Reversible supraventricular tachycardia and left bundle branch block in a marathon runner with exertional heat stroke in the Po Valley.

We report the case of a 52-year-old marathon runner admitted to our emergency department for exertional heat stroke (EHS). The electrocardiogram (ECG) showed a supraventricular tachycardia, probably an atrial flutter with 2:1 block, conducted with left bundle branch block. After 10 minutes of aggressive fluid management and rapid external cooling, the ECG returned to normal. As the high-sensitivity cardiac troponin I was elevated, coronary angiography and an electrophysiological study were performed, revealing normal coronary arteries and excluding inducible arrhythmias. As reported in the current literature, our findings confirm that the electrocardiographic changes and elevation of cardiac markers in EHS do not reflect cardiac ischemia, but rather a myocardial injury due to the pathophysiological response to dehydration and hyperthermia, which markedly impaired stroke volume and cardiac output. EHS is a life-threatening condition with a complex pathophysiology caused by thermoregulatory failure. Diagnosis is not always straightforward, but early recognition and timely management (the "golden hour") with rapid cooling and intravenous fluids are crucial to prevent irreversible and fatal organ damage. EHS is defined by a rectal temperature > 40.5 °C with symptoms or signs of neurological dysfunction, such as confusion, drowsiness, or seizures, which can rapidly worsen with delirium, coma, and cardiac arrest. With this case report, we want to remind emergency physicians that early diagnosis and appropriate management of EHS can avoid death and inappropriate treatment. (www.actabiomedica.it).

Primary Hyperparathyroidism overlapping with Multiple Sclerosis: a catastrophic marriage.

Primary hyperparathyroidism (PHPT) often leads to neurological or psychiatric disorders, thus mimicking different diseases. Here we present a 77-years old man visited in the Emergency Department complaining for fatigue, multiple falls, nausea, anorexia, and constipation. Symptoms were rapidly worsening, and on admission he appeared sleepy, responsive to verbal stimulus, disoriented, dehydrated, unable to maintain upright position. He suffered from mild, relapsing and remitting Multiple Sclerosis (MS) since the age of 45, at that moment not requiring treatment. The laboratory tests displayed severe hypercalcemia (16.8 mg/dL), slightly decreased level of serum phosphorus (2.8 mg/dL), very high levels of parathyroid hormone (PTH) (508 pg/mL). A parathyroid mass (35x21x32 mm) in left paratracheal position was found with Computed Tomography (CT) of the neck. After correcting hypercalcemia, he was operated on day 18, thus confirming the parathyroid adenoma, that was successfully removed. One month later, the patient was completely well, and able to walk without any help, like three months before. The lab tests' values obtained during the control visit showed complete normalization of calcium-phosphate metabolism. Diabetes, too, was going better, allowing a reduction in metformin dosage. At the best of our knowledge this is the first described case of a clinically significant overlapping between symptoms due to a long-lasting mild MS and an unrecognized, severe, PHPT. This case underlines the importance of a thorough metabolic evaluation of each patient presenting worsening of his neuromuscular and/or neuropsychiatric condition, even when previously known to be affected by a defined neurologic or psychiatric disease.

Hypovolemic shock due to Wunderlich syndrome (spontaneous renal haemorrhage): a case report and literature review.

Wunderlich syndrome (WS) or spontaneous renal haemorrhage is a rare and life-threatening condition often leading to haemorrhagic shock. WS is characterized by an acute onset of non-traumatic subcapsular and perirenal haematoma formation due to several causes, including neoplasms, cystic rupture, vasculitis, coagulopathies, and infections. The classical presentation includes acute flank or abdominal pain, a palpable flank mass and hypovolemic shock (Lenk's triad). Nausea, vomiting, fever, and haematuria can also be present. Computed tomography angiography is mandatory to localize the source of haemorrhage. Super-selective embolization can be performed to stop bleeding, while surgery is reserved to haemodynamic unstable patients and neoplastic cases. We describe a case of WS in a 79-year-old male patient, who rapidly developed hypovolemic shock requiring urgent nephrectomy.

Acute chest pain and dyspnoea as clinical presentation of primary membranous nephropathy. A case report and literature review.

