Look Past the Bleed! A Case of Non-Traumatic Thoracic Aortic Pseudoaneurysm Presenting as Haemoptysis.

Introduction: Aortic pseudoaneurysms are a type of contained rupture where most of the aortic wall is breached, leaving only a thin rim of the remaining wall or adventitia to hold the blood. This condition carries a high risk of rupture and potentially fatal complications. Typically, patients present with chest pain; haemoptysis can also occur, though rarely. Case description: A 64-year-old male who presented with two episodes of haemoptysis, with no history of cardiovascular surgery or trauma. A chest computerized tomography (CT) followed by an aortogram revealed a thoracic aortic pseudoaneurysm and the patient underwent surgical aortic repair without any complications. This case underscores the rare presentation of thoracic aortic pseudoaneurysm. Discussion: Haemoptysis is a rare manifestation of thoracic aorta pseudoaneurysm and can be a warning sign of impending rupture. Haemoptysis may occur due to formation of aortopulmonary fistula or direct erosion of pseudoaneurysm into lung parenchyma. Conclusion: It is imperative for clinicians to recognise such manifestations early for prompt diagnosis and prevention of complications. LEARNING POINTS: Recognise haemoptysis as the manifestation of thoracic aortic pseudoaneurysm.Early diagnosis and treatment are crucial due to high rate of complications and mortality.Trauma and cardiovascular surgery are the most common cause for thoracic aortic pseudoaneurysm; however, sometimes it can occur due to atherosclerosis.

Myocardial Infarction and Complete Heart Block in a Patient With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery (ALCAPA).

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital malformation. We present a case of an elderly patient with ALCAPA presenting with complete heart block and non-ST-elevation myocardial infarction years after diagnosis and surgical correction. An 81-year-old female with a history of ALCAPA presented to the emergency department with chest pain and progressive mental deterioration. She was bradycardic and hypotensive. An electrocardiogram revealed a complete heart block. Troponin was 4.04 ng/mL. She received atropine and underwent transcutaneous pacing. Left heart catheterization revealed complete occlusion of the mid-left circumflex artery, which was intervened with balloon angioplasty and chronic total occlusion of the right coronary artery. She was supported with temporary transvenous pacing, did not require further pacing support, and was discharged home. Previous records unearthed that in 1988 she had presented with syncope and was diagnosed with ALCAPA, filling from right-to-left collaterals with large and ectatic coronaries. At the time, she underwent surgical correction with excision of the left coronary from the pulmonary artery and reimplantation in the left coronary cusp along the posterior aorta. She had remained asymptomatic after her surgery until this presentation. ALCAPA is extremely rare in adults. Insufficient collaterals to the left ventricle cause inadequate blood supply, leading to ischemia in adults, predisposing them to arrhythmias and risk of sudden death. Adults with ALCAPA remain at increased risk of adverse cardiac events later in life, requiring long-term monitoring.

Navigating a Complex Case of Mycobacterium Xenopi in a Patient with Blue Rubber Bleb Nevus Syndrome.

Introduction: Blue rubber bleb nevus syndrome is a rare disorder of venous malformations, with around 200 cases reported. We present a case of Mycobacterium xenopi infection in a patient with blue rubber bleb nevus syndrome. Case Description: A 40-year-old female with blue rubber bleb nevus syndrome, asthma, and bronchiectasis came to the pulmonology clinic with shortness of breath and a cough. She was recently admitted for a bronchiectasis exacerbation but continued to have a worsening productive cough and fevers. The most recent CT scan of the chest showed interval stable right upper lobe fibrocavitary disease, demonstrating gradual progression over two years. She had occasional positive cultures for Mycobacterium Avium Complex and M. xenopi one year previously, assumed to be a colonizer and not treated. Most recent hospital cultures were negative for bacteria and an acid-fast bacilli smear. She was sent to the emergency department for bronchiectasis exacerbation and returned to the clinic six weeks later with two sputum cultures growing M. xenopi. It was decided to treat M. xenopi as this was likely the cause of her cavitary lung lesion and frequent infections. Azithromycin, rifampin, and sulfamethoxazole/trimethoprim were initiated. Intravenous amikacin was added later on. She finally had a right partial lung resection done after one year at an outside hospital. She was on and off antibiotics for M. xenopi for approximately three years with negative repeat cultures for non-tuberculous mycobacteria. Conclusion: Due to the high mortality of M. xenopi infections (which can be as high as 69%), treatment of at least twelve months is recommended. To our knowledge, this is the first reported case of M. xenopi in a patient with blue rubber bleb nevus syndrome. LEARNING POINTS: The decision to initiate treatment for non-tuberculous mycobacterium infections is often challenging with prolonged treatment.Lifetime monitoring is required in patients with blue rubber bleb nevus syndrome, which can have pulmonary complications.M. xenopi has the highest mortality among non-tuberculous mycobacterium infections and requires at least 12 months of treatment.

