Corneal endothelial cells changes in different stages of Keratoconus: a multi-Centre clinical study.

PURPOSE: To assess the corneal endothelial cells morphology and count in keratoconus patients and their correlation with different stages of keratoconus. METHODS: Prospective non randomized multi-centric clinical study included 150 eyes of 150 keratoconus patients. Four centers in Egypt participated in this study included: Departments of Ophthalmology in Alexandria University, Tanta University and Port Said University and Alex I-Care hospital. Pentacam (Wavelight Oculyzer II) and specular microscopy (Tomey EM-3000) were done to all eyes. Keratoconic eyes were classified according to Amsler classification into stage 1, 2 and 3. Stage 1 included 99 eyes, stage 2 included 32 eyes & stage 3 included 19 eyes. RESULTS: The mean age of keratoconus patients was 24.07 ± 6.154 years. Forty five cases were males (30%) and 105 cases were females (70%). There was statistically significant difference in endothelial cell density (p < 0.001) and coefficient of variation (p = 0.012) between different stages of keratoconus eyes. Regarding cell surface area, there was statistically significant difference in cell surface area between different stages of keratoconus eyes (p < 0.001). In addition, for cell morphology, there was statistically significant difference between different stages of keratoconus eyes (p < 0.001). CONCLUSIONS: Qualitative and quantitative structural changes were seen in endothelial cells of keratoconus eyes by using specular microscopy. For stages 1 and 2, keratoconus may not affect the corneal endothelim significantly. The endothelium in stage 3 shows significant changes regarding polymegathism and pleomorphism.

Cardiac Muscle Injury and Echocardiographic Plus Electrocardiographic Findings in Patients With 2019 Novel Coronavirus (COVID-19): A Retrospective Cohort Study.

Background: Myocardial injury has been described in coronavirus-2019 (COVID-19). Few studies have reported cardiovascular imaging data with transthoracic echocardiography (TTE) and electrocardiography (ECG) findings in COVID-19 patients, and their correlation with mortality. Methods: We conducted a retrospective cohort study that included COVID-19 patients from March 2020 through February 2021 who had TTE and ECG during hospital admission. Myocardial injury was defined by an elevated high-sensitivity troponin T level > 20 ng/L. Bivariate analysis was used to compare patients with myocardial injury and those without. Multivariate logistic regression analysis was performed to identify the variables associated with mortality. Results: A total of 438 patients were included. The mean age was 62.1 ± 14.9 years, and 58.9% were male. A total of 149 patients died, with a mortality rate of 34%. A total of 260 patients (59.4%) had myocardial injury. The average left ventricular ejection fraction was 59.8% ± 11.2%, with 30 patients (6.8%) having an ejection fraction of < 40%. Patients with myocardial injury had higher mortality than those without (P < 0.05, χ2 test). A multiple regression analysis model indicated that age, race and/or ethnicity, the development of acute respiratory distress syndrome, shock, the need for vasopressors, mechanical ventilation, and hemodialysis were the variables significantly associated with mortality. Conclusion: COVID-19 patients with myocardial injury had higher mortality than those without. Age, race and/or ethnicity, acute respiratory distress syndrome, shock, the need for vasopressors, mechanical ventilation, and hemodialysis were the clinical variables associated with mortality. The TEE and ECG variables studied were not significantly associated with mortality.