Membranous nephropathy (MN) is the commonest cause of nephrotic syndrome (NS) in adult male patients worldwide. Most of the cases (80%) are idiopathic (primary MN, PMN), whereas about 20% are associated with autoimmune diseases, malignancies or exposures (secondary MN). PMN is a kidney-specific autoimmune glomerular disease mediated by antibodies to the M-type phospholipase A2 receptor (anti-PLA2R) (85%), thrombospondin type 1 domain containing 7A (THSD7A) (3-5%), or by other still unidentified mechanisms (10%). Most of the patients with PMN present with NS (80%). Clinical course of PMN is characterised by spontaneous remissions (40%) and relapses (15-30%). One third develop end-stage renal disease (ESRD) within 5 to 15 years from the onset. Anti-PLA2R/THSD7A antibodies levels correlate with proteinuria, clinical course, and outcomes. The treatment still remains matter of debate. Hypertension, proteinuria, and hyperlipidaemia must be treated in all patients. Immunosuppressive therapy is indicated in patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis. With proper management, only 10% or less will develop ESRD over the subsequent 10 years. Here we report a case of a 34-year-old male patient with a ten-year history of asymptomatic PMN, treated with ACE-inhibitors, who presented to our emergency room for acute chest pain and exertional dyspnoea due to ESRD that required urgent dialysis. (www.actabiomedica.it).

Incidence and predictive factors of acute diseases in patients with syncope: the ESCAPE study.

According to the 2018 ESC guidelines, emergency physicians shall primarily aim to identify syncopal episodes associated with an underlying acute principal disease. Therefore, in this study, we aimed to assess the incidence of syncope associated with acute principal diseases (APDs) and to identify predictive factors reflecting the presence of these underlying conditions. We retrospectively evaluated all patients presenting with syncope during a 6-month period to the local emergency department, collecting incidence of syncopal cases associated with APDs, personal information, clinical features, and laboratory abnormalities, which were compared between syncopal patients with or without APDs. A syncope-associated APD could be diagnosed in 346/1279 patients (27.1%). In the majority of cases, the cause was a non-cardiovascular acute condition (67%), mostly non-life-threatening such as infectious diseases (34.4%) and acute diseases with pain, fluid loss or hypotension (23.7%). Severe acute cardiovascular conditions were less frequent (4.2%). Cardiogenic syncope, no previous history of syncopal episodes, not full agreement with typical clinical features of syncope, alterations of vital parameters, and laboratory abnormalities were also found to be independently associated with syncope-associated APDs. Syncope may be frequently associated with APDs of varying severity, though mostly non-clinically threatening, thus confirming that this condition shall be considered a symptom and not a disease. Emergency physicians should hence be first engaged in troubleshooting an underlying pathology when facing patients with syncope, for timely identifying patients at higher risk of short-term adverse events and reducing inappropriate admissions and diagnostic investigations, especially in the presence of hypotensive syncope elicited by non-severe concurrent conditions.

Hypertensive crisis and pulmonary edema following rituximab-induced anaphylaxis.

Rituximab is a monoclonal antibody against the protein CD20. Various lymphomas as well as non-malignant immune disorders are treated with this antibody. Hypersensitivity reactions associated with the use of rituximab include urticaria, hypotension, chest tightness, vomiting, oxygen desaturation and bronchospasm. A very uncommon case of hypertensive crisis and pulmonary edema following rituximab-induced hypersensitivity reaction in an 80-year-old man receiving rituximab for non-Hodgkin lymphoma is reported. Anaphylaxis manifesting as coronary vasospasm following drug treatment, including rituximab, could be proved a serious condition in patients who need specific treatment. In these patients desensitization protocols seem to be mandatory.

Diagnostic significance of combining D-dimer with high-sensitivity cardiac troponin I for improving the diagnosis of venous thromboembolism in the emergency department.

