Recurrent Intra-Stent Coronary Restenosis in a Carrier of Non-Disease-Specific Antinuclear Antibodies.

Intracoronary in-stent restenosis (ISR) is a phenomenon that generally occurs between 3 and 6 months after stent placement. With the introduction of drug-eluting stents (DES), the incidence of ISR has decreased but not disappeared. We report a case of reiterant in-stent restenosis of an 81-year-old female patient who underwent multiple percutaneous coronary intervention and two coronary artery bypass surgeries. ISR is possibly associated with extra-stent, stent-related and intra-stent factors. Here, we excluded the first two and focused on the intra-stent factors that seem more likely in our case. A challenging diagnostic workup led us to the hypothesis of a coronary vasculitis potentially triggered by some component of the stent in a predisposed patient carrier of non-disease-specific ANA, with an exaggerated immune response. No recurrence of ISR occurred after the introduction of steroids. Biological and intra-stent causes of ISR should be taken into careful consideration to aim for the early detection of the underlying mechanism of restenosis and to embrace the best therapeutic strategy. LEARNING POINTS: Intra-stent restenosis is possibly associated with extra-stent, stent-related and intra-stent factors.Coronary vasculitis is potentially triggered by some component of the stent in a predisposed patient.Immunosuppressive treatment should be taken into consideration in case of recurrent intra-stent restenosis.

Pericardial anisakiasis: unravelling diagnostic challenges in an unprecedented extra-abdominal manifestation: a case report.

Background: Anisakis infects humans by consuming contaminated undercooked or raw fish, leading to gastric anisakiasis, gastro-allergic anisakiasis, or asymptomatic contamination. Although larvae usually die when penetrating the gastric tissue, cases of intra- and extra-abdominal spread were described. We report the first probable case of pericardial anisakiasis. Case summary: A 26-year-old man presented to the emergency department because of progressive lower limb oedema and exertional dyspnoea. Two months prior, he had consumed raw fish without any gastrointestinal symptoms. The echocardiogram reported a circumferential pericardial effusion ('swinging heart') and mildly reduced left ventricular ejection fraction (LVEF). He was diagnosed with myopericarditis after a cardiac magnetic resonance. A fluorodeoxyglucose positron emission tomography scan revealed an intense pericardial metabolism. Blood tests exhibited persistent eosinophilia and mild elevation of Anisakis simplex IgE-as for past infestation. A pericardial drainage was performed, subsequently, serial echocardiograms revealed a spontaneous recovery of his LVEF. No autoimmune, allergic, or onco-haematologic diseases were identified. Based on a history of feeding with potentially contaminated raw fish and on long-lasting eosinophilia, we suspected a pericardial anisakiasis, despite a low but persistent titre of specific IgE. Albendazole was administered for 21 days, along with colchicine and ibuprofen for 2 months; pericardial effusion resolution and eosinophil normalization occurred two weeks after. Discussion: We hypothesized that Anisakis larvae may have migrated outside the gastrointestinal tract, penetrating the diaphragm and settling in the pericardium, causing pericarditis and pericardial effusion. Clinicians should know that the pericardium may be another extra-abdominal localization of anisakiasis, beyond pleuro-pulmonary involvement.

Diagnostic delays in modern medicine. A case report.

Modern medicine has evolved toward ultra-specialization and sectoralization of medical specialties. This approach may provide an advantage for the quality of care of a single disease but implies the risk of not appropriately addressing comprehensive care. It may sometimes result in overall diagnostic delays due to the prescription of additional diagnostic tests, that could be appropriate considering the single specialist approach but do not consider the overall clinical context of the patient. We describe the case of a patient with multiple comorbidities, who experienced a multiple specialistic approach, without a holistic view.

Infective endocarditis in octogenarians. A retrospective study in a single, high-volume surgical centre.