Contexte: Des atteintes myocardiques ont été décrites en présence d'une infection par le coronavirus 2019 (COVID-19). Quelques études ont rapporté des données d'imagerie cardiovasculaire obtenues par échocardiographie transthoracique (ETT) et électrocardiographie (ECG) chez des patients atteints de la COVID-19, et leur corrélation avec la mortalité. Méthodologie: Nous avons mené une étude de cohorte rétrospective comprenant des patients atteints de la COVID-19 entre mars 2020 et février 2021 qui ont été soumis à une ETT ou à une ECG pendant leur hospitalisation. L'atteinte myocardique était définie comme un taux élevé de troponine T de haute sensibilité > 20 ng/L. Une analyse à deux variables a été utilisée pour comparer les patients présentant une atteinte myocardique et ceux qui n'en présentaient pas. Une analyse de régression logistique à multiples variables a été menée pour définir les variables qui étaient associées à la mortalité. Résultats: L'étude comptait un total de 438 patients. L'âge moyen était de 62,1 ± 14,9 ans; 58,9 % étaient des hommes. Un total de 149 patients sont décédés, soit un taux de mortalité de 34 %. Un total de 260 patients (59,4 %) présentaient une atteinte myocardique. La fraction d'éjection ventriculaire gauche moyenne était de 59,8 % ± 11,2 %, alors que 30 patients (6,8 %) affichaient une fraction d'éjection inférieure à 40 %. Le taux de mortalité était plus élevé chez les patients qui présentaient une atteinte myocardique que chez ceux qui n'en présentaient pas (p < 0,05, test χ2). Selon un modèle d'analyse de régression multiple, l'âge, la race et/ou l'ethnicité, l'apparition du syndrome de détresse respiratoire aiguë, l'état de choc, le besoin de vasopresseurs, la ventilation artificielle et l'hémodialyse étaient les variables fortement liées à la mortalité. Conclusion: Parmi les patients atteints de la COVID-19, la mortalité était plus élevée chez ceux qui présentaient une atteinte myocardique que chez ceux qui n'en présentaient pas. L'âge, la race et/ou l'ethnicité, le syndrome de détresse respiratoire aiguë, l'état de choc, le besoin de vasopresseurs, la ventilation artificielle et l'hémodialyse étaient les variables cliniques liées à la mortalité. Les variables d'ETT et d'ECG étudiées n'avaient pas de lien important avec la mortalité.

Refractory cardiogenic shock caused by zinc phosphide toxicity.

Zinc phosphide toxicity is a rare entity that presents most frequently among farmers in developing countries who use it as a rodenticide. The phosphine gas released after the ingestion inhibits cytochrome c oxidase, disrupting the mitochondrial physiology and oxidative phosphorylation and causing myocardial stunning. Here we present a case of a 20-year-old man who attempted suicide with zinc phosphide toxicity. Initially, he was hemodynamically stable with a normal ejection fraction; however, in a few hours, he deteriorated quickly and became hemodynamically unstable, with rapid deterioration of his ejection fraction to 20%. He was started on norepinephrine and then dobutamine; however, he had cardiac arrest from refractory cardiogenic shock despite resuscitative measures.

Ustekinumab-Induced Fatal Acute Heart Failure in a Young Female: A Case Report.

Data regarding short- and long-term cardiovascular complications of biological agents is lacking. Herein, the authors reported a case of abrupt onset of acute heart failure induced by ustekinumab treatment for resistant pityriasis rubra pilaris in a young healthy female with no past cardiac history. Although medical management was immediately initiated for cardiogenic shock, the patient passed away.

Correlation between echocardiographic measurements and right heart hemodynamic parameters in patients undergoing evaluation for pulmonary hypertension.

Echocardiograms provide important information for the evaluation and management of patients with pulmonary hypertension. Right ventricular free wall strain measurements provide additional information about the longitudinal contractile function of the right ventricle. Clinical information, including echocardiographic measurements and right heart hemodynamic parameters, on patients undergoing right heart catheterization for evaluation of possible pulmonary hypertension was collected retrospectively. This study included 60 patients (35 women) with a mean age of 62.6 ± 14.8 years. For World Health Organization categories, 32 patients were in Group 1, 12 in Group 2, 4 in Group 3, 3 in Group 4, and 7 had mixed clinical features of both Group 2 and Group 3. The mean pulmonary artery pressure was 40.6 ± 13.2 mm Hg. The right atrial volume index had significant positive correlations with the brain natriuretic peptide level, right ventricular volume index, left atrial volume index, and right atrial pressure and negative correlations with the cardiac index and mixed venous oxygen saturation. The mean right ventricular free wall strain was -17.85 ± 5.56%; it did not have significant correlations with right heart hemodynamic parameters. Therefore, the right atrial volume index but not the right ventricular strain index provides important objective information for the evaluation of patients with possible pulmonary hypertension.

A Case of Pericardial Decompression Syndrome Following Surgical Pericardial Fluid Drainage.