BACKGROUND: Although cardiac troponins are valuable tools for risk stratification in patients with venous thromboembolism (VTE), their significance remains elusive in diagnosing venous thrombosis. METHODS: D-dimer (age-adjusted cut-off) and high-sensitivity cardiac troponin I (HS-cTnI; reference limit, <10.5 ng/L in women and <17.8 ng/L in men) were measured in 2199 consecutive patients (1106 women and 1093 men; mean age, 63±20 years), admitted to the Emergency Department of the University Hospital of Parma during a 3-month period. Overall, 53 patients were finally diagnosed with VTE (12 with deep vein thrombosis and 41 with pulmonary embolism). RESULTS: The diagnostic performance (area under the curve; AUC) of D-dimer and HS-cTnI was 0.70 and 0.71 for all VTE episodes, 0.70 and 0.63 for deep vein thrombosis (DVT), 0.70 and 0.74 for pulmonary embolism (PE), respectively. The combination of positive values of both biomarkers yielded better diagnostic performance than D-dimer values alone for diagnosing PE (AUC, 0.80; p<0.001 vs. D-dimer alone), but not for diagnosing DVT (AUC, 0.73; p=0.458 vs. D-dimer alone). In patients with PE, positive HS-cTnI values in patients with concomitantly positive D-dimer values yielded identical diagnostic sensitivity compared to D-dimer positivity alone (i.e., 1.00), but nearly double diagnostic specificity (i.e., 0.71 vs. 0.40). Positive HS-cTnI values (AUC, 0.68), but not D-dimer positivity (AUC, 0.51), were associated with 30-day hospital readmission of VTE patients. CONCLUSIONS: The results of this study open intriguing opportunities for combining HS-cTnI and D-dimer in the diagnostic approach of patients with PE.

Salernitan Medical School or Langobardic Medical School?

Already famous since the high Middle Ages, the Salernitan Medical School reached its whole scientific role between the 11th and 12th century, declining later due to the rising of modern universities. Information on the earliest period of the School is very poor but, starting from the 10th century, we know that Salernitan physicians were widely recognized as researchers and healers. This paper is focused on the heavy role recognized to the Langobards (first) and Normans (later) on development of the Salernitan Medical School. A special role must be recognized to Alfanus I, Gariopontus and Trotula de Ruggiero: they left memories on their enterprises and many manuscripts of great relevance for the development of Middle Ages and Renaissance Medicine. Their multicultural experience dragged the Salernitan School to become the greatest expression of medical science of its age. This role was expressed in the "Regimen Sanitatis Salernitanum" or "Flos Medicinae Salerni", a book that resumes the highest knowledges on general hygiene, dietetics, physiotherapy, comparative anatomy and surgery. The book had a tremendous success, having more than 300 editions in many languages up to 1846. It was an essential reference for western medical literature up to Renaissance. Furthermore, Langobards took care of health laws, mainly in the Rotari edict, which included laws on medical practice and on the physicians' role. (www.actabiomedica.it).

Severe rhabdomyolysis induced by co-administration of cocaine and heroin in a 45 years old man treated with rosuvastatin: a case report.

The term rhabdomyolysis describes a damage involving striated muscle cells or fibers, often complicated by acute kidney injury. This syndrome can have different causes, but it is generally divided into two main categories: traumatic and non-traumatic rhabdomyolysis. Among medical causes, drugs and abuse substances play a pivotal role, being opioids, alcohol, cocaine and other substances of abuse. Among drugs, the case of statins is certainly the best known. Here we describe a paradigmatic case of a man treated with success and good tolerance for years with rosuvastatin, who developed a severe rhabdomyolysis complicated by AKI needing hemodialysis, after the assumption of two substances of abuse (cocaine and heroin). Emergency physicians need to be aware of this syndrome, since it must be clinically suspected in order to ask the Laboratory for appropriate tests. Given that troponins are now widely accepted as the unique biochemical "gold standard" for diagnosing acute coronary syndromes, CK and myoglobin (the "gold standard" tests for diagnosing rhabdomyolysis) have been erased from admission test panels of the vast majority of emergency departments.

Spinal cord infarction. A case report and narrative review.

