Unraveling the Uncommon: A Case Report of Giant Cell Myocarditis and Examination of Existing Literature.

BACKGROUND Idiopathic giant cell myocarditis (IGCM) is an uncommon and frequently fatal type of myocarditis. It primarily affects young individuals and has the potential to result in heart failure and life-threatening arrhythmias. IGCM seems to be dependent on activation of CD4-positive T lymphocytes and can show improvement with treatment aimed at reducing T-cell function. We present a case of a 65-year-old patient who presented with features of acute heart failure refractory to guideline-directed medical therapy (GDMT), due to IGCM. A review of the natural history and treatment of IGCM is also presented. CASE REPORT A 65-year-old woman with multiple comorbidities was admitted to our hospital for ventricular tachycardia in the setting of progressive non-ischemic heart failure, unresponsive to GDMT. This led to further investigation, including an endomyocardial biopsy, which revealed inflammatory infiltration, with multinucleated giant cells and lymphocytes in the absence of granuloma formation, prompting a diagnosis of IGCM. An implantable cardioverter-defibrillator (ICD) was placed for secondary prevention of sudden cardiac death and the patient was initiated on combined immunosuppressive therapy. Owing to numerous comorbidities, she was determined to be unsuitable for a heart transplant. Unfortunately, she eventually died from complications secondary to the disease. CONCLUSIONS IGCM remains a challenging clinical diagnosis with a poor long-term outcome without heart transplantation. This case highlights the importance of considering atypical causes of heart failure in patients who do not respond to conventional therapies. Early recognition and appropriate management, involving medical and interventional approaches, are crucial in improving outcomes for patients with IGCM.

Gastric Lipomas: A Case Series and Review of the Literature.

Introduction: The purpose of this case series was to review a rare subset of tumors known as gastric lipomas, which are typically found incidentally. The motivation for this study arose from the identification of 2 cases within our institution in a short period. Case Presentation: The study involved a review of the diagnosis and management of 2 patients presenting with gastric lipomas at our institution after symptoms of gastrointestinal bleeding. With the advent of new radiologic investigations such as computed tomography and magnetic resonance imaging and advances in endoscopy, there are new approaches to identifying and managing these tumors. On further evaluation of the literature, we found that despite the availability of minimally invasive endoscopic techniques such as mucosal resection and submucosal dissection in the setting of large tumors, most patients tend to have to resort to surgical management. Conclusion: This case series underscores the rarity of gastric lipomas and their often-incidental discovery. Further investigation into endoscopic approaches for managing these tumors is needed, and additionally, there is a need to explore a potential association between gastric lipomas and malignancy, as chronic inflammation of the overlying mucosa may play a significant role.

Clinical predictors and outcomes of pulmonary infarction in patients with central pulmonary embolism.

BACKGROUND: Given the heterogeneity of predisposing factors associated with pulmonary infarction (PI) and the lack of clinically relevant outcomes among patients with acute pulmonary embolism (PE) complicated by PI, further investigation is required. METHODS: Retrospective study of patients with central PE in an 11-year period. Data were stratified according to the diagnosis of PI. Multivariable logistic regression analysis was used to analyze factors associated with PI development and determine if PI was associated with severe hypoxemic respiratory failure and mechanical ventilation use. RESULTS: Of 645 patients with central PE, 24% (n = 156) had PI. After adjusting for demographics, comorbidities, and clinical features on admission, only age (OR 0.98, CI 0.96-0.99; p = 0.008) was independently associated with PI. Regarding outcomes, 35% (n = 55) had severe hypoxemic respiratory failure, and 19% (n = 29) required mechanical ventilation. After adjusting for demographics, PE severity, and right ventricular dysfunction, PI was independently associated with severe hypoxemic respiratory failure (OR 1.78; CI 1.18-2.69, p = 0.005) and mechanical ventilation (OR 1.92; CI 1.14-3.22, p = 0.013). CONCLUSIONS: Aging is a protective factor against PI. In acute central PE, subjects with PI had higher odds of developing severe hypoxemic respiratory failure and requiring mechanical ventilation.

Focal Alveolar Hemorrhage Secondary to Hydralazine-Associated Antineutrophilic Cytoplasmic Antibody Vasculitis.

Hydralazine is rarely associated with antineutrophilic cytoplasmic antibody (ANCA) vasculitis. In the appropriate clinical scenario, such as in a patient with pulmonary, renal, or cutaneous manifestations, finding antibodies against nuclear and cytoplasmic neutrophil antigens may suggest drug-induced vasculitis after exposure to hydralazine. We present the case of an elderly man diagnosed with focal alveolar hemorrhage with elevated concentrations of anti-myeloperoxidase antibody, anti-proteinase-3 antibody, and antinuclear antibodies in the setting of prolonged hydralazine therapy. We observed a rapid clinical improvement with hydralazine discontinuation and systemic corticosteroids. We did not observe further disease activity while on mycophenolate mofetil six months later.

