Symptomatic Junctional Bradycardia Due to Untreated Hypothyroidism After Beta-Blocker Discontinuation: A Case Report.

Hypothyroidism is known to cause bradycardia, but there are no direct comparisons of the level of thyroid-stimulating hormone (TSH) to heart rate (HR) to assist in therapeutic hormonal management. This case presents a patient who developed symptomatic junctional bradycardia and underwent serial TSH testing to attempt to improve her HR while minimizing systemic toxicity from levothyroxine. The patient had a history of paroxysmal atrial fibrillation on beta-blocker therapy and hypothyroidism and developed symptomatic junctional bradycardia following a lapse in her thyroid supplementation. Upon initiation of hormonal replacement therapy, serial TSH levels were assessed as she continued to have episodic bradycardia with severe hypertension. Given the lack of evidence correlating TSH levels to HR, this case report calls for further studies to be conducted to create reliable guidelines in therapeutic management to prevent bradycardia events while minimizing systemic levothyroxine toxicity.

Complete AV Block in Vaccinated COVID-19 Patient.

Background. Coronavirus 2019 (COVID-19) was initially identified approximately in December 2019 at Wuhan, China, as patients presented with vague prodromal and respiratory symptoms. With the developing investigation of its clinical manifestation, cardiac symptoms have been widely reported including acute coronary syndromes, myocarditis, arrhythmias, heart failure, and cardiac arrest. Case Summary. An 84 year-old male with history of coronary artery disease, hypertension, and hyperlipidemia presented to an outside urgent care with prodromal symptoms. The patient had received the second Pfizer vaccine three months prior. This presentation, he was found to be COVID-19 positive as well as bradycardic with a complete AV block. He was transferred to a tertiary center for further evaluation and management. However, after transfer, the patient refused further invasive cardiac interventions and after medical therapy was discharged home in complete AV block. Discussion. We report a novel case of a Pfizer-vaccinated patient whose initial presenting symptoms of COVID-19 included a complete AV block as well as the challenges and difficulties in approaching such patients. Although this patient's etiology of his complete AV block may result from multiple factors, given the acuity in setting of concurrent COVID-19 infections, top differentials include viral myocarditis, COVID-19-induced Takotsubo cardiomyopathy complicated by a complete AV-block, or a direct conduction pathway infection. Management of patients should focus on a multidisciplinary approach, and prevention is critical via vaccination.

A Meta-Analysis: Coronary Artery Calcium Score and COVID-19 Prognosis.

Background: Multiple studies have investigated the correlations of mortality, mechanical ventilation, and intensive care unit (ICU) admissions with CAC scores. This analysis overviews the prognostic capability of CAC scoring in mortality, mechanical ventilation, and ICU admission for hospitalized COVID-19 patients. Methods: Online search was conducted on PubMed, Cochrane Library, and Scopus from inception to 22 November 2021 to identify studies involving CAC scores in relation to ICU admission, mechanical ventilation, and death rates. Results: A total of eight studies were analyzed. In the absence of CAC group compared with the presence of CAC score, there was an increase in mortality in the presence of CAC (RR 2.24, 95% CI, 1.41−3.56; p < 0.001). In the low CAC group and high CAC group, high CAC group had increase in mortality (RR 2.74; 95% CI, 1.94−3.86; p < 0.00001). There was no statistical difference in outcomes of mechanical ventilation and ICU admission between any of the groups. Conclusion: This meta-analysis strictly examined the outcomes of interest in death, mechanical ventilation, and ICU admission while comparing the CAC scores in patients with COVID-19. Given these findings, CAC scoring can aid in stratifying patients, thus allowing earlier interventions in rapidly developing illnesses.

ANCA vasculitis: A manifestation of Post-Covid-19 Syndrome.

The SARS-CoV-2 infection has been found to present with different degrees of response and variable levels of inflammation. Patients who have recovered from the initial infection can develop long-term symptomatology. We present a unique case of a middle aged-healthy man who developed complications of ANCA-associated vasculitis after recovering from a mild COVID-19 infection. A previously healthy 53-year-old male presented with hemoptysis and acute renal failure. One month prior, the patient tested positive for COVID-19; not requiring hospitalization. Physical exam findings included bilateral lower extremity petechiae. CT Chest showed bilateral diffuse patchy lung consolidations with cavitary lesions with urinalysis revealing erythrocytes, +1 protein. Hemodialysis and workup for pulmonary-renal syndromes were initiated. Infectious workup results included: negative COVID-19, negative MTB-PCR, respiratory culture revealing yeast. Additional workup revealed; elevated CRP, D-Dimer, and Fibrinogen. Notably, the patient had; decreased C3 and C4 levels; negative Anti-GBM antibody; negative Anti-streptolysin-O; and positive ANCA assay, Proteinase antibody, and mildly positive Myeloperoxidase antibody. Worsening coagulopathy and atrophic kidneys delayed renal biopsy for definitive diagnosis. The patient's respiratory status acutely worsened during hemodialysis with imaging showing markedly increased pulmonary infiltrates. Upon urgent intubation, active frank red bleeding was noted, and the patient sustained 2 cardiac arrests with eventual expiration. Much is to be learned from the Novel SARS-CoV-2 virus and suspected complications. This case highlights a unique complication of COVID-19 leading to a possible AAV and the importance of keeping a broad differential when treating patients who have recovered from the initial infection.