A Shocking Case of Far-Field Atrial Oversensing in Giant-Cell Myocarditis.

We report a unique case of delivery of inappropriate implantable cardioverter-defibrillator therapies related to a "perfect storm": presence of an integrated lead, insufficient lead slack related to right heart dilation resulting in shock coil misplacement, myocarditis with loss of R waves, and the concomitant occurrence of an incessant atrial tachycardia. (Level of Difficulty: Advanced.).

Negative pressure pulmonary edema-related diffuse alveolar hemorrhage associated with Sevoflurane and cigarette smoking.

Negative-pressure pulmonary edema (NPPE)-related diffuse alveolar hemorrhage (DAH) is an underdiagnosed clinical entity seen with alveolar capillary damage. The pathophysiology of type I NPPE is generation of a negative pleural pressure against an upper airway obstruction. We suspect this process was facilitated by preexisting alveolar damage with smoking and administration of the irritating and coagulopathic inhaled anesthetic sevoflurane. We present a case of a healthy 31-year-old man who developed postoperative hemoptysis, diffuse ground-glass opacity and infiltrates on computed tomography (CT) of the chest, anemia, and hypoxic respiratory failure. A diagnosis of DAH was made and a serologic workup for systemic disorders including vasculitis and connective tissue diseases was negative. The patient rapidly improved with supportive care and had complete resolution of his bilateral infiltrates on repeat chest x-ray two weeks later. Our literature review identified three cases of DAH in the setting of sevoflurane administration. Our case illustrates the importance of including NPPE-related DAH on the differential of post-operative hemoptysis, especially in association with sevoflurane administration and a history of cigarette smoking.

Perioperative genitourinary infection associated with sodium-glucose co-transporter 2 inhibitor use.

Context: Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a novel treatment approved for type 2 diabetes mellitus to lower hyperglycemia, systolic blood pressure, and promote weight loss. Commonly reported serious adverse events include increased mycotic urogenital infections, orthostatic hypotension, and normoglycemic ketoacidosis. Case report: We present a case of a 47-year old man with a history of type 2 diabetes mellitus initiated on the SGLT-2 inhibitor canagliflozin preoperatively before a penile implant, who presented with late postoperative MRSA bacteremia and scrotal abscess requiring implant extraction. Conclusion: As the SGLT-2 inhibitors are gaining in popularity, prescribers must be aware of the potential adverse genitourinary infectious outcomes. Providers should use caution and avoid initiating SGLT-2 inhibitors in the perioperative setting, and may even consider holding or discontinuing this medication in the setting of impending GU surgery.

There may be more than meets the eye with Clostridium perfringens bacteremia.

We present the case of an 89-year-old man with a 1 month history of fevers and fatigue. Blood cultures were positive for Clostridium perfringens. The patient had worsening abdominal distension in which an abdominal computed tomography scan uncovered a colonic mass, and further work-up revealed poorly differentiated adenocarcinoma. The patient was treated with antibiotics, but unfortunately, given his age and the new malignancy, he was discharged to hospice care. The association between clostridial bacteremia and colon cancer has been well described in the literature and is further discussed in this article. This case highlights the importance of recognizing possible occult malignancy in the right clinical setting in patients found to have clostridial bacteremia.

Duodenal diverticulum: incidental finding with potentially dangerous outcomes.

We present the case of an 83-year-old woman with a past medical history significant for schizoaffective disorder, presenting to our emergency department with the complaint of 'pain'. Given the non-specific complaint and the limited history obtained, CT imaging was performed on her chest and abdomen which incidentally found a large duodenal diverticulum. This manuscript discusses the incidence of duodenal diverticula and the potential associated complications.

Aerococcus urinae, a rare cause of infective endocarditis.