Pericardial decompression syndrome (PDS) is a rare and serious complication that follows often-initially-uncomplicated pericardial drainage in patients with pericardial effusion and tamponade physiology. The pathophysiology of PDS is not yet completely understood, although several mechanisms have been postulated. In this report, we present a case of PDS in a 70-year-old male with end-stage renal disease (ESRD) after he underwent a surgical pericardial window for drainage of a moderate pericardial effusion with tamponade physiology. This case provides further evidence that rapid pericardial decompression, notably with pericardiotomy, can lead to acute life-threatening low cardiac output heart failure, particularly in patients with underlying cardiac risk factors. Early recognition, diagnosis, and supportive treatment in the ICU are crucial for improving survival rates in these patients.

2019 Novel Coronavirus Vaccination among Post-graduate Residents and Fellows.

BACKGROUND: Coronavirus-2 (COVID-19) has caused a worldwide pandemic since December 2019. Since then, clinical trials with vaccines have been started and completed, and at present, 3 COVID-19 vaccines have been approved for use in the United States. Healthcare providers were among the first to get vaccinated, but the precise attitudes of healthcare workers toward vaccination are uncertain. OBJECTIVE: To understand residents and fellows' attitudes toward vaccination and record any side effects after vaccination. METHODS: We conducted an anonymous survey that was open from 3-1-2021 to 3-12-2021 using distribution lists from the Graduate Medical Education office on the Lubbock campus of the Texas Tech University Health Sciences Center after getting approval from the Institutional Review Board (L21-088). RESULTS: Eighty-one residents and fellows (26.6% out of 304) responded to our survey. Among those who responded, 63 (77.8 %) were between 25 and 35 years old, and 41 (50.6%) were males. Seventy-seven (95.1%) received the vaccine (Pfizer-BioNTech), 78 (96.3%) reported that they supported vaccination, and 3 (3.7%) reported that they did not want vaccination. Eight members (9.8%) had tested positive for COVID-19 infection before vaccination, but only 1 (1.23%) had tested positive for COVID-19 antibodies. All residents and fellows reported side effects after the vaccination, including pain at the injection site (77; 100%), local redness (9; 11.6%), local swelling (13; 16.8%), fever (25; 32.5%), fatigue (25; 32.5%), chills (34; 44.1 %), headache (38; 49.4%). CONCLUSIONS: Most medical trainees have a high interest in COVID-19 vaccination; however, a few reported that they did not want vaccination.

Seckel syndrome presenting with complete heart block.

Seckel syndrome is a rare autosomal recessive disorder characterized by facial dysmorphic features known as bird-headed dwarfism. Only about 100 cases have been reported. Cardiac anomalies have been described as a potential association with Seckel syndrome. We report a 21-year-old woman with Seckel syndrome and epilepsy who presented with status epilepticus. She was hypotensive and bradycardic. Her electrocardiogram showed complete heart block. She was placed on transcutaneous pacer with no response. A transvenous pacemaker was placed before inserting a suitable permanent pacemaker for her size. This is the third case of complete heart block associated with Seckel syndrome and raises concern about the potential association.

Diuretic Resistance in Heart Failure.

Decompensated heart failure accounts for approximately 1 million hospitalizations in the United States annually, and this number is expected to increase significantly in the near future. Diuretics provide the initial management in most patients with fluid overload. However, the development of diuretic resistance remains a significant challenge in the treatment of heart failure. Due to the lack of a standard definition, the prevalence of this phenomenon remains difficult to determine, with some estimates suggesting that 25-30% of patients with heart failure have diuretic resistance. Certain characteristics, including low systolic blood pressures, renal impairment, and atherosclerotic disease, help predict the development of diuretic resistance. The underlying pathophysiology is likely multifactorial, with pharmacokinetic alterations, hormonal dysregulation, and the cardiorenal syndrome having significant roles. The therapeutic approach to this common problem typically involves increases in the diuretic dose and/or frequency, sequential nephron blockade, and mechanical fluid movement removal with ultrafiltration or peritoneal dialysis. Paracentesis is potentially useful in patients with intra-abdominal hypertension.