BACKGROUND: Infective endocarditis (IE) is a severe disease associated with high morbidity and mortality. Little is known about the best management of elderly patients with IE. In these patients, surgery may be challenging. Our study aimed to describe IE's features in octogenarians and to identify the independent predictors of mortality, focusing on the prognostic impact of disability. METHODS: We retrospectively analyzed 551 consecutive patients admitted to a single surgical centre with a definite diagnosis of non-device-related infective endocarditis; of these, 97 (17.6%) were older than 80 years. RESULTS: In patients under eighty, males were mostly involved with a sex ratio exceeding 2:1. This ratio was inverted in older people, where the female gender represented 53.6% of the total. Enterococci (29.8 vs. 17.4%, p = 0.005) were significantly more frequent than in younger people. Comorbidities were more frequent in elderly patients; consequently, EuroSCORE II was higher (median ± IQR 16.4 ± 21.1 vs. 5.0 ± 10.3, p = 0.001). In octogenarians, IE was more frequently left-sided (97.9 vs. 89.8%, p = 0.011). Octogenarians were more often excluded from surgery despite indication (23.7 vs. 8.1%, p = 0.001) and had higher three-year mortality (45.3 vs. 30.6%, p = 0.005) than younger patients. In elderly patients, age did not independently predict mortality, while exclusion from surgery and a high grade of disability did. CONCLUSIONS: Octogenarians with IE have specific clinical and microbiological characteristics. Older patients are more often excluded from surgery, and the overall prognosis is poor. Age per se should not be a reason to deny surgery, while disability predicts futility.

Mesalazine-induced myopericarditis: a case series.

Background: Inflammatory bowel diseases (IBD) are characterized by chronic inflammation of the gastrointestinal tract but can have multiorgan involvement. Mesalazine (5-ASA) is a key therapeutic agent in IBD. Mesalazine has rare but potentially life-threatening side effects such as cardiac injury. Case summary: We present two cases of myopericarditis, documented also with cardiac magnetic resonance, that we attributed to 5-ASA hypersensitivity: the first is a young woman with ulcerative colitis who developed myopericarditis after the initiation of 5-ASA, with a good clinical response after discontinuation; the second is a 79-year-old man who developed symptoms of heart failure after the diagnosis of IBD and the introduction of 5-ASA. Discussion: Mesalazine may cause rare but potentially life-threatening cardiac injury, which can be difficult to distinguish from acute IBD-induced cardiac inflammation.

Impact of cardiac surgery on left-sided infective endocarditis with intermediate-length vegetations.

OBJECTIVE: The best strategy to manage patients with left-sided infective endocarditis (IE) and intermediate-length vegetations (10-15 mm) remains uncertain. We aimed to evaluate the role of surgery in patients with intermediate-length vegetations and no other European Society of Cardiology guidelines-approved surgical indication. METHODS: We retrospectively enrolled 638 consecutive patients admitted to three academic centres (Amiens, Marseille and Florence University Hospitals) between 2012 and 2022 for left-sided definite IE (native or prosthetic) with intermediate-length vegetations (10-15 mm). We compared four clinical groups: medically (n=50) or surgically (n=345) treated complicated IE, medically (n=194) or surgically (n=49) treated uncomplicated IE. RESULTS: Mean age was 67±14 years. Women were 182 (28.6%). The rate of embolic events on admission was 40% in medically treated and 61% in surgically treated complicated IE, 31% in medically treated and 26% in surgically treated uncomplicated IE. The analysis of all-cause mortality showed the lowest 5-year survival rate for medically treated complicated IE (53.7%). We found a similar 5-year survival rate for surgically treated complicated IE (71.4%) and medically treated uncomplicated IE (68.4%). The highest 5-year survival rate was observed in surgically treated uncomplicated IE group (82.4%, log-rank p<0.001). The analysis of the propensity score-matched cohort estimated an HR of 0.23 for uncomplicated IE treated surgically compared with medical therapy (p=0.005, 95% CI: 0.079 to 0.656). CONCLUSIONS: Our results suggest that surgery is associated with lower all-cause mortality than medical therapy in patients with uncomplicated left-sided IE with intermediate-length vegetations even in the absence of other guideline-based indications.

