Stress cardiomyopathy - a unique presentation of diabetic ketoacidosis.

We have documented a unique instance of diabetic ketoacidosis (DKA)-induced stress-related cardiomyopathy (CMP) in a 46-yr-old Caucasian female with type I diabetes mellitus. In times of stress, tissues with high capacity for aerobic metabolism, like myocardium, can preferentially change their metabolic substrate to ketones. The myocyte has a decreased ability to metabolize glucose and free fatty acids in stress CMP. To the best of our knowledge this is the first report of stress CMP complicating DKA. A possible mechanism for the same is hypothesized.

Conundrum of elevated HbA1C and hypoglycemia-a rare cause.

A white diabetic patient on insulin therapy presented with recurrent hypoglycemia despite very high glycosylated hemoglobin (HbA1c) values. Hemoglobin (Hb) variants, chemically modified Hb, and abnormalities of red cell turnover cause errors in HbA1c measurement. Widely prevalent Hb variants affecting HbA1c estimation include HbS and HbC in African Americans, HbE in southeast Asians, and carbamyl-Hb in uremic patients. In addition, there are at least 893 other Hb variants as of 2005, many of which affect HbA1c estimation. HbA1c values are also affected by methodology of estimation. Our patient had HbJ, which is rare amongst whites. The relationship between HbA1c values and mean plasma glucose allows estimation of expected HbA1c. Significant discrepancy between expected and measured HbA1c should be evaluated. Considering Hb variants, evaluating for the same and estimating HbA1c with the appropriate method under such circumstances are described. Numerous new or rare Hb variants will be diagnosed if suspicion is appropriately entertained.

Diffuse neurofibrillary tangles with calcification (DNTC): Kosaka-Shibayama disease in America.

Alzheimer's disease and Pick's disease are representative dementias. Cases which do not fit prototypes are termed unclassifiable dementias. New dementia subtypes are identified when a conglomerate of clinical, radiologic and pathologic findings are consistently identified. One such variant is diffuse neurofibrillary tangles with calcification (DNTC), which has been reported almost exclusively from Japan. Significant pathological advances in this decade have established DNTC as a distinct entity. Although initially the diagnosis was neuropathologic, increasing knowledge about DNTC has made it possible for a clinical diagnosis to be made. We report a clinical case of DNTC in a Caucasian American. The diagnosis of DNTC was based on his atypical senile dementia, anomia, apathy and parkinsonian features, normal serum biochemistry, and evidence of basal ganglia and cerebellar calcification with predominant temporal lobe atrophy on neuroimaging. To the best of our knowledge, this is the first clinical description of DNTC from the United States.

Recurrent pulmonary edema induced by coronary-subclavian steal syndrome during hemodialysis.

We describe a case of recurrent pulmonary edema after hemodialysis despite the patient being at ideal dry weight. Coronary-subclavian steal syndrome can cause serious complications in end-stage renal disease patients on hemodialysis. This is a case of subclavian steal, made worse by hemodialysis, using an upper limb hemodialysis fistula. Complete resolution of symptoms followed percutaneous stenting of the arteriosclerotic subclavian artery. A high index of suspicion of this physiological phenomenon is needed for diagnosis.

Takotsubo cardiomyopathy--a new variant and widening disease spectrum.

Classic takotsubo cardiomyopathy had left ventricular apical ballooning. Variants with mid-ventricular ballooning without involvement of the apex have been described. We describe a new variant of takotsubo cardiomyopathy where apical contraction was preserved while the rest of the ventricle was dyskinetic.

Cardiac herniation and volvulus with acquired dextrocardia: echocardiographic diagnosis.

We report an extremely rare cause of elevated jugular venous pulse where two esoteric causes for the same-cardiac volvulus and cardiac herniation have occurred together. Echocardiographic evidence for making the diagnosis of cardiac volvulus--subcostal long axis, subcostal short axis, and suprasternal views--have been presented. Awareness of this complication is necessary as immediate intervention is mandatory for a positive outcome.