Intestinal angioedema caused by an acquired C1 esterase inhibitor deficiency associated with underlying splenic marginal zone lymphoma.

A 75-year-old woman presented with recurrent abdominal pain and vomiting for 1 year and was later found to have splenomegaly and pancytopenia. This case report depicts a clinical picture of intestinal angioedema, a challenging diagnosis, and an underlying rare syndrome of acquired C1 esterase inhibitor deficiency associated with splenic marginal zone lymphoma.

Docetaxel-induced acute myositis: a case report with review of literature.

Docetaxel is an anti-microtubule agent and a highly effective treatment of locally advanced and metastatic breast cancer. There are several adverse effects associated with docetaxel, such as myelosuppression, peripheral neuropathy, fluid retention, and asthenia. One of the most well-known side-effects of this medication is mild to moderate myalgia. Here, we report a case of a 49-year-old female with stage 3 breast cancers who developed severe acute myositis following docetaxel use. The mechanism of docetaxel-induced myositis remains unclear; however, physicians still need to be aware of the possibility of this complication in patients with cancer and a history of exposure to this medication.

The clinical associations with cardiomegaly in patients undergoing evaluation for pulmonary hypertension.

BACKGROUND: Chest radiographs can identify important abnormalities in patients undergoing diagnostic evaluation for cardiovascular diseases. Cardiomegaly often reflects cardiac chamber dilation, or cardiac muscle hypertrophy, or both conditions. The clinical implications of cardiomegaly depend on the underlying clinical disorder. Does cardiomegaly have any clinical, laboratory, echocardiographic, and right heart catheterization associations in patients undergoing evaluation for pulmonary hypertension? METHODS: Patients referred to a pulmonary vascular disease clinic for possible pulmonary hypertension underwent a comprehensive evaluation that included right heart catheterization. These patients also had chest radiographs, laboratory studies, and echocardiograms. The patients were divided into two groups based on the presence or absence of cardiomegaly. RESULTS: This study included 102 patients (63.7% female) with a mean age of 62.3 ± 15.0 years. Patients with cardiomegaly (n = 64) had elevated BNP, BUN, and creatinine levels. They had elevated right atrial pressures, right ventricular pressures, and pulmonary artery pressures and reduced cardiac indices and reduced mixed venous oxygen saturations. There were no differences in echocardiographic parameters between the two groups. CONCLUSIONS: This study demonstrates that the presence of cardiomegaly on chest radiographs has important clinical implications, including increased BNP levels and increased right heart pressures, in patients undergoing evaluation for pulmonary hypertension. Consequently, the presence of cardiomegaly supports the need for additional evaluation, including right heart catheterization, and provides useful information for primary care physicians and specialists.

Invasive pneumococcal disease confirmed in five different sites including Austrian syndrome in a male patient with methamphetamine abuse.

A 60-year-old man with no significant medical history was found unresponsive by his neighbour; he had neck stiffness on physical examination in the emergency department. He later developed acute hypoxic respiratory failure requiring endotracheal intubation. He is a binge drinker on weekends, and methamphetamine was detected in his urine. Contrast-enhanced CT of the chest, abdomen and pelvis revealed multifocal pneumonia, bilateral psoas abscesses and right infraspinatus muscle abscess. Blood, sputum and cerebrospinal fluid cultures grew Streptococcus pneumoniae Transthoracic echocardiography (TTE) revealed tricuspid endocarditis with mild valve insufficiency. He was initially treated with intravenous antibiotics and underwent incision and drainage of right psoas abscess. However, he still had recurrent fever and confusion. Repeat TTE showed larger vegetation, and he also developed septic emboli at the posterior basal right lower lobe pulmonary artery. The patient underwent tricuspid valve debridement and was finally discharged after completing 6 weeks of intravenous antibiotic treatment.

Pulmonary mucormycosis mimicking a tracheobronchial tumor in a patient with diabetic ketoacidosis.

Pulmonary mucormycosis is a life-threatening infection caused by a fungus that is part of the Mucorales family. Diabetes ketoacidosis has been classically described as the main risk factor for the disease. Tracheobronchial mucormycosis is an infrequent form of pulmonary mucormycosis that presents as a tracheobronchial tumor obstructing the airway. Few cases have been reported in the literature. We present a case of pulmonary mucormycosis that presented initially as a collapsed right upper lung, mimicking a tracheobronchial tumor. Early detection and treatment are key to avoid fatal outcomes.

