Between a Rock and a Hard Place: Percutaneous Aspiration and Debulking for Tricuspid Valve Endocarditis

Right-sided infective endocarditis (IE) constitutes about 10% of total IE cases. Of these, tricuspid endocarditis comprises about 90% of all right-sided IE cases with intravenous drug use (IVDU) as its strongest risk factor. In patients with larger vegetations (>20 mm) or with persistent bacteremia, surgical intervention is often the standard of care. With FDA approval in 2014 and limited cases with regards to its application in tricuspid endocarditis, AngioVac (AngioDynamics, Latham, NY) has been used as a less invasive, off-label, bridging agent for tricuspid IE treatment. We present a case of a 40-year-old man with a past medical history of IVDU who presented with tricuspid endocarditis. His blood cultures were positive for methicillin-susceptible Staphylococcus aureus bacteremia. A transthoracic echocardiogram showed a 2.7 x 1.1 cm vegetation of the tricuspid valve. The patient was thought to be a poor surgical candidate for multifactorial reasons including patient preference, hemodynamic instability, and a hospital course that was complicated by septic emboli and infectious glomerulonephritis. The patient was unable to clear blood cultures despite appropriate antibiotic therapy. He subsequently underwent an AngioVac procedure with removal of the vegetation from his tricuspid valve achieving adequate source control, clear blood cultures, and resolution of endocarditis.

As this case illustrates, AngioVac should be considered an effective alternative to surgical intervention in tricuspid endocarditis. Further research and awareness of the utility of AngioVac in right-sided endocarditis are warranted and should be conducted.

Petechiae, Purpura, and a Pandemic: A Recipe for Scurvy

This case report presents the case of a 28-year-old man who developed scurvy during the coronavirus disease 2019 (COVID-19) pandemic. Scurvy is a disease resulting from a nutritional deficiency of vitamin C (ascorbic acid). It is a rare condition, whose signs and symptoms can vary from patient to patient. The treatment is vitamin C supplementation, which is often followed by a swift recovery. To our knowledge, this is the first reported case of scurvy during the COVID-19 pandemic. This article highlights a rare acquired bleeding disorder, which may manifest more commonly during a pandemic due to food scarcity or stay-at-home mandates in those already at risk.

Faculty development for the evaluation system: a dual agenda

Faculty development for the evaluation process serves two distinct goals. The first goal is to improve the quality of the evaluations submitted by the faculty. Providing an accurate assessment of a learner's capabilities is a skill and, similar to other skills, can be developed with training. Frame-of-reference training serves to calibrate the faculty's standard of performance and build a uniform language of the evaluation. Second, areas for faculty professional growth can be identified from data generated from learners' evaluations of the faculty using narrative comments, item-level comparison reports, and comparative rank list information. This paper presents an innovative model, grounded in institutional experience and review of the literature, to provide feedback to faculty evaluators, thereby improving the reliability of the evaluation process, and motivating the professional growth of faculty as educators.

Untangling the etiology of ascites

BACKGROUND

Amyloidosis is a systemic disease known to affect a vast range of organs, including the liver, heart, and kidney. When infiltrating the liver, amyloidosis typically does not present with cirrhosis. Typical presentation includes hepatomegaly with some mild laboratory abnormalities.

CASE REPORT

A 72-year-old man presented with a 2-week history of worsening abdominal, scrotal, and extremity swelling. He endorsed melanotic stools and intermittent dizziness with a 10-pound weight gain. Vitals revealed a blood pressure of 82/57 mmHg and a pulse of 83 beats/min with positive orthostatic changes. Mild bibasilar crackles were noted. His abdomen was moderately distended with a fluid wave present, but no hepatosplenomegaly was noted. He displayed anasarca with significant extremity and scrotal edema, but no jaundice, telangiectasias, or other stigmata of chronic liver disease were present. Liver function tests demonstrated a total bilirubin of 1.5 mg/dL (normal value: 0.2-1.2 mg/dL), AST 111 IU/L (normal value 5-34 IU/L), ALT 51 IU/L (normal value 5-55 IU/L), and GGT 583 U/L (12-64 U/L). Alkaline phosphatase was 645 U/L (40-150 U/L). Analysis of peritoneal fluid was consistent with portal hypertension due to liver disease. Given an atypical presentation of cirrhosis with unclear etiology, a biopsy was performed and revealed amyloid deposition.

CONCLUSIONS

Liver disease can be due to various etiologies, many of which can present ambiguously. Although the most typical etiologies have been well defined, we present a case of an atypical presentation of hepatic amyloidosis discovered in a patient with ascites and without typical hepatomegaly.