Severe mitral stenosis with atypical presentation: hemorrhagic pleural effusion--a case report and literature review.

Mitral stenosis is a well-described valvular heart disease. We report a 68-year-old patient with an unusual presentation of mitral stenosis. He presented with recurrent episodes of hemorrhagic pleural effusion. Afterwards, an extensive atrial thrombosis complicated his course of illness. We will discuss how the clinical presentation of mitral stenosis is mainly dictated by the underlying pathophysiology of the disease. Also, the need for anticoagulation in the setting of mitral stenosis is often linked to the presence of atrial fibrillation. We will discuss the independent risk factors for thromboembolism in the setting of mitral stenosis. Finally, a review of the current recommendation for anticoagulation is conferred.

C-reactive protein: the harbinger of cardiovascular diseases.

Coronary heart disease remains the major cause of mortality and morbidity in the United States and other western countries despite major advances in its treatment. During the last decades, many markers of coronary artery disease have been found which help predict future risk of cardiovascular events. High-sensitivity C-reactive protein has been studied extensively and was seen to be associated with a higher risk of cardiovascular events in patients with acute coronary syndromes and/or peripheral artery disease. Discussed in this review is the latest literature about this marker and its association with cardiovascular disease, as well as the latest therapeutic options available.

ST segment elevation in lead aVR: what to expect from this orphan?

Standard 12-lead electrocardiography is used to diagnose acute myocardial infarctions in patient presenting with ST elevation. The specificity of ST segment elevation for the corresponding area is more than 90 percent. It has been suggested that ST-segment elevation in lead aVR may indicate left main disease. We will present a patient who had an ST segment elevation in this lead. We will review the current data about this finding, as well as the significance of ST segment elevation in other leads.

Atrial flutter and myotonic dystrophy in a male adolescent treated with radiofrequency catheter ablation.

A variety of cardiomyopathies are due to familial disease. Most are primarily associated with cardiac involvement and can lead to hypertrophic, dilated, or restrictive cardiomyopathy. Myotonic dystrophy (MD) is a multisystem disease with autosomal dominant inheritance and variable penetrance. Cardiac diseases are important causes of morbidity and mortality in MD patients. Patients with primary MD should be carefully investigated with an electrocardiogram, stress test, and an echocardiogram to identify preclinical cardiac involvement and to prevent life-threatening complications. Any new onset of atrial flutter or atrial fibrillation in a young patient without any underlying cardiac abnormality should be investigated for underlying myopathy. The authors report on a male adolescent with MD who presented with atrial flutter. The patient had been diagnosed with MD at birth. He had an impaired ejection fraction of 38% to 45%. The patient described sharp chest pain in the retrosternal area, with no radiation, that was induced by exercise.

Electrocardiographic abnormalities and endocrine diseases--part a: hyperthyroidism.

Endocrine abnormalities can result in many different electrocardiographic abnormalities that can be confusing to the interpreting physician. Recognition and proper interpretation of these changes is helpful in the diagnosis, prognosis, and therapy of various endocrine diseases. Knowing these changes can help physicians avoid the diagnosis of myocardial ischemia, hypertrophy and arrhythmias in cases when the electrocardiographic changes are in reality because of disturbed endocrine function or the abnormal metabolic state.

Methadone and torsade de pointes: case report and review of the literature.

Methadone, a synthetic opioid, has been used for more than 35 years to treat heroin addiction. It is also an effective therapy for chronic pain. An increase in the mean dose used nationally to treat these patients has been reported. There is an ongoing debate over whether it is necessary to screen patients with an ECG before and during therapy with methadone. We present a patient who developed QT prolongation and sustained ventricular arrhythmias after her methadone dose was increased. Previous literature, as well as the mechanism and risk factors, will be reviewed in this article. Recommendations will be given as to when an ECG is preferably to be performed.

Tako-tsubo syndrome as a consequence of transient ischemic attack.

An 82-year-old woman presented to the emergency department with chest pain after sustaining a transient ischemic attack 1 week prior to presentation. Electrocardiography revealed ST-segment elevation in leads I, II, aVF, and V3 through V6. Coronary angiography demonstrated nearly normal coronaries but left ventriculography showed apical akinesis and basal hyperkinesis. One month later her follow-up echocardiography showed no wall motion abnormalities. Several reports of tako-tsubo syndrome or transient left ventricular apical ballooning have been described, especially in Japan. We present a case with the typical features of the syndrome after a cerebrovascular accident.

Streptococcus intermedius: an unusual cause of a primary empyema.

Despite the evolution of modern antibiotics, pleural space infection remains a common illness with significant morbidity and mortality. Every year up to 60 percent of the 1.2 million patients in the United States who present with community-acquired pneumonia develop parapneumonic pleural effusions. Few of these parapneumonic effusions progress to an empyema. Interestingly, in about 10 percent of the cases of empyema, no underlying pulmonary infection can be identified. These pleural space infections are called primary empyemas. We present a patient with a primary empyema caused by Streptococcus intermedius. Relatively few studies have investigated primary empyema caused Streptococcus intermedius. This case presentation serves as a reminder to the clinician about primary empyema caused by this micro-organism.