COVID-19 related biliary injury: A review of recent literature.

Since its emergence in 2019, it has become apparent that coronavirus 2019 (COVID-19) infection can result in multi systemic involvement. In addition to pulmonary symptoms, hepatobiliary involvement has been widely reported. Extent of hepatic involvement ranges from minor elevation in liver function tests (LFTs) to significant hepatocellular or cholestatic injury. In majority of cases, resolution of hepatic injury or improvement in LFTs is noted as patients recover from COVID-19 infection. However, severe biliary tract injury progressing to liver failure has been reported in patients requiring prolonged intensive care unit stay or mechanical ventilation. Due to the timing of its presentation, this form of progressive cholestatic injury has been referred to as COVID-19 cholangiopathy or post-COVID-19 cholangiopathy, and can result in devastating consequences for patients. COVID-19 cholangiopathy is recognized by dramatic elevation in serum alkaline phosphatase and bilirubin and radiologic evidence of bile duct injury. Cholangiopathy in COVID-19 occurs weeks to months after the initial infection and during the recovery phase. Imaging findings and pathology often resemble bile duct injury associated with primary or secondary sclerosing cholangitis. Etiology of COVID-19 cholangiopathy is unclear. Several mechanisms have been proposed, including direct cholangiocyte injury, vascular compromise, and cytokine release syndromes. This review summarizes existing data on COVID-19 cholangiopathy, including reported cases in the literature, proposed pathophysiology, diagnostic testing, and long-term implications.

Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis.

BACKGROUND: In prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE. METHODS: Large retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality. RESULTS: A total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20-1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05-1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18-1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02-1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0-1.05; p = 0.02) were independent predictors of adverse clinical outcomes. CONCLUSION: Among patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.

Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus.

INTRODUCTION: Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE. METHODS: This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up. RESULTS: Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE. CONCLUSION: We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT. HIGHLIGHTS: Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.

An 80-Year-Old Man with Ischemic Heart Disease Who Developed Thrombotic Thrombocytopenic Purpura Following Treatment with Ticagrelor.

BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is associated with widespread microvascular thrombosis, low platelet count, and hemolysis. Ticagrelor is a relatively new agent which functions as a reversible inhibitor of the P2Y12 receptor working to prevent platelet aggregation and is used with or without aspirin in patients with acute coronary syndrome to reduce the risk of myocardial infarction and stroke. We describe the case of an 80-year-old man with ischemic heart disease who developed this rare and potentially fatal adverse reaction known as TTP following treatment with ticagrelor. CASE REPORT We report the case of an 80-year-old man who presented with an acute change in mental status 4 months after initiating ticagrelor following percutaneous coronary intervention. Laboratory testing on presentation revealed evidence of microangiopathic hemolytic anemia, thrombocytopenia, and elevated creatinine levels, suggestive of acute renal failure. The combination of his clinical symptoms and laboratory findings were concerning for TTP, likely secondary to ticagrelor use. The patient was treated with therapeutic plasma exchange, systemic steroids, and hemodialysis, which led to resolution of the hemolysis and recovery of renal function. CONCLUSIONS Although the association between ticagrelor and TTP is rare, early recognition of this life-threatening complication is essential to decrease morbidity and mortality associated with TTP. Since ticagrelor is now more commonly used, it is important that clinicians be aware of this complication.

Coronavirus disease-19 infection and angioedema in African Americans: A case series.

Rationale: Few case series have described the simultaneous development of angioedema in patients with coronavirus 19 disease (COVID-19). Most of these reports were described in at-risk patients for developing bradykinin angioedema. Therefore, we aim to describe 5 African American patients who developed simultaneous COVID-19 and angioedema. Methods: This was a case series of hospitalized patients with simultaneous angioedema and COVID-19 infection in a single center from May 2020 to February 2022. We used descriptive statistics. The study was approved by the institutional review board. Results: Their median age was 55 years (range 28-66); all patients were African American, and 3/5 were males. All patients developed angioedema within a week of hospitalization. Two subjects had prior history of ACEI-related angioedema but were not exposed to ACEI recently, whereas 1 subject was on chronic lisinopril therapy for the last 3 years. All patients had orofacial involvement; the most common locations were lips (5/5) and tongue (3/5). None had histaminergic features of angioedema (either skin rash or peripheral eosinophilia). 4/5 subjects had respiratory symptoms and chest imaging features of COVID-19 pneumonia, whereas 3/5 subjects developed severe COVID-19 infection. Most patients were treated with standard combination of H1 and H2 blockers, and corticosteroids. A total of 2/5 subjects were intubated; one patient developed refractory tongue swelling, received tracheostomy for extubation, and died due to COVID-19 pneumonia. The median length of angioedema improvement was 44 hours (range 20-168 hours). The median length of hospital stay was 15 days (range 1-49). Conclusion: We described 5 cases of angioedema in COVID-19 patients that shared risk factors and features of bradykinin-related angioedema.

