Kidney dysfunction due to AA amyloidosis in a morbidly obese female.

Kidneys are commonly involved in systemic amyloidosis. Systemic AA amyloidosis is known to be associated with states of chronic inflammation such as autoimmune conditions, chronic infections, and malignancies. Obesity is increasingly recognized to be a risk factor for low-grade, chronic inflammation. We report a 48-year-old female with morbid obesity who presented with unexplained persistent mild kidney dysfunction and low-grade proteinuria. Attempt at evaluating the cause of kidney dysfunction included performing kidney biopsy despite technical challenges. Kidney biopsy showed AA amyloidosis with predominant vascular deposition, explaining the absence of nephrotic-range proteinuria. Evaluation for secondary causes of systemic AA amyloidosis was negative. While our patient was treated with sleeve gastrectomy for morbid obesity with reasonable response, it is likely that ongoing chronic inflammation, reflected by her laboratory markers, resulted in AA amyloidosis. Treatment with anakinra, an interleukin-1 antagonist, led to improvement in the laboratory markers in the next 6 months, and her kidney function remained stable. This report highlights an important cause of kidney dysfunction in morbid obesity, an atypical presentation of AA amyloidosis, and emphasizes the value of kidney biopsy in such patients.

Spindle Cell Hemangioma of the Lung: A Case Report.

Spindle cell hemangioma (SCH) is an uncommon tumor that usually presents as a subcutaneous or deep dermal nodule affecting the extremities of young people. It is primarily a benign vascular neoplasm with a tendency to recur locally. Reports describing SCH diagnosed in muscles, retroperitoneum, mediastinum, and even in the spinal cord occasionally surface in the literature. We report a very rare case of SCH diagnosed in the lung.

Sex Disparity in the Effect of Obesity in Hospitalized COVID-19 Patients: A Retrospective Cohort Study From the New York City Metropolitan Area.

INTRODUCTION:  Obesity has been recognized as a risk factor for poor outcomes in coronavirus disease 2019 (COVID-19) illness. We analyzed the impact of patient characteristics including obesity on hospital mortality and specifically analyzed the effect of obesity by body mass index (BMI) class and by sex. METHODS:  This retrospective case series included adult patients consecutively hospitalized with confirmed COVID-19 illness between March 12, 2020 and May 13, 2020, at a teaching hospital in the New York City (NYC) metropolitan area. Data were manually extracted from electronic health records by the authors and included demographics, comorbidities, laboratory parameters, and outcomes (hospital mortality or discharge). We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. RESULTS:  Some 348 patients were included in this study, of whom 207 were discharged and 141 died in the hospital. Multivariable regression showed increasing odds of in-hospital death with older age and excess weight. Interestingly obesity increased mortality in women [odds ratio (OR) 4.4, confidence interval (CI) (1.4-13.5) p=0.01] but not among men [OR 1.4, CI (0.5-3.6) p=0.5]. Among women, the effect of excess weight on mortality was seen in a "dose-effect" fashion, with increasingly higher odds of mortality from progressively worsening obesity (OR ranging between 2.7 and 6.9). Out of all the comorbidities, only obesity positively correlated with peak levels of C-reactive protein (CRP). CONCLUSION:  Advancing age is a risk factor for in-hospital death during COVID-19 illness. Obese women could be at a higher risk for mortality due to COVID-19 and should take extra precautions to prevent contamination by social distancing and other measures. Immunomodulators may be more effective in obese women affected by COVID-19. Further studies are needed to help elucidate this association.

Arrhythmia prevalence among patients with polymyositis-dermatomyositis in the United States: An observational study.

