Tropheryma whipplei Endocarditis Presenting as Valvulopathy and Multiple Septic Emboli.

A 63-year-old man was admitted to the hospital for nausea, vomiting, and right flank pain. He was found to have septic emboli in multiple organs secondary to aortic valve endocarditis. He was started on broad-spectrum antibiotics and underwent valve replacement. Blood cultures from admission were negative, but a blood polymerase chain reaction (PCR) test for fastidious difficult-to-culture pathogens showed a positive result for Tropheryma whipplei. Valve histopathological evaluation confirmed Tropheryma whipplei endocarditis. He was treated with intravenous penicillin followed by oral trimethoprim-sulfamethoxazole. A high index of suspicion for causes of culture-negative endocarditis needs to be maintained when blood cultures are negative despite clear evidence of endocarditis especially with large vegetation sizes and other complications such as septic emboli. Multiple imaging modalities are available to assist with diagnosis including transthoracic and transesophageal echocardiogram as well as cardiac computed tomography. A blood PCR test can identify the implicated pathogen in a more expeditious manner compared to valve histopathological evaluation. Treatment is complex and usually requires surgical intervention and prolonged antimicrobial therapy.

Percutaneous retrieval of an embolized Watchman device on a papillary muscle in the left ventricle.

The use of left atrial appendage occlusion (LAAO) devices have gained prominence as an alternative to long-term anticoagulation therapy in patients with atrial fibrillation at risk of stroke and high risk of bleeding. While these devices have shown efficacy in reducing stroke risk, there have been reported cases of embolization of the Watchman device. There are very few cases of successful percutaneous retrieval of embolized Watchman devices from the left ventricle (LV), as many of these cases require open heart surgery for safe removal. We are presenting a case of an 80-year-old male whose Watchman device embolized to the LV and was entrapped on the LV papillary muscle that was then successfully retrieved via percutaneous methods, which shows the percutaneous options remain a viable strategy to retrieve LAAO devices from the LV.

Cerebral Embolism and MINOCA Secondary to Left Atrial Myxoma after Occlusion of Atrial Septal Defect by Amplatzer Occluder: A Case Report.

Primary heart tumors are rare, with atrial myxomas being the most common type. Atrial myxomas can lead to embolisms, heart obstruction, and systemic symptoms. Herein, we report a case of 72-year-old woman who presented with a left atrial myxoma at the atrial septal defect occluder, a new acute cerebral infarction, and MINOCA (myocardial infarction with no obstructive coronary atherosclerosis). Left atrial myxoma is a common primary cardiac tumor; however, left atrial myxomas arising after percutaneous atrial septal defect occlusion are rare. Additionally, the patient presented with a new case of multiple systemic emboli. The patient underwent surgical resection of a left atrial myxoma, occluder, and left atrium, and atrial septal repair, and was discharged with good recovery for outpatient follow-up. The possibility of a cardiac tumor, especially an atrial myxoma, which can lead to a series of complications, should be considered at the closure site after percutaneous atrial septal closure. Therefore, active surgical treatment and long-term follow-up are warranted in such cases.

Coronary Embolism Among Patients With ST-Segment-Elevation Myocardial Infarction and Atrial Fibrillation: An Underrecognized But Deadly Association.

BACKGROUND: The prevalence and impact of coronary emboli (CE) in patients with ST-segment-elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI. METHODS AND RESULTS: We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P<0.05), more likely to be female (43% versus 22%, P<0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P<0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45-day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P<0.05 and group A versus group B: 20% versus 8%, P=not significant); this trend persisted at 2-year follow-up (group A versus group C: 24% versus 6%; P<0.05 and group A versus group B: 24% versus 17%, P=not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45-day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P<0.05). CONCLUSIONS: In patients presenting with STEMI and AF, CE was associated with excess early mortality. REGISTRATION: URL: clinicaltrials.gov. Identifier: NCT05679843.

