CT-Guided Pericardiocentesis in a Case of Tension Pneumopericardium and Tamponade Secondary to an Enteropericardial Fistula

Tension pneumopericardium is most commonly traumatic. Nontraumatic etiologies are rare, but have been reported with gastropericardial and esophagopericardial fistulas. We present the case of a 54-year-old patient who developed a tension pneumopericardium with tamponade secondary to a perforated marginal ulcer in the proximal jejunum with an enteropericardial fistula. (Level of Difficulty: Intermediate.).

Heart Failure with Preserved Left Ventricular Ejection Fraction: A Complex Conundrum Simply Not Limited to Diastolic Dysfunction

Over the last two decades, the changing paradigm of heart failure with preserved ejection fraction (HFpEF) has transformed our understanding not only of the pathophysiology of this clinical entity but also the diagnostic and therapeutic approaches aimed at treating this complex patient population. No longer HFpEF should be seen as simply left ventricular diastolic dysfunction but as a group of that in addition of having small and thick left ventricles with abnormal diastolic filling patterns as their main pathophysiologic abnormality; they also have whole host of different abnormalities. In fact, this heterogeneous clinical entity embodies numerous mechanisms and is linked to multiorgan dysfunction, with hypertension and obesity playing a major role. Although we have gained an enormous amount of understanding not only on the causes but also the downstream effects of HFpEF, there is still much to be learned before we can fully comprehend this complex clinical entity. It is the main intention of this review to synthesize the most recent attributes, mechanism, diagnostic tools, and most useful therapeutic alternatives to be considered when evaluating patients either complaining of dyspnea on exertion as well as exercise intolerance or those recently admitted with HF symptoms but with normal LVEF in the absence of any other valvular abnormalities.

Gastrointestinal bleeding in recipients of left ventricular assist devices-a systematic review

The twenty-first century has revolutionized the management of congestive heart failure with the widespread use of left ventricular assist devices and other treatment modalities that improve morbidity and mortality after the failure of medical management. These novel devices come with significant side effects. One of the most common side effects of left ventricular assist devices is the increased frequency of lower gastrointestinal bleeding compared to heart failure patients without left ventricular assist devices. Multiple etiologies of recurrent gastrointestinal bleeding in such patients have been studied. The decreased amount of von Willebrand factor polymers is now recognized as one of the most common causes of increased incidence of gastrointestinal bleeding in patients with left ventricular assist devices alongside increased arteriovenous malformations. Multiple treatment modalities have been identified to prevent and treat gastrointestinal bleeding in these patients. Since the use of left ventricular assist devices is becoming more prevalent in patients with advanced heart failure, we decided to conduct this systematic review. The article summarizes the incidence, pathophysiology, and management of lower gastrointestinal bleeding in patients with left ventricular assist devices.

Echocardiographic indices of left ventricular function and filling pressure are not related to blood pool activity on pyrophosphate scintigraphy

BACKGROUND

Pyrophosphate (PYP) imaging has a high diagnostic accuracy for transthyretin cardiac amyloidosis (ATTR-CA). Indeterminate findings are often reported due to persistent blood pool activity, presumed to be from low cardiac output. We evaluated the relationship between blood pool activity on PYP imaging and echocardiographic indices of cardiac function.

METHODS

Clinical and imaging data of 189 patients referred for PYP scintigraphy were evaluated. All patients underwent planar imaging and SPECT (diagnostic standard). Among those with a negative PYP SPECT, persistent left ventricular blood pool activity on planar images was inferred by a visual score ≥2 or a heart-to-contralateral (HCL) ratio ≥ 1.5. Absence of blood pool activity was inferred when both visual score was < 2 and HCL was < 1.5. Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), stroke volume index (SVi), and left atrial pressure (LAP) were calculated from standard transthoracic echocardiograms.

RESULTS

ATTR-CA was present in 43 (23%) patients. Among those with a negative PYP SPECT, 11 patients had significant blood pool activity. Patients with ATTR-CA had a lower LVEF, SVi, and GLS, with a higher LAP, compared to those without ATTR-CA. Among those without ATTR-CA, there were no significant differences in these parameters.

CONCLUSION

Approximately 8% of patients with a negative PYP SPECT have significant blood pool activity. Measures of cardiac function are not different among those with and without blood pool activity. PYP SPECT should be routinely performed in all patients to avoid false image interpretation.

Multimodality imaging for diagnosis of subclinical hereditary transthyretin cardiac amyloidosis

We present a case of a patient with worsening visual acuity and dense vitreal debris who was found to have vitreal transthyretin amyloid (ATTR) infiltration. Cardiac workup, performed to identify systemic amyloidosis, demonstrated focal myocardial amyloid infiltration on pyrophosphate (PYP) scintigraphy and cardiac magnetic resonance (CMR), resulting in a diagnosis of subclinical ATTR cardiac amyloidosis (ATTR-CA). Patient was identified as a carrier of p.S70R mutation which results in an aggressive ATTR phenotype. Patient is tolerating transthyretin silencer therapy well. Through this case, we discuss the role of a multimodality imaging approach for the diagnosis of subclinical ATTR-CA.