BACKGROUND: Systemic inflammation has been associated with atherosclerotic cardiovascular diseases (ASCVD) and arrhythmia occurrence in rheumatologic conditions such as rheumatoid arthritis. Polymyositis and dermatomyositis (PD) are rare rheumatologic conditions characterized by symmetrical proximal muscle weakness and, in the case of dermatomyositis, cutaneous eruption. Although there is literature associating PD with ASCVD, no population-level studies have analyzed arrhythmia risk in PD. OBJECTIVE: The purpose of this study was to assess the prevalence of arrhythmia and its subtypes by age and sex in patients with PD and to determine associations between arrhythmia and PD. METHODS: This retrospective cohort study included adults for whom hospitalizations had been recorded in the National Inpatient Sample database in the United States between 2016 and 2018. Patients with PD were matched (1:10) by age to patients without PD. Prevalence of arrhythmia was calculated in the 2 groups and compared by sex and age groups. Associations between PD and arrhythmia were determined after adjustment for common arrhythmia risk factors. RESULTS: From 107,001,355 hospitalizations, 32,085 adults with PD were matched to 320,850 controls. Patients with PD aged <70 years had a higher prevalence of arrhythmia and higher adjusted odds of arrhythmia compared with controls. This increased risk was only seen for supraventricular arrhythmias. Adults with PD had increased odds of in-hospital mortality if they had an arrhythmia diagnosis (odds ratio 3.3; 95% confidence interval 2.5-4.5; P <.001). CONCLUSION: We found a higher prevalence and odds of arrhythmias, particularly supraventricular arrhythmias, in young and middle-aged patients with PD compared with matched controls. Arrhythmias were associated with significant mortality among patients with PD.

Atherosclerotic Cardiovascular Disease Prevalence Among Patients With Celiac Disease in the United States: An Observational Study.

OBJECTIVE: To assess the prevalence of atherosclerotic cardiovascular disease (ASCVD) by age and sex in patients with celiac disease and to determine associations between ASCVD and celiac disease. PATIENTS AND METHODS: This is a retrospective cohort study which included adults (>18 years old) who had hospitalizations recorded in the National Inpatient Sample database in the United States from January 1, 2005, to December 31, 2014. Patients with celiac disease were matched (1:5) by age, sex, race, and calendar year to patients without celiac disease. Prevalence of ASCVD was calculated in patients with celiac disease and controls, and compared by sex and age groups. Associations between celiac disease and ASCVD were determined after adjustment for common cardiovascular risk factors. RESULTS: Among 371,776,860 patients hospitalized in the United States between 2005 and 2014, 227,172 adults with celiac disease were matched to 1,133,701 controls. Young women with celiac disease (age <40 years) had a higher prevalence of ASCVD and higher adjusted odds (aOR) of ASCVD when compared with controls (aged 18 to 29 years aOR, 2.22 [95% CI 1.41 to 3.5]; P<.001; and aged 30 to 39 years aOR 1.54 [95% CI 1.19 to 1.99]; P<.001). Adults with celiac disease of all ages and sexes had increased adjusted odds of death if they had ASCVD (aOR aged <40 years 7.31 [95% CI 2.49 to 21.46]; P<.001; and aOR aged ≥40 years 2.02 [95% CI 1.68 to 2.42]; P<.001). CONCLUSION: We found significantly higher prevalence and adjusted odds of ASCVD in young women with celiac disease when compared with matched controls. ASCVD was associated with significant mortality among patients with celiac disease.

Thyrotoxic Periodic Paralysis Causing Back Pain and Leg Weakness: An Unusual Presentation of Hyperthyroidism.

Thyrotoxic periodic paralysis (TPP) is a rare muscular disorder, characterized by muscle weakness and hypokalemia triggered by thyrotoxicosis. In Asian populations, 2% of patients with thyrotoxicosis are affected, compared to only 0.1-0.2% of non-Asians. The vast majority of patients are male. Muscle weakness ranges in severity from very mild to life-threatening, due to respiratory compromise. We present a case of a previously healthy 39-year-old Hispanic male who presented with sudden quadriparesis and quickly recovered after being treated for hypokalemia and thyrotoxicosis. TPP, although unusual, is important to recognize as it is a potentially fatal condition that requires close monitoring and is readily reversible with appropriate therapy. Any cause of thyroid hormone excess can cause TPP, with Graves' disease being the most common etiology. Acute treatment includes potassium repletion, while long-term management focuses on determining and treating the cause of thyrotoxicosis, since maintaining a euthyroid state will prevent further episodes of TPP.

