Perspectives on Heyde's Syndrome and Calcific Aortic Valve Disease.

Heyde's syndrome is a multisystem disorder describing the association between calcified aortic stenosis, gastrointestinal tract bleeding from arteriovenous malformations, and acquired von Willebrand syndrome. Several studies have reported an increase in prevalence of gastrointestinal arteriovenous malformation in patients with aortic stenosis and vice versa; however, the incidence of Heyde's syndrome remains controversial. In general, the syndrome is prevalent in the elderly population. The pathogenesis and management remain controversial as well. Our review, provides a unique case to highlight the diagnosis and management of Heyde's syndrome while also briefly describing the prevalence, etiology, diagnosis, and management of calcific aortic valve disease in general.

A Rare Case of Statin-Induced Diplopia: An Often-Overlooked but Reported Side Effect.

Statins are a class of medications indicated for atherosclerotic cardiovascular diseases and dyslipidemia. Ever since their introduction, various side effects have been reported with their use. Statin-induced myopathy is a well-established side effect of the medication, ranging in severity from mild myotoxicity to fatal rhabdomyolysis, with or without an increase in creatine kinase levels. Statin-induced diplopia, ptosis, or ophthalmoplegia are very rare, but they have been reported as adverse events in a handful of cases. These adverse events typically result from the progressive weakening of the external ocular musculature or the levator palpebrae superioris muscle. In this report, we present a rare case of statin-induced diplopia in a patient who had been on atorvastatin therapy for years. We believe this report will increase awareness among physicians about such an adverse event related to statins.

Acute Multiple Cerebral Watershed Infarctions as the Initial Presentation of COVID-19 in a Young Male Patient: A Case Report.

Cerebrovascular diseases appear to be one of the most serious complications of coronavirus disease 2019 (COVID-19). In this report, we present a case of a 38-year-old male with a past medical history significant only for hypertension, who presented to the emergency department (ED) with confusion and multiple focal neurologic deficits. Brain imaging showed acute multiple cerebral watershed infarctions. Upon further investigation and laboratory workup, the hypercoagulability and vasculitis panels were found to be negative, and other differential diagnoses were ruled out. In light of a number of emerging reports of COVID-19-related ischemic stroke, our patient was also screened for the disease, and surprisingly the test came back positive. We believe this case report will highlight the importance of conducting neurological examinations in COVID-19 patients, since timely workup and prompt interventions may reduce morbidity and mortality.

A Case of Hypokalemic Periodic Paralysis in a Young Athlete.

Hypokalemic periodic paralysis (HPP) is one of the group muscle disorders that can cause sudden onset paresis or paralysis. It is a quite rare, yet, potentially life-threatening condition that, if appropriately and promptly diagnosed and treated, can be completely reversed. Other forms of periodic paralysis include thyrotoxic periodic paralysis, hyperkalemic periodic paralysis, and Anderson syndrome. We are presenting a case of a young male who presented to the emergency department (ED) with sudden paralysis to shed light on such a diagnosis and on other differential diagnoses.

Uncommon Pathogen in an Unexpected Host: A Rare Case of Rothia mucilaginosa Infective Endocarditis in an Immunocompetent Patient Without an Underlying Valvular Disease.

Rothia mucilaginosa is an infrequent opportunistic pathogen that affects immunocompromised patients, with a high affinity to prosthetic devices. Infections in immunocompetent individuals are extremely rare and usually related to pre-existing valvular heart disease. We report the first case of Rothia endocarditis in an immunocompetent patient without an underlying valve disease.

Atrial Fibrillation as a Possible Adverse Reaction to Evolocumab.

Evolocumab is a recently FDA-approved proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) that reduces the risk of myocardial infarction, stroke, and coronary revascularization in individuals with established atherosclerotic cardiovascular disease. We report an extremely rare possible side effect, atrial fibrillation (AF), encountered with evolocumab to increase the awareness among physicians of such a possibility.

Isolated Third Nerve Palsy as a Rare and Solo Presentation of Internal Carotid Artery Dissection in a Young Female - a Surprising Finding in the Angiogram.

Internal carotid artery dissection (ICAD) is a known but uncommon cause of ischemic stroke among young and middle-aged patients. A common presentation includes ipsilateral headache, unilateral oculosympathetic palsy (partial Horner syndrome), or ischemic stroke but some reported cases present with less common manifestations, such as lower cranial nerve syndrome (IX, X, XI, XII). However, third cranial nerve palsy is an extremely rare presentation of ICAD. We present a case of ICAD with pseudoaneurysm presenting with third nerve palsy, with ptosis, outward deviation, and binocular diplopia, emphasizing the importance of considering ICAD as a differential diagnosis in patients with third nerve palsy due to the anatomical proximity of ICA to third nerve within the cavernous sinus.

Southern Tick-Associated Rash Illness: Florida's Lyme Disease Variant.

Southern tick-associated rash illness (STARI) is an emerging zoonotic disease causing an annular rash with central clearing that is almost identical to erythema migrans seen in Lyme disease. It is spread by Amblyomma americanum tick bite. Although it is still debatable, this zoonotic disease is thought to be caused by Borrelia lonestari spirochete. At this time, there is no approved diagnostic modality nor approved treatment for such an illness. Here we describe a rare case of STARI in a 63-year-old female and shed light on the differences between STARI and Lyme disease.

