A Rare Case of Severe Manifestation of COVID-19 Infection Presenting as Immune-Related Thrombotic Thrombocytopenic Purpura With Multiorgan Involvement Treated With Plasmapheresis, Steroids, Rituximab, and Caplacizumab.

Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) caused by decreased activity of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). Platelet-rich thrombi in small vessels lead to fragmentation of RBCs causing microangiopathic hemolytic anemia (MAHA). Therapeutic plasma exchange is life-saving and is the mainstay of the treatment of TTP. Higher dose IV steroids along with rituximab are used as an adjunct to plasma exchange. Our case report describes a 26-year-old healthy male who presented with new onset seizures and encephalopathy. Blood work demonstrated anemia, severe thrombocytopenia, elevated lactate dehydrogenase, decreased haptoglobin, and elevated creatinine, and peripheral blood smear showed marked schistocytosis indicating MAHA. Plasma exchange and high-dose steroids were started on a presumptive diagnosis of TTP. ADAMTS13 activity was undetectable and ADAMTS13 inhibitor levels were elevated. Rituximab and caplacizumab were then added. Symptoms of encephalopathy improved by day five and platelet counts started improving by day nine. After several days of plasma exchange, he showed a "clinical response" with several weeks of active treatment. The association between coronavirus disease 2019 (COVID-19) infection and the severity of TTP with multiorgan failure is not well understood yet. Although we describe a successful multimodal approach to the management of TTP, which we believe is secondary to COVID-19 infection, further research is warranted to analyze and understand the pathophysiology by which COVID-19 infection causes TTP. It would help in establishing standardized therapy in the future.

A Rare Case of Persistent ST-Elevation Myocardial Infarction Post-Tissue Plasminogen Activator With White Clot Extraction in a Middle-Aged Woman on Medroxyprogesterone Acetate.

ST-elevation myocardial infarction (STEMI) occurs when vulnerable intravascular plaques rupture and produce eventual occlusion of the coronary circulation. With the increased prevalence of coronary artery disease, STEMIs and NSTEMIs are very well-studied and have generally been known to be caused by red and white thrombi, respectively. STEMIs have been more commonly associated with red clots, while NSTEMIs tend to be caused by white clots. Recent studies have also shown that a third of STEMIs are due to white clot formation, resulting in transmural infarction, most commonly seen at the coronary artery bifurcation. However, no cases of white clot STEMIs post-recombinant tissue plasminogen activator (rTPA) administration have been described in the literature. The data regarding the utility of rTPA in lysing white clots is limited, questioning the overall efficacy of rTPA with white clot lysis. This case report presents a patient on depot contraceptive who had a persistent STEMI despite rTPA administration and was found to have formed a white clot, which was extracted on thrombectomy. As this unique presentation and its associated risk factors are explored in the future, we hope that this case report contributes to the body of knowledge in the detection and management of white clot MIs in the context of rTPA efficacy.

Coronary Vasospasm Associated With Synthetic Marijuana Resulting in Transient Electrocardiogram Changes and Troponin Elevation.

Chest pain is a common presentation in the emergency department requiring prompt evaluation and risk stratification to assess for acute coronary syndrome versus non-cardiac causes. In the past, cocaine has been documented to be associated with the presentation of acute myocardial infarction. This case report describes a rare case of coronary vasospasm with transient electrocardiogram (EKG) changes and significantly elevated troponin in an individual presenting with a recent history of synthetic marijuana use. This report highlights the initial presentation, progression, and management of synthetic marijuana-associated coronary vasospasm mimicking the presentation of acute myocardial infarction. This is a unique case that describes not only the clinical presentation with dynamic EKG changes but also significantly elevated biomarkers, as would be seen with acute myocardial infarction. Challenges associated with synthetic marijuana-mediated coronary vasospasm are not only related to the management but also present a diagnostic challenge because it is not easily detected by urinary drug screen compared to traditional marijuana.

Abnormal Longitudinal Strain in Takotsubo Cardiomyopathy: A Case Report.

In recent years, the prognostic utility of global longitudinal strain (GLS) has evolved significantly in the evaluation and management of a wide array of cardiac conditions. Various studies have described the use of GLS in the evaluation of various cardiac pathologies, including heart failure, aortic stenosis, and acute myocardial infarction. Evaluation utilizing speckle-tracking echocardiography (Echo) has been shown to be sensitive in the assessment of global and regional myocardial function. In that context, GLS can be used as a surrogate marker of myocardial function, especially in cases of acute myocardial infarction. Although GLS has been shown as a sensitive marker for myocardial ischemia, it has been a significantly underutilized modality in the evaluation of Takotsubo cardiomyopathy (TC); an acute myocardial stress reaction, which can mimic acute coronary syndrome on presentation. With this case report, we present a case of left ventricular TC with abnormal longitudinal strain affecting the entirety of the apex and all three major coronary artery distribution territories. Our case report illustrates how GLS can be a sensitive marker for myocardial dysfunction in cases of TC. The extent of abnormality and distribution of strain has a pathognomonic 'evil eye' appearance, which was described in previous studies and is consistent with TC. GLS may help identify patients with TC prior to proceeding with left heart catheterization and would be significantly beneficial in TC and may have further implications on the overall prognosis and management of TC in the future.

Improved Neurological Outcome in a Patient With Complicated Mitral Valve Endocarditis Treated With Daptomycin-Rifampin Regimen.

Complicated infective endocarditis (IE) with symptomatic neurological involvement is associated with a poor prognosis. Vancomycin is the first-line antibiotic employed for the treatment of IE as general resistance of Methicillin-resistant Staphylococcus aureus (MRSA) to vancomycin is low and the antibiotic is well tolerated. In this case report, we describe a case of severely complicated MRSA endocarditis initially treated unsuccessfully with vancomycin. Our patient presented with severe encephalopathy with multiple septic infarctions noted on imaging. After treatment with a daptomycin-rifampin regimen, significant clinical improvement was noted. Based on the findings of this case report, what remains to be analyzed further with future studies is whether the daptomycin-rifampin regimen effect is independent of initial vancomycin-based treatment as most cases of IE are first treated with vancomycin and are only transitioned into daptomycin-rifampin regimen after treatment failure or persistent positive blood cultures, as is described in this case.

COVID-19 Myocarditis: Rationale for Early Diagnosis and Intervention.

Myocarditis is a common cardiovascular manifestation seen in patients diagnosed with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. However, because of the similarity of presentation with other cardiopulmonary pathologies, identification of coronavirus disease 2019 (COVID-19) related myocarditis can be challenging. Transthoracic echocardiography is a key component in initial diagnosis. COVID-19 related myocarditis is increasingly identified as an underlying problem in COVID-19 patients with low ejection fraction. Early recognition is critical with a low threshold for screening echocardiogram. Utilization of cardiac MRI (CMRI) can be helpful in recognition of early manifestations of COVID-19 myocarditis, with the added benefit of avoidance of invasive testing such as endomyocardial biopsy (EMB). Once diagnosis is established, disease-specific treatment can lead to rapid recovery of ventricular systolic function. We present a case series including two similar cases of COVID-19 myocarditis in which we utilized echocardiography as an early diagnostic tool and prompt treatment led to better prognosis.