary nodules. Accurate diagnosis is crucial to guide appropriate management decisions and optimize patient outcomes.

Cardiac Sarcoidosis Presented With Hiccups: A Case Report and Literature Review.

Sarcoidosis is a multisystem disorder of unknown etiology commonly associated with hilar lymphadenopathy and granulomas. Cardiac involvement is less common; however, sarcoidosis is a known cause of restrictive cardiomyopathy. It typically presents as new-onset arrhythmias or heart failure, although cases of sudden cardiac death have been reported. We present a case of a 56-year-old male with a known history of pulmonary sarcoidosis, not on active treatment, who presented to the emergency department with a week of continuous hiccups every few seconds associated with non-exertional dyspnea. An initial computed tomography (CT) scan of the chest showed multiple stellate-like ground-glass opacities and the progression of bronchiectasis. Troponins were negative. On the initial electrocardiogram (EKG), he was found to be in atrial flutter and was admitted to the medical floor. Cardiology was consulted for suspected cardiac sarcoidosis, and they recommended transfer to the tertiary care center for further evaluation. Upon arrival, the patient underwent catheter ablation for atrial flutter and returned to sinus rhythm after the procedure. The initial nuclear scan with gallium was not suggestive of cardiac sarcoidosis. However, subsequent cardiac magnetic resonance imaging (MRI) showed cardiac involvement. Due to the high risk of arrhythmias, the patient was scheduled for implantable cardioverter defibrillator placement before discharge. The patient was given oral prednisone. The patient was discharged in stable condition, and interrogation of the device found it well functioning, and no significant arrhythmias were noted. Presentation of cardiac sarcoidosis can be variable, and any should be considered in any patient with a known history of sarcoidosis who presents with atypical symptoms above the diaphragm, such as hiccups or with new-onset arrhythmias.

Cardiac Arrest as the Initial Presentation of Undiagnosed Kawasaki Disease: A Case Report and Literature Review.

Kawasaki Disease (KD) is a self-limited acute vasculitis that mainly affects medium-sized arteries in childhood, with the coronary arteries being one of the main targets. A well-known complication is a coronary aneurysm with myocardial ischemia. We report the case of a 29-year-old female with an insignificant past medical history who presented with sudden cardiac arrest. Labs were significant for elevated troponin, consistent with non-ST elevation myocardial infarction, given diffuse ST depression on the electrocardiogram. The patient underwent a coronary angiogram that revealed diffuse coronary artery disease with multiple ulcerations, aneurysms, and occlusions consistent with KD, despite denying prior history. Cardiac arrest may be the initial presentation of undiagnosed KD and should be considered as one of the differential diagnoses.

Reverse Takotsubo Cardiomyopathy in a Critically Ill Patient in the ICU: A Case Report With Literature Review.

Takotsubo, or stress cardiomyopathy (SC), is described as a transient systolic dysfunction of the apical segments of the left ventricle mainly triggered by emotional or physical stress resembling the presentation of an acute coronary syndrome in the absence of obstructive coronary artery disease. Reverse Takotsubo SC is a rare variant of SC that presents with basal ballooning instead of apical ballooning seen in classic SC. We present a case of a 74-year-old male who was admitted to the ICU with septic shock. Laboratory test results showed elevated troponin. An echocardiogram showed reduced cardiac contractility and relative hypokinesis of the basal and mid segments compared to the apical segments, consistent with reverse Takotsubo SC, which recovered after 10 days. It can happen in critically ill patients in the ICU secondary to severe sepsis and could contribute to hemodynamic worsening, affecting the final clinical outcomes.

A Rare Case of Transient Second-Degree Mobitz Type II Heart Block Complicating a Saddle Pulmonary Embolism.

Presentations of pulmonary embolism (PE) are often associated with various cardiac arrhythmias and conduction abnormalities detected on electrocardiograms (EKG). We describe a 65-year-old female with no known history of heart disease or arrhythmias who presented with an acute onset of shortness of breath. Initial EKG showed right bundle branch block (RBBB), and first-degree atrioventricular (AV) block with subsequent development of second-degree Mobitz type II AV block. The patient's clinical appearance was highly suggestive of a massive pulmonary embolism with hemodynamic instability, and treatment with alteplase (tPA) was given, followed by heparinization. A CT pulmonary angiography confirmed the provisional diagnosis and revealed a large saddle embolus within the right and left main pulmonary arteries. Subsequent EKG showed resolution of the RBBB, first-degree AV block, and second-degree AV block. The patient improved clinically and was discharged to a subacute rehab facility with follow-up appointments. This case highlights that pulmonary embolism may present with many EKG changes, including RBBB, first-degree, second-degree, or complete heart block. Early recognition of PE and thrombolytic treatment can improve cardiac function and restore heart rhythms. Further evaluation for underlying conduction abnormalities can later be performed.

Paradoxical Worsening of Pulmonary Hypertension Following Closure of Arteriovenous Fistula: A Case Report and Literature Review.

This case report presents the atypical instance of a 59-year-old female patient with end-stage renal disease (ESRD) who was initially referred to the pulmonary clinic for evaluation due to a low diffusing capacity of the lung for carbon monoxide (DLCO). Pulmonary hypertension (PH) was suspected, and a subsequent right heart catheterization (RHC) confirmed PH attributed to group 5 PH, leading to the decision to close the unused arteriovenous fistula (AVF) to manage PH. Unexpectedly, a follow-up RHC showed a worsening of PH with elevated pulmonary capillary wedge pressure (PCWP), revealing an additional component of post-capillary group 2 PH. This case emphasizes the significance of recognizing a low DLCO as a potential trigger for PH assessment, especially in patients with comorbidities like ESRD. Furthermore, it highlights the unusual yet critical occurrence of PH exacerbation following AVF closure.