Case report: a breathtaking complication after ablation-using multi-modal imaging for timely diagnosis of acquired pulmonary vein stenosis and its implication for effective management.

Background: Acquired pulmonary vein stenosis (PVS) is a rare, but serious, complication that can develop after treatment with ablations for atrial fibrillation. Prompt diagnosis is difficult because it can often present similarly to other pulmonary disease processes. Case summary: We describe a 62-year-old female with history of persistent symptomatic atrial fibrillation that resolved status post two radio-frequency ablations who presents with ongoing dyspnoea, productive cough, pleuritic chest pain, and haemoptysis over multiple admissions. She was misdiagnosed with recurrent pneumonias and pulmonary embolism that failed to improve her symptoms. She was referred to our centre for further evaluation finding severe stenosis in the left superior pulmonary vein with complete obliteration of the left inferior pulmonary vein on computed tomography scan. Multi-modal imaging including an echocardiogram and pulmonary angiogram was used to confirm the diagnosis. Percutaneous intervention with transvenous pulmonary vein venoplasty with pulmonary vein stenting of the left upper pulmonary vein was offered which resolved the patient's aforementioned symptoms. Conclusion: Prompt diagnosis of acquired pulmonary vein stenosis is critical to plan for effective management. Our case highlights the need to consider PVS with a high index of clinical suspicion when a patient's medical history is significant for a prior history of ablation. We also review the use of multi-modal imaging to diagnose and plan for effective management with percutaneous intervention.

Getting around the gut: a unique management challenge of thyroid storm precipitated by amphetamine-associated duodenal ischaemia leading to compromised enteric absorption.

Thyroid storm is a rare, life-threatening endocrine emergency with a high mortality rate of up to 30%. We present a unique management challenge of a critically ill patient who developed thyroid storm in the setting of a duodenal perforation from amphetamine-associated non-occlusive mesenteric ischaemia. The diagnosis of 'thyroid storm' was made based on clinical criteria and a Burch-Wartofsky score of 100. During emergent exploratory laparotomy, a 1 cm duodenal perforation with surrounding friable tissue was found and repaired. Intraoperatively, a nasogastric tube was guided distal to the area of perforation to allow for enteric administration of medications, which was critical in the setting of thyroid storm. Therapeutic plasma exchange achieved biochemical control of our patient's thyroid storm but ultimately did not prevent in-hospital mortality.