Cardiac sarcoidosis in a carrier of transthyretin gene mutation: a case report.

Background: Sarcoidosis is a rare multiorgan inflammatory disorder of unknown aetiology, characterized by the formation of non-caseating granulomas in the affected organs. Cardiac involvement is underrecognized and observed in up to 25% of cases in autopsy studies, and is associated with a high mortality rate, especially due to sudden cardiac death due to ventricular arrhythmias. Case summary: A 41-year-old man well known to our hospital because of his father's diagnosis of cardiac amyloidosis, and carrier of transthyretin (TTR) gene mutation, was hospitalized following a resuscitated cardiac arrest. The patient was hospitalized a month before for a syncopal episode with demonstration of preserved left ventricular ejection fraction (LVEF) with akinetic basal septum at heart ultrasound and normal coronary. Chest computed tomography, performed in the emergency department, was significant for hilar lymphadenopathies and pulmonary nodules highly suggestive of sarcoidosis. A subsequent 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed multiorgan phlogistic involvement, including the myocardium. After the diagnosis of cardiac sarcoidosis, the patient was started on steroids therapy and underwent ICD implantation. A follow-up 18-FDG-PET showed a reduction of organs glucose uptake and a follow-up echo an improvement in LVEF. Despite that, he occurs occasional recording of repetitive ventricular arrhythmias and one appropriate ICD shock during the next 12 months. Discussion: Cardiac sarcoidosis is an insidious disease. Its diagnosis can be challenging, with no specific finding in echocardiography. The best strategy would be multi-modality imaging involving both magnetic resonance imaging with late gadolinium enhancement and 18-FDG-PET, followed by biopsy to confirm the diagnosis. Multi-modality imaging should be further used to evaluate the response to treatment and assess prognosis. Since the patient was a known carrier of the TTR gene mutation, many efforts were made in order to come up with the correct diagnosis considering that both cardiac amyloidosis and cardiac sarcoidosis are non-ischaemic cardiomyopathy with systemic involvement.

Persistent respiratory failure after SARS-CoV-2 infection: The role of dual energy computed tomography. A case report.

Background: COVID-19 disease is often complicated by respiratory failure, developing through multiple pathophysiological mechanisms, with pulmonary embolism (PE) and microvascular thrombosis as key and frequent components. Newer imaging modalities such as dual-energy computed tomography (DECT) can represent a turning point in the diagnosis and follow-up of suspected PE during COVID-19. Case presentation: A 78-year-old female presented to our internal medicine 3 weeks after initial hospitalization for COVID-19 disease, for recrudescent respiratory failure needing oxygen therapy. A computed tomography (CT) lungs scan showed a typical SARSCoV-2 pneumonia. Over the following 15 days, respiratory function gradually improved. Unexpectedly, after 21 days from symptom onset, the patient started complaining of breath shortening with remarkable desaturation requiring high-flow oxygen ventilation. CT pulmonary angiography and transthoracic echocardiography were negative for signs of PE. Thereby, Dual-energy CT angiography of the lungs (DECT) was performed and detected diffuse peripheral microembolism. After 2 weeks, a second DECT was performed, showing a good response to the anticoagulation regimen, with reduced extent of microembolism and some of the remaining emboli partially recanalized. Discussion: DECT is an emerging diagnostic technique providing both functional and anatomical information. DECT has been reported to produce a much sharper delineation of perfusion defects than pulmonary scintigraphy, using a significantly lower equivalent dose of mSv. We highlight that DECT is particularly useful in SARS-Cov-2 infection, in order to determine the predominant underlying pathophysiology, particularly when respiratory failure prolongs despite improved lung parenchymal radiological findings.

Impact of septic cerebral embolism on prognosis and therapeutic strategies of infective endocarditis: a retrospective study in a surgical centre.