End-Stage Renal Disease Patients on Chronic Hemodialysis Fare Better With COVID-19: A Retrospective Cohort Study From the New York Metropolitan Region.

Introduction Several comorbid conditions have been identified as risk factors in patients with coronavirus disease 2019 (COVID-19). However, there is a dearth of data describing the impact of COVID-19 infection in patients with end-stage renal disease on hemodialysis (ESRD-HD). Methods This retrospective case series analyzed 362 adult patients consecutively hospitalized with confirmed COVID-19 illness between March 12, 2020, and May 13, 2020, at a teaching hospital in the New York City metropolitan area. The primary outcome was severe pneumonia as defined by the World Health Organization. Secondary outcomes were the (1) the Combined Outcome of Acute respiratory distress syndrome or in-hospital Death (COAD), and (2) need for high levels of oxygen supplementation (HiO2). Results Patients with ESRD-HD had lower odds for poor outcomes including severe pneumonia [odds ratio (OR) 0.4, confidence interval (CI) 0.2-0.9, p=.04], HiO2 [OR 0.3, CI (0.1-0.8), p=.02] and COAD [OR 0.4, CI (0.2-1.05), p=.06], when compared to patients without ESRD. In contrast, higher odds for severe pneumonia, COAD and HiO2 were seen with advancing age. African Americans were over-represented in the hospitalized patient cohort, when compared to their representation in the community (35% vs 18%). Hispanics had higher odds for severe illness and HiO2 when compared to Caucasians. Conclusions Patients with ESRD-HD had a milder course of illness with a lower likelihood of severe pneumonia and a lesser need for aggressive oxygen supplementation when compared to patients not on chronic dialysis. The lower odds of severe illness in ESRD-HD patients might have a pathophysiologic basis and need to be further explored.

Analysis of Male Sex as a Risk Factor in Older Adults With Coronavirus Disease 2019: A Retrospective Cohort Study From the New York City Metropolitan Region.

Background Advancing age and male sex have been identified as risk factors for poor outcomes in coronavirus disease 2019 (COVID-19). However, there is a dearth of data investigating the impact of age on the risk reported with male sex. We aimed to determine the risk associated with male sex in people of different age groups, that is, in people younger or older than 65 years of age. Methods This is a retrospective cohort study that included 370 adult patients hospitalized with COVID-19 between March 12, 2020, and May 13, 2020, at a 242-bed teaching community hospital in the New York City metropolitan region. Patients were classified into younger (age<65 years, n=132) and older individuals (age>=65, n=238). We calculated odds ratios for poor outcomes in men compared to women separately in these two groups. Results Among older individuals, there was no difference in the odds of poor outcomes between men and women. In contrast, among younger people, men had higher odds of severe pneumonia, need for high oxygen support, acute kidney injury and acute liver injury when compared to women. Conclusions Among people older than 65 years, sex did not impact disease severity and outcomes in COVID-19. Thus, older women were equally likely to have severe COVID-19 when compared to age-matched men. In contrast, among younger middle-aged adults (29-64 years), men had higher odds of end-organ damage from COVID-19 compared to women. Based on these observations, age is a more important driver of poor outcomes in COVID-19 than sex. Public health policies need to create awareness for the increased risk of older individuals to COVID-19, regardless of sex.

Incidence and Risk Factors for Acute Kidney Injury and Its Effect on Mortality in Patients Hospitalized From COVID-19.

