Hematologic and Oncologic Emergencies.

This article reviews both hematologic and oncologic emergencies that may be seen in the intensive care setting. Hematologic emergencies, including autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and disseminated intravascular coagulation, as well as oncologic emergencies including tumor lysis syndrome, superior vena cava syndrome, and cardiac tamponade secondary to metastatic disease, are discussed in detail. This review focuses on the pathophysiology, clinical features, diagnosis, and treatment of each entity.

"Circumnavigation": A Worthy Descriptor to Depict Torrential Mitral Regurgitation and a Reverence to Ferdinand Magellan.

"Circumnavigation" is never used as a verb in cardiology. Hypertrophic obstructive cardiomyopathy is a complex entity that often involves the mitral valve leading to eccentric mitral regurgitation. Utilizing multimodality imaging, assessing the severity of mitral regurgitation, and phenotyping the type of myocardial hypertrophy are achievable with certainty. We describe a case of a 42-year-old male who presented with palpitations and was ultimately diagnosed with hypertrophic obstructive cardiomyopathy with a mitral regurgitation. The torrential mitral regurgitation jet was so severe that it was "circumnavigating" the left atrium. In addition, we also draw historical parallelism with Magellan's heroic "circumnavigation" of the globe as we celebrate 500 years of his journey. Furthermore, we also describe the multimodality assessment of hypertrophic obstructive cardiomyopathy utilizing transthoracic echocardiography and cardiac magnetic resonance imaging. We discuss the challenges in quantifying such severe mitral regurgitation with any individual imaging modality.

The Impact of Connective Tissue Diseases on the Inpatient Outcomes of Congestive Heart Failure Patients.

Background Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are autoimmune diseases with chronically elevated inflammatory activity. Treatments typically have been aimed at decreasing inflammation. While RA and SLE are known to have a high incidence of congestive heart failure (HF), the mechanism behind this remains elusive. We sought to assess the outcomes of HF patients with either RA or SLE as opposed to HF patients without RA or SLE. Methods We conducted a retrospective analysis of the Healthcare Utilization Project - National Inpatient Sample Database from 2010 to 2015 (third quarter). Patients with a primary admitting diagnosis of HF were queried, and those with or without a diagnosis of either SLE or RA were separated into two groups. In-hospital mortality, total charges (TOTCHG), and length of stay (LOS) were analyzed with a multivariate regression model adjusted for demographical and comorbidity variables, using generalized linear models with family binomial, gamma, and negative-binomial, respectively. A p-value smaller than 0.05 was deemed statistically significant. All the statistical analyses were performed in R 3.5.5 (R Core Team, 2013, http://www.R-project.org/). Results  The in-hospital mortality (3.4% v/s 4.43%), mean TOTCHG ($46k v/s $51k), and mean LOS (5.79 v/s 6.12 days) were significantly lower in HF patients with RA/SLE when compared with HF patients without RA/SLE. A younger age (70.5 v/s 72.6 years) and a female preponderance (75% v/s 51%) were evident in the RA/SLE group. Both groups consistently showed a significant disparity in the rates of hospitalization, which was inversely related to household income. p-value was less than 0.001 for all the above outcomes. Conclusions  RA/SLE patients are associated with better in-hospital outcomes of HF. The underlying mechanism is unclear in terms of this paradox. Given the fact that the majority of RA/SLE patients are treated with agents aimed at decreasing inflammation, this may shed light on the role of inflammation being an important contributor to HF and implicate a future therapeutic direction.

A Rare Case of Statin-induced Immune-mediated Necrotizing Myopathy.

Statin-associated myopathy comprises of a spectrum of conditions ranging from benign myalgias to statin-induced immune-mediated necrotizing myopathy. Statin-induced immune-mediated necrotizing myopathy is an autoimmune condition wherein there is a destruction of normal skeletal muscular architecture that can be severely debilitating if not recognized promptly. Given its rarity, management is a challenge. We present one such case that was managed with aggressive immunosuppression.

Thyrotoxic Periodic Paralysis- A Diagnostically Challenging Rare Clinical Entity.

Thyrotoxic periodic paralysis (TPP) is characterized by a classic triad of muscle paralysis, hypokalemia, and hyperthyroidism. The underlying thyroid disorder is often very subtle making it challenging to recognize TPP. It is a completely reversible condition if diagnosed early; however, it is associated with fatal outcomes if delayed.

Talaromycosis in a Patient on Nintedanib for Interstitial Lung Disease.

Talaromycosis is a fungal infection caused by Talaromyces sp. that is predominantly prevalent in patients with acquired immunodeficiency syndrome in the United States. It is also rarely seen in other individuals who are otherwise immunosuppressed. With the advent of immunotherapy and increasing usage of these novel agents in treating several conditions, the prevalence of talaromycosis may increase, especially in people from endemic regions who might harbor a dormant infection. Clinical presentation is non-specific with respiratory symptoms such as shortness of breath, cough, or even fever that can delay the diagnosis. Little is known about the exact pathogenesis of the condition, and management is largely based on anecdotal evidence and small-sized studies. We present the case of an individual on nintedanib, a tyrosine kinase inhibitor that blocks fibroblast growth factor receptor and used for the treatment of interstitial lung disease, who was diagnosed with talaromycosis.