High-Risk Apical Hypertrophic Cardiomyopathy Requiring an Implantable Cardioverter-Defibrillator: A Case Report of an Overlooked Etiology.

Apical hypertrophic cardiomyopathy is a rare variant of hypertrophic cardiomyopathy characterized by abnormal heart muscle thickening, specifically affecting the left ventricle's apex. Classically revealing both giant T-wave inversions in the precordial leads of an electrocardiogram and a spade-like configuration of the left ventricular cavity on ventriculograms, the diagnosis of the apical variant has evolved with cardiac magnetic resonance imaging. Despite being well known among East Asian populations, the diagnosis of apical hypertrophic cardiomyopathy is often underestimated and overlooked among American patients due to the non-specific nature of echocardiography. In this case report, we present the diagnosis of apical hypertrophic cardiomyopathy in a middle-aged African American male with chronic palpitations. The diagnosis was confirmed using cardiac magnetic resonance imaging, which revealed extensive myocardial fibrosis. Ultimately, the patient was treated with an implantable cardioverter-defibrillator. Our case aims to enhance the understanding and facilitate the recognition and management of apical hypertrophic cardiomyopathy, particularly among non-Asian individuals. Current challenges revolve around robust risk stratification strategies for patients at high risk for sudden cardiac death that require device therapy.

Recovery of Transient High-Grade Atrioventricular Block Managed With Corticosteroid Therapy Without Device Implantation in Newly Diagnosed Cardiac Sarcoidosis: A Case Report.

Atrioventricular blocks (AVBs) presenting in cardiac sarcoidosis (CS) remain an ongoing challenge for clinicians. While most initiate immunosuppressive therapy with the goal of pursuing device implantation, there is some ambiguity as to which patient cohorts actually benefit from device therapy. We present a case of a 39-year-old African American male with a past medical history of hypertension and no prior cardiac history who presented with substernal chest pain in the setting of a hypertensive emergency. He was later diagnosed with cardiac sarcoidosis by cardiac magnetic resonance imaging. His hospital course was complicated by transient Mobitz II atrioventricular block. He was started on prednisone, and while initially scheduled for an implantable cardioverter-defibrillator (ICD), his conduction block recovered. Through a multidisciplinary approach, the patient was discharged on medical management with outpatient follow-up. Since his initial hospitalization, the patient has not had any concerning cardiovascular events over the past year and has not been treated with device therapy. Our case illustrates the feasibility of effectively managing patients with cardiac sarcoidosis presenting with transient atrioventricular blocks only with corticosteroid therapy without needing device implantation.

Euglycemic diabetic ketoacidosis caused by empagliflozin complicated by failure to thrive in a geriatric patient.

Euglycemic diabetic ketoacidosis (euDKA) is a rare but deadly complication of sodium-glucose cotransport-2 (SGLT-2) inhibitors. Primarily indicated for the treatment of Type 2 Diabetes Mellitus, the incidence of euDKA is expected to rise as SGLT-2 inhibitors become a mainstay therapy for diabetics with heart failure. Diagnosis of euDKA can be difficult given the presence of normoglycemia and is especially challenging among geriatric patients that are complicated by additional comorbidities. We present a case of an elderly male with multiple comorbidities who presented for dehydration and altered mentation from a nursing home facility. Laboratory investigations showed signs of acute renal failure, uremia, electrolyte abnormalities, and severe metabolic acidosis due to high levels of plasma beta-hydroxybutyrate. He was admitted to the medical intensive care unit (ICU) for further management. A presumptive diagnosis of euDKA was strongly suspected due to his laboratory data and medication reconciliation which revealed the recent initiation of empagliflozin. The patient was promptly started on a standardized treatment protocol for DKA with continuous infusion of regular insulin with strict glucose monitoring, along with intravenous fluids, and a small dose of sodium bicarbonate infusion as per current standard guidelines. With the rapid improvement in symptoms and metabolic derangements, the diagnosis was confirmed. Geriatric patients from nursing home facilities are a high-risk cohort who if not properly cared for by nursing staff can develop dehydration, malnutrition and worsening frailty including sarcopenia that exposes them to increased risk of medication side effects, such as euDKA. Clinicians should consider euDKA in their differential diagnosis in elderly patients with overt or relative insulinopenia who are receiving SGLT-2 inhibitors when presenting with acute changes in health and mentation.