Cardiotoxicity Induced by Capecitabine and Oxaliplatin in Gastric Cancer Treatment: A Rare Case of Cardiac Arrest and Cardiogenic Shock.

Introduction: Combination-based adjuvant chemotherapy utilising capecitabine and oxaliplatin is widely used in gastric cancer treatment. Rare but severe cardiac events such as prolonged QT, cardiac arrest and cardiogenic shock can result from their use. Case description: A 45-year-old female with gastric adenocarcinoma was started on capecitabine-oxaliplatin chemotherapy one week before presenting to the emergency department with weakness. Blood pressure was 78/56 mmHg, heart rate 140 bpm and oxygen saturation 85%. She became unresponsive with pulseless ventricular fibrillation; CPR was initiated with immediate intubation. She received two shocks with a return of spontaneous circulation. Laboratory tests revealed serum potassium (3.1 mmol/l), magnesium (1.1 mg/dl) and troponin (0.46 ng/ml). An EKG revealed sinus tachycardia with a prolonged QT interval (556 ms). The combined effects of capecitabine, oxaliplatin and electrolyte abnormalities likely contributed to the QT prolongation. An echocardiogram demonstrated an ejection fraction of 10%-15%. An emergent right-heart catheterisation showed right atrial pressure of 10 mmHg and pulmonary artery pressure of 30/18 mmHg; cardiac output and index were not recorded. An intra-aortic balloon pump was placed, and she was admitted to the ICU for cardiogenic shock requiring norepinephrine, vasopressin and dobutamine. A repeat echocardiogram showed a significantly improved ejection fraction of 65%, and she was discharged. Discussion: Capecitabine and oxaliplatin cardiotoxicity is an exceedingly rare occurrence, with both drugs reported to cause QT prolongation. Conclusion: Healthcare providers must recognise the QT prolongation effects of capecitabine and oxaliplatin, leading to life-threatening cardiac arrhythmias. LEARNING POINTS: Recognise the QT-prolonging effects of capecitabine and oxaliplatin-based chemotherapy.Recognise that cardiogenic shock and cardiac arrest with capecitabine and oxaliplatin-based chemotherapy can occur in individuals with benign cardiac history, especially early in treatment.

Safety and Efficacy of Ferric Carboxymaltose in Heart Failure With Preserved Ejection Fraction and Iron Deficiency.

Heart Failure with Preserved Ejection Fraction (HFpEF) is a prevalent cardiovascular condition characterized by a complex pathophysiology and limited therapeutic options. Coinciding iron deficiency often compounds the clinical picture, contributing to symptom burden and adverse outcomes. The review underscores the urgency for effective treatments in light of its increasing incidence and considerable healthcare burden. It highlights the clinical significance of addressing iron deficiency in HFpEF patients. FCM emerges as a promising therapeutic modality, demonstrating the ability to rapidly restore iron stores and enhance patients' quality of life while reducing hospitalization rates and mortality. The review thoroughly elucidates the impact of iron deficiency on HFpEF symptoms and outcomes, elucidating how FCM effectively mitigates these challenges. Detailed discussions encompass FCM's mechanism of action, pharmacokinetics, and safety profile. Notably, FCM's adaptability to diverse patient profiles and clinical settings is emphasized, reinforcing its clinical utility. Clinical evidence, including study designs, patient cohorts, and key findings, affirms FCM's potential as a valuable therapeutic option. Real-world data analysis further underscores FCM's practicality and safety beyond controlled clinical trials. The review concludes by addressing future research directions and critical research gaps, accentuating the need for mechanistic insights, long-term outcome studies, and refined patient selection criteria. As FCM increasingly integrates into clinical practice, it offers promise in revolutionizing HFpEF management, addressing an unmet need in this intricate cardiovascular condition.

Neuroblastoma: A Case of Massive Hepatomegaly.

Neuroblastoma is the most common embryonal tumor of childhood and has a variable presentation. Stage 4S neuroblastoma, described as a localized primary tumor in an infant with metastasis to skin, liver, or bone marrow, is an exception to the poor prognosis seen in widespread metastasis of neuroblastoma. Survival in infants with this stage of the disease is over 90%. Stage 4S with massive liver involvement, however, confers a poor prognosis. We need more research on the optimum treatment modality for patients with Stage 4S disease and massive hepatomegaly to improve patient outcomes.

Delayed Presentation of a Retained Fecalith.

A fecalith is a common cause of acute appendicitis, and laparoscopic surgery is the mainstay of its management. Literature review shows that a fecalith may be retained in the gut following a laparoscopic appendectomy in some rare cases. In most cases, the fecalith becomes symptomatic with time due to the formation of an abscess, fistulous tract, or inflammation of the appendicular stump (stump appendicitis). We report a case of retained appendicular fecalith presenting with symptoms similar to acute appendicitis, 15 years after laparoscopic appendectomy.