Vertebral body and spinal cord infarction in a pile-driver operator with fibrocartilaginous disc embolism.

We describe the case of a male heavy machinery operator who presented from work with a rapidly evolving spinal cord syndrome. Spinal MRI revealed thoracic vertebral body and cord infarction and evolving mild disc prolapse attributed to fibrocartilaginous disc embolism (FCDE). FCDE should be considered as one of the aetiological mechanisms of acute spinal cord infarction in pile-driver/heavy machinery operators, especially in association with adjacent vertebral body infarction and intervertebral disc prolapse. Magnetic resonance imaging (MRI) changes may evolve, warranting early follow-up MRI in appropriate cases.

Otitis media aguda: una causa poco frecuente de síndrome de Lemierre / Acute otitis media: a rare cause of Lemierre's syndrome

El síndrome de Lemierre es una patología poco frecuente y potencialmente letal, que se origina como complicación de una infección localizada a nivel de cabeza y cuello que se extiende al espacio carotídeo. Se asocia a tromboflebitis séptica de la vena yugular interna y con frecuencia produce embolias sépticas a distancia. Se presenta generalmente como un cuadro de fiebre y odinofagia de varios días de evolución tras el antecedente de una infección orofaríngea aparentemente resuelta. Otros focos infecciosos menos frecuentes pueden corresponder a mastoiditis, sinusitis u otitis media aguda. El diagnóstico es fundamentalmente clínico y apoyado en las pruebas de imagen, como la ecografía Doppler y la tomografía computarizada cervical con contraste. El tratamiento consiste en antibioterapia prolongada con adecuada cobertura para anaerobios, especialmente Fusobacterium necrophorum, el patógeno más frecuente. El papel de la anticoagulación en el síndrome de Lemierre es controvertido. Se presenta un caso de síndrome de Lemierre secundario a una otitis media aguda

Lemierre's syndrome is a rare and potentially lethal disease that originates as a complication of a localized infection at the head and neck level that extends to the carotid space. It is associated with septic thrombophlebitis of the internal jugular vein and often produces septic emboli at a distance. It usually presents as a picture of fever and odynophagia several days after the history of an apparently resolved oropharyngeal infection. Other less frequent infectious foci may correspond to mastoiditis, sinusitis or acute otitis media. The diagnosis is fundamentally clinical and supported by imaging tests such as Doppler ultrasound and cervical CT with contrast. The treatment consists of prolonged antibiotic therapy with adequate coverage for anaerobes, especially Fusobacterium necrophorum, which is the most frequent pathogen. The role of anticoagulation in Lemierre's syndrome is controversial. We present a case of Lemierre's syndrome secondary to acute otitis media

Isquemia mesentérica aguda. Diagnóstico y tratamiento / Acute mesenteric ischemia. Diagnosis and treatment

La isquemia mesentérica aguda es un estado de hipoperfusión brusca del intestino que ocasiona un problema clínico muy grave con elevada morbimortalidad. La sintomatología es inespecífica y el diagnóstico, a menudo, se consigue mediante una laparotomía exploradora, a veces tardía, cuando el cuadro de peritonitis ya se ha establecido. Para mejorar el pronóstico de esta entidad es fundamental el diagnóstico precoz. Los datos analíticos (leucocitosis, elevación de lactato y dímero-D) y la realización de una angiotomografía computarizada permiten con bastante fiabilidad establecer el diagnóstico y su posible causa (embolia, trombosis arterial, trombosis venosa o síndrome isquémico no oclusivo). El principio quirúrgico básico es la resección de los segmentos necróticos intestinales y la reinstauración de la circulación esplácnica. La cirugía abierta ha sido el tratamiento quirúrgico de elección en las últimas décadas, pero las técnicas endovasculares (guías, catéteres, stent, etc.) son hoy día una parte integral del arsenal terapéutico de los cirujanos vasculares. En este artículo de revisión se comentan las principales características diagnósticas y los opciones de tratamiento de esta grave enfermedad