First case of Arcobacter species isolated in pericardial fluid in an HIV and COVID-19 patient with worsening cardiac tamponade.

Arcobacter spp. is an emerging pathogen that is increasingly recognized as a cause of human infections. Gastrointestinal manifestations are most described in the case report literature. We present a case of the first documented case of Arcobacter spp. isolated in pericardial fluid in an immunocompromised patient with worsening cardiac tamponade that was successfully managed with an urgent pericardiocentesis and ensuing steroids, antibiotics, and a pericardial drain. The patient had a past medical history of HIV, latent syphilis, PCP pneumonia, ESRD, and hypertension, and presented with worsening dyspnea, subjective fever, myalgias, cough, pleuritic chest pain, and pericardial rub. Diagnostic workup revealed a positive COVID-19 PCR test, elevated high-sensitive cardiac troponins, elevated CRP, elevated D-dimer, and elevated creatinine. An ECG revealed diffuse ST-segment elevation, and imaging showed cardiomegaly with pulmonary vascular congestion and diffuse interstitial edema. Urgent TTE showed a large circumferential pericardial effusion with tamponade physiology present. Culture on aerobic blood agar grew Arcobacter spp. of unknown specific species, and blood cultures were also positive for Arcobacter spp. Treatment involved intravenous meropenem for five days, followed by oral ciprofloxacin, low-dose colchicine, and a tapered dose of ibuprofen. Repeat laboratory data and TTE showed complete resolution of the pericardial effusion and improved left ventricular function. This case highlights the potential for Arcobacter spp. to cause severe infections and the importance of considering it as a possible pathogen in patients with atypical presentations.

A Case Report of Culture-Negative Necrotizing Fasciitis With Low Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score: A Diagnostic Dilemma.

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is a diagnostic tool used to help clinicians identify necrotizing fasciitis (NF) in its early stages. This tool uses six laboratory values including the patient's white blood cell count, C-reactive protein level, serum sodium level, creatinine level, and hemoglobin level to help with risk stratification. Each of these laboratory values is assigned a point value and the total score is used to determine the likelihood that a patient has NF, with a score of 6 or higher considered to be strongly indicative. The LRINEC score has gained popularity in recent years, having been included in guidelines and society recommendations for the management of NF. However, some studies have challenged the validity of the LRINEC score. Prompt and accurate diagnosis of NF is imperative given the associated mortality rate, which can be as high as 30%-40%, especially if the diagnosis is delayed. We present a case of a patient with a delayed diagnosis of NF that was initially missed in the early stages in the setting of a low LRINEC, however, growing clinical suspicion eventually led to an accurate diagnosis and management.

A Diagnostic Pitfall of Transthoracic Echocardiography: A Case of a Missed Large Mitral Valve Thrombus in the Setting of Suspected Nonbacterial Thrombotic Endocarditis.

Transthoracic echocardiography (TTE) is frequently utilized in the initial evaluation of cardioembolic stroke. However, the diagnostic utility of TTE is often operator-dependent, and in conjunction with anatomical limitations, there is a range of sensitivities reported in the literature specifically in the evaluation of nonbacterial thrombotic endocarditis (NBTE). Thus, relying on TTE findings to rule out NBTE in the setting of cardioembolic stroke evaluation can lead to misdiagnosis in the absence of confirmatory transesophageal echocardiography (TEE). We present a case of a 67-year-old female with a past medical history of hypertension, diabetes mellitus, human immunodeficiency virus (HIV), and recurrent ischemic strokes who was referred by her neurologist for TEE. Despite an initial TTE with a bubble study showing no evidence of intra-atrial septum, left ventricular thrombus, or any valvular pathology, there remained high suspicion of a cardioembolic source due to the bi-hemispheric presentation of the patient's previous strokes. Prior electrocardiography and cardiac event monitor showed normal sinus rhythm. Her TEE revealed a large, dense thrombus measuring 1.0 x 0.8 centimeters involving the anterior mitral valve leaflet with associated moderate mitral regurgitation. The patient was placed on systemic anticoagulation and discharged home with outpatient follow-up with cardiology. Our case highlights the diagnostic pitfalls of TTE use in the evaluation of cardioembolic stroke with a particular emphasis on NBTE in addition to discussing the rationale for follow-up TEE when TTE is otherwise unrevealing.

