Unleashing an Underlying Serious Cardiac Arrhythmia: A Case of Coronary Vasospasm With Atypical Presentation.

This case report highlights the atypical presentation of coronary artery vasospasm in a 59-year-old patient presenting with syncope due to ventricular arrhythmia. Despite initially elevated troponin levels and non-significant lesions observed during left heart catheterization, the patient experienced recurrent chest pain and dizziness, prompting further evaluation. Ultimately, coronary vasospasm was identified as the likely differential diagnosis, supported by various diagnostic modalities including electrocardiogram, Zio patch monitoring, transthoracic echocardiogram, cardiac MRI, and CT angiography. Management involved the initiation of calcium channel blocker therapy, leading to a non-eventful follow-up in the cardiology clinic.

Leiomyosarcoma: Lung Metastasis.

Uterine leiomyosarcoma distant metastasis is common, and lung metastasis has been reported. However, unique cases have been identified either with late onset of metastatic disease or with large size of lung metastasis. A typical approach to avoid metastasis would be a hysterectomy. Nonetheless, metastatic recurrence is common. We encountered a case at our hospital with leiomyosarcoma metastatic to the lungs. Lung metastasis was noted to be 17 cm in diameter. This size has not yet been reported in the literature to the best of our knowledge.

Occult Non-small Cell Lung Cancer Presenting as Paraneoplastic Gastroparesis: A Case Report and Literature Review.

Paraneoplastic gastrointestinal syndromes rarely precede the actual detection of an overt cancer with gastroparesis being a very rare initial presentation. To increase the clinical awareness of this rare clinical entity, we present a case of severe gastroparesis that was later proven to be associated with an occult poorly differentiated non-small cell lung cancer. We then continue to briefly review the relevant literature on paraneoplastic gastrointestinal syndromes to date. A 61-year-old African-American man presented with two months history of severe post-prandial nausea, vomiting and bloating associated with unintentional weight loss of 20 pounds. General physical examination revealed cachexia, temporal muscle wasting and clubbing of nails in both hands. The following investigations were normal or negative: basic metabolic panel, liver function tests, chest X-ray and esophagogastroduodenoscopy. Computed tomography (CT) scan of the abdomen showed residual food in the stomach and scintigraphic gastric emptying studies were consistent with gastroparesis. CT scan of the chest was performed which revealed a spiculated nodule sized 9 mm in right upper lobe of the lung with right hilar lymphadenopathy. Positron emission tomography (PET) scan revealed hyper-metabolic activity in the right upper lobe nodule and right hilar adenopathy. Nodule resection and biopsy revealed a poorly differentiated non-small cell lung carcinoma. Due to the concern of paraneoplastic origin of his gastroparesis further serological testing showed positive anti-neuronal nuclear antibodies type 1 (Anti-Hu) and cytoplasmic purkinje cell antibodies (Anti-Yo). The patient was started on a chemotherapy combination of Carboplatin and Paclitaxel with a three-week course of local radiation therapy. Moreover, for the relief of his severe gastrointestinal (GI) symptoms dietary modifications, pro-kinetic agents and psychological counseling were used with gradual clinical improvement observed on follow-up visits.

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature.

Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH, many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. A literature search was conducted using the electronic database engines MEDLINE, PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trials and Cochrane Database of Systematic Reviews) from inception to April 2018 to identify published articles and reports addressing outcomes in patients treated for HH with IPCs. The risk of bias was rated for each study using the Cochrane criteria. The search strategy retrieved 370 papers, of which four case series were selected with a total of 111 patients. After the insertion of IPCs for HH, spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients at a mean duration of 73-222 days. As far as secondary outcomes were concerned, the frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage two (2.9%) out of 68 patients, pleural fluid infection five (4.5%) out of 111 patients and catheter-site cellulitis one (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study, wherein 12 (20%) out of 60 patients developed recurrence of pleural effusion. We conclude IPCs as an acceptable therapeutic option for the management of refractory pleural effusion in patients with HH. Although trans-jugular intrahepatic portosystemic shunt (TIPS) and liver transplantation are the gold standards for the management of pleural effusion in these patients, cost and availability are the major concerns with these treatment modalities. IPCs are a safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.

Suppressed without a Cause: A Case of Idiopathic Immune Deficiency.

We report a case of a 45-year-old male who presented with a headache, fever, vomiting, somnolence, and difficulty walking for 10 days. His cerebrospinal fluid studies revealed cryptococcal meningitis. Chest and abdominal computed tomography (CT) scans showed splenomegaly along with mediastinal, retroperitoneal and inguinal lymphadenopathy. CD4 count turned out to be 208 µL-1. Human immunodeficiency virus (HIV) testing, serum protein electrophoresis, serum light chains and quantitative immunoglobulins were non-diagnostic and CD4 lymphopenia was attributed to acute infection. However, a persistent CD4 lymphopenia was seen in subsequent outpatient testing, which prompted a detailed workup for secondary causes of immunodeficiency. Repeated lymph node biopsies with analytic cytometric immunophenotypic analysis were normal, as was the bone marrow biopsy with detailed immunophenotypic and cytogenetic studies. The patient was hence being treated as a case of idiopathic CD4 lymphocytopenia.

