Acquired Thrombotic Thrombocytopenic Thrombocytopenia Presenting As Urinary Tract Infection and Perianal Abscess: A Case Review.

Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening hematologic disorder characterized by hemolytic anemia, thrombocytopenia, renal failure, fever, and neurologic dysfunction. While cases often do not present with all five characteristics (<5%), TTP can be hereditary or acquired, often due to a deficiency or dysfunction of the ADAMST13 enzyme. Here, we describe a case of infection-induced acquired TTP in a middle-aged male with urinary tract infection (UTI) and perianal abscess. Suspicion arose from hematologic abnormalities, fever, thrombocytopenia, acute renal failure, and the presence of an underlying infection. A PLASMIC score of 6 (indicating a 72% probability of ADAMTS13 deficiency) prompted ADAMTS13 level testing, revealing levels <5% with the presence of an inhibitor, confirming TTP diagnosis. Treatment with high-dose steroids and daily plasma exchange yielded a swift platelet response, necessitating only two to three days of plasma exchange. In addition, incision and drainage of the perianal abscess were performed. The patient was discharged on daily prednisone and initiated on four doses of weekly Rituximab to mitigate recurrence risk. This case underscores the importance of early suspicion and treatment in infectious triggers such as UTI/perianal abscess, offering crucial diagnostic and prognostic insights.

Olanzapine-induced cardiomyopathy: A mimicker of obesity cardiomyopathy?

Olanzapine, an atypical antipsychotic medication, has gained prominence in the treatment of schizophrenia and related psychotic disorders due to its effectiveness and perceived safety profile. However, emerging evidence suggests a potential link between olanzapine use and adverse cardiovascular effects, including cardiomyopathy. This narrative review explores the mechanisms, clinical implications, and management strategies associated with olanzapine-induced cardiomyopathy. A comprehensive review of the literature was conducted to investigate the relationship between olanzapine and cardiomyopathy. The search included epidemiological studies, clinical case reports, and mechanistic research focusing on the pathophysiology of olanzapine-induced cardiomyopathy. The review also examined treatment strategies for managing this potential complication. Olanzapine-induced cardiomyopathy is hypothesized to be associated with metabolic disturbances and receptor antagonism. The metabolic effects of olanzapine, such as weight gain, insulin resistance, and dyslipidemia, share similarities with obesity-related cardiomyopathy. Additionally, olanzapine's antagonism of certain receptors may contribute to cardiovascular stress. The review highlighted that patients with new-onset heart failure and significant weight gain while on olanzapine should be closely monitored for signs of cardiomyopathy. Early detection and prompt withdrawal of olanzapine, along with initiation of goal-directed medical therapy, are crucial for mitigating this potentially life-threatening condition. The relationship between olanzapine and cardiomyopathy is complex and not yet fully understood. However, the potential for significant cardiovascular risk necessitates vigilance among healthcare providers. Early identification and management of olanzapine-induced cardiomyopathy can improve patient outcomes. Further research is needed to elucidate the precise mechanisms behind this adverse effect and to develop optimized treatment strategies for patients requiring antipsychotic therapy.

Early Mammogram Screening's Impact on Early Breast Cancer Detection in Underserved Populations.

Background Breast cancer remains a pressing public health challenge in the United States, ranking as one of the most prevalent cancers and the second leading cause of cancer-related deaths among women. This study investigates the effectiveness of early mammogram screening in underserved populations. Methods Data from female patients receiving primary care at a tertiary hospital in Nashville between January 2022 and January 2023 were retrospectively analyzed. Inclusion criteria encompassed females aged 40 or older with initial mammogram screenings before turning 50. Exclusions included genetically or environmentally related risk factors, cosmetic motivations, age above 50 at first screening, and screenings prompted by physical exams. Results Of 150 eligible women aged 40-49, the majority (n=121, 80.7%) had normal findings, 18.0% (n=27) had benign lesions, and 1.3% (n=2) had suspicious/malignant lesions. About 30.7% (n=46) underwent additional testing due to suspicious masses, with ultrasounds and diagnostic mammograms being common. The breast malignancy positivity rate was 1.33% (n=2) for the study population and 4.3% among those requiring additional testing. The positivity rate for the population of Black American descent is 1% (n=2), and for the Hispanic population, it is 6.25% (n=1). Discussion Breast cancer remains a significant concern, with disparities in screening guidelines and varying age of diagnosis. Overdiagnosis and false positives are challenges, with our study highlighting potential benefits in early screening, particularly for populations with unique risk factors, such as smokers. However, the study's limitations, including a small sample size and demographic bias, necessitate larger, more diverse studies to establish stronger correlations. Shared decision-making in early mammogram screening is emphasized. Conclusion Early mammogram screening in the 40-49 age group may detect breast cancer cases, but guidelines remain inconsistent. The study recommends early screening at age 40, with awareness of potential advantages and disadvantages. Larger, more comprehensive studies are needed to inform breast cancer screening practices better.