Spinal cord infarction is a rare but severe disorder, consistently less frequent than ischemic brain injury. It constitutes only 1-2% of all neurological vascular emergencies. Here we describe a case of spinal cord infarction in a 68-year-old Caucasian man without any neurological problem in his clinical history. The patient presented to the Emergency Department complaining for sudden onset of lower limbs weakness, as well as pain and mild loss of sensitivity in both legs. These symptoms suddenly arose after a 10 minutes bicycle race. He underwent a CT angiography, which confirmed the presence of a fusiform aneurysm of infra-renal abdominal aorta with thrombotic apposition on right lateral side and some ulcerated thrombi. As such, the patient underwent a spinal cord Magnetic Resonance Imaging, that showed images compatible with an acute ischemic injury (infarction) from D11 to medullary cone. He was then treated with low molecular weight heparin, aspirin, and methylprednisolone, and was then admitted to the Stroke Unit. He gradually regained lower limbs sensitivity totally, but the strength was only partially restored. Although a rare entity, Emergency Physicians should always keep in mind this possibility when evaluating patients with sudden loss of sensitivity and/or strength in their lower limbs.

Updates on Rabies virus disease: is evolution toward "Zombie virus" a tangible threat?

Human rabies disease is caused by Rabies Lyssavirus, a virus belonging to Rhabdoviridae family. The more frequent means of contagion is through bites of infected mammals (especially dogs, but also bats, skunks, foxes, raccoons and wolves) which, lacerating the skin, directly inoculate virus-laden saliva into the underlying tissues. Immediately after inoculation, the Rabies virus enters neural axons and migrates along peripheral nerves towards the central nervous system, where it preferentially localizes and injuries neurons of brainstem, thalamus, basal ganglia and spinal cord. After an initial prodromic period, the infection evolves towards two distinct clinical entities, encompassing encephalitic (i.e., "furious"; ~70-80% of cases) and paralytic (i.e., "dumb"; ~20-30% of cases) rabies disease. The former subtype is characterized by fever, hyperactivity, hydrophobia, hypersalivation, deteriorated consciousness, phobic or inspiratory spasms, autonomic stimulation, irritability, up to aggressive behaviours. The current worldwide incidence and mortality of rabies disease are estimated at 0.175×100,000 and 0.153×100,000, respectively. The incidence is higher in Africa and South-East Asia, nearly double in men than in women, with a higher peak in childhood. Mortality remains as high as ~90%. Since patients with encephalitic rabies remind the traditional image of "Zombies", we need to think out-of-the-box, in that apocalyptic epidemics of mutated Rabies virus may be seen as an imaginable menace for mankind. This would be theoretically possible by either natural or artificial virus engineering, producing viral strains characterized by facilitated human-to-human transmission, faster incubation, enhanced neurotoxicity and predisposition towards developing highly aggressive behaviours.

Predicting mortality with cardiac troponins: recent insights from meta-analyses.

The introduction of cardiac troponin (cTn) testing in clinical practice has been one of the most important breakthroughs that have occurred in the recent history of laboratory medicine. Although it is now uncontestable that cTn values are essential for diagnosing acute coronary syndrome (ACS), solid evidence is also emerging that assessment of either cardiac troponin I (cTnI) or T (cTnT) may provide valuable prognostic information in the general healthy population, as well as in patients with a vast array of cardiac and extra-cardiac diseases. We have hence performed a critical review of the scientific literature for identifying meta-analyses which have investigated the potential contribution of cTns in predicting the risk of death in health and disease. According to the articles identified with our research, we can conclude that increased cTn values may be considered independent risk factors for all-cause mortality in the general population, as well as in patients with ACS, in those undergoing revascularization procedures, or with stable coronary artery disease (CAD), heart failure (HF) and atrial fibrillation (AF). Measurement of cTn may then be helpful for stratifying the mortality risk in non-cardiac hospitalized patients, in those with critical illness or sepsis, syncope, stroke, acute aortic dissection, pulmonary diseases, brain injury, renal failure, vascular and non-cardiac surgery. Although this evidence has notable clinical implications, the cost-effectiveness of population screening with high-sensitivity (hs) cTn immunoassays has not been proven so far.

Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge.

