Left Ventricular Non-compaction Cardiomyopathy: A Case Report and Literature Review.

Left Ventricular Non-Compaction Cardiomyopathy (LVNC) is a rare myocardial disorder characterized by abnormal myocardial tissue formation in which the left ventricular wall appears to be trabecular with prominent intertrabecular recesses. The diagnosis of LVNC is predominantly reliant on cardiac imaging, namely thoracic echocardiography, however, cardiac MRI is indicated in conditions in which echocardiography is inconclusive. Diagnostic criteria for both echocardiography and cardiac MRI differ, however, the general principle of diagnosis is a comparison of the thickness of non-compacted to compacted myocardial tissue. The management of LVNC is nearly identical to that of Heart Failure with reduced Ejection Fraction (HFrEF), however, anticoagulation is an additional measure of management to the thrombogenic nature of non-compacted myocardial tissue. Here, we discuss a case of LVNC and the current data on its management.

A Case of Liquorice-Infused Marijuana Causing Syndrome of Apparent Mineralocorticoid Excess.

Marijuana has long been used both for recreational and medicinal purposes. Most of the available forms of marijuana contain additives such as liquorice to enhance its flavour. Liquorice increases the amounts of cortisol in the body and produces metabolic abnormalities seen in primary hyperaldosteronism[1]. Liquorice extracts are mixed with marijuana in the same way as for tobacco[2,3]. We describe a case of apparent mineralocorticoid excess due to excessive smoking of liquorice-laced marijuana. To our knowledge, this is the first reported case of apparent mineralocorticoid excess caused by marijuana use. LEARNING POINTS: First report of liquorice-laced marijuana causing syndrome of apparent mineralocorticoid excess (SAME).Since its legalisation, marijuana is reported to be the most used substance second only to alcohol. With the increased availability of marijuana, the health care providers and consumers must be cognisant of its side effects.It is a dose-dependent phenomenon. The effects vary from minor clinical symptoms to fatal arrhythmias based on the amount consumed.

Pleurisy secondary to nonthrombotic pulmonary emboli in a patient with intravenous drug use.

Patients with injection drug use can have nonthrombotic pulmonary emboli (NTPE) of foreign insoluble particles that are either parts of the equipment used or mixed with the drug as an additive. These foreign particles can become a nidus for infection and inflammation. We present a case of a 31-year-old man with active intravenous drug use who initially presented with signs and symptoms of pleurisy and was found to have NTPE of septic refractile crystalline material as seen on bronchial wash and brush biopsy. We believe our patient likely had embolism of either crack particles, needle fragments or cotton-wool fragments that led to a localized inflammatory reaction and infection. This highlights the importance of obtaining detailed history and diagnostic workup. Once the diagnoses of bacterial endocarditis and thrombophlebitis are ruled out with blood cultures, transthoracic echocardiogram, trans-esophageal echocardiogram and/or CT scan (depending on the suspicion), NTPE should be considered and bronchoscopy with bronchoalveolar lavage with biopsy should be performed.

Isolated Respiratory Failure as a Presentation for Early Perinuclear Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune inflammatory disease that usually affects the small-sized vasculature, most notably of the lungs and kidneys. One of the challenges of suspecting and diagnosing the condition lies in the insidious and unclear symptoms of presentation. In this case report, we discuss the case of a patient who initially presented with solely unclear pulmonary symptoms, without other organ system dysfunction.

Coincidence of Events Causing Paradoxical Hypotension in a Patient with an Intra-Aortic Balloon Pump.

The left ventricular outflow tract is a region of the left ventricle that lies between the anterior leaflet of the mitral valve and the ventricular septum. Dynamic left ventricular outflow tract obstruction (LVOTO) has classically been observed in patients with hypertrophic obstructive cardiomyopathy (HOCM) where it occurs secondary to asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. However, there are some instances that lead to hypercontractility of the myocardium, and with a combination of other physiological conditions, result in SAM of a mitral valve leaflet, leading to LVOTO in the absence of phenotype. We present such a case of an acute inferolateral wall myocardial infarction that was complicated by cardiogenic shock, requiring an intra-aortic balloon pump (IABP) and inotropic support which paradoxically provoked LVOTO. A reduction in IABP counterpulsation from 1:1 to 1:3 and the addition of intravenous fluids and a beta blocker resulted in significant improvement in blood pressure with rapid tapering of pressors. Inotropes and IABP, although helpful in cardiogenic shock, have the potential to induce or worsen the LVOTO, which can lead to a vicious cycle of worsening hypotension and increasing adrenergic drive that further deteriorates myocardial viability. Timely diagnosis with an echocardiogram and the withdrawal of inotropic and IABP support has the potential to improve haemodynamics and, thereby, outcome. LEARNING POINTS: Dynamic left ventricular outflow tract obstruction (LVOTO) should be one of the differentials in patients with cardiogenic shock, especially if it is refractory in the setting of an intra-aortic balloon pump.The diagnosis of LVOTO by echocardiography should result in immediate implementation of therapy to eliminate the factors that can potentially intensify the obstruction.

