'Chasing the dragon': new knowledge for an old practice.

Heroin administration by "chasing the dragon," whereby the user places freebase heroin on aluminum foil, heats it below with a flame, and inhales the pyrolysate through a straw, can be associated with the rare development of a delayed-onset spongiform leukoencephalopathy. We report the case of a 46-year-old woman with a psychiatric diagnosis of depression and heroin dependence by "chasing the dragon" admitted with features of altered mental status and later development of catatonia, abulia, and akinetic mutism. A brain magnetic resonance image evidenced bilateral symmetric high-signal lesions in the white matter of the cerebrum and cerebellum on T2-weighted images compatible with toxic leukoencephalopathy. The patient's condition resolved after a hospital stay of 2 months with supportive treatment. Acute onset of neurobehavioral changes, including confusion, apathy, and cerebellar signs in a person with exposure to heroin, should prompt one to consider toxic leukoencephalopathy as a cause of presentation.

Dual chamber pacing relieves obstruction in Japanese-variant hypertrophic cardiomyopathy.

Japanese-variant or apical hypertrophic cardiomyopathy (HCM) is a specific type of HCM, first described in Japan and initially thought to carry a benign prognosis. However, current evidence suggests that these patients experience severe symptoms and are at increased risk of ventricular arrhythmias and death, especially in the presence of an apical akinetic chamber. The management of patients who do not respond to medical therapy is challenging. We describe a patient with Japanese-variant HCM, with an apical akinetic chamber and severe symptoms who failed medical therapy. The use of dual chamber pacing relieved obstruction and significantly improved the patient's symptoms.

Bilateral Bochdalek hernias presenting as respiratory failure in an elderly patient.

Bochdalek hernia occurs from a congenital defect of the diaphragm, allowing the passage of abdominal structures into the thoracic cavity, limiting lung expansion and ventilatory function. Bochdalek hernia is common in neonates but rarely occur in adults; there are only 4 documented cases in the elderly population. We present a case of an 88-year-old woman with severe hypoxia and respiratory failure that required ventilatory support, in whom bilateral Bochdalek hernias progressed over the years and severely invaded the thoracic cavity, causing acute decompensation. This is a rare condition in adults but can cause substantial morbidity when the involvement of the thoracic cavity is severe.

Visceral angioedema due to angiotensin-converting enzyme inhibitor therapy.

Visceral angioedema is an uncommon but serious complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. We report a case, review the literature, and discuss the incidence, features, and clinical recognition of this condition.

Infectious atherosclerosis: is the hypothesis still alive? A clinically based approach to the dilemma.

Among the multiple factors involved in the pathophysiology of heart disease, infections have been proposed to play a role in atherosclerosis with most of the available evidence implicating Chlamydia pneumonia, influenza virus and Mycoplasma pneumoniae. Based on a model case presentation, we speculate that in the absence of traditional risk factors and in the context of an ongoing respiratory infection caused by a pro-inflammatory pathogen (M. pneumoniae) along with a past positive serologic history for potentially proven atherogenic microorganism (C. pneumoniae) and infection may elicit potentially pathogenic events on vascular wall cells and leukocytes of atheromatous lesions, supporting the hypothesis that such infections may potentiate atherosclerotic cardiovascular disease (CVD).

Association of BMI and cardiovascular risk stratification in the elderly African-American females.

We aimed to estimate the association of BMI and risk of systemic hypertension in African-American females aged 65 years and older. In this retrospective, cross-sectional study, medical charts were randomly reviewed after obtaining institutional review board approval and data collection was conducted for height, weight, BMI, age, ethnicity, gender, and hypertension. A multivariable logistic regression analysis was performed. The mean BMI was significantly higher in hypertensive subjects than normotensives (30.3 vs. 29 kg/m2; P = 0.003). A higher proportion of hypertensive subjects had a BMI >23 kg/m2 as compared to normotensives (88.9% vs. 83.5%; P = 0.023). When the log odds of having a history of hypertension was plotted against BMI as a continuous variable, we found that the odds showed an increasing trend with increasing BMI and a steep increase after a BMI of 23 kg/m2. When BMI was analyzed as a categorical variable, a BMI of 23-30 kg/m2 was found to have an odds ratio of 1.43 (95% confidence interval 1.01-2.13; P = 0.05) and a BMI of >30 kg/m2 had an odds ratio of 1.76 (95% confidence interval 1.17-2.65; P = 0.007) when compared to a BMI of <23 kg/m2. This association remained significant in both univariate and multivariate analysis. We conclude that BMI is an independent predictor of hypertension in elderly African-American females. Our results indicate that the risk of hypertension increased significantly at BMI of >23 kg/m2 in this ethnic group. Weight reduction to a greater extent than previously indicated could play an integral role in prevention and control of high blood pressure in this particular population.