BACKGROUND: Atrial fibrillation is the most frequent cardiac arrhythmia. It has been estimated that 6-12 million people worldwide will suffer this condition in the US by 2050 and 17.9 million people in Europe by 2060. Atrial fibrillation is a major risk factor for ischemic stroke and provokes important economic burden along with significant morbidity and mortality. AIM: We provide here comprehensive and updated statistics on worldwide epidemiology of atrial fibrillation. METHODS: An electronic search was conducted for atrial fibrillation. The epidemiologic information was retrieved from the Global Health Data Exchange database, which is regarded as one of the most comprehensive worldwide catalogs of surveys, censuses, vital statistics, and other health-related data. RESULTS: A total of 3.046 million new cases of atrial fibrillation worldwide were registered in the database during 2017. The estimated incidence rate for 2017 (403/millions inhabitants) was 31% higher than the corresponding incidence in 1997. The worldwide prevalence of atrial fibrillation is 37,574 million cases (0.51% of worldwide population), increased also by 33% during the last 20 years. The highest burden is seen in countries with high socio-demographic index, though the largest recent increased occurred in middle socio-demographic index countries. Future projections suggest that absolute atrial fibrillation burden may increase by >60% in 2050. CONCLUSIONS: Our analyses suggest that atrial fibrillation incidence and prevalence have increased over the last 20 years and will continue to increase over the next 30 years, especially in countries with middle socio-demographic index, becoming one of the largest epidemics and public health challenges.

Google search volume predicts the emergence of COVID-19 outbreaks.

BACKGROUND AND AIM: Digital epidemiology is increasingly used for supporting traditional epidemiology. This study was hence aimed to explore whether the Google search volume may have been useful to predict the trajectory of coronavirus disease 2019 (COVID-19) outbreak in Italy. MATERIALS AND METHODS: We accessed Google Trends for collecting data on weekly Google searches for the keywords "tosse" (i.e., cough), "febbre" (i.e., fever) and "dispnea" (dyspnea) in Italy, between February and May 2020. The number of new weekly cases of COVID-19 in Italy was also obtained from the website of the National Institute of Health. RESULTS: The peaks of Google searches for the three terms predicted by 3 weeks that of newly diagnosed COVID-19 cases. The peaks of weekly Google searches for "febbre" (fever), "tosse"( cough) and "dispnea" (dyspnea) were 1.7-, 2.2- and 7.7-fold higher compared to the week before the diagnosis of the first national case. No significant correlation was found between the number of newly diagnosed COVID-19 cases and Google search volumes of "tosse" (cough) and "febbre" (fever), whilst "dyspnea" (dyspnea) was significantly correlated (r= 0.50; p=0.034). The correlation between newly diagnosed COVID-19 cases and "tosse" (cough; r=0.65; p=0.008) or "febbre" (fever; 0.69; p=0.004) become statistically significant with a 3-week delay. All symptoms were also significantly inter-correlated. Conclusions; Continuously monitoring the volume of Google searches and mapping their origin can be a potentially valuable instrument to help predicting and identifying local recrudescence of COVID-19.

Impact of the COVID-19 epidemic on census, organization and activity of a large urban Emergency Department.

BACKGROUND: The spread of coronavirus disease 2019 (COVID-19) is overwhelming the response of many regional health services across Italy. This article aims to report and discuss the data of the first 8 weeks of COVID-19 epidemic in the emergency department (ED) of the University Hospital of Parma. METHODS: The ED visits were analyzed as follows: total ED visits, divided in COVID-19/ non-COVID-19 cases, and in trauma-related/non-trauma-related cases; outcome (i.e., discharged, admitted, dead in the ED) of patients, altogether or stratified according to triage class; age classes of the entire ED population. RESULTS: Total ED visits decreased starting from the first days of the outbreak, then exhibiting progressive growth afterwards. COVID suspected cases rapidly increased, whereas non-COVID suspected dropped and remained well below the standard. Trauma-related cases declined, both as ED visits and as hospital admissions. The percentage and absolute number of patients admitted to hospital wards progressively increased, rapidly overwhelming the number of cases that could be discharged. The admission rate in the lowest priority classes also displayed a marked increase. The youngest age classes dramatically declined, whilst the oldest progressively increased, remaining considerably over the standard rate of the local ED. CONCLUSIONS: The COVID-19 pandemic has obliged the health care systems to undergo a paradigm shift. Even triage criteria have partially lost their meaning, as shown by the dramatic increase of hospital admissions, even in the lowest priority classes. A deep re-organizational process of the ED was undertaken. Hospitals must be constantly resilient and prepared to these new emergencies in terms of equipment, medical and nurses staff, larger bed capacity in short time, availability of intensive and sub-intensive beds, and flexibility.