BACKGROUND: Infective endocarditis still has high mortality and invalidating complications, such as cerebral embolism. The best strategies to prevent and manage neurologic complications remain uncertain. This study aimed to identify predictors of cerebral septic embolism and evaluate the role of surgery in these patients in a real-world surgical centre. METHODS: We retrospectively analyzed 551 consecutive patients admitted to our department with a definite diagnosis of non-device-related infective endocarditis; of these, 126 (23%) presented a neurologic complication. RESULTS: Cerebral embolism was significantly more frequent in patients with large vegetations (p = 0.004), mitral valve infection (p = 0.001), and Staphylococcus aureus infection (p = 0.025). At multivariable analysis, only vegetation length was an independent predictor of cerebral embolism (HR per unit 1.057, 95% CI 1.025-1.091, p 0.001), with a best predictive threshold of 10 mm at ROC curve analysis (AUC 0.54, p = 0.001). Patients with neurologic complications were more often excluded from surgery despite an indication to it (16% vs 8%, p = 0.001). If eligible, they were treated within two weeks from diagnosis in similar proportions as patients without cerebral embolism with a similar survival rate. Predictors of mortality were hemorrhagic lesions (p = 0.018), a GCS < 14 (p = 0.001) or a severe degree of disability (p = 0.001) at presentation. The latter was the only independent predictor of mortality at multivariable analysis (HR 2.3, 95% CI 1.43-3.80, p = 0.001). CONCLUSIONS: The present study highlights the prognostic value of functional presentation and the safety of cardiac surgery, when feasible, in patients with cerebral septic embolism.

Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: a substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) registry.

AIMS: To evaluate the current management and survival of patients with left-sided infective endocarditis (IE) complicated by congestive heart failure (CHF) in the ESC-EORP European Endocarditis (EURO-ENDO) registry. METHODS AND RESULTS: Among the 3116 patients enrolled in this prospective registry, 2449 (mean age: 60 years, 69% male) with left-sided (native or prosthetic) IE were included in this study. Patients with CHF (n = 698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro-aortic involvement, vegetations >10 mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p ≤ 0.019). Patients with CHF experienced higher 30-day and 1-year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30-day (odds ratio[OR] 2.37, 95% confidence interval [CI] [1.73-3.24; p < 0.001) and 1-year mortality (hazard ratio [HR] 1.69, 95% CI 1.39-2.05; p < 0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity (n = 618 [88.5%] for each group, both p < 0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30-day mortality following multivariable analysis, after adjustment for age, sex, Charlson comorbidity index, cerebrovascular accident, Staphylococcus aureus IE, streptococcal IE, uncontrolled infection, vegetation size >10 mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE (OR 0.22, 95% CI 0.12-0.38; p < 0.001) and in 1-year mortality (HR 0.29, 95% CI 0.20-0.41; p < 0.001). CONCLUSION: Congestive heart failure is common in left-sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30-day and 1-year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive.

Echocardiographic Abnormalities in Adults With Anorexia Nervosa.

Anorexia nervosa (AN) is a psychiatric disorder that may lead to cardiac complications. The objective of this study was to evaluate global and regional longitudinal strain changes in patients affected by AN as an early marker of myocardial damage. We prospectively enrolled 48 consecutive patients with AN and 44 age-matched and gender-matched healthy controls. In all subjects, we performed echocardiography, including global longitudinal strain (GLS) measurement. A subset of 33 patients with AN had further echocardiographic examinations during the follow-up. Compared with healthy controls, patients with AN had a greater prevalence of pericardial effusion (9 of 48 vs 0 of 44, p = 0.003), a smaller left ventricular mass (63 ± 15 vs 99 ± 30 g, p < 0.001), a lower absolute value of GLS (-18.9 ± 2.8 vs -20.2 ± 1.8%, p = 0.010) and of basal LS (-15.4 ± 6.0 vs -19.4 ± 2.6%, p < 0.001). The bull's eye mapping showed a plot pattern with blue basal areas in 18 of 48 patients with AN versus 1 of 44 controls (p < 0.001). During the follow-up, of 13 patients with blue areas in the first bull's eye mapping, 11 recovered completely, and of 20 patients with a red bull's eye at the first examination, none presented blue areas at the second one. In conclusion, GLS is significantly altered in patients with AN, and a basal blue pattern on bull's eye mapping identifies more severe cases. These changes seem to be reversible.