Ludwig's Angina.

Ludwig's angina is a bacterial infection of the tongue and floor of the mouth. It can be life-threatening if not treated promptly. Treatment includes IV antibiotics and, in some cases, surgical intervention. In this report, we describe a case with an unusual presentation. Early recognition of the condition in such cases is vital to prevent potential complications. LEARNING POINTS: Ludwig's angina, even though a well-established clinical entity, can be hard to recognize clinically.Early recognition of the condition is vital for the prevention of complications.A low threshold for surgical treatment should be maintained when surgery is indicated.

A Rare Case of Eustachian Valve Endocarditis in a Young Male With Poorly Controlled Type 1 Diabetes Mellitus.

The eustachian valve (EV) is a vestigial structure found at the junction of the inferior vena cava and the right atrium, a remnant of the embryological sinus venosus that may persist throughout life. Right-sided infective endocarditis of the eustachian valve remains a distinctly rare and under-diagnosed entity. Commonly known risk factors of eustachian valve endocarditis (EVE) are intravenous drug use, in-dwelling intracardiac devices, and central lines, although more recently immunocompromised states, e.g. uncontrolled diabetes mellitus and old age, have been recognized as risk factors for the disease. Although Staphylococcus aureus has been the most commonly implicated organism, cases of infections with gram-negative organisms are emerging. We present a 47-year-old male with uncontrolled type 1 DM who initially presented to the ED with complaints of low back pain and dysuria and was later found to have eustachian valve endocarditis ultimately treated with intravenous antibiotics.

Herbal Teas and Thrombocytopenia: A Curious Case of Yellow Dock and Burdock-Induced Thrombocytopenia.

Immune thrombocytopenia (ITP) is a bleeding disorder characterized by a decreased number of platelets. It is an immune system-mediated condition, with formation of antibodies against a structural platelet antigen. Although the pathogenesis remains elusive, primary disease is idiopathic and comprises 80% of cases. However, quite a few secondary causes have been established including Helicobacter pylori, varicella-zoster virus and cytomegalovirus. A few cases with an incidental association with herbal medications have been reported, but this causality has not been studied in detail. Here we present the case of 38-year-old African-American woman who presented with symptomatic thrombocytopenia, with a platelet count of 5 K/µl 1 week after she had consumed herbal tea containing Rumex crispus (yellow dock) and Arctium lappa (burdock). The association between unstudied herbs and ITP needs further research, given the widespread use of these substances and ongoing public uncertainty about their benefits. LEARNING POINTS: Over-the-counter herbal products marketed as having beneficial effects are not always harmless and can have clinically significant side effects.When investigating the causes of thrombocytopenia, physicians should be aware of and search for this rare cause.Treatment for herbal tea-induced thrombocytopenia is the same as for immune thrombocytopenia (i.e., steroids and platelet transfusion if there is actively bleeding).

Reactivation of Tuberculosis in the Setting of COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) was declared a pandemic by WHO in March 2020. The causative organism has since undergone a series of mutations. COVID-19 primarily being a respiratory illness causes pre-existing pulmonary diseases to show worse clinical outcomes. About one-third of the world's population is thought to be infected with latent Mycobacterium tuberculosis (MTB). Both previous and newly developed tuberculosis (TB) infection are risk factors for COVID-19 and are associated with poor outcomes. T lymphocytes play a pivotal role in defense against MTB and with evidence suggesting depletion of T lymphocytes in COVID-19, it can be postulated that COVID-19 can increase the risk of reactivation of latent TB.  Given that a large population around the globe is infected with latent tuberculosis, it is interesting to study and note cases where the virus leads to the reactivation of latent tuberculosis infection. Herein, we present a 76-year-old Brazilian male recently treated for COVID-19 pneumonia, presenting with new-onset cough and weakness diagnosed with latent MTB reactivation.