RESUMEN
A male patient in his 60s, with a history of tobacco use, presented with fever, weight loss, and cough, and was ultimately diagnosed with histoplasmosis. Initial treatment with itraconazole (ITZ) led to symptom improvement. However, two months later, he returned with lower extremity swelling and dyspnea. Imaging showed pleural effusions and reduced ejection fraction, suggesting itraconazole-induced cardiac toxicity. Transition to voriconazole and initiation of guideline-directed medical therapy improved symptoms. This case report delves into the cardiac side effects of itraconazole, notably heart failure, and elucidates the potential underlying mechanisms. Our goal is to emphasize the importance of monitoring patients on itraconazole for potential cardiac complications, necessitating timely intervention to mitigate adverse outcomes.
RESUMEN
A coronary artery aneurysm (CAA) denotes a localized dilation of the coronary artery, while a coronary artery fistula signifies an aberrant connection between a coronary artery and a cardiac chamber or adjacent vessel. Here, we present a case study of a 68-year-old female with a previously diagnosed right coronary artery-to-right atrial fistula concomitant with multiple right coronary artery aneurysms. Initially asymptomatic, the patient subsequently manifested atrial fibrillation. Management involved augmenting the patient's home regimen with metoprolol tartrate, followed by successful cardioversion and restoration of sinus rhythm. Given the stability of the fistula and the absence of symptomatic exacerbation, no further interventional measures were undertaken. The patient was discharged with an adjusted metoprolol regimen and scheduled follow-up with her cardiologist. Subsequent imaging assessments unveiled progressive fistula expansion alongside the development of concurrent CAA, inciting deliberations concerning optimal treatment modalities.
RESUMEN
Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, yet they come with a spectrum of immune-related adverse events, including cardiac complications. We present the case of a 72-year-old male with metastatic renal cell carcinoma who developed complete heart block and ventricular arrhythmias following pembrolizumab therapy. Despite no evidence of myocarditis, the patient's condition rapidly deteriorated, ultimately resulting in his demise. This case underscores the critical need for vigilance in recognizing and managing potential cardiotoxicity associated with ICIs. Additionally, it highlights the importance of multidisciplinary collaboration in optimizing diagnostic and therapeutic strategies for patients undergoing immune checkpoint inhibitor therapy.
RESUMEN
Cocaine overdose remains a significant public health concern worldwide, with potentially life-threatening consequences. The range of presentation can vary from mild autonomic hyperactivity to severe vasoconstriction, causing multiorgan ischemia and even death. In cases of high-dose intoxication, the presentation can be atypical. In this case report, we present a compelling case of a patient who initially presented with cardiac arrest and atypical signs. The patient made a remarkable recovery and returned almost to her baseline. This case provides valuable prognostic insight into the outcomes of severe multiorgan failure resulting from cocaine toxicity.
RESUMEN
Atrioventricular (AV) nodal blockers have a wide variety of medical uses, including the management of hypertension and cardiac arrhythmias. Like any other drug, they can carry side effects and toxicity. We present a case of a patient with a constellation of findings consistent with bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia (BRASH) syndrome. A 75-year-old female with a history of paroxysmal atrial fibrillation and heart failure with preserved ejection fraction presented to the hospital with shortness of breath. She was discharged two weeks prior to the presentation from another hospital after being treated for atrial fibrillation with a rapid ventricular response. She was discharged on metoprolol and diltiazem. Upon presentation to the hospital, the patient was noted to be bradycardic and hypotensive with blood work notable for acute kidney injury and hyperkalemia, consistent with BRASH syndrome. She received a dose of intravenous (IV) glucagon followed by infusion and received epinephrine infusion. Once clinically stable, she was discharged with her home dose of metoprolol and a reduced dose of diltiazem with a close follow-up with cardiology. Early recognition of BRASH syndrome as a unique clinical entity rather than different pathologic conditions is important to improve morbidity and mortality in these patients.
RESUMEN
BRAF mutations are estimated to be present in 2-4% of non-small cell lung carcinoma (NSCLC) cases. BRAF inhibitor (dabrafenib) and MEK inhibitor (trametinib) are currently approved to treat NSCLC harboring the BRAF V600E mutation. However, the use of this new combined targeted therapy can be associated with severe and life-threatening toxicities. Here, we describe the case of a 77-year-old male with a history of BRAF-positive lung adenocarcinoma with metastasis to the brain, adrenals, and small bowel (jejunum), currently on dual therapy with dabrafenib and trametinib, who presented with refractory epistaxis. The dual therapy regimen was started one month prior to his presentation. After initial stabilization with anterior nasal packing, intravenous and nebulized tranexamic acid (TXA) in the emergency department (ED), he suddenly developed respiratory decompensation. He needed emergent intubation for acute hypoxic respiratory failure and airway protection secondary to profuse bleeding. He was extubated 24 hours later as the epistaxis was manageable, and the nasal packing was removed. Shortly after extubating, he started coughing copious amounts of blood and developed respiratory distress with stridor requiring re-intubation. A large blood clot was noted to be partially occluding the vocal cords on laryngoscopy and was removed during intubation. An emergent flexible fiberoptic bronchoscopy was performed with the retrieval of a large blood clot extending from the oropharynx down into the distal trachea. There was no evidence of acute bleeding within the lung after the clot was removed. Workup to explore the cause of his bleeding included a coagulation profile, which was unrevealing. His bleeding was most likely consistent with a side effect of his treatment with dabrafenib and trametinib. Life-threatening bleeding has been reported as a side effect of the combination therapy with dabrafenib and trametinib in metastatic melanoma. Also, in the phase 2 clinical trial (BRF113928) of dabrafenib plus trametinib in patients with previously untreated BRAF V600E-mutant metastatic NSCLC, 3.2% of subjects developed a grade III or IV hemorrhage. Our case aims to raise physicians' awareness of one of the significant side effects of this combination therapy especially since this combination is being used more frequently and now also in lung cancer.