We present the case of an elderly male who was initially seen in our hospital for a urinary tract infection that was treated with oral ciprofloxacin. He was admitted 2 weeks later with altered mental status and fever, and was found to have bacteraemia with Aerococcus urinae Owing to altered mental status a brain MRI was performed which showed evidence of embolic stroke. Following this, a transesophageal echocardiogram showed severe mitral regurgitation and a vegetation >1 cm involving the mitral valve with associated destruction of posterior valve leaflets. The patient was started on antibiotics intravenous penicillin G and intravenous gentamicin for a total duration of 6 weeks. He underwent mitral valve replacement on day 4 of hospitalisation. The postoperative course was complicated by ventilator-dependent respiratory failure, requiring tracheostomy and eventual transfer to a skilled nursing facility. Unfortunately, he died after 2 weeks of stay at the facility.

Hypertriglyceridemic pancreatitis associated with confounding laboratory abnormalities.

We present the case of a 36-year-old woman who presented to our hospital with epigastric abdominal pain and tenderness. Laboratory evaluation identified high lipase, normal amylase, pseudohyponatremia, and relatively falsely low triglyceride levels (initial value of 2,329 mg/dl which on repeat was found to have corrected value of >10,000 mg/dl). The overall clinical picture was consistent with acute pancreatitis due to hypertriglyceridemia. The patient was commenced on IV insulin and eventually required plasmapheresis with good clinical outcome. This case highlights the importance of being cognizant of falsely low amylase and TG levels that can be present in patients with hypertriglycereidemic pancreatitis.

Rare case of stress cardiomyopathy due to intramuscular epinephrine administration.

We report a case of a 37-year-old woman who presented to our hospital with retrosternal chest pain following intramuscular administration of epinephrine due to presumed anaphylaxis. On arrival, she was found to have ST segment depression in the anterolateral leads on ECG and elevated cardiac troponins. She was diagnosed with stress cardiomyopathy based on left ventricle dysfunction and angiographically normal coronary arteries on cardiac catheterisation. To the best of our knowledge, this is the third reported case of takotsubo cardiomyopathy following appropriately dosed intramuscular administration of epinephrine for anaphylaxis. This case highlights the importance of considering stress cardiomyopathy in patients presenting with chest pain syndrome following systemic administration of epinephrine.

Calcitriol mediated hypercalcaemia with silicone granulomas due to cosmetic injection.

We present a case of a 41-year-old woman with medical history significant for urolithiasis presenting to our hospital for psychiatric evaluation due to worsening depression and suicidal ideations for the past 2 weeks. Initial laboratory results show hypercalcaemia of 13.5 mg/mL that led to consulting internal medicine. On further questioning, the patient admitted to cosmetic silicone injections in her buttocks which were causing calcium deposition under her skin, leading to disfigurement of the sacrum and lumbar regions. She underwent further evaluation with CT and laboratory testing, which effectively ruled out malignancy and primary hyperparathyroidism. The hypercalcaemia was diagnosed as non-PTH-dependent with high levels of 1,25-dihydroxyvitamin D and low PTH. She eventually underwent tissue biopsy confirming the presence of silicone granulomas responsible for the calcitriol-mediated hypercalcaemia. This case reminds one to keep a broad differential especially in patients with hypercalcaemia in which malignancy and primary hyperparathyroidism have been ruled out.

Mind the gap: a case of severe methanol intoxication.

We report a case of a 37-year-old woman with non-insulin-dependent diabetes on sitagliptin, an alcohol abuser who was brought unresponsive to the emergency department of our hospital. On arrival, the patient was intubated and mechanically ventilated due to a low Glasgow Coma score of 3/15. Initial laboratory testing identified profound high anion gap metabolic acidosis. Owing to the dubious circumstances and the depth of acidosis, methanol and ethylene glycol intoxication was suspected. Further evaluation revealed a significantly increased serum osmolal gap. Pending volatile compound screen, fomepizole was started and urgent haemodialysis undertaken. Subsequent brain MRI identified changes in putamen of bilateral basal ganglia, suggestive of methanol intoxication. The patient was later found to have an initial methanol level of 237 mg/dL. She was successfully extubated on day 2 of hospitalisation, with residual cognitive and visual deficits.