Double-valve infective endocarditis: clinical features and prognostic impact-a retrospective study in a surgical centre.

Most cases of infective endocarditis (IE) involve a single valve, and little is known concerning IE that simultaneously affects two valves. The involvement of more than one valve may imply more severe and extensive cardiac lesions. In these patients, surgery may be challenging. We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of double-valve IE (DVIE). We retrospectively included in the analysis that 440 consecutive patients with definite active IE in a single surgical centre. DVIE occurred in 75 of the total enrolled 440 patients (17%) and involved mostly the combination of mitral and aortic valves (N = 63, 84%). Most patients had double-native IE (N = 45, 60%). Staphylococci were less frequent in patients with double-valve than single-valve IE (SVIE). The proportion of patients undergoing valve repair among those treated surgically was higher for patients with DVIE than for SVIE (p < 0.03). Valve repair of at least one valve was associated with non-significant better survival than double replacement. DVIE was associated with higher all-cause mortality than SVIE (p < 0.013) and a higher relapse rate (p = 0.023). DVIE was not associated with a higher risk of composite non-fatal adverse events. DVIE represents a considerable proportion of overall cases of IE, mainly involving aortic and mitral valves, with a jet lesion on the mitral valve; Staphylococcus is significantly less frequent than in SVIE; DVIE is independently associated with higher mortality and relapse rate; finally, mitral valve repair is feasible in a considerable proportion of surgical cases.

Carfilzomib-induced thrombotic microangiopathy. A case report.

INTRODUCTION: Drug-induced thrombotic microangiopathy (DITMA) is an acquired condition resulting from exposure to a drug that induces the formation of platelet-rich thrombi in small arterioles or capillaries secondary to drug-dependent antibodies or direct tissue toxicity. Carfilzomib is a selective proteasome inhibitor approved to treat selected patients with Multiple Myeloma (MM). It is one of the drugs with the strongest evidence for a causal association with non-antibody-mediated DITMA. CASE REPORT: A 75-year-old man presented to the emergency department for the outbreak of vomit, asthenia, oliguria and dark stool emission. He was recently diagnosed with multiple myeloma, treated with lenalidomide, dexamethasone and carfilzomib. Laboratory exams were significant for microangiopathic haemolytic anaemia, thrombocytopenia and new-onset renal failure. ADAMTS-13 levels were in range, and no infectious signs were found both in blood nor in stool test. MANAGEMENT & OUTCOME: A carfilzomib induced thrombotic microangiopathy was soon suspected. Thus, since daily haemodialysis and supportive care did not seem to get a fast enough recovery, the patient was treated with eculizumab with a good general outcome. DISCUSSION: Drug-induced thrombotic microangiopathy is a rare and often life-threatening acquired condition whose diagnosis can be challenging and whose therapy is not always limited to supportive treatment and drug avoidance. Carfilzomib, along with other proteasome inhibitors, is one of the described potential drugs which can trigger such a manifestation.

Cerebral lesions in hematological malignancies: a case report.

