Acute partial papillary muscle rupture as a rare complication following non-ST elevation myocardial infarction.

Papillary muscle rupture is a life-threatening complication of acute myocardial infarction that most commonly occurs 2-7 days after the infarct. We present a rare case of acute partial anterolateral papillary muscle rupture following non-ST elevation myocardial infarction. Our patient was an elderly male who had a detached anterolateral papillary muscle, which required emergent mitral valve replacement. Papillary muscle rupture is a rare complication of acute myocardial infarction, and anterolateral muscle rupture occurs even less commonly. When papillary muscle rupture is diagnosed, patients need to be emergently referred to cardiothoracic surgery as mortality without surgery is over 90% within a week.

Managing Acute Intermediate Risk Pulmonary Thromboembolism in a Patient Who Developed Heparin-Induced Thrombocytopenia: Review of Current Guidelines and Literature.

Intermediate-risk pulmonary embolism describes hemodynamically stable patients with evidence of right ventricular strain, whereas high-risk pulmonary embolism comprises hemodynamic decompensation resulting in cardiogenic shock. The clinical manifestations of the two aforementioned conditions are challenging to treat in the setting of heparin-induced thrombocytopenia (HIT). Without immediate therapeutic anticoagulation, patients can subsequently deteriorate and require additional advanced therapies, with the end-goal of restoring pulmonary artery perfusion. We present the case of a male with bilateral intermediate-risk pulmonary emboli who developed type 2 HIT prompting different selection of appropriate management strategies.

Type 2 Decompensated Diabetes Mellitus Weaned off Subcutaneous Insulin Therapy by Utilizing a Continuous Glucose Monitoring Device.

A case series was conducted on three patients diagnosed with decompensated type 2 diabetes mellitus (T2DM) who had hemoglobin A1c (HbA1c) levels ranging from 9.5% to above 14%. Patients were self-monitoring blood glucose (SMBG) levels four times a day. These patients were seen at the resident continuity clinic and were placed on continuous glucose monitor (CGM) devices to monitor their blood glucose levels. To improve the effectiveness of the treatment closely, a CGM team consisting of transitional year and internal medicine residents was arranged. The CGM team provided comprehensive education and written instructions on dietary changes, insulin administration, and physical activity at monthly follow-up appointments. Before the instructions were given to the patients, they were reviewed and approved by the supervising attending physician who was a board-certified endocrinologist. Our CGM team successfully managed these three patients with T2DM by tailoring their insulin regimens by using real-time CGM data. With the help of close CGM monitoring, patients were successfully transitioned from requiring multiple subcutaneous insulin injections to oral anti-diabetics. After the transition, patients' T2DM remained well-controlled with an HbA1c level of less than 7% at their follow-up appointments. This case series demonstrated the successful implementation of CGM-guided T2DM treatment in a continuity clinic managed by residents. To our knowledge, the use of CGM-guided T2DM treatment in the setting of resident care has never been reported in the United States before. This may serve as a benchmark for other continuity clinics which residents run across the country.

Fluid management in septic patients with pulmonary hypertension, review of the literature.

The management of sepsis in patients with pulmonary hypertension (PH) is challenging due to significant conflicting goals of management and complex hemodynamics. As PH progresses, the ability of right heart to perfuse lungs at a normal central venous pressure (CVP) is impaired. Elevated pulmonary vascular pressure, due to pulmonary vasoconstriction and vascular remodeling, opposes blood flow through lungs thus limiting the ability of right ventricle (RV) to increase cardiac output (CO) and maintain adequate oxygen delivery to tissue. In sepsis without PH, avoidance of volume depletion with intravascular volume replacement, followed by vasopressor therapy if hypoperfusion persists, remains the cornerstone of therapy. Intravenous fluid (IVF) resuscitation based on individualized hemodynamic assessment can help improve the prognosis of critically ill patients. This is accomplished by optimizing CO by maintaining adequate preload, afterload and contractility. Particular challenges in patients with PH include RV failure as a result of pressure and volume overload, gas exchange abnormalities, and managing IVF and diuretic use. Suggested approaches to remedy these difficulties include early recognition of symptoms associated with pressure and volume overload, intravascular volume management strategies and serial lab monitoring to assess electrolytes and renal function.

Myxedema Coma: A Rare Case of Shock Post-Pericardial Window Procedure.

The clinical features of severe hypothyroidism vary in presentation, ranging from subclinical symptoms to multiorgan failure referred to as myxedema coma. The cornerstone treatments of myxedema coma include aggressive thyroid hormone replacement combined with excellent supportive care in the intensive care unit. We report a rare case of a 56-year-old female with history of hypothyroidism treated with levothyroxine, who developed myxedema coma post-pericardial window surgery for a large pericardial effusion. She was supported with substantial doses of vasopressors and inotropes for shock. In addition, she was initiated on lung-protection ventilation for acute respiratory distress syndrome. After the diagnosis of myxedema coma was made, she was started on intravenous levothyroxine and hydrocortisone with great sustained clinical response. This case illustrated myxedema coma as an unusual cause of shock in post-operative patients with past medical history of hypothyroidism.

Viral Myocarditis Mimicking ST-Segment Elevation Myocardial Infarction Complicated by Thrombocytopenia and Vasculitic Peripheral Neuropathy.

Symptomatic myocarditis is classically featured by a flu-like prodrome, dyspnea on exertion, palpitations, substernal chest pain, and abnormal electrocardiogram (ECG). The clinical diagnosis has often been challenging due to its similarities to acute coronary syndrome. Our case involved a patient who presented with claudication of bilateral lower extremity and ST-segment elevation myocardial infarction (STEMI) in the inferior leads. On cardiac catheterization, nonobstructed coronary arteries with left ventricular ejection fraction (LVEF) of 30% were demonstrated. His clinical presentation was consistent with suspected myocarditis, and he improved with immunosuppression. In addition, his thrombocytopenia and severe symptoms of peripheral neuropathy responded to both immunotherapy and anticoagulation. This case highlights the interplay between history taking, physical examination, and multimodal diagnostic imaging.

Non-surgical extirpation of a non-infectious expanding tricuspid valve mass by percutaneous aspiration thrombectomy.

Marantic endocarditis refers to a noninfectious lesion, usually in the aortic and mitral valves, that is most commonly seen in advanced malignancy and systemic lupus erythematosus. Inflammatory conditions, including antiphospholipid syndrome (APS), are a rare etiology making up less than 20% of reported cases. The condition is thought to be due to a hypercoagulable state and found postmortem with rates in autopsy series ranging from 0.9% to 1.6%. In comparison to infective endocarditis, marantic endocarditis has a greater tendency for valve vegetations to embolize. Common treatment modalities include anticoagulation or valve replacement. Although percutaneous aspiration thrombectomy of right-sided heart chamber thrombi exists, there are limited reports demonstrating its use with regards to treatment of right-sided endocarditis. We present the case of an older male with a history of Factor V Leiden and APS who was admitted due to a rapidly expanding mass on the tricuspid valve (TV). Despite serial blood cultures being negative, the patient received adequate antibiotic therapy for more than 4 weeks. Transthoracic echocardiogram showed an enlarged TV vegetation with an increased diameter from 10 to 30 mm over 6 weeks. Due to the patient's high operative risk and concern for embolization complications, a multidisciplinary decision was made to perform percutaneous aspiration thrombectomy of the TV vegetation. Subsequent biopsy of the lesion confirmed it was noninfectious and nonmalignant. Thus, the patient was started on systemic anticoagulation for prevention of thromboembolic events.