The Evolution of Renal Denervation for the Treatment of Hypertension: Insights from Trials and Prospects for Clinical Practice.

Hypertension affects 1.3 billion adults globally, with severe health implications if left untreated. Despite efforts, research suggests only a fraction achieve adequate control. Renal denervation (RDN) therapy has emerged as a potential solution, particularly for treatment-resistant cases. RDN targets the dysregulated sympathetic nervous system activity frequently encountered in resistant hypertension. Recent FDA approval of advanced RDN catheter systems in 2023 signifies a pivotal advancement in hypertension management. As an adjunctive to pharmacotherapy, RDN holds promise as a therapeutic modality in achieving optimal blood pressure control and attenuating hypertension-related morbidity and mortality. Further research elucidating the nuances of patient selection, procedural standardization, and long-term outcomes is warranted to optimize the clinical utility of RDN in the management of hypertension. This manuscript compiles evidence for the use of RDN and reviews the long-term safety data from recent trials.

Statins and New Onset Diabetes Mellitus.

Statins have become one of the forefront medications in the prevention of cardiovascular morbidity and mortality in the 21st century. Apart from lowering low density lipoprotein-C (LDL-C), statins also play an important role in atherosclerotic plaque stabilization and regression. In the last two decades, there is growing evidence that statins have the potential to cause new onset diabetes mellitus (NODM). This is more pronounced in those with preexisting risk factors of developing diabetes. While several theories have been postulated, the exact mechanism behind the diabetogenic effect of statins remains unknown. Although NODM is associated with the use of statins, the overall benefits statins provide in terms of cardiovascular disease prevention far outweigh the effects of glycemic profile worsening.

Mediastinal actinomycosis masquerading as a mass: a case of progressive dysphagia in an immunocompromised patient.

Actinomycosis is a rare endogenous infection characterised by indolent progression, contiguous spreading, abscess formation and draining sinuses. Here, we present a case of Schaalia odontolytica causing a mediastinal abscess that is unique in its acuity and location. Our patient presented with worsening dysphagia, and CT of her chest revealed a new mass in the posterior mediastinum displacing the oesophagus. Oesophagram revealed mild motility disorder, but no masses or ulcers within the oesophagus. Oesophagogastroduodenoscopy with endoscopic ultrasound revealed extrinsic compression of the oesophagus. Fine-needle aspiration of the mass yielded purulent fluid, which was cultured. A single colony of S. odontolytica was isolated. Initially, medical treatment was favoured, but as she developed worsening dysphagia, the abscess was drained. She continued on long-term antibiotic therapy after drainage and had complete resolution of the abscess at 1 year.

Gastroduodenal artery aneurysm - an extremely rare but insidious cause of abdominal pain: a case report.

An arterial aneurysm is a localized weakening of the artery wall that results in pathological dilatation. All intra-abdominal artery aneurysms are labeled as visceral artery aneurysms (VAA), apart from the aorto-iliac artery aneurysms. VAA´s are rare, gastroduodenal artery aneurysms (GDAA), constituting 1.5% of visceral artery aneurysms. A woman in her early 80s´ presented with chronic epigastric pain, weight loss, and nausea. Conservative management was unsuccessful. Imaging revealed a GDAA, prompting endovascular coil embolization. Subsequent evaluation confirmed Polyarteritis Nodosa (PAN), treated with rituximab. The report underscores the diagnostic challenges, emphasizing the need for a multidisciplinary approach using imaging and angiography. GDAA's potential life-threatening rupture necessitates prompt intervention, as illustrated in this case. The rare association with PAN, although infrequent, underscores the importance of considering underlying etiologies in multiple visceral aneurysms. Early diagnosis and intervention are pivotal for this uncommon yet potentially lethal condition.

Crowned Dens Syndrome: A Challenging Diagnosis in Older Adults Presenting With Acute Neck Pain.

Crowned dens syndrome (CDS) is a rare syndrome of calcium pyrophosphate dihydrate (CPPD) deposition on the odontoid process of the second cervical vertebra leading to unique clinical presentation and radiographical findings. Symptoms usually overlap with more common etiologies, including meningitis, stroke, and giant cell arteritis. Thus, patients struggle with extensive evaluation before diagnosing this uncommon condition. There are few case reports and case series of CDS in the literature. Patients respond well to treatment, but unfortunately, there is a high rate of relapse. Here we present an interesting case of a 78-year-old female patient who presented with acute onset headache and neck pain.

ST-Elevation Myocardial Infarction Precipitated by Disseminated Intravascular Coagulation: A Therapeutic Challenge.