Nausea, Vomiting, and Dyspepsia Following Solid Organ Abdominal Transplant.

Background and objective Multiple comorbidities may contribute to high readmission rates post-transplant procedures. In this study, we aimed to assess the rates and factors associated with hospital readmissions for dyspeptic symptoms among transplant patients. Methods This was a retrospective analysis of adult patients who underwent solid organ transplants at our institution. Pregnant patients or those patients with preexisting gastroparesis were excluded from the study. Readmissions associated with the International Classification of Diseases (ICD) codes for nausea/vomiting, weight loss, failure to thrive, abdominal pain, and/or bloating were included. Factors associated with 30-day and frequent readmissions (two or more) were explored. Results A total of 931 patients with solid organ transplants were included; 54% had undergone kidney transplants while 34% were liver transplants. Of note, 30% were readmitted within the first 30 days after discharge following transplant while 32.3% had frequent readmissions. A post-transplant upper endoscopy (EGD) was performed in 34% with food residue discovered in 19% suggesting gastroparesis. However, since only 22% of these patients had a gastric emptying study, only 6% were formally diagnosed with gastroparesis, which was independently associated with both 30-day [odds ratios (OR): 2.58, 95% confidence intervals (CI): 1.42-4.69] and frequent readmissions (OR: 6.71, 95% CI: 3.45-13.10). The presence of pre-transplant diabetes (35%) was significantly associated with a diagnosis of gastroparesis following transplant (OR: 5.17, 95% CI: 2.79-9.57). The use of belatacept (OR: 0.63, 95% CI: 0.42-0.94, p=0.023) was associated with a decrease in the odds of 30-day readmissions. Conclusion A significant number of patients were readmitted due to dyspeptic symptoms after solid organ transplants. Diabetes and gastroparesis were significantly associated with higher odds of readmissions while the use of belatacept appeared to be a protective factor.

Risk factors associated with intubation and readmissions in patients with angioedema: A single-center experience al. / Ann Allergy Asthma Immunol 127 (2021) xxx-xxx"?>.

BACKGROUND: Given the heterogeneity of etiologies, pathophysiology, and presentation of angioedema, variations in clinical outcomes, such as intubation and hospital readmissions, need further clarification. OBJECTIVE: To determine the factors associated with intubation and hospital readmissions in patients with angioedema. METHODS: Retrospective study of patients evaluated with a diagnosis of angioedema in a 6-year period. Demographic and clinical data, such as medication use, family history, comorbidities, and symptoms, were recorded. Multivariable logistic regression was used to analyze factors associated with intubation, whereas Cox regression was used to analyze readmissions. RESULTS: Of 636 patients, the most common cause of angioedema was that induced by angiotensin-converting enzyme inhibitor (ACEI) at 58%. The overall mortality was 0.5%. After adjusting for sex, race, comorbidities, and type of angioedema, smoking (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.93; P = .02), calcium channel blocker therapy (OR, 1.91; 95% CI, 1.18-3.10; P = .009), histaminergic symptoms (OR, 3.21; 95% CI, 1.93-5.33; P < .001), and age (OR, 1.02; 95% CI, 1.00-1.04; P = .02) were independently associated with increased odds of intubation. Involvement of either the pharynx, larynx, or tongue was associated with higher odds of intubation (OR, 20.96; 95% CI, 10.63-41.33; P < .001). A total of 10% of the patients had a readmission for angioedema within 90 days, and 75% occurred within 30 days. After multivariable Cox regression analysis, only chronic obstructive pulmonary disease and asthma (OR, 2.13; 95% CI, 1.12-4.07; P = .02) and ACEI-related angioedema (OR, 2.93; 95% CI, 1.33-6.47; P = .008) were significantly associated with readmissions. CONCLUSION: Smoking, calcium channel blocker use, histaminergic symptoms, age, and upper airway involvement were markedly associated with intubation. The presence of chronic obstructive pulmonary disease, asthma and ACEI-related angioedema were independently associated with increased odds of readmission.

Spinal Cord Injury Increases Pro-inflammatory Cytokine Expression in Kidney at Acute and Sub-chronic Stages.