Improving Access to Cardiovascular Care Through Telehealth: A Single-Center Experience.

Background: Historically, access to healthcare has been a serious shortcoming of our healthcare system. Approximately 14.5% of US adults lack readily available access to health care and this has been worsened by the coronavirus disease 2019 (COVID-19) pandemic. There are limited data on the use of telehealth in cardiology. We share our single-center experience in improving access to care via telehealth at the University of Florida, Jacksonville cardiology fellows' clinic. Methods: Demographic and social variables were collected 6 months before and 6 months after the initiation of telehealth services. The effect of telehealth was determined via Chi-square and multiple logistic regression while controlling for demographic covariates. Results: We analyzed 3,316 cardiac clinic appointments over 1 year. Of these, 1,569 and 1,747 were before and after the start of telehealth, respectively. Fifteen percent (272 clinical encounters) out of the 1,747 clinic visits during the post-telehealth era were through telehealth, completed via audio or video consultation. Overall, there was a 7.2 % increase in attendance after the implementation of telehealth (P value < 0.001). Patients who attended their scheduled follow-up had significantly greater odds of being in the post-telehealth group while controlling for marital status and insurance type (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.07 - 1.62). Patients who attended had higher odds of having City-Contract insurance - an institution-specific indigenous care plan (OR: 3.51, 95% CI: 1.79 - 6.87) compared to private insurance. Patients who attended also had higher odds of being previously married (OR: 1.34, 95% CI: 1.05 - 1.70) or married/dating (OR: 1.39, 95% CI: 1.05 - 1.82) compared to patients who were single. Surprisingly, telehealth did not lead to an increase in the use of Mychart, our electronic patient portal (P value = 0.55). Conclusions: Telehealth enhanced patients' access to care by improving appointment show-rate in a cardiology fellows' clinic during the COVID-19 pandemic. Telehealth as a resource adjunct to traditional care in cardiology fellows' clinic should be further explored.

A Case of Sick Sinus Syndrome With Prolonged Asystole Masquerading as a Transient Ischemic Attack.

Sick sinus syndrome (SSS) is a term used to describe dysfunction of the sinoatrial (SA) node that can lead to various cardiac arrhythmias that predominately manifest in the elderly. Commonly implicated arrhythmias vary from inappropriate bradycardia, tachycardia, sinus pauses, and rarely sinus arrest. Despite being a common reason for permanent pacemaker implantation, little is known regarding the incidence of SSS and there is even less reporting on SSS complicated by prolonged asystole. We present a case highlighting an infrequently observed manifestation of SSS with recurrent, prolonged ventricular asystolic episodes that were causing previously unexplained episodes of confusion and agonal breathing. Our patient was a 75-year-old male with a past medical history of hypertension, dyslipidemia, and prior transient ischemic attacks (TIAs) that presented after an acute mental status change. The initial leading differential diagnosis was believed to be a TIA and he was admitted to neurology service for further evaluation. The patient had recurring episodes of confusion associated with agonal breathing that upon closer review of the cardiac telemetry revealed sinus bradycardia to the 40s interrupted by several prolonged episodes of asystole, the longest lasting 20 seconds. Due to his symptoms and to avoid potential deterioration resulting in hemodynamic instability, the electrophysiology service urgently placed a temporary transvenous pacemaker and then later implanted a leadless pacemaker. On outpatient follow-up, he no longer had episodes of confusion, and no further asystolic episodes were noted on his device check.

