RESUMEN
A 43-year-old white woman presented to the emergency department with confusion, agitation, and progressive dyspnea. Chest x-ray revealed pulmonary edema. Initial diagnostic considerations were pneumonia, pulmonary embolism, sepsis, central nervous system infection, substance toxicity, and heart failure. Her salicylate level was 92.6 mg/dL, and an arterial blood gas revealed a respiratory alkalosis and nonanion gap metabolic acidosis, consistent with salicylate poisoning. Noncardiogenic pulmonary edema is an atypical presentation of salicylate toxicity, and this case highlights the importance of an early toxicology screen to make a time-critical diagnosis and provide specific treatment.
Asunto(s)
Edema Pulmonar/inducido químicamente , Edema Pulmonar/diagnóstico , Edema Pulmonar/terapia , Salicilatos/envenenamiento , Adulto , Diagnóstico Diferencial , Femenino , HumanosRESUMEN
Background: Pump thrombosis is a serious complication of continuous-flow left ventricular assist device (CF-LVAD) therapy. In this study, we aim to report a novel protocol of an intermittent, low-dose, and slow infusion of tissue plasminogen activator (alteplase). Case summary: We treated seven LVAD pump thrombosis events (HeartMate® II and HeartWare) in four patients with a median age of 52 years (31-63), and all were female. The protocol was applied from January 2015 to December 2018, and it consisted of an intermittent, low-dose, and slow infusion of systemic thrombolytic therapy in the intensive care unit. This therapy resulted in successful resolution of pump thrombosis in six out of seven events. Bleeding complication occurred in one patient, which included a ruptured haemorrhagic ovarian cyst and a small cerebellar intra-parenchymal haemorrhage. All patients were discharged home in a stable condition, except one patient who died during hospitalization because of severe sepsis, pump thrombosis with subsequent pump exchange, and multi-organ failure. Discussion: A low-dose, prolonged, and systemic thrombolytic infusion protocol is an effective and relatively safe treatment that can lead to a sustained resolution of pump thrombosis with low bleeding complications and failure rates.
RESUMEN
BACKGROUND: We hypothesized that among patients presenting with dyspnea on exertion (DOE), those who were found to have hyperdynamic left ventricle (i.e. LVEF ≥ 70%) on stress radionuclide myocardial perfusion imaging (RNMPI), are more likely to have features of diastolic dysfunction on transthoracic echocardiography. METHODS: Medical records of 1892 consecutive patients who presented between February 2011 and September 2012 with the chief complaint of DOE and were referred to stress RNMPI were reviewed. Among these, patients who had no evidence of reversible ischemia and had hyperdynamic left ventricle on perfusion imaging, were selected and their recent echocardiograms were reviewed for evidence of diastolic dysfunction. Logistic regression analysis was used to develop an equation to predict diastolic dysfunction with the ejection fraction as the predictor. A two-way analysis of variance model was used to detect differential patterns of ejection fraction across diastolic dysfunction and gender. RESULTS: A hyperdynamic left ventricle identified on stress RNMPI was found to be a significant predictor of diastolic dysfunction on echocardiography in logistic regression analysis (odds ratio = 1.24, 95% CI = 1.13-1.35, p < 0.0001). A hyperdynamic left ventricle on stress RNMPI has a specificity of 96.77% (CI 83.24-99.46%) and a positive predictor value of 97.83% (CI 88.43-99.64%) in identifying diastolic dysfunction. CONCLUSION: In patients presenting with DOE who have no evidence of reversible ischemia on radionuclide stress testing but have hyperdynamic left ventricle, a search should be made for alternate cardiac etiology for this complaint such as diastolic dysfunction and heart failure with preserved ejection fraction.