Right Atrial Thrombi, the Management Conundrum: 2 Case Reports.

BACKGROUND There are no guidelines providing an algorithmic approach for the management of right atrial thrombi, to date, owing to a lack of strong supporting studies. In this case series, we describe 2 cases of high-risk patients with massive right atrial thrombi who had different outcomes. CASE REPORT Case 1: A 62-year-old man with ischemic cardiomyopathy and atrial fibrillation, who was on a permanent pacemaker for sick sinus syndrome and was noncompliant with medication for 2 years, presented to the Emergency Department for evaluation of a 2-month history of progressive shortness of breath and swollen neck veins. A cardiac ultrasound confirmed a large right atrial thrombus, and a computed tomography (CT) pulmonary angiogram was negative for pulmonary emboli. He was managed with a heparin infusion and thrombolytic therapy with favorable evolution. Case 2: A 66-year-old man, with a past medical history of nonischemic cardiomyopathy, atrial fibrillation, deep venous thrombosis, and pulmonary emboli a year earlier, presented to an urgent care unit with sudden onset of shortness of breath. A cardiac ultrasound confirmed a large right atrial thrombus, and a CT pulmonary angiogram confirmed bilateral pulmonary emboli. He was managed with a heparin infusion and EkoSonic endovascular system therapy. He subsequently needed venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation and underwent mechanical aspiration thrombectomy. The patient's evolution was unfavorable. CONCLUSIONS In the absence of an evidence-based guideline to approach right atrial thrombi, management should be individualized for each patient, based on the type of thrombi, hemodynamic status, and presence or absence of associated pulmonary emboli.

Acute Myocardial Infarction With Cardiogenic Shock Due to Pericardial Constriction and Multivessel Coronary Obstruction.

We present a rare case of cardiogenic shock and multivessel coronary compression due to focal pericardial inflammation and constriction. The patient was treated in the acute phase with coronary stenting and temporary mechanical support. Multimodality imaging was essential in elucidating the diagnosis. (Level of Difficulty: Beginner.).

A Rare Culprit of Infective Endocarditis in an IV Drug User: Burkholderia cepacia.

Infective endocarditis (IE) is an infection of the cardiac native or prosthetic valves typically caused by Staphylococcus aureus, viridans streptococci group, and coagulase-negative staphylococci. Risk factors include congenital heart disease, structural and valvular heart disease, implantation of prosthetic heart valves, and intravenous (IV) drug abuse. IE caused by organisms such as Burkholderia cepacia is rarely seen. We herein present a case of a patient with a history of IV drug abuse previously treated for Staphylococcus aureus IE with newly diagnosed IE secondary to B. cepacia. He was taken to the operating room for mitral valve replacement after an echocardiogram revealed severe mitral regurgitation. He was successfully treated with antibiotics. After 2 months, at follow-up, the patient remained free from mechanical valve-related events, had no new occurrences of fever, and had no other symptoms of infection. He reported good exercise tolerance.

The Worm that Clogs the Lungs: Strongyloides Hyper-Infection Leading to Fatal Acute Respiratory Distress Syndrome (ARDS).

BACKGROUND Strongyloides stercoralis is an intestinal helminth. Parasitism is caused by penetration of the larvae through the skin. It is endemic in tropical and subtropical regions of the world and in the United States occurs in the southeastern region. It has a tendency to remain dormant or progress to a state of hyper-infection during immunosuppression. CASE REPORT We present the case of a 70-year-old Nigerian who developed fatal ARDS secondary to Strongyloides infection after been treated with steroids for treatment of autoimmune necrotizing myopathy. Despite adequate management with mechanical ventilation and appropriate antifungal therapy, the patient died on day 19 of hospitalization. CONCLUSIONS S. stercoralis is known to affect every organ in the body. ARDS is often an overlooked complication of Strongyloides hyper-infection, which is often deadly. Immediate diagnosis and treatment are important for patient survival.

A Case of Systemic Lupus Erythematosus Presenting as Autoimmune Myelofibrosis.

BACKGROUND Systemic lupus erythematosus (SLE) is characterized by multiorgan involvement and presence of autoantibodies. SLE has a broad range of presentations and manifestations, and as such, its course and organ involvement are unpredictable. The disease results from the interaction of genes, environment, and random effects combining to lead to a loss of tolerance to self-antigens and active autoimmunity. Autoimmune myelofibrosis is a type of non-malignant bone marrow fibrosis that occurs in the presence of systemic autoimmune disease. Cytopenias such as anemia, leukopenia, and thrombocyotopenia are common manifestations of SLE; however, myelofibrosis is a less common and far less recognized complication of SLE. CASE REPORT We report a case of a young African American female who presented with severe anemia and leukopenia, subsequently diagnosed with myelofibrosis and then eventually SLE. The identification of myelofibrosis in SLE is critical as it can be a devastating condition when untreated. Fortunately, autoimmune myelofibrosis in SLE is reversible with treatment of the underlying condition. CONCLUSIONS Autoimmune myelofibrosis is a rare complication of SLE. Autoimmune myelofibrosis could be the first and only presenting feature of SLE. It is sensible to recognize this relationship, as prompt diagnosis and treatment is crucial. Corticosteroids have been shown to be useful in treating both SLE and the associated autoimmune myelofibrosis.

