Pyomyositis presenting as myonecrosis secondary to methicillin-resistant Staphylococcus aureus bacteremia in chronic lymphocytic leukemia.

The incidence of pyomyositis in immunocompromised patients with HIV, diabetes, myelodysplastic syndromes, and acute lymphocytic leukemia is well documented. However, there are only a few reports of pyomyositis and myonecrosis in patients with chronic lymphocytic leukemia (CLL). We present a rare case of pyomyositis presenting as myonecrosis secondary to methicillin-resistant Staphylococcus aureus bacteremia in a 72-year-old patient with CLL. Pyomyositis, although rare, warrants increased provider awareness and management, especially among CLL patients who pose diagnostic and treatment challenges.

A Delayed Case of Pericarditis Following Recovery From COVID-19 Infection.

Pericarditis is a rare cardiac complication of coronavirus 19 (COVID-19) infection. Recent case reports describe severe sequelae of pericarditis, including cardiac tamponade, developing within days of initial COVID-19 symptoms. We present a case of pericarditis with slower onset and milder symptoms, developing over a period of a few weeks in an immunocompetent male who recovered from COVID-19 several months earlier. A 65-year-old male presented to an emergency department several times for one week of worsening chest and neck symptoms, along with fever. He had been symptom-free after a three-day course of cough, myalgias, and fever with positive COVID-19 testing, approximately 70 days earlier. He was ultimately admitted for fever and pericarditis with an associated pericardial effusion and positive PCR testing for COVID-19. Pericarditis should be considered in the differential diagnosis for patients with COVID-19 and unexplained persistent chest symptoms. The possibility of recurrent or atypical latent infection should additionally be considered in the months following the initial COVID-19 infection. Bedside ultrasound may facilitate early diagnosis and management of COVID-19 associated pericarditis.

Intensive Blood Pressure Targets for Diabetic and Other High-Risk Populations: A Pooled Individual Patient Data Analysis.

Optimal blood pressure (BP) targets for different populations, especially diabetics, remain uncertain after conflicting data on intensive management. We assessed whether a <120 mm Hg systolic target is beneficial and whether certain patient populations differ in response. Individual patient data of 14 094 patients from 2 randomized control trials was pooled. Seven thousand forty patients were assigned to an intensive target of <120 mm Hg and 7054 patients to a standard target of <140 mm Hg in an intention-to-treat analysis. The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, and cardiovascular mortality. Interactions between treatment and baseline characteristics were assessed. Secondary outcomes included nonfatal myocardial infarction, stroke, heart failure, cardiovascular mortality, and overall mortality. Intensive management significantly lowered primary outcome rate (hazard ratio, 0.83; 95% confidence interval, 0.74-0.92; P<0.001). No significant interaction was observed between treatment effect and diabetes mellitus status (P=0.16). Significantly reduced secondary outcomes included stroke (hazard ratio, 0.75; P=0.033) and heart failure (hazard ratio, 0.76; P=0.014). No significant interactions were observed between treatment effect and baseline age, sex, race, cardiovascular disease history, systolic BP, or diastolic BP (P values: 0.40, 0.95, 0.54, 0.18, 0.86, and 0.67, respectively). BP targets of <120 mm Hg improved cardiovascular outcomes. Diabetic patients responded similarly to this intervention, as did those with different age, sex, cardiovascular disease history, baseline BPs, and race. The intensive group had increased risk of intervention-related adverse outcomes (3.97% versus 1.53%; P<0.001). Clinicians should consider <120 mm Hg systolic targets for a variety of patients, including diabetics.

Heart failure and the discrepancy between trials of intensive blood pressure management: an analysis of individual patient data.

BACKGROUND: ACCORD and SPRINT are the best randomized controlled trial data evaluating the effects of blood pressure targets below 140 mmHg. These trials had contradictory results regarding the benefits of intensive antihypertensive therapy. We investigate if this discordance was driven by SPRINT's inclusion of Heart Failure in its primary outcome, as this is a parameter not included in ACCORD's original primary outcome. This analysis helps to resolve a significant area of contention. METHODS: Individual patient data from 4733 participants in ACCORD were analyzed from time of randomization. All participants were diabetic and at increased cardiovascular risk. Participants were assigned to their original intervention, a standard blood pressure target of less than 140 mmHg or an intensive target of less than 120 mmHg. Primary composite outcome was defined as in SPRINT: a composite of first occurrence of myocardial infarction, stroke, heart failure, death from cardiovascular causes, and other acute coronary syndromes. RESULTS: Primary outcome was not significantly different between standard and intensive groups [HR: 0.89; 95% CI: (0.76-1.03); p = 0.108]. The primary composite outcome occurred in 370 participants in the standard group (15.6%) and 324 participants in the intensive group (13.7%), with an event rate of 3.38% per year for the standard group and 3.01% per year for the intensive group. CONCLUSIONS: Differing results between ACCORD and SPRINT are not attributable to ACCORD's exclusion of Heart Failure from its original primary outcome measurement. No significant differences in primary outcome were observed between intensive and standard blood pressure groups in the ACCORD patients under the SPRINT primary outcome definition. Caution should be taken in extrapolating the intensive blood pressure control benefits of SPRINT to the diabetic population.