BACKGROUND: Progressive multifocal leukoencephalopathy is a rare central nervous system disease, resulting from reactivation of latent John Cunningham virus. Monoclonal antibodies have recently become a relevant risk factor for developing progressive multifocal leukoencephalopathy. We report the case of a 62-year-old Caucasian man who was admitted to our department in June 2020 because of right homonymous hemianopia. Magnetic resonance imaging findings were first interpreted as an intracranial relapsed lymphoma, so brain biopsy was performed, but no neoplastic cell was found. Histological sample only showed a large number of macrophages. The patient came back to our attention because of the worsening of neurological symptoms. A second magnetic resonance imaging showed widespread lesions suggestive of a demyelinating process. John Cunningham virus DNA was detected by polymerase chain reaction assay of the cerebrospinal fluid (over 9 million units/µL). The patient was treated supportively, but the outcome was poor. DISCUSSION: A multidisciplinary assessment should be performed for differential diagnosis of cerebral lesions in hematologic malignancies. Progressive multifocal leukoencephalopathy should be suspected in cases of subacute neurological symptoms and imaging findings consistent with it, especially if the patient received immunosuppressive or immunomodulatory drugs.

Cancer and Infective Endocarditis: Characteristics and Prognostic Impact.

Background: The interplay between cancer and IE has become of increasing interest. This study sought to assess the prevalence, baseline characteristics, management, and outcomes of IE cancer patients in the ESC EORP EURO-ENDO registry. Methods: Three thousand and eighty-five patients with IE were identified based on the ESC 2015 criteria. Three hundred and fifty-nine (11.6%) IE cancer patients were compared to 2,726 (88.4%) cancer-free IE patients. Results: In cancer patients, IE was mostly community-acquired (74.8%). The most frequently identified microorganisms were S. aureus (25.4%) and Enterococci (23.8%). The most frequent complications were acute renal failure (25.9%), embolic events (21.7%) and congestive heart failure (18.1%). Theoretical indication for cardiac surgery was not significantly different between groups (65.5 vs. 69.8%, P = 0.091), but was effectively less performed when indicated in IE patients with cancer (65.5 vs. 75.0%, P = 0.002). Compared to cancer-free IE patients, in-hospital and 1-year mortality occurred in 23.4 vs. 16.1%, P = 0.006, and 18.0 vs. 10.2%; P < 0.001, respectively. In IE cancer patients, predictors of mortality by multivariate analysis were creatinine > 2 mg/dL, congestive heart failure and unperformed cardiac surgery (when indicated). Conclusions: Cancer in IE patients is common and associated with a worse outcome. This large, observational cohort provides new insights concerning the contemporary profile, management, and clinical outcomes of IE cancer patients across a wide range of countries.

Diffuse prothrombotic syndrome after ChAdOx1 nCoV-19 vaccine administration: a case report.

BACKGROUND: Vaccine-induced immune thrombotic thrombocytopenia is emerging as one of the most relevant side effects of adenoviral-based vaccines against coronavirus disease 2019. Given the novelty of this disease, the medical community is seeking new evidence and clinical experiences on the management of these patients. CASE PRESENTATION: In this article, we describe the case of a 73-year-old Caucasian woman who presented with diffuse prothrombotic syndrome, both in the arterial and venous districts, following the first dose administration of ChAdOx1 CoV-19 vaccine. The main thrombotic sites included the brain, with both a cortical ischemic lesion and thromboses of the left transverse and sigmoid sinuses and the lower limbs, with deep venous thrombosis accompanied by subsegmental pulmonary thromboembolism. The deep venous thrombosis progressively evolved into acute limb ischemia, requiring surgical intervention with thromboendoarterectomy. Anticoagulation was maintained throughout the whole hospitalization period and continued in the outpatient setting using vitamin K antagonists for a recommended period of 6 months. CONCLUSIONS: This case describes the management of vaccine-induced immune thrombotic thrombocytopenia in a complicated clinical scenario, including multisite arterial and venous thromboses. Given the complexity of the patient presentation, this case may implement the comprehension of the mechanisms and clinical features of this disease; it also provides a picture of the challenges related to the management, often requiring a multidisciplinary approach.

Heart valve disease in hypocomplementemic urticarial vasculitis syndrome: from immune-mediated degeneration to embolic complications of infective endocarditis-a case report.

