From the Gut to the Heart: A Rare Case of Salmonella dublin Pericarditis.

BACKGROUND Salmonella infections manifest typically as self-limiting gastroenteritis after the consumption of contaminated food. Extra-intestinal manifestations of Salmonella infections such as pericarditis are rare and are usually seen in severely immunocompromised individuals. Prior case reports suggest high rates of morbidity and mortality associated with Salmonella pericarditis. Here, we present a rare case of Salmonella dublin pericarditis. CASE REPORT A 45-year-old man presented to the Emergency Department reporting chest pressure and shortness of breath. An echocardiogram showed a large pericardial effusion without tamponade physiology. Pericardial window was performed, with removal of 700 cubic centimeters of bloody fluid, with presence of fibrinous debris in the pericardial cavity. A pericardial biopsy showed chronic pericarditis, and a lymph node biopsy was negative for malignancy. Antinuclear antibody (ANA), Lyme antibodies, and human immunodeficiency virus (HIV) testing were negative. Tissue culture revealed Salmonella species. Subsequent blood cultures grew Salmonella spp. Further history-taking revealed frequent travel and recent treatment with steroids for suspected Bell's palsy. Initially, the patient was treated with ceftriaxone, which was switched to ciprofloxacin after susceptibility testing revealed ceftriaxone resistance. Final identification of the organism revealed Salmonella dublin. The patient was discharged on colchicine, ibuprofen, and a 4-week course of ciprofloxacin. Outpatient follow-up showed improvement in inflammatory markers and symptoms. CONCLUSIONS This case illustrates the rarity of Salmonella-associated pericarditis, the importance of assessing a patient's risk factors, and obtaining an extensive history when searching for an etiology of pericarditis. Investigation into why a patient was susceptible to an infection with this organism should include medication assessment and age-appropriate cancer screening. Prompt identification and treatment of the offending organism can help prevent mortality.

A complete heart block in a young male: a case report and review of literature of cardiac sarcoidosis.

Cardiac sarcoidosis is one of the uncommon causes of heart failure. Generally, it presents in the form of varying clinical manifestations ranging from asymptomatic to fatal arrhythmias such as ventricular tachycardia and complete heart block. It is difficult to make a diagnosis strictly based on clinical grounds. However, in the setting of extracardiac sarcoidosis and patients presenting with advanced heart block or ventricular arrhythmia, direct cardiac involvement should be suspected. The definitive diagnosis of cardiac sarcoidosis can be made from endomyocardial biopsy, but it is falling out of favor due to patchy myocardial involvement, considerable procedure-related risks, and advancement in additional imaging modalities. Once cardiac sarcoidosis has been diagnosed, management of the disease remains challenging. Steroids are considered the mainstay of therapy, and implantable cardioverter defibrillator therapy can be considered in a selected group of patients at greater risk for malignant ventricular arrhythmias.

Severe Ketoacidosis Associated with Canagliflozin (Invokana): A Safety Concern.

Canagliflozin (Invokana) is a selective sodium glucose cotransporter-2 (SGLT-2) inhibitor that was first introduced in 2013 for the treatment of type 2 diabetes mellitus (DM). Though not FDA approved yet, its use in type 1 DM has been justified by the fact that its mechanism of action is independent of insulin secretion or action. However, some serious side effects, including severe anion gap metabolic acidosis and euglycemic diabetic ketoacidosis (DKA), have been reported. Prompt identification of the causal association and initiation of appropriate therapy should be instituted for this life threatening condition.

Prevalence of masked hypertension in African Americans.

