The Longest Known Survival of a Patient With Bioprosthetic Aortic Valve Replacement: A 42-Year Follow-Up.

Aortic valve replacement (AVR) is a frequently performed procedure for treating aortic valvulopathy. AVR involves replacing the damaged aortic valve with either a mechanical or a bioprosthetic valve. While many factors are involved when selecting between the two options, age and patient preference are the deciding factors at this point. Mechanical valves demonstrate long-standing durability that overlaps with the accompanied bleeding risk due to lifetime anticoagulant therapy, making them a more favorable choice for younger patients. Bioprosthetic valves are preferred for older patients as they show a reduced risk of thrombogenicity. However, bioprosthetic valves have a higher incidence of structural valve degeneration (SVD) than mechanical valves. Our case report focuses on a 76-year-old patient who had undergone an AVR with a bioprosthetic valve at the age of 33, which has still not demonstrated any valve deterioration. As the longest known case of bioprosthetic durability, this patient provides useful data for designing bioprosthetic valves more resistant to structural degeneration and thereby better suited to younger patients or those at higher risk of bleeding.

Primary Cough Headache: A Case Report.

Primary cough headache (PCH) is an uncommon condition characterized by episodes of sudden onset, bilateral headaches typically lasting from a second to two hours. Headaches are notably associated with Valsalva maneuvers such as coughing or straining but not a prolonged physical exercise in the absence of intracranial abnormalities. We report an unusual presentation of PCH in a 53-year-old female suffering from episodes of severe sudden-onset headaches that lasted several hours. The headaches were initially precipitated by coughing as is typical with PCH but were unusual in the way the triggers for the episodes evolved. Headaches began occurring without any association of Valsalva maneuvers and ultimately occurred with no discernible trigger. The patient initially came to the cardiologist's office who then referred her to a neurologist for further evaluation. The neurologist initially prescribed methylprednisolone tablets, primarily to suppress the cough. Magnetic resonance imaging, magnetic resonance angiography (MRA) of the brain, and a head CT scan were then performed to rule out possible secondary causes such as a mass, intracranial bleed, aneurysms, or other vascular anomalies. The neurologist prescribed indomethacin and topiramate four and nine days after diagnosis of PCH, respectively. After five days, the beta blocker metoprolol tartrate was prescribed as the patient's blood pressure was rising significantly in correlation to the headaches. The above treatment was effective in limiting the intensity and duration of the headaches and the symptoms resolved after four weeks. This case contributes towards the understanding of the potential evolution of PCH presenting with triggers unassociated with Valsalva maneuvers and ultimately occurring with no known trigger as well as providing an example of PCH with an unusually long duration.

An Unusual Case of Malignant Melanoma with Metastasis to the Placenta During Pregnancy.

Introduction: We describe an unusual case of metastatic melanoma of the brain with an unknown primary site during pregnancy. Case Description: A 35-year-old woman in the third trimester of pregnancy presented with ataxia, nausea, vomiting, headaches and diplopia. CT of the brain revealed a hyper-attenuating 2.1 cm mass in the fourth ventricle with mild obstructive hydrocephalus. A healthy newborn was delivered by urgent caesarean section. Craniotomy and resection of the brain lesion confirmed melanoma. Pathology of the placenta reported a 'focal nest of melanocytes identified in intervillous space'. Discussion: Brain and maternal placenta pathology findings were consistent with melanoma, making this case relevant because of the possibility of metastatic melanoma in a fetus. Conclusion: Epidemiological data on congenital and infantile melanoma are scarce. Also, there is no database for long-term follow-up of children born to pregnant mothers with metastatic melanoma. Delayed presentation of melanoma in the child cannot be ruled out. LEARNING POINTS: Melanoma brain metastasis is an uncommon initial presentation during pregnancy.During pregnancy, vague symptoms such as headaches and nausea can easily be attributed to the pregnancy itself rather than more serious conditions like cancer.Metastatic melanoma diagnosed during pregnancy with disease in the placenta is a rare occurrence and should trigger close follow-up of the neonate secondary to concerns of transplacental metastasis.

A Rare Cause of Pedunculated Polyps Caused by Strongyloides.

Introduction: Strongyloidiasis is a systemic disease caused by the nematode Strongyloides stercoralis. Strongyloides is unique among parasites in that it can remain undetected for decades. Although patients may present with the typical symptoms of a skin rash, cough or diarrhoea, a rare manifestation of infection is pseudopolyposis in the colon. This case highlights the unique finding of pseudopolyposis in a patient with strongyloidiasis with negative stool studies. Case description: We present the case of an 81-year-old man with a delayed diagnosis of strongyloidiasis. The patient initially presented to the clinic for evaluation of productive cough and was treated empirically for bronchitis. He subsequently developed vomiting and diarrhoea with imaging revealing circumferential wall thickening of the ascending colon, consistent with colitis. Although stool tests were negative, the patient was treated with antibiotics, and then underwent a colonoscopy which revealed multiple polyps. Biopsy results confirmed Strongyloides infection. The patient was treated with ivermectin and improved. Discussion: This case describes the unique finding of colonic pseudopolyposis in a patient infected with Strongyloides in rural southwest Virginia. Strongyloidiasis is often misdiagnosed due to its non-specific gastrointestinal symptoms and the chronic nature of the disease. Although stool studies are routinely negative for parasitic infection, CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context. Determining the definitive diagnosis in a timely manner is crucial for establishing the specific treatment and for resolution of the disease. LEARNING POINTS: CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context; stool studies may be negative, as in this case.Internists should know the incidence, even if it is low, of certain parasitic infections in their local area.Strongyloides infection in the colon can mimic colitis and initiating the wrong treatment can lead to worse outcomes.

Competitive Flow: Closure of Internal Thoracic Artery Graft After Successful Coronary Artery Bypass Graft Surgery.

The internal thoracic artery has a patency rate of 85%-95% at 10-15 years post coronary artery bypass graft surgery. Development of total occlusion of the internal thoracic artery within a short period (< 6 months) after the surgery is exceedingly rare. However, competitive flow between the native vessel and the conduit internal thoracic artery, or competitive flow between the 2 conduit internal thoracic arteries in a multiple arterial grafting procedure can jeopardize 1 of the 2 conduit internal thoracic arteries. We report the cases of 2 patients who had bilateral internal thoracic artery grafts, with total occlusion of 1 of the 2 grafts within a short period (6 months) after successful coronary artery bypass graft surgery.

L'artère thoracique interne a un taux de perméabilité des greffons de 85 % à 95 % 10 à 15 ans après un pontage aortocoronarien. L'apparition d'une occlusion totale de l'artère thoracique interne dans un court délai (< 6 mois) après l'intervention est extrêmement rare. Cependant, le flux compétitif entre le vaisseau natif et l'artère thoracique interne de conductance ou le flux compétitif entre les 2 artères thoraciques internes de conductance dans une procédure de greffe artérielle multiple peuvent menacer l'une des 2 artères thoraciques internes de conductance. Nous rapportons les cas de 2 patients ayant subi une greffe bilatérale de l'artère thoracique interne et présenté une occlusion totale de l'un des 2 greffons peu (6 mois) après un pontage aortocoronarien réussi.