Evaluating the Safety of Ultra-Low-Dose Estrogen Contraception in Sickle Cell Trait With Focus on Cerebral Venous Sinus Thrombosis.

Ultra-low-dose combination estrogen-progestin contraceptive pills (OCP) have been marketed as being safer to use than previously higher estrogen-containing OCPs. While multiple large studies have shown a dose-dependent association between estrogen and deep vein thrombosis, there remains sparse guidance or data as to whether patients with sickle cell trait should avoid estrogen-containing OCPs regardless of the dosage. We present a case of a 22-year-old female with a history of sickle cell trait who had recently been started on an ultra-low-dose norethindrone-ethinyl estradiol-iron (1-20 mcg) that presented with headache, nausea, vomiting, and obtunded. Initial neuroimaging was significant for an extensive superior sagittal sinus thrombosis with extension into the confluence of dural venous sinuses, right transverse sinus, right sigmoid sinus, and right internal jugular vein which ultimately required systemic anti-coagulation. Her symptoms largely resolved within four days after starting anti-coagulation. She was discharged on day six to complete a six-month course of oral anti-coagulation. At her neurology follow-up three months later, the patient reported resolution of all symptoms. This study evaluates the safety of ultra-low-dose estrogen-containing contraceptive pills in the sickle cell trait population with special focus on cerebral sinus thrombosis.

Monkeypox-induced proctitis: a case report of an emerging complication.

PURPOSE: At the outset of the 2022 human monkeypox virus outbreak, the World Health Organization described the self-limited disease as a rash illness associated with nonspecific symptoms such as fever, myalgias, and lymphadenopathy. Historically, the infection caused by this zoonotic virus has presented with rashes primarily on the face, palms, and soles of feet. However, emerging case report literature from the 2022 recent outbreak highlighted more atypical presentations ranging from ocular manifestations to myocarditis. CASE DESCRIPTION: We present a case of a 32-year-old African American male with a past medical history of poorly controlled acquired immunodeficiency syndrome and external hemorrhoids that presented for worsening rectal pain. The patient was afflicted with diffuse skin lesions even present on his hemorrhoids. Initial imaging significant circumferential rectal thickening consistent with proctitis. Subsequent polymerase chain reaction testing confirmed active monkeypox infection, and a 14-day course of twice daily tecovirimat 600 mg was initiated to treat disseminated monkeypox infection. After improved pain control and starting antiviral treatment, the patient was discharged two days later. CONCLUSION: As more cases of monkeypox-associated proctitis emerge, clinicians should keep this disease in their differential due to the growing atypical presentations that have diverged from previous patterns to avoid the risk of misdiagnosing another sexually transmitted infection. Additionally, appropriate medical management is still not definitive and requires further development of evidence-based protocols to treat such patients.

COVID-19-associated Brugada pattern electrocardiogram: Systematic review of case reports.

AIMS: To summarize published case reports of patients diagnosed with coronavirus disease 2019 (COVID-19) and Brugada pattern electrocardiogram (ECG). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist were followed. A literature search was conducted using PubMed, EMBASE, and Scopus up until September 2021. The incidence, clinical characteristics, and management outcomes of COVID-19 patients with a Brugada pattern ECG were identified. RESULTS: A total of 18 cases were collected. The mean age was 47.1 years and 11.1% were women. No patients had prior confirmed diagnosis of Brugada syndrome. The most common presenting clinical symptoms were fever (83.3%), chest pain (38.8%), shortness of breath (38.8%), and syncope (16.6%). All 18 patients presented with type 1 Brugada pattern ECG. Four patients (22.2%) underwent left heart catheterization, and none demonstrated the presence of obstructive coronary disease. The most common reported therapies included antipyretics (55.5%), hydroxychloroquine (27.7%), and antibiotics (16.6%). One patient (5.5%) died during hospitalization. Three patients (16.6%) who presented with syncope received either an implantable cardioverter defibrillator or wearable cardioverter defibrillator at discharge. At follow-up, 13 patients (72.2%) had resolution of type 1 Brugada pattern ECG. CONCLUSION: COVID-19-associated Brugada pattern ECG seems relatively rare. Most patients had resolution of the ECG pattern once their symptoms have improved. Increased awareness and timely use of antipyretics is warranted in this population.