Acute coronary syndrome (ACS) can manifest as ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA). Common etiologies for STEMI include atherosclerotic plaque disruption or erosion manifesting as type 1 myocardial ischemia (MI). Causes of type 2 MI presenting as STEMI may include spontaneous coronary artery dissection, coronary artery spasm, and coronary embolism. STEMI is an emergency mandating immediate coronary intervention. We present a case of STEMI as a complication of disseminated intravascular coagulation (DIC). This case highlights the unique challenge of managing STEMI with active DIC.

Angioedema in the Absence of C1 Esterase Inhibitor Deficiency in a Young Patient With Anti-dsDNA Negative Lupus Nephritis.

Hereditary angioedema (HAE) is an autosomal dominant condition marked by a lack of functioning C1 esterase inhibitor (C1-INH). In contrast, acquired angioedema (AAE) due to a deficiency of C1 esterase inhibitor (AAE-C1-INH) may be the manifestation of an underlying lymphoproliferative, neoplastic, or autoimmune condition. Both are potentially fatal. The C1q protein is normal in HAE but low in AAE. A third mechanism has been reported to cause angioedema, especially in systemic lupus erythematosus (SLE) patients. AAE, which happens in association with SLE, may respond well to steroids. Here we present a case of AAE in a young female with SLE that led to upper airway compromise, requiring endotracheal intubation. Early detection and treatment of such cases can lead to an outstanding prognosis by preventing airway compromise and anoxic brain injury. Even though it is a condition of either very young or middle-aged patients, practitioners must be aware of this uncommon disease linked with SLE in adolescents and young adults.

Metastatic Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis and Pott's Disease.

Tuberculous spondylitis (Pott's disease) is among the frequent extra-pulmonary presentations of tuberculosis (TB). The global incidence of lung adenocarcinoma is on the rise, and it is a rare differential diagnosis of miliary shadows on chest imaging. It has a predilection to metastasize to ribs and spine in particular. There is a very close clinical and radiological resemblance in the presentation of spinal metastasis of lung cancer and Potts's disease. It poses a diagnostic challenge to clinicians particularly in TB endemic areas to arrive at an accurate diagnosis, leading to disease progression and poor outcome. We report a 54-year-old female patient presented with constitutional symptoms of on and off fever and back pain. Her chest X-ray revealed miliary shadows, and acid-fast bacilli (AFB) sputum smear and TB polymerase chain reaction (PCR) test came negative; radiological diagnosis of tuberculous spondylitis was done on computerized tomography (CT) chest and magnetic resonance imaging (MRI) spine. Subsequent bronchoscopy and bronchoalveolar lavage (BAL) cytology showed malignant cells and CT-guided lung biopsy confirmed lung adenocarcinoma with spinal and brain metastasis. Despite being started on chemo-immunotherapy and radiotherapy her outcome was poor due to advanced metastatic disease. This case highlights the significance of considering metastatic adenocarcinoma of the lung a rare but ominous possibility in the differential diagnosis of miliary shadows on chest imaging. Early bronchoscopy and biopsy must be considered in all patients presenting with miliary pulmonary lesions and spinal lesions to make a correct diagnosis, preventing an unnecessary delay in starting proper treatment and poor outcome. It also emphasizes the importance of better understanding the different radiographic features of the two common mimics, spinal tuberculosis, and metastatic spinal tumors.

The Role of Anticoagulation in Post-COVID-19 Concomitant Stroke, Myocardial Infarction, and Left Ventricular Thrombus: A Case Report.

BACKGROUND Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects the lungs but can involve any organ. The medical community is struggling to cope with the critical illness associated with the disease. On top of that, patients who have recovered from COVID-19 have presented with complications such as thrombotic episodes in various organs both during and after being infected with SARS-CoV-2. A COVID-19-associated prothrombotic state has been mentioned in multiple recent research articles. The role of anticoagulants is debatable, because even after receiving them prophylactically, many patients have experienced thrombotic episodes. The situation, therefore, represents a challenge to the medical community. CASE REPORT We report on a COVID-19-associated prothrombotic state in a 65-year-old man with no history of comorbid illness. Initially, he presented with right-sided weakness and was found to have had an acute ischemic stroke. Urgent imaging after the stroke revealed changes on electrocardiography that were remarkable for left bundle branch block. The patient's elevated cardiac enzyme levels correlated with a silent acute myocardial infarction (MI). His echocardiogram revealed a left ventricular (LV) thrombus. He was managed with a multidisciplinary approach involving Neurology, Cardiology, and Medicine. CONCLUSIONS COVID-19-associated prothrombotic episodes involving arterial and venous systems have been reported in the literature. But concomitant stroke, acute MI, and LV thrombus rarely have been documented. The role of prophylactic or therapeutic anticoagulation is still unclear because even when patients are on these drugs, they continue to develop thrombotic episodes. Indeed, further studies are required to develop a standard management plan for what can be a fatal situation.