Tinospora cordifolia (Guduchi/Giloy)-Induced Liver Injury: A Case Review.

Tinospora cordifolia (Guduchi/Giloy) is a relatively common herbal supplement whose use has recently become prominent in Southeast Asia. It was promoted to the public in India as an immunity booster, especially against the novel COVID-19. There have been reports, mostly from India, of an association between Guduchi/Giloy and liver injury. We present a 50-year-old female with a history of Hashimoto thyroiditis, who presented with abdominal discomfort and nausea of two weeks duration, which coincided with starting HistaEzeTM supplement containing Tinospora cordifolia. The vital signs upon presentation showed no significant abnormalities. Labs were significant for severely elevated transaminases; however, viral panels, autoimmune serologies, and imaging studies were unremarkable. Roussel Uclaf causality assessment method (RUCAM) score was at 6, which was indicative of probable drug/herb-induced liver injury. HistaEzeTM was discontinued, and the patient took a three-day course of oral steroids with significant interval improvement in clinical status, as evidenced by progressive normalization of the transaminases level. The transaminases decreased by greater than 50% within two weeks of discontinuation and trended back to baseline within three months. This case highlights the worldwide availability and use of Tinospora cordifolia, which can cause liver injury that appears to be idiosyncratic and possibly immune-mediated. Further research on the precise mechanism of its hepatotoxicity is warranted.

The Rare Case of Esophageal Cancer Presenting With Hematemesis in a 29-Year-Old Adult.

Esophageal cancer is a disease with high mortality. This is mainly due to late presentations with nonspecific symptoms. Despite advances in surgery and chemoradiotherapy, it is the eighth most common cancer but the sixth deadliest. It is reportedly common in older patients but rare in young ones. In this case report, we present a 29-year-old male patient with no prior medical condition who presented with hematemesis to the emergency unit and was found to have esophageal cancer with the biopsy. Not only is esophageal cancer rare in young adults, but hematemesis is a rare symptom in esophageal cancer patients.

Ipsilateral Orolingual Angioedema Following Alteplase Administration for the Treatment of Suspected Acute Ischemic Stroke.

Intravenous tissue plasminogen activator (tPA) remains the standard of treatment for patients presenting with acute ischemic stroke within the treatment window. In most patients, this often leads to an effective and life-prolonging intervention in the acute setting. This is, however, not without complications, which sometimes could be potentially fatal. Hemorrhagic complications, such as hemorrhagic conversion and bleeding, are the most discussed; however, facial angioedema has also been reported. We present a case of a 72-year-old African American male who developed right-sided ipsilateral orolingual angioedema 20 minutes after starting a tPA infusion. He was subsequently managed with antihistamine medications and steroids with interval resolution of symptoms. This case highlights the need for close monitoring while on tPA infusion, early detection, and management of potential facial angioedema complications. It also serves as a template for further studies focusing on preventative strategies for tPA-induced angioedema.

Acute Cardiovascular Complications of COVID-19: A Systematic Review.

Since the pandemic in 2019, coronavirus 2019 (COVID-19) has continued to be linked with a variety of organ systems and complications. While it is generally considered a respiratory disease, its link with the heart is widely discussed in the literature. This article focuses on the acute cardiovascular complications of COVID-19 and the possible predictors of these complications. Our study included 97 articles (58 case reports, eight case series, 23 retrospective cohort studies, five prospective cohort studies, and three cross-sectional studies). Several mechanisms have been proposed to explain COVID-19-induced cardiovascular complications, with cytokine-induced inflammation and direct cardiac damage noted as the significant focus. Patients with underlying cardiovascular complications such as hypertension and diabetes were noted to be at increased risk of acute cardiovascular complications, as well as an increased risk of severe disease and death. Also, acute myocardial infarction and arrhythmias were two of the most common acute cardiovascular complications noted in our review. Other acute cardiovascular complications are myocarditis, takotsubo syndrome, acute thromboembolic events, and pericardial complications. This article provides an updated review of acute cardiovascular complications of COVID-19, its pathogenesis, and risk stratification and emphasizes the need for high suspicion in patients with underlying cardiovascular risk factors.

An Unusual Case of Severe Aortic Stenosis and Triple-Vessel Coronary Artery Disease in a Patient Presenting With Intermittent Chest Pain.

