A Case Report of Brugada Syndrome Associated With Physical Trauma.

Brugada syndrome is an autosomal dominant channelopathy that usually affects healthy young males without apparent structural heart disease. It is associated with a spectrum of variable and dynamic clinical manifestations, high risk of life-threatening ventricular arrhythmias, and sudden cardiac death. Our patient demonstrated transient and dynamic EKG changes of both type 1 (coved) and type 2 (saddleback) ST elevation, suggestive of the Brugada pattern that was associated with physical chest trauma and stressful situations. While common triggers like fever and certain drugs are well-recognized, this case illustrates the potential for physical stress and trauma to unmask or aggravate Brugada syndrome, albeit without definitive evidence for a causal link. Ultimately, this report underscores the importance of considering a broad differential diagnosis, including Brugada syndrome, in patients presenting with unexplained syncope or characteristic EKG changes, even when traditional triggers are absent.

Embolic Phenomena of Libman-Sacks Endocarditis and Antiphospholipid Syndrome.

Patients with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS) are at high risk of developing arterial or venous thromboembolism and a state of systemic hypercoagulability. Libman-Sacks endocarditis (LSE) is a type of non-bacterial endocarditis usually seen in patients with systemic lupus erythematosus and antiphospholipid antibody syndrome. These vegetations dislodge easily and can cause profound neurological and systemic complications in the form of emboli. We describe one such case of a young woman with known SLE who presented with an acute middle cerebral artery (MCA) stroke and was found to have APS with extensive mitral valve vegetation, indicating Libman-Sacks endocarditis on echocardiography. Recognizing the increasing frequency of both APS and LSE in patients with SLE and screening patients, especially the younger population with SLE, for APS is vital. Furthermore, in those patients presenting with embolic events, echocardiography plays a key role as it can help expedite the diagnosis of LSE. Our case report also reiterates that warfarin, when compared to direct oral anticoagulants (DOAC), is superior in decreasing future embolic events.

Comparative Effectiveness of Various Radiofrequency Ablation Catheters in the Ablation of Typical Atrial Flutter.

INTRODUCTION: Although ablation of typical atrial flutter (AFL) can be easily achieved with radiofrequency energy (RF), no studies compare the effectiveness of different ablation catheters. Our study aimed to compare the efficacy of various types of ablation catheters in treating typical AFL. METHODS: We analyzed patients with AFL who underwent RF ablation by a single operator at our institution. Successful ablation was evidenced by a bidirectional conduction block (trans-isthmus conduction time ≥ 130 ms or double potentials ≥ 90 ms). Logistic regression was used to compare success rate and linear regression to compare lesion time. RESULTS: Out of 222 patients, only six did not meet the success criteria (2.7%). The catheters used were non-irrigated, large-tip, internally irrigated (Chili II Boston Scientific), and externally irrigated (non-force-sensing) catheters (Cool Path, Abbott). An externally irrigated force-sensing catheter (TactiCath, Abbott) was used with > 10 gm of force and (LPLD) setting (30 W- 45 °C- 60 s), and high-power short-duration (HPSD) setting (50 W- 43 °C - 12 s). No complications were encountered. The catheter type had no statistically significant association with ablation success. With the use of externally irrigated catheter with contract force-sensing and HPSD settings, statistically significantly shortening of lesion time was achieved 758.3 s, [CI - 1128.29, - 388.35 s] followed by LPLD by 419.0 s [CI - 808.49, - 29.47 s]. CONCLUSIONS: The typical atrial flutter radiofrequency ablation procedure had a high success rate, which was not influenced by the type of ablation catheter. Contact force ablation catheter and HPSD are associated with shorter total lesion time.

Septic Shock Secondary to Tricuspid Valve Vegetation Requiring Surgical Debulking.

Tricuspid valve endocarditis is increasing in incidence owing to the prevalent use of intravenous substances. Although most patients respond well to intravenous antibiotics over the course of six weeks, some patients require surgical intervention. A multilayered approach to diagnosis with both transthoracic and transesophageal echocardiography (TEE) is recommended for optimal diagnosis and management. In this article, we report a case of septic shock resulting from tricuspid valve infective endocarditis in a young woman with a history of intravenous drug use who ultimately required cardiothoracic surgical intervention for tricuspid valve vegetation. The sensitivity and specificity of TEE for vegetation on the native valves are about 96% and 90%, respectively. Timely surgical intervention may increase the likelihood of tricuspid valve repair by preventing further destruction of leaflet tissue. Transthoracic echocardiogram (TTE) and TEE have complementary roles in the diagnosis and evaluation of endocarditis. With this case report, we emphasize the importance of multimodality imaging and early surgical intervention to prevent further embolism and destruction of tricuspid valve leaflet tissue.