BACKGROUND: Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare disease due to small vessel inflammation and characterized by chronic urticarial vasculitis and arthritis. Multi-organ manifestations may include glomerulonephritis, ocular inflammation (uveitis, episcleritis), and recurrent abdominal pain. To the best of our knowledge, just other nine cases of HUVS with cardiac valvular involvement have been reported in the literature. CASE SUMMARY: A 32-year-old woman presented to the emergency department because of a cerebral haemorrhage. She suffered from a severe HUVS form with cardiac valvular involvement. In the previous years, she underwent cardiac surgery twice for aortic and mitral valves immune-mediated degeneration. The neurologic event was secondary to Listeria monocytogenes aortic endocarditis, complicated by a cerebral embolism and periaortic abscess. DISCUSSION: Patients with HUVS rarely present valvular heart disease. The latter is mostly secondary to an inflammatory process. Valve degeneration and immunosuppressive therapy increase the risk of infective endocarditis, with dramatic consequences for the prognosis of these patients. Valvular involvement is a sporadic but potentially fatal complication of HUVS, which should be taken in mind in the multidisciplinary evaluation of these patients.

Case report of a peculiar aneurysm of the ascending aorta: when there is much more beyond an incidental finding.

BACKGROUND: Aneurysms of the thoracic aorta are common in male patients around the VI-VII decade of life and most have a degenerative aetiology; otherwise, the occurrence of this disease at a younger age should prompt the search of rarer causes. We report a singular case of ascending aortic aneurysm (AAA) in a young man. CASE SUMMARY: A large AAA accompanied by multivessel dilatation and renal failure of unknown onset was incidentally found in a 23-year-old male during the diagnostic work-up after a car accident. A systemic disease was therefore suspected, and a full clinical investigation revealed the uncommon diagnosis of sarcoidosis accompanied by large vessel vasculitis. DISCUSSION: Only a few reports in the literature describe the concurrence of sarcoidosis and large vessel vasculitis (Takayasu arteritis), which may share non-specific immunoinflammatory abnormalities. This case underlines the importance of a multisystem diagnostic approach even in front of an incidental finding that is inconsistent with patient's age.

Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience.

BACKGROUND: Intravenous drug abuse (IDA) is a known risk factor for infective endocarditis (IE) and is associated with frequent relapses, but its prognostic impact is still debated. The potential futility of surgery in this population is a further issue under discussion. We aimed to describe the clinical characteristics, the therapeutic strategy, and the prognosis associated with IDA in IE. METHODS: We retrospectively analysed 440 patients admitted to a single surgical centre for definite active IE from January 2012 to December 2020. RESULTS: Patients reporting IDA (N = 54; 12.2%) were significantly younger (p < 0.001) and presented fewer comorbidities (p < 0.001). IDA was associated with a higher proportion of relapses (27.8 vs. 3.3%, p < 0.001) and, at multivariable analysis, was an independent predictor of long-term mortality (HR 2.3, 95%CI 1.1-4.7, p = 0.015). We did not register multiple relapses in non-IDA patients. Among IDA patients, we observed 1 relapse after discharge in 9 patients, 2 relapses in 5 patients and 3 relapses in 1 patient. In IDA patients, neither clinical and laboratory variables nor the occurrence of even multiple relapses emerged as indicators of an adverse risk-benefit ratio of surgery in patients with surgical indication. CONCLUSIONS: IE secondary to IDA affects younger patients than those with IE not associated with IDA. Probably due to this difference, IE secondary to IDA is not associated with significantly higher mortality, whereas the negative, long-term prognostic impact of IDA emerges in multivariate analysis. Considering the good prognosis of patients with uncomplicated IE treated medically, surgery should be reserved to patients with a strict- guidelines-based indication. However, since there are no clear predictors of an unfavourable risk-benefit ratio of surgery in patients with surgical indication, all patients with a complicated IE should be operated, irrespective of a history of IDA.