Plasmapheresis as an adjuvant therapy for hypertriglyceridemia-induced pancreatitis.

Hypertriglyceridemia is an uncommon cause of pancreatitis. A serum triglyceride level of more then 1000 to 2000 mg/dL is an identifiable risk factor. Interestingly, serum pancreatic enzyme levels may be normal or only minimally elevated in such cases. The reduction of triglyceride level to below 1000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment for the hypertriglyceridemia associated with pancreatitis includes dietary restriction of fat and administration of lipid-lowering agents. It is thought that within 24 to 48 hours of the onset of pancreatitis, in the majority of patients, triglyceride levels fall rapidly as a result of fasting status, as the absorption of chylomicrons to the blood is cut off. Experiences with plasmapheresis are limited. We report a case of hypertriglyceridemic necrotizing pancreatitis with mildly elevated amylase and lipase, treated successfully with plasmapheresis.

Intercostal artery aneurysm complicating aortic coarctation in a 71-year-old-woman.

We present a case of aortic coarctation associated with many intercostal artery aneurysms in a 71-year-old woman. The intercostal aneurysm appeared, radiographically, as a very well demarcated lung mass with hilar enlargement giving the false idea of lung tumor and adenopathy. The case illustrates the importance of keeping such a diagnosis in mind in patients presenting with an abnormal chest x-ray. To our knowledge this is the first case report of aortic coarctation complicated by intercostal aneurysm at this age group.

Cranial nerve VIII involvement in a patient with progressive systemic sclerosis.

Systemic sclerosis is a multisystem disorder characterized by abundant fibrosis of the skin, blood vessels, and visceral organs. Cranial nerve involvement is an uncommon feature of this connective tissue disorder, and when it occurs it is the trigeminal nerve that is primarily affected. We report an elderly woman who presented with sensorineural hearing loss and was then diagnosed with the CREST syndrome of progressive systemic sclerosis (calcinosis cutis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia). Involvement of the eighth cranial nerve with scleroderma and CREST syndrome is rare, but appears to be the cause of sensorineural hearing loss in our patient.

Acinetobacter baumannii pneumonia: a case report and review of the literature.

Bacteria that constitute the genus Acinetobacter were originally identified in the first decade of the 20th century. However, it was not until the last decade that its role as an opportunistic pathogen was fully appreciated. It is now clear that Acinetobacter is an important cause of nosocomial infection and contributes significantly to the patient's morbidity and mortality. The prevalence of infection with A. baumannii has increased significantly during the last decade. At the same time, A. baumannii has developed one of the most impressive patterns of antibiotic resistance ever observed, establishing it as an important nosocomial pathogen. It has been nicknamed the "Gram-negative MRSA" because of its frequent resistance to commonly used antibiotics. Infection with A. baumannii should be suspected in hospitalized patients who are not responding to initial empiric antibiotic treatment, and the therapeutic approach should be customized according to when the pathogen is isolated.

Hepatitis C and dilated cardiomyopathy.

In North America, viral infection is the most common cause of myocarditis. A number of common viral infections have been implicated. With the increased identification of patients with hepatitis C, there is recent evidence derived from myocardial molecular biology studies suggesting an association between HCV infection and the development of myocarditis. This may be followed by dilated cardiomyopathy. Primarily researchers overseas have supported the recognition of this association. We recently cared for a patient who appears to fulfill the clinical criteria of hepatitis C-induced cardiomyopathy.

Treating amiodarone-induced thyrotoxicosis with radioactive iodine.

Amiodarone use in the United States is increasing including a role in advanced cardiac life support protocols. There has been a significant increase in hypothyroidism, destructive thyroiditis (type II), and iodine-induced thyrotoxicosis (type I) with amiodarone. Preexisting thyroid disease and status of iodine intake can determine the nature of iodine-induced thyroid disease. Treating amiodarone-induced thyrotoxicosis (AIT) may include traditional antithyroid agents, glucocorticoids, and surgery. Usually, it is assumed the radioactive iodine uptake (RAIU) will be low, and this choice as a treatment modality is excluded at the initial visit. We report a satisfactory outcome in a patient with AIT using radioactive iodine. The role of radioactive iodine in treating AIT is reviewed

Right-sided heart thromboembolism and pulmonary embolism.

We report a patient with an evidence of bilateral calf deep vein thrombosis, hemodynamically significant pulmonary embolism, and echocardiographic evidence of right heart thromboemboli with "popcorn" appearance. She responded well to thrombolytics and low molecular weight heparin with resolution of symptoms and improvement of echocardiographic abnormalities.