Acute mesenteric ischemia is a state of sudden hypoperfusion of the bowel that causes a serious clinical problem with high morbidity and mortality. The symptoms are non-specific and the diagnosis is often achieved by an exploratory laparotomy, sometime later, when the peritonitis has been already established. Early diagnosis is essential to improve the prognosis of this pathology. Analytical data (leukocytosis, elevated lactate and D-dimer), and performing a computed tomography angiography helps establish the diagnosis and possible cause (embolism, arterial thrombosis, venous thrombosis, or non-occlusive ischemic syndrome). The main treatment is surgical resection of necrotic bowel segments and the restoration of the splanchnic circulation. Open surgery has been the treatment of choice in recent decades, but the endovascular techniques (guides, catheters, stent, etc.) are nowadays an integral part of the armamentarium of vascular surgeons. This review article discusses the main diagnostic features and treatment options for this serious disease

Trombosis arterial subclavioaxilar y embolización distal tras luxación glenohumeral anterior traumática / Subclavian-axillary arterial thrombosis and distal embolisation after traumatic anterior glenohumeral dislocation

La lesión vascular arterial asociada a la luxación anterior de hombro es una complicación rara, pero potencialmente devastadora, a menudo en el contexto de traumatismos de alta energía o heridas penetrantes. Se trata de una urgencia médica que puede llegar a comprometer la viabilidad y funcionalidad del miembro, incluso la vida del paciente si no es identificada precozmente y tratada de forma adecuada. Sin embargo, su diagnóstico puede ser difícil, pues precisa un alto índice de sospecha. La presencia de una trombosis de la arteria axilar con una luxación de hombro por un mecanismo de baja energía es extraordinariamente poco frecuente, especialmente cuando se presenta de forma subaguda con embolismo en la arteria radial

Arterial vascular injury associated with anterior dislocation of the shoulder is a rare but potentially devastating complication, often seen in the context of high-energy trauma or penetrating injury. It is a medical emergency that can compromise both the viability and functionality of the limb, as well as the patient's life if it is not identified early and treated properly. However, its diagnosis can be difficult, since it requires a high index of suspicion. The presence of an axillary artery thrombosis after shoulder dislocation resulting from low-energy trauma is extremely rare, even more so with subacute clinical presentation associated with embolism to the radial artery

Embolia arterial periférica por projétil de arma de fogo em civis: diagnóstico confirmado pelo ultrassom vascular / Peripheral arterial emboli due to bullet projectile: diagnosis confirmed by vascular ultrasound

Descrevemos um caso de oclusão arterial aguda por projétil de arma de fogo. Devido à raridade do caso (23 relatos em 20 anos) e a importância do diagnóstico diferencial precoce, uma revisão bibliográfica foi realizada. Foram abordados aspectos do quadro clínico, diagnóstico diferencial e tratamento. Neste caso, o diagnóstico por meio de ultrassom vascular da complicação foi publicado pela primeira vez.

We describe a case of acute arterial occlusion caused by a firearm bullet. Since the case is rare (23 cases in 20 years), and due to the importance of early diagnosis, a bibliographic review was performed. Aspects of the clinical picture, differential diagnosis and treatment were approached. In this case, diagnosis by a vascular ultrasound was published for the first time.

Embolia coronariana associada a prolapso de valva mitral / Coronary embolism associated with mitral valve prolapse

Embolia coronariana é um evento raro. Neste trabalho, relatamos caso de pacientes, sexo masculino, de 64 anos, com um evento embólico coronariano associado a prolapso e rotura de valva mitral mixomatosa, situação essa extremamente incomum.