An Italian registry of chest pain patients in the emergency department: clinical predictors of acute coronary syndrome.

BACKGROUND: The aim of this study was to describe the population of patients arriving in several Italian Emergency Departments (EDs) complaining of chest pain suggestive of acute coronary syndrome (ACS) in order to evaluate the incidence of ACS in this cohort and the association between ACS and different clinical parameters and risk factors. METHODS: This is an observational prospective study, conducted from the 1st January to the 31st December 2014 in 11 EDs in Italy. Patients presenting to ED with chest pain, suggestive of ACS, were consecutively enrolled. RESULTS: Patients with a diagnosis of ACS (N.=1800) resulted to be statistically significant older than those without ACS (NO ACS; N.=4630) (median age: 70 vs. 59, P<0.001), and with a higher prevalence of males (66.1% in ACS vs. 57.5% in NO ACS, P<0.001). ECG evaluation, obtained at ED admission, showed new onset alterations in 6.2% of NO ACS and 67.4% of ACS patients. Multiple logistic regression analysis showed that the following parameters were predictive for ACS: age, gender, to be on therapy for cardio-vascular disease (CVD), current smoke, hypertension, hypercholesterolemia, heart rate, ECG alterations, increased BMI, reduced SaO2. CONCLUSIONS: Results from this observational study strengthen the importance of the role of the EDs in ruling in and out chest pain patients for the diagnosis of ACS. The analysis put in light important clinical and risk factors that, if promptly recognized, can help Emergency Physicians to identify patients who are more likely to be suffering from ACS.

Anaphylactic cardiovascular collapse manifesting as myocardial infarction following salad consumption. A case of Kounis variant type I syndrome.

Anaphylactic cardiovascular events constitute an underrated cause of medical emergencies in hospitalized patients. Coronary arteries and myocardium are targeted by anaphylactic mediators leading to acute coronary syndrome and imminent cardiovascular collapse. Early diagnosis and high clinical suspicion are required to secure prompt life-saving treatment in these cases. However, physicians of both Cardiology and Internal Medicine Departments are not familiar with this condition. Recently, we diagnosed and treated a case of anaphylactic cardiovascular collapse manifesting as acute myocardial infarction following salad consumption. Notably, Kounis anaphylaxis-associated acute coronary syndrome is a rare cause of ST segment elevation myocardial infarction with normal or diseased coronary arteries. We recommend that Kounis syndrome and its variants should be taken into consideration in the differential diagnosis of ischemic heart disease in patients with signs of allergic reaction and/or medical history of previous allergic reactions, who experience acute coronary syndrome after exposure to certain environmental stimuli.

Prognostic Value of Troponins in Patients With or Without Coronary Heart Disease: Is it Dependent on Structure and Biology?

Convincing evidence has emerged that cardiac troponins (cTns) T and I are the biochemical gold standard for diagnosing cardiac injury, and may also be used as efficient screening and risk stratification tools, especially when measured with the new high-sensitivity (hs-) immunoassays. In this narrative review, we aim to explore and critically discuss the results of recent epidemiological studies that have attempted to characterise the prognostic value of cTns in patients with or without cardiovascular disease, and then interpret this information according to cTn biology. Overall, all recent studies agree that higher blood levels of cTns reflect the larger risk of cardiovascular events and/or death, both in the general population and in patients with cardiovascular disease. Additional evidence has shown that the clinical information provided by assessment of both cTns molecules is greater compared to that of either protein alone, and this is mostly due to differential metabolism and clearance of cTnI and cTnT after release in the bloodstream. Although it seems likely that the prognostic value of these biomarkers may be higher than that of other conventional cardiovascular risk factors such as cholesterol or C reactive protein, large and reliable cost-effectiveness investigations are needed to define whether cTns-based population screening may be biologically plausible, clinically effective and economically sustainable.