The effects of chronic and acute physical activity on working memory performance in healthy participants: a systematic review with meta-analysis of randomized controlled trials.

BACKGROUND: Understanding how physical activity (PA) influences cognitive function in populations with cognitive impairments, such as dementia, is an increasingly studied topic yielding numerous published systematic reviews. In contrast, however, there appears to be less interest in examining associations between PA and cognition in cognitively healthy individuals. Therefore, the objective of this review was to evaluate and synthesize randomized controlled trial (RCT) studies that investigated the effects of both chronic and acute PA on working memory performance (WMP) in physically and cognitively healthy individuals. METHODS: Following the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, a systematic review of studies published between August 2009 and December 2016 was performed on RCTs investigating the effects of chronic and acute PA on WMP with healthy participants as the sample populations. Searches were conducted in Annual Reviews, ProQuest, PsycARTICLES, PsycINFO, PubMed, and Web of Science. Main inclusion criteria stipulated (1) healthy sample populations, (2) PA interventions, (3) WMP as an outcome, and (4) RCT designs. Descriptive statistics included cohort and intervention characteristics and a risk of bias assessment. Analytical statistics included meta-analyses and moderation analyses. RESULTS: From 7345 non-duplicates, 15 studies (eight chronic PA and seven acute PA studies) met the inclusion criteria and were evaluated. Overall, there was noticeable variance between both cohort and intervention characteristics. Sample populations ranged from primary school children to retirement community members with PA ranging from cycling to yoga. The majority of studies were characterized by "low" or "unclear" risk of selection, performance, detection, attrition, reporting, or other biases. Meta-analysis of chronic PA revealed a significant, small effect size while analysis of acute PA revealed a non-significant, trivial result. Age and intensity were significant moderators while allocation concealment, blinding, and intervention length were not. CONCLUSIONS: Chronic PA can significantly improve WMP while acute PA cannot. The limiting factors for acute PA studies point to the diversity of working memory instruments utilized, unequal sample sizes between studies, and the sample age groups. Large-scale, high-quality RCTs are needed in order to provide generalizable and more powerful analysis between PA and WMP in a systematic approach.

Vitamin D Deficiency in HIV-Infected Children.

OBJECTIVES: Improvement in life expectancy with the use of combination antiretroviral therapy has come with the recognition of the complications associated with chronic human immunodeficiency virus infection. Vitamin D has been of particular interest because of its effect on bone health and immune functions. The purpose of this study was to assess vitamin D status in children in relation to the duration and severity of their human immunodeficiency virus infection and nutritional status, as well as to determine whether there was any effect of seasonality. METHODS: The study design was cross-sectional and all children 0 to 21 years of age were eligible to participate. RESULTS: A total of 59 participants provided informed consent, with 54 subjects completing all study activities. Thirteen (24.1%) had sufficient vitamin D levels, 13 (24.1%) had insufficient levels, and 28 (51.9%) had deficient levels per the guidelines of the Endocrine Society. In our univariate analysis, younger age was associated with higher vitamin D levels (P = 0.030). Higher CD4 counts were associated with higher vitamin D levels (P = 0.018). A significant association between the vitamin D intake per day and vitamin D level was seen (P = 0.013). In the multivariate analysis, the best ordinal logistic regression model had the CD4 count as predictor (P < 0.005), higher CD4 counts were associated with decreased odds of vitamin D deficiency (odds ratio 0.47, 95% confidence interval 0.28-0.80). CONCLUSIONS: Vitamin D deficiency was common among the patients included in this study.