Although relatively uncommon, premature coronary artery disease (CAD) is a significant cause of mortality and morbidity. A key risk factor for this condition is the presence of familial hyperlipidemia (FH), which is a genetic disorder of impaired cholesterol metabolism. While aortic stenosis is relatively common in the older population, it is rare in young adults, and its presence should raise concern for a bicuspid valve. We present the case of a 37-year-old male patient with intermittent chest pain and physical examination findings of multiple-site xanthomas and echocardiography/angiography findings of severe aortic stenosis and severe three-vessel CAD, respectively. FH was noted as the most critical risk factor in this patient. He was subsequently managed with surgical aortic valve replacement (SAVR) and simultaneous coronary bypass graft surgery with interval symptom improvement. Cholesterol-lowering agents - high-intensity statins/ezetimibe - were started to control cholesterol levels. Guideline-directed medical therapy for CAD/aortic valve replacement (AVR) with beta-blockers, angiotensin-converting enzyme inhibitors, antiplatelet therapy, and warfarin therapy was also employed. This report highlights a case of acute coronary syndrome (ACS) in a young adult and how early detection and treatment of risk factors can lead to a good prognosis.

Paradoxical Left Ventricular Hypertrophy by Echocardiogram and Low Voltage ECG: A Key Clue in the Diagnostic Workup of Two Distinct Presentations of Cardiac AL Amyloidosis.

Cardiac amyloidosis remains a rare disease caused by the extracellular deposition of abnormal proteins-amyloids in the myocardium. These protein structures in the myocardium are associated with high morbidity and mortality, with prognosis hinging on early detection and treatment. Three main types of cardiac amyloidosis have been identified: light chain (AL), familial or senile (ATTR), and secondary amyloidosis which is associated with chronic inflammation. Cardiac amyloidosis classically presents as diastolic heart failure with symptoms of volume overload low voltage on electrocardiogram (ECG) and echocardiographic features of diastolic dysfunction and paradoxical left ventricular hypertrophy (paradoxical with respect to low voltage on ECG). Early suspicion should trigger additional laboratory and imaging workup to facilitate early detection. Early detection remains critical to prognosis. Herein, we present two patients admitted to a safety-net hospital within one month of each other with distinct presentations yet important, overlapping characteristics that led to the diagnosis of AL amyloidosis in both patients.

A Case of Wellens Syndrome in a Young Adult With Intermittent Chest Pain: Understanding the Unique Pattern and Clinical Correlation.

Wellens syndrome is a unique electrocardiographic (ECG) pattern usually suggestive of critical stenosis of the left anterior descending (LAD) coronary artery. Providers must recognize this pattern as it frequently occurs in symptom-free periods and represents a pre-infarction stage requiring early intervention. We present the case of a 39-year-old male with a past medical history of hypertension who was brought to the emergency department due to complaints of worsening recurrent intermittent squeezing left-sided chest pain of two months duration. Cardiac enzymes were within limits. ECG done at triage was significant for biphasic T waves in leads V2-V5 consistent with type A Wellens syndrome. The cardiology team consulted, with the patient subsequently having a percutaneous coronary intervention to the mid and proximal portion of the LAD. The patient was later discharged on the third day of admission on guideline-directed medical therapy, with plans to follow up closely with the cardiology clinic. This case highlights the significance of using the characteristics pattern of Wellens syndrome in providing critical diagnostic and prognostic value. This article aimed to promote awareness of Wellens syndrome, the clinical correlation, and the role of timely acute management.

Tachycardia-Induced Cardiomyopathy in a Young Adult: The Significance of Early Diagnosis and Treatment.

Tachycardia-induced cardiomyopathy (TIC) is gradually gaining the attention it deserves as one of the most common causes of reversible cardiomyopathy. Although TIC appears common, there has been limited data, especially among young adults. Patients with tachycardia and left ventricular dysfunction should be suspected of having TIC, with or without established etiology of heart failure, because TIC can develop by itself or contribute to cardiac dysfunction. We present a case of a previously healthy 31-year-old woman with persistent nausea and vomiting, poor oral intake, fatigue, and persistent palpitations. Vital signs at presentation were significant for tachycardia of 124 beats per minute, which she reported was similar to her baseline heart rate of 120s per minute. There were no apparent signs of volume overload at the presentation. Labs were significant for microcytic anemia with hemoglobin/hematocrit of 10.1/34.4 g/dL, and mean corpuscular volume was low at 69.4 fL; other labs were unremarkable. Transthoracic echocardiography obtained at admission was significant for mild global left ventricular hypokinesis, systolic dysfunction with an estimated left ventricular ejection fraction of 45-50%, and mild tricuspid regurgitation. Persistent tachycardia was suggested as the primary cause of cardiac dysfunction. The patient was subsequently started on guideline-directed medical therapy, including beta blockers, angiotensin-converting enzyme inhibitors, and spironolactone, with eventual normalization of the heart rate. Anemia too was also treated. Follow-up transthoracic echocardiography done four weeks after was notable for significant interval improvement in left ventricular ejection fraction of 55-60%, with a heart rate of 82 beats per minute. The case illustrates the need for early identification of TIC regardless of the patient's age. It is essential that physicians consider it in the differential diagnosis of new-onset heart failure because prompt treatment leads to the resolution of symptoms and improvement of ventricular function.

