Acute Mesenteric Ischemia in a Chronically Anticoagulated Patient With Atrial Fibrillation: Anticoagulation Reversal, Management and Preventing Recurrence.

Acute mesenteric ischemia (AMI) is caused by an interruption of the blood supply to the small intestine. Atrial fibrillation is a common cause of thromboembolic AMI. Patients taking direct oral anticoagulants (DOACs) for anticoagulation in atrial fibrillation are prone to anticoagulation failure and can present with thromboembolism. We present an interesting case of a 69-year-old female with a past medical history of chronic atrial fibrillation treated with a DOAC (apixaban) who was diagnosed with AMI despite being compliant with her anticoagulant. Her anticoagulation was promptly reversed and she was taken for urgent surgical intervention yielding a good outcome. Later, due to the failure of anticoagulation on apixaban her anticoagulant was changed to warfarin to prevent the recurrence of thromboembolism and follow-up showed she was doing well.

Management of Chronic Portal Vein Thrombosis in a Cirrhotic Patient With Pancytopenia and Grade II Esophageal Varices.

Chronic portal vein thrombosis (PVT) is a major vascular complication of liver cirrhosis. Patients may be asymptomatic and chronic PVT might be detected incidentally on imaging. PVT is associated with worsening liver disease, poorer clinical outcomes, and might proceed to life-threatening intestinal ischemia. Management of chronic PVT with anticoagulation has been shown to be successful in promoting recanalization and reducing thrombus extension in patients with cirrhosis. However, optimal anticoagulation for PVT in cirrhosis has not yet been addressed in any large-scale trial, and the decision to anti-coagulate varies on a case by case presentation. We report the case of a 62-year-old male patient with a history of liver cirrhosis, pancytopenia, and grade II esophageal varices presenting with abdominal pain who was incidentally found to have chronic thrombosis of the portal vein on imaging and was managed appropriately with a good outcome.

Retraction: A Challenging Case of Electrical Storm in an Implantable Cardioverter Defibrillator Patient.

[This retracts the article DOI: 10.7759/cureus.9600.].

A Challenging Case of Electrical Storm in an Implantable Cardioverter Defibrillator Patient.

Implantable cardioverter defibrillators (ICD) have become indispensable in managing life-threatening ventricular arrhythmias. On average, 50%-70% of the patients receive a device-based therapy within the first two years post implantation. A few patients experience the electrical storm (ES). ES is a syndrome of recurrent ventricular tachycardia or fibrillation occurring two or more times in a 24-hour period, calling for the need of electrical cardioversion or defibrillation to stabilize the patient. We present the case of a patient with severe cardiomyopathy who presented with resistant ES after failing to respond initially to conventional medications like amiodarone and lidocaine. Propofol infusion was not an option due to his severe cardiomyopathy and hypotensive shock state. Aggressive treatment with intravenous medications stabilized his ES and he was eventually transferred to an outside facility for ventricular tachycardia ablation.

Valacyclovir-Induced Thrombotic Thrombocytopenic Purpura.

Valacyclovir is a well-tolerated antiviral drug. Thrombotic thrombocytopenic purpura is a rare adverse effect of valacyclovir therapy. Mostly, it has been reported in clinical trials and case reports in patients with high dose or low dose therapy in immunocompromised patients. Herein we write a case report of the immunocompetent patient, who was taking very low dose valacyclovir therapy for his recurrent genital herpes. This case emphasizes the role of low dose (1000 mg/day) valacyclovir therapy causing thrombotic thrombocytopenic purpura in an immunocompetent patient with no other explainable trigger.

Adherence to the United States Preventative Services Task Force Female Screening Guidelines: An Internal Medicine Residency Program Experience.

Background Various guidelines exist for female preventative screening tests and medical resident physician adherence to the United States Preventive Services Task Force (USPSTF) guidelines varies. National screening rates for breast cancer and osteoporosis have improved but they are still below the expected target. Material and methods Ambulatory medical clinic records of female patients from the period July 2015 to December 2017 were reviewed for breast cancer and osteoporosis screening. Resident performance and commitment with regards to ordering the aforementioned screening tests according to the USPSTF guidelines were compared to the most recent national screening rates for mammograms and dual-energy X-ray absorptiometry (DXA) scans. Results Of the 1327 charts reviewed, 1025 was included in the study. Of the 545 mammograms performed, 93% of them were indicated according to the USPSTF guidelines (P < 0.0001, 95% CI: 125.9-342.0). A total of 480 mammograms were not ordered, of which 6% were indicated and 93.9% were not indicated. Out of a total of 107 DXA scans performed, 88.7% were correctly indicated (P < 0.0001, 95% CI: 37.11-132.9). Conclusion Resident physician adherence to the USPSTF screening guidelines for breast cancer and DXA scans were higher than the national and state screening rates. Our well-structured educational project (strong faculty mentorship, resident to patient continuity of care and the reasonable resident-clinic load) resulted in higher screening rates.

