ECG lead misplacement in the frontal and horizontal plane mimicking A myocardial infarction.

BACKGROUND/AIMS: Electrocardiogram (ECG) is an inexpensive, fundamental screening tool used in daily clinical practice. It is essential in the diagnosis of life-threatening conditions, such as acute myocardial infarctions, ventricular arrhythmias etc. However, ECG lead misplacement is a common technical error, which may translate into wrong interpretations, unnecessary investigations, and improper treatments. METHODS/RESULTS: We report a case of a multiple ECG lead misplacement made across two different planes of the heart, resulting in a bizarre series of ECG, mimicking an acute high lateral myocardial infarction. Multiple ECGs were done as there were abrupt changes compared to previous ECGS. Patient was pain free and administration of potentially harmful procedures and treatments were prevented. CONCLUSION: Our case demonstrated the importance of high clinical suspicion in diagnosing ECG lead misplacement. It is the responsibility of both the healthcare workers who are performing and interpreting the ECG to be alert of a possible lead malposition, to prevent untoward consequences to the patient.

A Rare Combination: Dengue Fever Complicated With Guillain-Barre Syndrome.

Guillain-Barre syndrome (GBS) is an uncommon neurological complication of dengue viral infection. It is more commonly reported with Campylobacter jejuni, Epstein-Barr virus, and Cytomegalovirus infection. We report an uncommon case of a 49-year-old man with dengue fever, who developed bilateral lower limb weakness and areflexia on day two of dengue illness. He was diagnosed with GBS as a sequel of dengue infection with the nerve conduction study showing evidence of demyelinating neuropathy. He recovered gradually without immunotherapy and was discharged after a week of hospitalization.

Verapamil-Induced Hypotension in End-Stage Renal Disease: The Role of Calcium Gluconate.

Verapamil is a useful drug in supraventricular tachycardias, atrial flutters, and fibrillations. However, its usage is accompanied by an undesirable side effect of hypotension. This limits its usage in patients where even the slightest reduction of blood pressure for a brief period may prove detrimental, e.g., in patients with critical coronary artery disease. Intravenous calcium given as pretreatment to verapamil prevented verapamil-induced hypotension. Its usage after hypotension restored the blood pressure to its baseline level. All these occur without the loss of the antiarrhythmic effect of verapamil. Furthermore, the pharmacokinetics of verapamil is unaltered in patients with chronic kidney disease. Thus, no dosage adjustment is required in this population. Here we describe a case of verapamil-induced hypotension in a patient with end-stage renal failure, which was reverted with intravenous calcium administration without altering the atrioventricular blockade effect of verapamil.

Acute Liver Injury, Rhabdomyolysis, and Acute Kidney Injury Following Mass Envenomation by Wasps in Malaysia.

A wasp sting is not uncommon in rural areas, especially in developing countries. While severe allergic reactions to wasp sting are well known, many are unaware of its dangerous systemic toxic reactions. In addition, these systemic toxic reactions occur more gradually as compared to anaphylaxis reactions, which occur rapidly. These deadly systemic reactions can be deceiving, as the local reactions may seem benign and harmless. In an untrained eye with a low index of suspicion, these systemic toxic reactions may be missed without repeated laboratory evaluations and may prove fatal without the timely institution of supportive treatments.

Septic pulmonary emboli in pulmonary valve endocarditis with concurrent ventricular septal defect and coronary artery disease: a case report.

Background: Infective endocarditis (IE) is one of the common causes of life-threatening infections. Compared to left-sided endocarditis, right-sided infective endocarditis is rarer, with pulmonary valve endocarditis much rarer than the tricuspid valve. Its diagnosis poses a challenge, owing to its rarity, low index of clinical suspicion, and lack of availability of appropriate diagnostic measures. Risk factors include indwelling central venous catheter, sepsis, intravenous drug use, pacemaker with lead infection, or ventricular septal defect (VSD). Case summary: We describe a case of pulmonary valve endocarditis that led to septic pulmonary emboli in a patient scheduled for elective bypass surgery for triple vessel disease. There was an incidental finding of VSD on echocardiography, which is also a risk factor for pulmonary valve endocarditis owing to the jet of VSD to the pulmonary valve. The patient was given 4 weeks of antibiotics and subsequently underwent coronary artery bypass graft, pulmonary valve replacement, and VSD closure. Discussion: Our case demonstrated the importance of high clinical suspicion and vigilance of diagnosing pulmonary valve endocarditis when dealing with pyrexia of unknown origin in a patient with a congenital VSD as VSD-associated pulmonary valve endocarditis remained a rare disease. Besides, an active search for clinical and radiological signs of pulmonary embolization is necessary in patients with right-sided endocarditis especially those with large and mobile vegetation. A conservative approach or valve repair is recommended for most patients with right sided IE affecting the tricuspid or pulmonary valve.

Atrial septal defect with Crochetage sign presenting with pulmonary artery thrombosis.

Atrial septal defect (ASD) is the most common congenital heart disease observed in adult. Several ECG findings are considered sensitive for the diagnosis of ASD. We describe a 50 years old man who displayed Crochetage sign, incomplete right bundle branch block (IRBBB) and right ventricular strain pattern on ECG. Crochetage sign is highly specific for ASD and it correlates with shunt severity. The diagnostic specificity for ASD increases if the R waves have both Crochetage patterns and IRBBB. It is important not to confuse Crochetage signs with IRBBB abnormalities on ECG. Our patient was ultimately diagnosed with a large ASD measuring 3 cm with bidirectional shunt and concomitant pulmonary thrombosis. This illustrates that high suspicion of the ASD with the use of good-old ECG signs remains relevant in this modern era. This also reminds us that patients with Eisenmenger syndrome are at higher risk for pulmonary thrombosis.