A Band That Causes Leaky Valves: Severe Mitral Regurgitation due to Left Atrial Fibrous Band-A Case Report and Literature Review.

Left atrial fibrous band is a rare clinical and echocardiographic finding characterized by the presence of a fibrous band attached to the mitral valve. Diagnosis is accomplished with transesophageal echocardiography (TEE), live 3D imaging, or cardiac MRI. Most patients are asymptomatic and incidental findings. However, in rare cases, an atrial fibrous band can produce symptoms such as dyspnea on exertion, fatigue, and lightheadedness secondary to mitral regurgitation (MR) which can lead to heart failure if unattended to. More serious complications such as cardioembolic phenomenon can occur. We herein report a case of a 55-year-old male with hypertension who presented with dyspnea on exertion and chest pain. Transthoracic echocardiography (TTE) showed mitral valve prolapse with moderate to severe mitral regurgitation. TEE showed an atrial fibrous band. Given the patient's poor exercise tolerance, he was taken to surgery for a mitral annuloplasty.

Venovenous Extracorporeal Membrane Oxygenation in a Gravid Patient with Acute Respiratory Distress Syndrome: A Case Report.

BACKGROUND Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), is a technique used to provide prolonged cardiac and respiratory support to persons whose heart and lungs are unable to deliver adequate perfusion or gas exchange to sustain life. It is indicated in patients with severe ARDS, severe hypothermia, and cardiac and respiratory failure when other conventional methods fail. CASE REPORT We report the case of a 22-year-old gravid 2 Para 1 woman who presented to the Emergency Department with pyelonephritis, who subsequently developed sepsis that progressed to ARDS. She was managed successfully with extracorporeal membrane oxygenation [ECMO] for 5 days, with heparin used as an anticoagulant. After significant improvement, she was successfully de-cannulated and extubated. CONCLUSIONS The use of ECMO in pregnancy and post-partum can be associated with several complications to both mother and fetus. With appropriate patient selection, good knowledge of the procedure, and early initiation, successful outcomes can be attained.

A Rare Culprit of Simultaneous Arteriovenous Thromboembolism: Acute Viral Perimyocarditis.

Simultaneous arteriovenous embolism is extremely rare. Herein, we present a rare case of systemic arteriovenous emboli in a healthy 33-year-old male after an episode of acute viral perimyocarditis. The culprits are postulated to be viral-induced myocardial necrosis and resulting proinflammatory state in the setting of negative malignant, autoimmune, genetics, and chronic infectious conditions. The patient was successfully managed with guideline-directed medical therapy and safely discharged to a subacute rehabilitation facility.

Atypical Presentation of Small Lymphocytic Lymphoma with Pericardial Effusion.

BACKGROUND Small lymphocytic lymphoma (SLL) is a low-grade B-cell non-Hodgkin lymphoma and is the solid tumor equivalent of chronic lymphocytic leukemia (CLL) that is found in the peripheral blood. SLL typically presents with lymphadenopathy and is rarely associated with cardiac involvement. This report is of a case of lymphomatous pericardial effusion in a 61-year-old woman who presented with dyspnea. CASE REPORT A 61-year-old woman presented to the emergency department with a three-month history of worsening shortness of breath on exertion. Her symptoms progressed to shortness of breath at rest, with night sweats and chills. She had no weight loss. She was found to have a pericardial effusion, and an urgent pericardiocentesis was performed to prevent cardiac tamponade. Analysis of the pericardial fluid was consistent with a diagnosis of SLL. A bone marrow biopsy and a biopsy of a renal mass were consistent with a diagnosis of SLL. She was treated with rituximab and bendamustine with granulocyte-colony stimulating factor (G-CSF) support and was discharged home. CONCLUSIONS A case is presented of a rare association between SLL and pericardial effusion with a favorable outcome following urgent pericardiocentesis to prevent cardiac tamponade followed by chemotherapy.

Misdiagnosis: Acute Chest Syndrome That Evolved into Acute Respiratory Distress Syndrome in a Patient without a Documented History of Hemoglobinopathy.

Acute chest syndrome (ACS) is a feared complication of sickle cell disease. Here is a case of a patient who presented with symptoms suggestive of acute chest syndrome yet had a delayed diagnosis presumably due to the lack of documented history of sickle cell disease of the patient, consequently evolving into acute respiratory distress syndrome (ARDS). He was subsequently diagnosed with heterozygous sickle cell SC disease on hemoglobin electrophoresis. After appropriate management with mechanical ventilator, broad-spectrum empiric intravenous antibiotics, exchange transfusion, and intravenous fluid resuscitation, the patient was medically optimized and safely discharged home, with significant improvement noted on successive follow-up visits.