Non-Conforming Still's Disease With Low Ferritin and No Skin Rash: A Case Report.

Adult Still's disease (ASD) is an inflammatory disorder with an unclear etiology. It is a rare disease that was first described more than a century ago. Its common characteristics are daily fevers, arthritis, and skin rash. ASD is diagnosed after excluding infections, malignancies, and connective tissue diseases. It has a female predominance. Classic skin rash and high serum ferritin levels are commonly associated with this condition and help in the diagnosis. Due to a lack of pathognomic clinical and laboratory features, a valid diagnostic criterion, the Yamaguchi criteria, is generally used for the diagnosis. The disease has a good prognosis with appropriate treatment. We present the case of a young gentleman who presented with fever, anemia, and leucocytosis; however, his serum ferritin levels were normal, and there was no typical salmon-colored skin rash. Hyperferritinemia developed later in the disease course, leading to a diagnosis of ASD.

Fade to black!

Black pleural effusion is a rare entity and may be a diagnostic dilemma. This interactive case discusses the various steps involved to reach the diagnosis. https://bit.ly/3dFJPTS.

Oropharyngeal Candidiasis as a Presenting Symptom of Crohn's Disease.

Oropharyngeal candidiasis is a common condition in immunosuppressed patients. Inflammatory bowel disease (IBD) is a prevalent medical condition which commonly presents with intestinal and extra intestinal manifestations. Crohn's disease (CD) tends to present more with extraintestinal symptoms. Here, we report the case of a 22-year-old male who presented with oropharyngeal candidiasis and weight loss without abdominal symptoms, and a negative HIV serology. After a through diagnostic workup, he was found to have CD. Under CD treatment, his symptoms improved.

Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis.

Miliary shadows on chest imaging have wide differential diagnoses. The most common etiology is infectious, such as miliary tuberculosis (TB) and histoplasmosis, but miliary shadows can be the presentation of sarcoidosis, pneumoconiosis, and secondary metastasis to the lungs from primary cancers of the thyroid, kidney, and trophoblasts as well as sarcomas. Here we present the case of a 35-year-old Indian male who presented with a 2-month history of dry cough and shortness of breath. Chest imaging showed diffuse bilateral miliary nodules. The initial impression was that of miliary pulmonary TB. Subsequent bronchoscopy with a transbronchial biopsy confirmed the diagnosis of pulmonary mucinous adenocarcinoma with brain metastasis, which is a rare and unusual presentation of primary lung cancer. The tumor was positive for ALK5A4 and PD-L1, and the patient was started on tyrosine kinase inhibitor immunotherapy, with a favorable response.

Multiple outbreaks of puffer fish intoxication in Bangladesh, 2008.

During April and June 2008, we investigated three outbreaks of marine puffer fish intoxication in three districts of Bangladesh (Narshingdi, Natore, and Dhaka). We also explored trade of marine puffer fish in Cox's Bazaar, a coastal area of the country. We identified 95 people who had consumed puffer fish; 63 (66%) developed toxicity characterized by tingling sensation in the body, perioral numbness, dizziness, and weakness, 14 of them died. All three outbreaks were caused by consumption of large (0.2-1.5 kg) marine puffer fish, sold in communities where people were unfamiliar with the marine variety of the fish and its toxicity. Coastal fishermen reported that some local businessmen distributed the fresh fish to non-coastal parts of the country, where people were unfamiliar with the larger variety, to make a quick profit. Lack of knowledge about marine puffer toxicity contributed to the outbreaks. Health communication campaigns will enhance people's knowledge and may prevent future outbreaks.

Cluster of Nipah virus infection, Kushtia District, Bangladesh, 2007.

OBJECTIVE: In March 2007, we investigated a cluster of Nipah encephalitis to identify risk factors for Nipah infection in Bangladesh. METHODS: We defined confirmed Nipah cases by the presence of IgM and IgG antibodies against Nipah virus in serum. Case-patients, who resided in the same village during the outbreak period but died before serum could be collected, were classified as probable cases. RESULTS: We identified three confirmed and five probable Nipah cases. There was a single index case. Five of the secondary cases came in close physical contact to the index case when she was ill. Case-patients were more likely to have physical contact with the index case (71% cases versus 0% controls, p = <0.001). The index case, on her third day of illness, and all the subsequent cases attended the same religious gathering. For three probable cases including the index case, we could not identify any known risk factors for Nipah infection such as physical contact with Nipah case-patients, consumption of raw date palm juice, or contact with sick animals or fruit bats. CONCLUSION: Though person-to-person transmission remains an important mode of transmission for Nipah infection, we could not confirm the source of infection for three of the probable Nipah case-patients. Continued surveillance and outbreak investigations will help better understand the transmission of Nipah virus and develop preventive strategies.