Coronary Artery Ectasia Presenting as a Non-ST Elevation Myocardial Infarction in a Young Adult: Case Presentation and Literature Review.

While acute coronary syndromes most commonly occur secondary to unstable atherosclerotic plaque, coronary aneurysms, also known as coronary artery ectasia (CAE), represent a less common etiology. Whereas coronary atherosclerosis accounts for about 50% of CAE, the remaining 50% are either congenital or secondary to a host of inflammatory and connective tissue disorders, with Kawasaki disease being a well-known association. Patients with CAE have worse outcomes than the general population regardless of the presence of associated atherosclerotic coronary artery disease. We report the case of a young male presenting with chest pain, a right bundle branch block on electrocardiography, an elevated troponin level, and a regional wall motion abnormality on echocardiography who is found to have diffuse coronary artery ectasia on coronary angiography and is managed medically with dual antiplatelet therapy.

Spontaneous pneumomediastinum in a healthy young female: A case report and literature review.

Spontaneous pneumomediastinum (SPM) is an uncommon finding in young adults presenting usually without any comorbidities or an underlying pathology. It is most commonly due to alveolar rupture in the setting of an inciting event such an underlying asthma, barotrauma, valsalva maneuver, or esophageal rupture. Individuals can have varying presentations, from chest pain, dyspnea and dysphagia, to anxiety, weakness, or facial and neck swelling. The majority of patients have subcutaneous emphysema on examination and can have abnormal laboratory findings such as an elevated C-reactive proteins and leukocytosis. Diagnostic modalities used include chest x-ray, CT scan, ultrasound and barium swallow or esophagram. Majority of individuals and treated conservatively with rest, analgesia and oxygen administration. The prognosis of SPM is usually good with resolution within several days in most cases and the recurrence rate is very low. We report the case of a 22-year-old female presented with SPM diagnosed by chest x-ray and chest CT scan who was treated conservatively with subsequent spontaneous resolution.

Post-Colonoscopy Colonic Perforation Presenting With Subcutaneous Emphysema: A Case Report.

Colonoscopy is performed for both diagnostic and therapeutic indications. Although rare, associated complications can be quite serious. The frequency of these complications depends mainly on the skills of the physicians doing the procedure, and the diagnostic or therapeutic indications. Major complications include adverse anesthetic related events, aspiration pneumonia, bleeding, and colonic perforation. We present a rare case of a post-colonoscopy perforation presenting with subcutaneous emphysema and free mediastinal, and intra-peritoneal air. The patient was successfully managed conservatively with complete resolution of symptoms.

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use.

BACKGROUND: The purpose of this study was to compare the outcome of Clostridium difficile infection (CDI) in patients on systemic steroids for various indications to patients not on steroids in term of disease severity, and associated morbidity and mortality. METHODS: We retrospectively reviewed records of all patients with CDI at our hospital from January 2011 to December 2016. Patients were evaluated for baseline characteristics, comorbidities, medications, disease severity, disease-related length of stay (LOS) from the diagnosis of CDI to discharge, need for surgical intervention, and disease-related mortality. Based on systemic steroids use, patients who were using steroids for different indications constituted the study population, and those with no steroids use were clustered as a control group. RESULTS: Of the 258 patients included, males were 127 (49%). Severe and severe-complicated CDI developed in 21/63 (33.3%) and 1/63 (1.6%) of patients on steroids (average daily dose of 20 mg), and in 73/195 (37.4%) and 5/195 (2.6%) of patients with no steroids use (P = 0.56 and P = 0.66, respectively). Surgical intervention was not required in the steroids group and 5/195 (2.7%) of patients not on steroids underwent bowel surgeries (P = 0.38). Mean LOS (days) was 11.6 ± 1.5 in the steroids group and 10.4 ± 0.7 in the no-steroids group (P = 0.4). CDI-related mortality occurred in 9/63(14.3%) of patients on steroids, and in 15/195 (7.7%) of patients not on steroids (P = 0.12; odds ratio (OR): 2; 95% confidence interval (CI): 0.8 - 4.8). CONCLUSION: There was no significant difference in the severity of CDI, need for surgical interventions, disease-related LOS and mortality in systemic steroids users compared to patients not on steroids.