Colovesical Fistula Complicating the First Symptomatic Episode of Acute Diverticulitis in a Young Adult.

Colovesical fistula is one of the known complications of acute diverticulitis. However, it is uncommon for a patient to present with a colovesical fistula without prior episodes of diverticulitis. In this case, we report a patient with acute diverticulitis presenting with a colovesical fistula with no antecedent history of any medical condition. The patient was treated with intravenous antibiotics and subsequently had a temporary laparoscopic colostomy. Although colovesical fistula caused by diverticular disease was once considered a relative contraindication to laparoscopic resection, this method is now being increasingly employed by experienced surgeons. Compared with laparoscopic colon resection surgery for uncomplicated diverticulitis, the minimally invasive treatment of colovesical fistula requires a longer operative time and advanced surgical skills.

Recurrent Left Atrial Myxoma: The Significance of Active Surveillance.

Cardiac myxoma recurrence is uncommon following surgical resection. Recurrence is about 2-3% in familial cases; however, recurrence is uncommon in sporadic cases. Most of the recurrences will occur during the first three to four years. Ten percent of myxomas are of the inherited autosomal dominant disorder called Carney's complex, while the rest appear sporadic. We are reporting a nonfamilial case of atrial myxoma, recurring rapidly seven years after resection of the initial left atrial myxoma with a pathologically proven clear margin and no malignant transformation. Cardiac neoplasms are rare and occur less commonly than metastatic disease of the heart. Congestive heart failure symptoms and thromboembolism account for nearly half of the presenting signs and symptoms. The initial presentation of our case was an embolic phenomenon, presenting with a stroke. The patient subsequently underwent resection of the mass, with pathology confirming the complete excision of the myxoma with a clear margin and no evidence of malignant transformation. Our patient was closely followed up in the clinic on annual transthoracic echocardiography surveillance, with a recurrence noted on surveillance echocardiography in 2021 (seven years after initial diagnosis) despite the patient being asymptomatic. This case illustrates transthoracic echocardiography as the mainstay of detection of recurrent left atrial myxoma; however, it also asks the question of how often patients need to be screened for recurrence of left atrial myxoma and for how long they need to have surveillance echocardiography. Clinical presentation and transesophageal echocardiographic views are extremely helpful in sharpening the accuracy of the diagnosis.

Thyrotoxicosis-Induced Cardiogenic Shock: Acute Management Using a Multidisciplinary Approach.

The development of heart failure and cardiomyopathy has been identified as an infrequent but life-threatening complication of thyrotoxicosis or thyroid storm. Thyrotoxicosis-induced cardiomyopathy and cardiogenic shock have been shown to be one of the major causes of sudden mortality in adults. However, the treatment of thyrotoxicosis with non-cardioselective beta-blockers has been implicated in the development of severe decompensation and even cardiogenic shock if cardiac function is not known and often requires a multidisciplinary care team to address it. Here, we have reported the case of a 63-year-old male with a past medical history of hyperthyroidism who presented to the emergency room with persistent shortness of breath. Vital signs were notable for hypotension, tachycardia with an irregular heartbeat, with ECG suggestive of atrial fibrillation with a rapid ventricular rate. The thyroid function test was significant for severely suppressed TSH, and the Burch-Wartofsky Score was >45. The patient rapidly decompensated shortly after being given IV metoprolol, subsequently requiring intubation and pressor support. Two-dimensional (2D) echocardiography (or echo) done afterward was significant for four-chamber dilation with mild global hypokinesis and reduced left ventricular ejection fraction. Endocrinology, Cardiology, and Pulmonary Critical Care teams were consulted to assist in multi-modality management. The administration of a non-cardioselective beta-blocker in decompensated heart failure was suggested as the cause of the rapid deterioration. Through a multi-modality management approach, the patient subsequently improved and was eventually discharged with the resolution of thyroid storm and cardiogenic shock, and with close follow-up with the primary care provider, endocrinologist, and cardiologist. This case illustrates the significance of a multidisciplinary team approach in the acute management of thyrotoxicosis-induced cardiogenic shock, as recommendations from the team were instrumental in helping the patient recover from the acute phase of the illness. Also, this case further highlights the significance of assessing the cardiac function, preferably performing echo before starting the patient on beta-blockers.