Capnocytophaga canimorsus infection led to progressively fatal septic shock in an immunocompetent patient.

BACKGROUND: Capnocytophaga canimorsus infection is rare, with a high fatality rate; however, there are few cases of death with a rapid course. This study reports a progressively fatal case of C. canimorsus. CASE PRESENTATION: A 68-year-old immunocompetent Japanese man was bitten and scratched on his right hand by a dog 6 days before emergency transportation to the emergency room with abdominal pain, back pain, and melena. The patient developed multiple-organ failure. Despite antibiotic therapy, transfusion, vasopressor therapy, and continuous renal replacement therapy, the patient died from uncontrolled metabolic acidosis 4.5 h after admission. Approximately 80 h after admission, blood cultures were positive for C. canimorsus. CONCLUSIONS: Capnocytophaga canimorsus infection can lead to rapid progression even in immunocompetent patients.

Electrical alternans induced by a brief period of myocardial ischemia during percutaneous coronary intervention: The characteristic ECG morphology and relationship to mechanical alternans.

BACKGROUND: Electrical alternans (EA) has not been fully studied in the current percutaneous coronary intervention (PCI) procedure. OBJECTIVE: The purpose of this study was to evaluate visible EA and the morphology of ST segment during PCI. METHODS: The incidence of visible EA and ST-segment morphology were studied while the coronary artery was occluded for 20 seconds. When data were available, the relationship between EA and blood pressure was analyzed. The clinical and electrocardiographic data were compared with those of the age- and sex-matched controls. RESULTS: During balloon inflation, visible EA was observed in 5 of 306 patients (1.6%) in the last 2 years. EA was limited to PCI in the proximal left anterior descending artery. The ST segment elevated to 10.1 ± 3.2 mm, followed by an alternating QRS complex with a lower ST segment (5.6 ± 1.9 mm; P = .0047) with characteristic ST-segment morphology, which is known as lambda pattern. The mean age of the 5 patients was 68 ± 20 years, and 4(80%). were men. After the release of inflation, the ST-segment level returned rapidly to baseline, followed by normalization of J point. Compared with controls, the maximal elevated ST segment was significantly higher in patients with EA (5.7 ± 2.7 mm; P = .0028). The occlusion of the proximal left anterior descending artery with more severe ischemia seemed to be a prerequisite for developing EA. A higher ST segment was associated with a lower blood pressure and vice versa. CONCLUSION: A short period of ischemia during PCI may induce visible EA and alternating QRS complexes with a characteristic ST-segment morphology. A higher ST segment was associated with a lower blood pressure and vice versa.

Long-term PT-INR levels and the clinical events in the patients with non-valvular atrial fibrillation: a special reference to low-intensity warfarin therapy.

BACKGROUND: Anticoagulation therapy is essential in atrial fibrillation (AF), and in Japan, less intense control is popular. PURPOSE: To assess the efficacy and safety with a special reference to low intensity warfarin therapy. SUBJECTS AND METHODS: In 488 out of 508 patients with non-valvular AF, prothrombin time-international normalized ratio (PT-INR) was kept at 1.6-2.59, and they were followed for 49.5 months: 2098 person-years. The mean age was 73.7±9.9 years and 62% were male. The patients were divided by age: ≥70 years and <70 years, and by the intensity of warfarin therapy: PT-INR at 1.6-1.99 and at 2.0-2.59, respectively. The clinical data and event rates, ischemic stroke and major bleeding, were compared among the subgroups. RESULTS: Heart failure, previous stroke, and higher CHADS2 score were more often reported in patients ≥70 years while males were involved more often as younger patients. A total of 166 of 339 patients ≥70 years and 69 of 149 patients <70 years belonged to the low intensity group. Ischemic stroke and major bleeding occurred in 1.47%/year and 1.27%/year, respectively but there was no difference between the two age groups and between the two intensities of warfarin therapy. Time in therapeutic range was a predictor for ischemic stroke. A fall of PT-INR to <1.6 was found in 41.9% with ischemic stroke and a rise >2.61 in 40.0% with major bleeding at the time of the events. Blunt trauma and concomitant use of antiplatelets were risks for intracranial hemorrhage in the patients ≥70 years. CONCLUSIONS: The event rates were similar between the low- (1.6-1.99) and high- (2.0-2.59) intensity warfarin therapy groups in aged patients: <70 years and ≥70 years. Time in therapeutic range and a transient fall or rise in PT-INR were risks for clinical events. Blunt head trauma and concomitant use of antiplatelets were risks for intracranial hemorrhage.

J-waves in patients with an acute ST-elevation myocardial infarction who underwent successful percutaneous coronary intervention: prevalence, pathogenesis, and clinical implication.

AIMS: The prevalence, clinical significance, and pathogenesis of J-waves were studied in the patients with an ST-elevation myocardial infarction (MI) after percutaneous coronary intervention (PCI). METHODS AND RESULTS: One hundred and fifty-two consecutive patients with an acute ST-elevation MI were included. The mean age was 68.6 ± 13.5 years, and 78.3% of the patients were male. Following successful PCI, 12-lead electrocardiograms (ECGs) were monitored, and J-waves were measured 1 week after the MI and analysed in relation to the location of the MI and arrhythmias. Clinical and ECG parameters were compared between the groups with and without J-waves. The rate dependency of the J-wave amplitude was analysed in the conducted atrial premature beats (APBs). J-waves were present in 60.5% (≥0.1 mV) or 48.9% (≥0.2 mV) of the 152 patients. The J-waves were more often located in the inferior leads and more frequently in an inferior MI. The presence of J-waves was associated with ventricular arrhythmias, including ventricular fibrillation. The J-wave amplitude increased in the conducted APB, mechanistically suggesting a phase 3 block. CONCLUSION: Many patients in the early recovery phase after an acute MI had J-waves. This ECG phenomenon was associated with an increased incidence of ventricular arrhythmias. The tachycardia-dependent augmentation of the J-wave amplitude suggested a mechanistic role of conduction delay.