Accumulating evidence supports that spinal cord injury (SCI) produces robust inflammatory plasticity. We previously showed that the pro-inflammatory cytokine tumor necrosis factor (TNF)α is increased in the spinal cord after SCI. SCI also induces a systemic inflammatory response that can impact peripheral organ functions. The kidney plays an important role in maintaining cardiovascular health. However, SCI-induced inflammatory response in the kidney and the subsequent effect on renal function have not been well characterized. This study investigated the impact of high and low thoracic (T) SCI on C-fos, TNFα, interleukin (IL)-1ß, and IL-6 expression in the kidney at acute and sub-chronic timepoints. Adult C57BL/6 mice received a moderate contusion SCI or sham procedures at T4 or T10. Uninjured mice served as naïve controls. mRNA levels of the proinflammatory cytokines IL-1ß, IL-6, TNFα, and C-fos, and TNFα and C-fos protein expression were assessed in the kidney and spinal cord 1 day and 14 days post-injury. The mRNA levels of all targets were robustly increased in the kidney and spinal cord, 1 day after both injuries. Whereas IL-6 and TNFα remained elevated in the spinal cord at 14 days after SCI, C-fos, IL-6, and TNFα levels were sustained in the kidney only after T10 SCI. TNFα protein was significantly upregulated in the kidney 1 day after both T4 and T10 SCI. Overall, these results clearly demonstrate that SCI induces robust systemic inflammation that extends to the kidney. Hence, the presence of renal inflammation can substantially impact renal pathophysiology and function after SCI.

Comparison of Patient Clinical characteristics and Outcomes Between Different COVID-19 Peak Periods: A Single Center Retrospective Propensity Matched Analysis.

Introduction While Coronavirus disease 2019 (COVID-19) specific treatments have been instituted, overall mortality rates among hospitalized patients remain significant. Our study aimed to evaluate patient clinical characteristics and outcomes comparing the different COVID-19 infection peak periods. Methods This is a retrospective study of all adult patients hospitalized with a confirmed diagnosis of COVID-19 between March 1 to April 24, 2020 and November 1 to December 31, 2020, which corresponded to the first and second waves of COVID-19 infection in our institution, respectively. Demographic and clinical characteristics of the patients were compared and used for propensity matching. Clinical outcomes, such as need for intubation, renal replacement therapy and inpatient mortality were subsequently compared between the two groups. Results Patients in the second COVID-19 wave had a significantly higher body mass index (32.58 vs 29.83, p <0.001), as well as prevalence of asthma (14% vs 8%, p=0.019) and chronic kidney disease (42% vs 18%, p <0.001). Almost all patients in the second COVID-19 wave received corticosteroid treatment (99% vs 30%, p <0.001), and significantly more patients received remdesivir (43% vs 2%, p <0.001). Meanwhile, none of the patients in the second COVID-19 wave were treated with tocilizumab or hydroxychloroquine. Differences in clinical outcomes, such as need for renal replacement therapy or intubation, and median length of stay were not statistically significant. Inpatient mortality remained largely unchanged between the two COVID-19 peak periods. Discussion/ Conclusion In our institution, after propensity matched analysis, clinical outcomes such as need for renal replacement therapy, intubation and inpatient mortality remained unchanged between the two COVID-19 peak periods.

Examining the Rate of Clostridioides (Formerly Clostridium) Difficile Infection Pre- and Post-COVID-19 Pandemic: An Institutional Review.

Background/ Rationale Clostridioides difficile infection (CDI) is transmitted via the fecal-oral route and is implicated in antibiotic-associated colitis. Similar to CDI, patients with coronavirus disease 2019 (COVID-19) require early identification and isolation, appropriate personal protective equipment, and environmental disinfection to prevent further transmission. In light of this similarity between isolation and protective requirements to prevent transmission of these diseases, we aim to investigate whether there was a decrease in the incidence of CDI during the peak periods of the COVID-19 pandemic compared to historical rates. Methods This is a single-center retrospective analysis of the rates of CDI in our institution. COVID-19 time periods were identified from March 2020 to January 2021 and peak periods (with >50 active patients per day) were defined. The non-COVID-19 periods were July 2017 to February 2020. Rates of CDI were also directly compared across the yearly time period. CDI rates were presented in a per 1000 patient days format. Rates were analyzed per year and during the COVID-19 peaks at our institution. Mann-Whitney U test was used to compare rates between two time periods, while differences across multiple time intervals were analyzed using the Kruskal-Wallis test. Results The median (interquartile range [IQR]) of CDI rates of infection per 1000 patient days for the non-COVID time period from July 2017 to February 2020 was 0.34 (0.23-0.45) while COVID time periods had higher 0.44 (0.25-0.51) rates of CDI although this was not statistically significant (p=0.224). However, there was a statistically significant difference (p=0.036) with COVID peak periods having higher rates of CDI 0.49(0.39-0.74) vs 0.34(0.23-0.44). Overall, there was no statistically significant difference in the rates of CDI across years or time periods (p=0.396). Discussion/Conclusion There was no difference in the rates of hospital-acquired CDI between COVID-19 and non-COVID-19 time periods at our institution.