Postoperative pulmonary complications after laparotomy.

BACKGROUND: The frequency of, and risks for, postoperative pulmonary complications (PPCs) after laparotomy are incompletely understood. The wide-ranging incidence of PPCs in the literature reflects methodological issues including variable definitions of PPCs and varied patient populations. OBJECTIVES: We sought to elucidate the incidence of PPCs after laparotomy and clarify risks for their development. METHODS: We conducted a retrospective study of all laparotomies in adult patients on the general surgery service at our university-affiliated hospital in 2004. The definition of PPCs was rigorous and relevant in terms of key outcomes (morbidity, mortality, length of stay). We used a template for the review of medical records to identify PPCs and their consequences. RESULTS: Twenty-five PPCs (7.0%) occurred in 359 laparotomies. Logistic regression modeling identified the following independent predictors of risk: upper abdominal incisions (OR 15.3; p = 0.025), reoperation (OR 7.1; p = 0.013), emergency surgery (OR 6.3; p = 0.001) and nasogastric tubes (OR 5.4; p = 0.008). PPCs were associated with increased mortality (OR 6.17; p = 0.01), intensive care unit care (OR 13.0; p = 0.001), increased mean hospital length of stay (17.7 days longer; p = 0.001) and longer mean postoperative length of stay (15.2 days longer; p = 0.001). CONCLUSIONS: The incidence of PPCs after laparotomy in this study is lower than in many prior reports and reflects the relevant definition of PPCs used. Upper abdominal surgery carried the greatest risk. Reoperation was a risk not identified previously. Emergency procedures and the use of nasogastric tubes were confirmed as key risks. Morbidity, mortality and lengths of stay were significantly increased after PPCs.

Benazepril induced isolated visceral angioedema: a rare and under diagnosed adverse effect of angiotensin converting enzyme inhibitors.

Angiotensin converting enzyme inhibitors are one of the most commonly prescribed medications and angioedema of upper aerogastric tracts is a well recognized complication. Isolated visceral angioedema with the use of angiotensin converting enzyme inhibitors is rare and is relatively under diagnosed. The visceral angioedema should be considered in patients taking angiotensin converting enzyme inhibitors who develop gastrointestinal complaints. We report a case of subacute intestinal obstruction from the use of benazepril, which was promptly resolved after withdrawing benazepril.

Candida parapsilosis endocarditis 8 months after transient candidemia.

We report a case of aortic valve endocarditis with aortic root abscess from Candida parapsilosis occurring 8 months after transient candidemia. Despite the fact that the patient was treated appropriately, candidemia persisted and later on presented with an embolic stroke as a complication of fungal endocarditis.

A diagnostic and management dilemma: combined paraneoplastic myasthenia gravis and Lambert-Eaton myasthenic syndrome presenting as acute respiratory failure.

BACKGROUND: Neuromuscular junction disorders are usually categorized as either presynaptic or postsynaptic. The most frequently encountered disorder of the postsynaptic neuromuscular junction is acquired myasthenia gravis. Lambert-Eaton myasthenic syndrome is a well-known prototype of the presynaptic autoimmune disorders of neuromuscular transmission. These major disorders of neuromuscular transmission are relatively common and distinctly recognized, but co-occurrence of these disorders (overlap myasthenic syndrome) is rare and has so far attracted little attention. REVIEW SUMMARY: This report describes a patient with acquired myasthenia gravis and immunologic coexistence of Lambert-Eaton myasthenic syndrome (overlap myasthenic syndrome) in association with abdominal/uterine leiomyosarcoma. The patient presented with acute respiratory failure, making identification and management of her illness challenging. A general overview of the complexities associated with overlap between myasthenia gravis and Lambert-Eaton myasthenic syndrome is provided and this patient's complicated clinical course and response to therapy are discussed. CONCLUSION: To our knowledge, this is the first report of overlap myasthenic syndrome in conjunction with abdominal leiomyosarcoma. The immunologic coexistence of acquired myasthenia gravis and Lambert-Eaton myasthenic syndrome in a patient with a malignant smooth-muscle tumor is intriguing and suggests that a common paraneoplastic process targeting 2 different onconeural antigens was the underlying pathogenic mechanism in this patient.

Cardiac troponin I release in non-ischemic reversible myocardial injury from parvovirus B19 myocarditis.

Cardiac troponin I is released from myocytes in both reversible and irreversible myocardial injury. The changes in myocyte membrane permeability resulting from the injury could be enough for the release of cardiac troponins from the free cytosolic pool of myocytes without structural damage. We report a case of parvovirus B19 myocarditis in a 26-year-old male who developed regional wall motion abnormalities and severe left ventricular systolic dysfunction with elevated serum levels of cardiac troponin I (peak=11.7 ng/ml). Diagnosis of parvovirus myocarditis was confirmed by presence of high titers of parvovirus B19 IgG and identification of parvovirus B19 DNA by polymerase chain reaction. Within a few days of supportive treatment, the regional wall motion abnormalities resolved, the cardiac function recovered, and the elevation in serum cardiac troponin I subsided. This case further denotes the possibility of release of cardiac troponin I in non-ischemic, reversible myocardial injury.