Sinus of Valsalva aneurysm presenting with chest pain.

Sinus of Valsalva aneurysm is a rare aortic root defect that can be dangerous due to its serious complications. It is defined as dilatation of one or more of the aortic valve sinuses. It is usually asymptomatic, and patients rarely present with chest pain, arrhythmias, or heart failure. We report a 29-year-old man who presented with atypical chest pain of 8 months with a normal cardiovascular exam. His laboratory work was unremarkable. Transthoracic echocardiography and transesophageal echocardiography showed a calcified sinus of Valsalva aneurysm arising from the noncoronary cusp. The patient underwent aneurysm repair surgery with no complications, and his chest pain resolved.

A Fractured Inferior Vena Cava Strut Migrating to the Right Ventricle Without Any Cardiovascular Complaint: A Case Report and Review of Literature.

The use of inferior vena cava filter (IVCF) as one of the last resorts for pulmonary embolism prevention has expanded over the decades. The migration of a broken strut to the right ventricle is a very unusual complication that, when present, has been associated with life-threatening events. We report a case of a 34-year-old female with an inferior vena cava (IVC) strut that migrated and was incidentally found embedded in the right ventricle without any cardiovascular signs or symptoms. This case provides evidence that such filters probably have higher rates of complications than what has been thought because those complications might remain asymptomatic.

Giant Left Ventricular Thrombus Formation in the Setting of Severe Aortic Stenosis and Heavy Cigarette Smoking.

The harmful effects of cigarette smoking on the human body have been well documented. However, whether tobacco use is an independent risk factor of valvular heart disease remains debatable. Cigarette smoking has been associated with an inflammatory state and increased levels of tumor necrosis factor alpha, which in turn activates protein kinases involved in ventricular remodeling. Subsequent ventricular dysfunction predisposes to the formation of mural thrombi which may lead to further worsening of hemodynamics. We present a case of severe aortic stenosis and giant left ventricular thrombus formation associated with chronic cigarette smoking.

Plexus Slim®-Induced Immune Thrombocytopenic Purpura.

Primary immune thrombocytopenic purpura (ITP) is a common cause of thrombocytopenia. Due to the many possible precipitating factors, the diagnostic approach can be complex in nature. Much of the published literature on drug-induced ITP (DITP) report on quinine-induced thrombocytopenia. Here we present a case of the proposed dietary cause of DITP by the weight loss supplement Plexus® which contains two potential thrombocytopenia-causing compounds, garcinia cambogia fruit extract, and chromium polynicotinate. This case highlights how a thorough patient history, including evaluation of supplement use and dietary habits, can be of the utmost importance in the workup of ITP.

Cardiogenic Pulmonary Edema.

The initial events in cardiogenic pulmonary edema involve hemodynamic pulmonary congestion with high capillary pressures. This causes increased fluid transfer out of capillaries into the interstitium and alveolar spaces. High capillary pressures can also cause barrier disruption which increases permeability and fluid transfer into the interstitium and alveoli. Fluid in alveoli alters surfactant function and increases surface tension. This can lead to more edema formation and to atelectasis with impaired gas exchange. Patients with barrier disruption have increased levels of surfactant protein B in the circulation, and these levels often remain high after the initial clinical improvement. Routine clinical assessment may not identify patients with increased extravascular fluid in the lungs; pulmonary ultrasound can easily detect pulmonary edema in patients with acute decompensation and in patients at risk for decompensation. Studies using serial pulmonary ultrasound could help characterize patients with cardiogenic pulmonary edema and help identify subgroups who need alternative management. The conventional management of cardiogenic pulmonary edema usually involves diuresis, afterload reduction and in some cases noninvasive ventilation to reduce the work of breathing and improve oxygenation. Patients with persistent symptoms, abnormal chest x-rays and diuretic resistance might benefit from alternative approaches to management. These could include beta agonists and pentoxifylline which warrant more study in patients with cardiogenic pulmonary edema.