Uremic Pericarditis and Cardiac Tamponade Resolving With Intensive Hemodialysis.

We present an interesting and complex case of cardiac tamponade due to uremic pericarditis (UP), resolving with intensive hemodialysis (HD). HD should be considered as first line management for patients with UP and pericardial effusion. Intensification of HD should be considered based on clinical presentation and severity of presentation.

ST-Elevation Myocardial Infarction from Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare but life-threatening condition which occurs due to non-traumatic separation of the coronary artery wall. It is more common in women, with an unclear, non-atherosclerotic mechanism. We report a unique case of spontaneous coronary artery dissection presenting as ST-elevation myocardial infarction (STEMI). A 54-year-old woman presented with fever and recurrent abscess. On presentation, she was tachycardic, tachypneic and hypoxic, requiring nasal cannula. Physical exam was notable for healing a wound on the right lower back, status post incision and drainage, with no erythema, edema, ecchymosis or purulent drainage. Laboratory investigations were remarkable for anemia. EKG showed sinus tachycardia with no ST-segment changes. Her hospital course was complicated by septic shock, renal failure, and acute hypoxic respiratory failure requiring intubation. Following extubation, she complained of sudden-onset, severe chest pain. EKG showed ST-elevations in the lateral and inferior leads, with an elevated high-sensitivity troponin level. Cardiac catheterization revealed SCAD involving the mid to distal right posterior descending artery (RPDA) with TIMI-3 flow in the distal RPDA. Given vessel tortuosity and poor target for stenting, was medically managed with dual antiplatelet therapy, a beta-blocker and an eptifibatide infusion for 12 h post-procedure. Extensive rheumatological workup negative. She remained hemodynamically stable with no new ST changes on subsequent EKGs. This is an uncommon medical emergency requiring prompt recognition, appropriate management and early intervention to prevent unfavorable patient outcomes.

Infective Endocarditis From Pseudomonas aeruginosa and Group C Streptococcus.

Endocarditis is a condition that is usually caused by an infection or inflammation of the endocardium. The disease is commonly seen among intravenous drug abusers, patients with intravenous catheters, and those who undergo cardiovascular and invasive dental procedures. Multiple different pathogens can cause endocarditis (bacterial, fungal, and viral) depending upon the patient's risk factors, epidemiology, and bacteria that are prevalent/endemic to the region. We present the case of a woman who had a history of polysubstance abuse, having presented to the hospital on multiple occasions with bacteremia with a previous admission for endocarditis, who developed a multi-bacterial infection at this presentation involving Pseudomonas aeruginosa and group C Streptococcus, which affected both the right and left side of the heart. In this paper, we reviewed common presentations of endocarditis caused by either bacteria, as well as recommendations for medical or surgical management of the condition.

Arterial and Venous Thrombosis From Delayed-Onset Heparin-Induced Thrombocytopenia.

Heparin Induced Thrombocytopenia (HIT) is a life threatening condition which is caused due to antibody formation following exposure to heparin or heparin products. It occurs due to the formation of Platelet Factor 4 antibodies (PF4). HIT is classified into 3 categories based on the duration between heparin exposure and onset of drop in platelet counts. A less common form of HIT is delayed onset HIT which occurs more than 9 days after exposure to heparin or heparin products. In this report we would like to present a rare case of delayed onset HIT which occurred in our patient who presented with rhabdomyolysis and Non ST elevation myocardial infraction (NSTEMI); which resulted in limb ischemia which needed to be treated by amputation of the affected area. We also highlight further management of patients who have thrombotic disease in the setting of HIT and review literature of how heparin or heparin products can be reintroduced in such patient who cannot be managed by other anticoagulation.

Spontaneous splenic rupture from indeterminate dendritic cell proliferation: a case report.

Spontaneous splenic rupture is a rare and life-threatening phenomenon, usually associated with an underlying infectious, inflammatory, hematological, neoplastic or rheumatologic condition. Indeterminate cell tumor is a rare neoplastic dendritic cell disorder that is poorly understood but shares immunophenotypic markers for Langerhans cells without Birbeck granules. A 73-year-old man presented with upper abdominal pain after an unwitnessed fall. Computed tomography angiography showed splenomegaly and a large ruptured splenic subcapsular hematoma. Intraoperative findings from an emergency laparotomy revealed a large hemoperitoneum and a ruptured spleen. Microscopic sections identified numerous, mostly poorly formed, small nodules classified as a proliferation of indeterminate dendritic cell tumors.

Asymptomatic hyponatremia precipitated by COVID-19 pneumonia.

COVID-19, also known as SARS-CoV-2, which originated in China in late 2019, has spread rapidly resulting in a global pandemic. COVID-19 has been linked to many different clinical manifestations, including hyponatremia. The cause of hyponatremia in acute COVID-19 infection is speculated to be multifactorial, including syndrome of inappropriate antidiuretic hormone secretion (SIADH), thought to be a result of inflammatory cytokines (Interleukin-6) and/or related to the gastrointestinal symptoms of this infection. SIADH in the setting of COVID-19 pneumonia is an established complication of this disease. This is the case of an 81-year-old woman with a history of hypertension, on thiazide diuretic, initially presented after a fall in the setting of COVID-19 pneumonia. She was treated with remdesivir and dexamethasone and then discharged to a rehab facility with normal labwork, including a sodium of 137 mmol/L. Two weeks later, routine labwork identified hyponatremia of 111 mmol/L. Her vital signs were normal, she was euvolemic on exam and alert/oriented with no complaints. Investigations into the etiology of her hyponatremia included a urine sodium of 72 mmol/L, serum osmolality of 231 mOsm/kg, urine osmolality of 454 mOsm/kg. We diagnosed hypo-osmolar hyponatremia due to SIADH. Management included fluid restriction and then tolvaptan, which ultimately corrected the serum sodium to 134 mmol/L. As COVID-19 is a new infection, little is known regarding its impact on electrolyte imbalances. Our patient recovered from pneumonia, then later developed severe hyponatremia possibly secondary to the lasting effects of inflammation in her lungs.

Epidural pneumorrhachis in COVID-19: a rare clinical entity.

Pneumorrhachis is an extremely rare clinical entity, involving air entrapment within the spinal canal. We present a unique case of epidural pneumorrhachis accompanying pneumomediastinum and pneumopericardium, in the setting of COVID-19 infection in a 62-year-old woman. Diagnostic testing was remarkable for elevated inflammatory markers, along with mild transaminitis and hyponatremia. CT scan of the chest revealed extensive patchy ground-glass opacities, with no evidence of pulmonary embolism. Intravenous antibiotics and steroids were initiated for management of advanced multifocal bilateral COVID-19 pneumonia. Her hospital course was complicated by rapidly worsening hypoxia accompanied by worsening inflammatory markers. Repeat chest CT showed worsening multifocal opacities, extensive pneumomediastinum, pneumopericardium, and subcutaneous emphysema extending into the lower neck soft tissues, posterior mediastinum, and supraclavicular regions. Neck CT confirmed diffuse subcutaneous emphysema from the mediastinum extending into the retropharyngeal space, neck, and anterior chest wall. Right-sided epidural air in the spinal canal spanning C6-T1 was also noted. She was evaluated by neurosurgery, continued on antibiotics for the epidural air, and transferred to the ICU for frequent monitoring of respiratory and neurological status, which remained stable. Although pneumorrhachis is an extremely rare clinical manifestation, prompt recognition can lead to appropriate early interventions and improved patient outcomes.