Masked hypertension (MH), the presence of normal office blood pressure (BP) with elevated ambulatory pressure, has been shown to correlate with organ damage. Population-based studies from Europe and Asia estimate a prevalence of 8.5% to 15.8%. Two small studies in African Americans estimate a prevalence >40%. Therefore, the authors utilized ambulatory BP monitoring (ABPM) to identify the prevalence of MH in our African American population. Pressure was recorded every 30 minutes while awake and every 60 minutes while asleep. Patients with 24-hour average BP ≥ 135/85 mm Hg, awake average BP ≥ 140/90 mm Hg, or asleep average BP ≥ 125/75 mm Hg had MH. Seventy-three participates had valid data. The mean age of the patients was 49.8 years, mean body mass index was 31.1, and 39 patients (53%) were women. Thirty-three patients (45.2%) had MH. Patients with MH had higher clinic systolic BP and trended toward higher BMI values. The authors corroborated the high prevalence of MH in African Americans. ABPM is critical to diagnose hypertension in African Americans, particularly in those with high-normal clinic pressure and obesity.

Difficult-to-wean: High index of suspicion.

PATIENT: Female, 57 FINAL DIAGNOSIS: Syryngomyelia • cervical SYMPTOMS: Acute respiratory insufficiency Medication: - Clinical Procedure: - Specialty: Pulmonology. OBJECTIVE: Rare disease. BACKGROUND: Failed planned extubation occurs in a minority of patients with acute respiratory failure requiring invasive mechanical ventilation. In patients presenting with acute respiratory failure with no identifiable cardiopulmonary causes, uncommon conditions, such as cervical spondylotic myelopathy, should be considered. In very rare instances, when cervical spondylotic myelopathy and syringomyelia present concomitantly, they can be devastating. CASE REPORT: A 57-year-old woman visited the emergency room (ER) after feeling unwell for several days. She was brought to the ER with acute respiratory distress and obtunded state with GCS of 6/15. She was hypotensive and agonally breathing. Her initial neurologic evaluation was unrevealing. Based on these findings, she was intubated. Over the next several days, she was difficult to wean from the ventilator and had persistent respiratory acidosis. After a short-lived extubation, the patient was again re-intubated. This time the neurologic evaluation showed decreased movements of all muscle groups against gravity and forces, with generalized weakness. An MRI of the brain and cervical spine demonstrated moderate degenerative disc disease and syringomyelia extending from C2 to C7 level. The patient underwent de-compression laminectomy. After failing several weaning trials, she underwent bronchoscopically-assisted tracheotomy. CONCLUSIONS: Acute cardiopulmonary and intensive care unit-acquired neuromuscular conditions have been attributed as a major cause of difficult weaning and extubation. Failure to identify and correct other rare combinations (such as cervical degenerative disc disease and syringomyelia) may cause acute respiratory failure and subsequent failure to wean and extubation, resulting in high rates of mortality and morbidity.

Acute warfarin toxicity: An unanticipated consequence of amoxicillin/clavulanate administration.

PATIENT: Male, 53 FINAL DIAGNOSIS: Acute Warfarin toxicity Symptoms: - MEDICATION: Warfarin Clinical Procedure: - Specialty: Hematology. OBJECTIVE: Unusual clinical course. BACKGROUND: Warfarin remains the most common anticoagulant in the management of thromboembolic diseases. However, its extensive drug interaction requires frequent monitoring and dose adjustments. Almost all antibiotics, including penicillins, have the potential to interact with warfarin causing either under or over anticoagulation which increases the risk for thrombus formation and significant bleeding respectively. CASE REPORT: A 53-year-old Caucasian male with a history of protein C deficiency and recurrent intravascular thrombosis developed a dental abscess. He was treated with amoxicillin/clavulanate 500/125 mg twice daily and referred to a dentist. He developed significant bleeding after tooth extraction. INR was 20.4. He received fresh frozen plasma and vitamin K with resolution of bleeding. CONCLUSIONS: While rare, clinically significant prolonged prothrombin time and potentially life threatening bleeding can occur when amoxicillin/clavulanate is concomitantly administered with warfarin. Prompt recognition and intervention is necessary to avoid life threatening complications from warfarin-amoxicillin/clavulanate interaction.