Characteristics and outcomes of diabetic patients with acute exacerbation of COPD.

RATIONALE AIMS AND OBJECTIVES: Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and diabetes mellitus form a special population due to an increased risk of hyperglycemia from the use of corticosteroids. There is limited data regarding specific outcomes in diabetic patients with AECOPD. METHODS: A retrospective data analysis of adult patients admitted to North Florida Division of the Hospital Corporation of America (HCA Healthcare) with a primary or secondary diagnosis of AECOPD from January 1, 2018, to December 31, 2018. We excluded patients who needed intensive care unit (ICU) care on day 0. Outcomes assessed included length of stay, mortality, and need for ICU transfer after 48 h from admission. Characteristics included age, sex, and race, comorbidities such as diabetes mellitus, chronic kidney disease, acute kidney injury, congestive heart failure, and anemia were analyzed. Comparisons were analyzed via binary and multivariate logistic regression models. RESULTS: A total of 3788 patients admitted for AECOPD were included; amongst them, 1356 patients (~36%) had diabetes mellitus. This subset of patients had higher rates of comorbidities. A significant portion of diabetic patients (72%) received intravenous rather than oral steroids, similar to non-diabetic patients. In addition, diabetic patients were more likely to develop acute kidney injury (14.2% vs 8.0%, p < 0.004) and decompensated heart failure (9.2% vs 4.6%, p < 0.001). Diabetic patients had higher length of stay and increased need for ICU transfer. However, diabetes itself did not independently affect length of stay (CI -0.028, 0.479, p = 0.081) when adjusted to comorbidities and patient's characteristics. Moreover, diabetes was independently associated with an increased need for transfer to ICU (Odds ratio 1.9, p = 0.031). The oral route of steroid use was associated with decreased LOS (ß coefficient - 0.9, p < 0.001). CONCLUSION: Diabetes mellitus is independently associated with increased ICU transfers amongst patients hospitalized with AECOPD. The use of oral steroids rather than intravenous steroids was independently associated with decreased length of stay in diabetic and non-diabetic patients. Despite no difference in intravenous vs. oral corticosteroids demonstrated in previous COPD trials, a significant portion of diabetic patients continue to receive intravenous corticosteroids. Further investigation is required to explore these findings.

Emphysematous Cholecystitis Secondary to Fusobacterium nucleatum.

Fusobacterium nucleatum may be implicated in cases of emphysematous cholecystitis (EC) and carries a high mortality risk, especially in individuals with heart disease, renal insufficiency, and underlying malignancy. Fusobacterium infections are rarely detected in the setting of cholecystitis possibly due to the difficulty with properly culturing the bacteria. We describe a case of a patient with EC in whom blood cultures were positive for growth of F. nucleatum in one of two samples. The patient was treated with empiric antibiotic therapy consisting of metronidazole and cefepime. In patients with EC and negative cultures, it is possible that they may have an undetected infection with fusobacteria, which carries a high mortality risk. As such, clinicians should maintain a high degree of suspicion of obligate anaerobic infection in patients who have negative blood culture for growth in the setting of EC and consider continuation of adequate antimicrobial coverage.

Cardio-oncology: Capecitabine Can Sometimes be Heatbreaking Capecitabine-Induced Takotsubo Cardiomyopathy Case Report and Literature Review.

Capecitabine has been more recognized for its cardiotoxicity with an incidence that varies widely. It demonstrates its toxicity in the forms of acute coronary syndrome, arrhythmias and, to a lesser extent, cardiomyopathy. There are several proposed theories including coronary vasospasm, endothelial injury, and oxidative stress. We present a case of capecitabine-induced cardiomyopathy in a patient with pancreatic cancer and mild coronary artery disease, and shed light on other cardio-toxic agents, their proposed mechanism of cardiotoxicity, and on cardiomyopathy in general.

Update on the Cardiovascular Benefits of Sodium-Glucose Co-Transporter-2 Inhibitors: Mechanism of Action, Available Agents and Comprehensive Review of Literature.

Despite the currently established treatment for heart failure (HF), HF remains a growing public healthcare problem with an increasing burden. Therefore, novel therapeutic innovations are needed to overcome this issue and improve HF prognosis. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are state-of-the-art in type 2 diabetes mellitus management. They inhibit the reabsorption of glucose from the proximal renal tubules, leading to increased glycosuria and decreased plasma glucose levels. SGLT2i use is growing significantly, especially after recent clinical trials demonstrating favorable cardiovascular and renal protective effects independently of blood glucose-lowering. The mechanisms by which SGLT2i demonstrate their cardio-renal protective effects remain incompletely understood but are thought to be related to potential diuretic and natriuretic effects along with other mechanisms that will be discussed in this article. Over the past few years, there has been significant research on the safety, efficacy, and quality of this class of medications. Here, we review the current guideline-directed medical therapy for HF, focus on SGLT2i mechanism of action and potential role in HF patients, and finally summarize the cardiovascular clinical trials with SGLT2.

Serious Adverse Events Associated With Hydroxychloroquine Amidst COVID-19 Pandemic: Case Series and Literature Review.

COVID-19 represents a global health crisis. Several studies are evaluating potential therapies including hydroxychloroquine (HCQ) which is given to patients based on limited observational evidence. However, it can cause serious adverse events. Moreover, recent studies showed no benefits due to HCQ. We present two COVID-19 patients treated with HCQ and had adverse events.