Oclusión de rama arterial retiniana en un paciente con ojo único. Abordaje mediante láser Nd: YAG / Branch retinal artery occlusion in a patient with one eye. Laser Nd: YAG approach

CASO CLÍNICO: Varón de 82 años que acude de urgencia al servicio de oftalmología por disminución súbita e indolora de la agudeza visual de su ojo izquierdo (OI), fue diagnosticado de una oclusión de rama arterial retiniana(ORAR) con émbolo visible. En 2012 padeció de una oclusión de arteria central retiniana (OACR) en el ojo derecho (OD). Se realizó embólisis con láser Nd:YAG en el OI, recuperando completamente el flujo arterial retiniano y mejorando el campo visual sin complicaciones secundarias. Conclusiones: La embólisis mediante láser Nd:YAG debe ser considerada en pacientes con ORAR con émbolo visible. Los riesgos y beneficios deben ser evaluados y comparados con la posible pérdida de agudeza visual, y otras complicaciones producidas por la oclusión arterial

CLINICAL CASE: An 82-year-old man was admitted to the emergency department complaining of a sudden painless visual loss in his left eye (OS). He was diagnosed with branch retinal artery occlusion (BRAO) with a visible embolus. In 2012, he had a central artery occlusion (CRAO) in his right eye (OD). An embolysis with Nd:YAG laser was attempted, the retinal arterial blood flow was restored completely and the visual field was improved, with no secondary complications. CONCLUSIONS: Nd:YAG laser embolysis is a treatment to be considered in patients with BRAO with a visible embolus. The risks and benefits of the procedure should be evaluated, comparing it with possible permanent loss of visual acuity and other vascular complications caused by BRAO

Embolia atrial de trombo flutuante da veia safena magna após escleroterapia com microespuma ecoguiada / Atrial embolism of floating thrombus of the great saphenous vein after microfoam ultrasound-guided sclerotherapy

A escleroterapia com microespuma vem sendo utilizada amplamente no tratamento da doença venosa varicosa. No entanto, a despeito da sua pouca invasividade e segurança, complicações potencialmente graves e letais já foram descritas, como o acidente vascular cerebral e parada cardiorrespiratória. Descrevemos um caso de embolia atrial tardia de trombo flutuante da junção safeno-femoral de veia safena magna varicosa, após escleroterapia com microespuma de polidocanol guiada por ultrassom, e o tratamento dessa complicação.

Microfoam sclerotherapy has been widely used in the treatment of varicose vein disease. However, despite its low invasiveness and safety, potentially serious and lethal complications have been described, such as stroke and cardiorespiratory arrest. We describe a case of delayed atrial embolism of floating thrombus in the saphenofemoral junction of a great saphenous varicose vein after microfoam ultrasound-guided sclerotherapy, as well as the treatment of this complication.

Complicações arteriais da síndrome do desfiladeiro torácico / Arterial complications of thoracic outlet syndrome

As manifestações clínicas da síndrome do desfiladeiro torácico são predominantemente neurológicas, sendo as complicações arteriais raras, mas potencialmente graves. Entre elas, devemos citar os aneurismas com complicações embólicas e a trombose. Os autores relatam o caso de uma mulher de 37 anos com costela cervical bilateral que apresentou embolia no membro superior direito originada de um aneurisma pós-estenótico da artéria subclávia direita, além de apresentar ectasia da subclávia esquerda também por compressão.

The clinical manifestations of thoracic outlet syndrome are mainly neurological. Although arterial complications are rare, they are potentially severe. Among these are aneurysms associated with embolism and thrombosis. The authors report a case of a 37 year-old woman with bilateral cervical rib that developed embolism in the right upper limb from a poststenotic right subclavian artery aneurysm and dilatation of the left subclavian artery, both due to compression.

Embolias silentes tras cardioversión eléctrica de fibrilación auricular: ¿qué aporta la resonancia magnética cerebral? / Silent embolism after electrical cardioversion of atrial fibrillation: what does brain magnetic resonance imaging provide?

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Embolias silentes tras cardioversión eléctrica de fibrilación auricular: ¿qué aporta la resonancia magnética cerebral? Respuesta / Silent embolism after electrical cardioversion of atrial fibrillation: what does brain magnetic resonance imaging provide? Response

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