Hyperammonemic Encephalopathy Secondary to Urinary Tract Infection.

Hyperammonemic encephalopathy (HE) refers to a clinical condition characterized by abrupt alteration in mental status (AMS) with markedly elevated plasma ammonia levels and frequently results in intractable coma and death. While hepatic cirrhosis is by far the most common etiology for hyperammonemia together with drugs such as valproic acid as well as urea cycle disorders, non-hepatic causes of hyperammonemia are rare and pose a clinical challenge. In this report, we describe a case of HE caused by obstructive urinary tract infection due to urease-producing bacteria in a 69-year-old man with two episodes of obstructive uropathy associated with AMS resolving with treatment with antibiotics and lactulose with normalization of ammonia level. We also provide a review of the literature with emphasis on the recognition of this serious entity of HE in the setting of obstructive uropathy to avoid the possible complications that include intractable coma and high mortality from this potentially treatable disorder.

Insect nephrocyte function is regulated by a store operated calcium entry mechanism controlling endocytosis and Amnionless turnover.

Insect nephrocytes are ultrafiltration cells that remove circulating proteins and exogenous toxins from the haemolymph. Experimental disruption of nephrocyte development or function leads to systemic impairment of insect physiology as evidenced by cardiomyopathy, chronic activation of immune signalling and shortening of lifespan. The genetic and structural basis of the nephrocyte's ultrafiltration mechanism is conserved between arthropods and mammals, making them an attractive model for studying human renal function and systemic clearance mechanisms in general. Although dynamic changes to intracellular calcium are fundamental to the function of many cell types, there are currently no studies of intracellular calcium signalling in nephrocytes. In this work we aimed to characterise calcium signalling in the pericardial nephrocytes of Drosophila melanogaster. To achieve this, a genetically encoded calcium reporter (GCaMP6) was expressed in nephrocytes to monitor intracellular calcium both in vivo within larvae and in vitro within dissected adults. Larval nephrocytes exhibited stochastically timed calcium waves. A calcium signal could be initiated in preparations of adult nephrocytes and abolished by EGTA, or the store operated calcium entry (SOCE) blocker 2-APB, as well as RNAi mediated knockdown of the SOCE genes Stim and Orai. Neither the presence of calcium-free buffer nor EGTA affected the binding of the endocytic cargo albumin to nephrocytes but they did impair the subsequent accumulation of albumin within nephrocytes. Pre-treatment with EGTA, calcium-free buffer or 2-APB led to significantly reduced albumin binding. Knock-down of Stim and Orai was non-lethal, caused an increase to nephrocyte size and reduced albumin binding, reduced the abundance of the endocytic cargo receptor Amnionless and disrupted the localisation of Dumbfounded at the filtration slit diaphragm. These data indicate that pericardial nephrocytes exhibit stochastically timed calcium waves in vivo and that SOCE mediates the localisation of the endocytic co-receptor Amnionless. Identifying the signals both up and downstream of SOCE may highlight mechanisms relevant to the renal and excretory functions of a broad range of species, including humans.

Staphylococcus lugdunensis Infectious Endocarditis Complicated by Embolic Stroke After Colonoscopy in a 58-Year-Old Female.

There are a significant number of colonoscopies and esophagogastroduodenoscopies (EGDs) done in the United States every year and post-endoscopic infections are frequently seen. Data demonstrating causality between endoscopic procedures and infectious endocarditis (IE) or that antibiotic prophylaxis prior to endoscopic procedures protects against IE is still lacking. Here we have presented the case of a patient who underwent diagnostic colonoscopy as part of a malignancy workup and was later found to be septic with Staphylococcus lugdunensis bacteremia and had IE. We hypothesized that the infection was most likely contracted during colonoscopy as a result of bacterial translocation from the perineal region to the bloodstream. This case report highlights the need for further studies investigating the efficacy of prophylactic antibiotics in reducing the risk of IE after colonoscopies.