OBJECTIVE: To determine the incidence of and risk factors for the development of acute kidney injury (AKI) and investigate the association between AKI and mortality in patients hospitalized with coronavirus disease 2019 (COVID-19) infection. PATIENTS AND METHODS: This retrospective case series includes the first 370 patients consecutively hospitalized with confirmed COVID-19 illness between March 10, 2020, and May 13, 2020, at a 242-bed teaching hospital. To determine independent associations between demographic factors, comorbid conditions, and AKI incidence, multivariable logistic regression models were used to estimate odds ratios adjusted for clinical covariates. RESULTS: Median age of patients was 71 (interquartile range, 59-82) years and 44.3% (145 of 327) were women. Patients with AKI were significantly older with a higher comorbid condition burden and mortality rate (58.1% [104 0f 179] vs 19.6% [29 of 148]; P<.001) when compared with those without AKI. Increasing age, chronic kidney disease, hyperlipidemia, and being of African American descent showed higher odds of AKI. Patients with AKI had significantly higher odds of mortality when compared with patients without AKI, and this effect was proportional to the stage of AKI. Increasing age and acute respiratory distress syndrome also revealed higher adjusted odds of mortality. CONCLUSIONS: Acute kidney injury is a common complication among hospitalized patients with COVID-19 infection. We found significantly higher odds of AKI with increasing age and among patients with hyperlipidemia, those with chronic kidney disease, and among African Americans. We demonstrate an independent association between AKI and mortality with increasingly higher odds of mortality from progressively worsening renal failure in hospitalized patients with COVID-19 infection.

Dextrocardia: When right is wrong!

INTRODUCTION/BACKGROUND: Dextrocardia is a malposition of the heart in the thoracic cavity. Dextrocardia has been known to cause diagnostic dilemmas with atypical presentations in acute coronary syndrome, as well as technical challenges in patients who require interventions such as coronary catheterization, transcutaneous aortic valve replacement, ablation for arrhythmias, or pacemaker/defibrillator placement. Transcription factor Pitx2 has been shown to have a fundamental role during cardio-genesis, and its misexpression has been implicated in arrhythmogenesis and congenital heart diseases including visceral situs inversus. This association between congenital heart diseases and arrythmias is intriguing and need exploring. We aimed to quantify the likelihood of arrhythmias in patients with dextrocardia. MATERIALS AND METHODS: A descriptive, retrospective study was conducted on the National Inpatient Sample (NIS) databases for the year 2016. Patients with dextrocardia and arrhythmias were selected based on appropriate diagnostic codes. We used propensity score-matching to assemble a matched cohort in which adults with dextrocardia and controls balanced on measured baseline characteristics. This was done to reduce the confounding effect of between-group imbalances on outcomes. Complex survey design, weights, and clustering were accounted for during analysis. Multivariate regression analysis was performed to determine the relationship of arrhythmias and length of hospitalization with dextrocardia. RESULTS: The prevalence of arrhythmias in patients with dextrocardia was significantly higher than the control group. Overall, the odds of arrhythmia were higher for patients in the dextrocardia group when compared to a propensity matched control group [adjusted Odds ratio OR 2.60, Confidence Interval (CI) (1.67-4.06), p<0.001]. When looking at only principal/primary diagnosis on admission, the odds of an admitting diagnosis of arrhythmia were significantly higher in the dextrocardia group when compared to the matched cohort [adjusted OR 3.70, CI (1.26-10.89), p 0.02]. The increased odds of arrhythmia in dextrocardia patients were mostly accounted for by the increased odds of atrial fibrillation/atrial flutter [OR 3.06, CI (1.02-9.18), p 0.046] in these patients. No significant difference was found in the odds of other arrhythmias or the length of stay between the two groups. CONCLUSION: In a large inpatient population, patients with dextrocardia were more likely to have arrhythmias especially atrial fibrillation/atrial flutter than patients without dextrocardia. Ours is the first study that investigates the clinical manifestations of molecular and embryologic associations between congenital heart disease and arrhythmias.