Mixing effects of three Eurasian plants on root decomposition in the existence of living plant community in a meadow steppe

In grasslands, roots of different plant species decay in combination in the presence of living plants, besides, most root decomposition studies are conducted on how roots of plants decomposed alone or in artificial compositions in the absence of living plants. Therefore, we evaluated how roots of different perennial plants induced effects on decomposition process under living plants and their associated mechanisms. By using litter bag technique, we determined the root decomposition process of three perennial plants, Leymus chinensis, Phragmites australis, and Kalimeris integrifolia grown in monocultures, bi- and tri-species mixtures, after 12 months of incubation under living plants and bare soil communities. We found both additive and non-additive effects on decomposition dynamics indicating that root mass losses of compositions cannot be calculated from decaying rates of individual species. The rich-nutrient roots of K. integrifolia in monocultures and in mixtures with other plant species decayed faster. Compared with bare soil, microbial activities were enhanced under living plant communities and hence stimulated decomposition rates. Our results indicated that microbial activities are important but secondary factors to root physico-chemical properties impacting root decomposition rates. In conclusion, the empirical relationships developed here are helpful to better understand the effects of root properties and microbial activities on decay rates.

Asystole following Regadenoson administration: Review of literature, risk factors and management

Regadenoson, a selective A2A receptor agonist, is widely used for vasodilator stress myocardial perfusion imaging and has a superior adverse effect profile when compared with other agents. However, with widespread use, there have been several reported cases of Regadenoson induced bradyarrhythmias and even asystole in patients with no known conduction system disease. In this article, we report a case of asystole following Regadenoson administration, evaluate mechanisms and risk factors for Regadenoson induced bradyarrhythmias to better identify patients at risk. We also review the available treatment options and propose recommendations for limiting its risk.

Comparison of planar with tomographic pyrophosphate scintigraphy for transthyretin cardiac amyloidosis: Perils and pitfalls

BACKGROUND

Tc-99m pyrophosphate (PYP) SPECT is recommended for indeterminate findings on planar imaging. We aimed to compare the findings on planar PYP scintigraphy alone to that of routinely performed PYP SPECT.

METHODS

PYP scintigraphy data of 133 patients (53% men; mean age 76 years) were evaluated. SPECT was routinely performed following 1-hour planar imaging, in all cases. Semiquantitative visual score and heart-to-contralateral (H/CL) ratio were determined in all patients as recommended.

RESULTS

PYP images from 35 patients (26%) were considered to be positive based on SPECT myocardial uptake. Among them, 20 (57%) had a H/CL ratio ≥1.5 and 34 had a visual score ≥ 2. SPECT identified myocardial uptake in one patient with a visual score < 2 and refuted the presence of myocardial uptake in two patients with a visual score ≥ 2. Visual score correlated well with SPECT (r = 0.94; P < .0001) and had an accuracy of 98% for tomographic myocardial uptake. Addition of H/CL ratio reduced the diagnostic performance of visual score.

CONCLUSIONS

Planar-derived visual score has an excellent accuracy for tomographic myocardial uptake, though it misclassifies a small proportion of patients. H/CL ratio decreases the diagnostic certainty of planar imaging. Tomographic imaging prevents misdiagnoses and should always be performed.

Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge

We report a case of acute viral pericarditis and cardiac tamponade in a patient with COVID-19 to highlight the associated treatment challenges, especially given the uncertainty associated with the safety of standard treatment. We also discuss complications associated with delayed diagnosis in patients who potentially may need mechanical ventilation.

Transient ST Segment Elevation in Two Patients with COVID-19 and a Normal Transthoracic Echocardiogram

We continue to learn about cardiac involvement in patients with COVID-19. These patients can develop acute coronary syndrome and severe myocarditis with a reduced ejection fraction. We describe two critically ill COVID-19 patients who developed ST elevation that resolved on repeat ECG without any intervention.

LEARNING POINT

ST elevation may occur in critically ill COVID-19 patients.

Report from the 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; 28-29 September 2018

The 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, 28-29 September 2018. This interactive multidisciplinary conference is attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancers. In addition, invited speakers from other provinces participate. Surgical, medical, and radiation oncologists, and allied health care professionals participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancers.

Community-acquired Pneumonia with Methicillin-resistant Staphylococcus Aureus in a Patient Admitted to the Intensive Care Unit: A Therapeutic Challenge

Methicillin-resistant Staphylococcus aureus (MRSA) was previously considered a purely nosocomial pathogen. However, community-acquired MRSA has recently emerged as an important cause of severe necrotizing community-acquired pneumonia (CA-MRSA) in previously healthy individuals. This new pathogen exhibits antibiotic resistance and is linked to extended hospital stay and higher mortality. CA-MRSA has presented new therapeutic challenges due to high vancomycin treatment failure and lack of specificity of clinical findings. There is emerging evidence that treatment with linezolid leads to better patient outcomes in patients with CA-MRSA. Through this case, we aim to raise awareness about early institution of therapy for CA-MRSA whenever it is suspected, to improve patient outcomes.

Colovesical Fistula: An Unusual Complication of Cytomegalovirus Colitis

Cytomegalovirus (CMV) is a double-stranded DNA virus that is associated with clinically significant disease in patients with advanced immunosuppression, particularly those with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). End-organ disease with CMV is classically associated with a CD4 cell count less than 50 cells/microliter. CMV colitis is the second most common manifestation of end-organ disease in this patient population. CMV-associated enteric fistula is a rare complication that has been described in only a few case reports in the literature. These cases describe gastrocolic, enterocutaneous, enterocolic, rectovaginal, and colocutaneous fistulae. However, colovesical fistula has not been described previously. Here, we report the first case of CMV-associated colovesical fistula in a patient with HIV infection and AIDS.

Immune Reconstitution Inflammatory Syndrome Associated Thrombocytopenia in a Patient with Human Immunodeficiency Virus Infection: A Rare Hematological Manifestation

Human immunodeficiency virus (HIV) associated thrombocytopenia was commonly encountered in the era prior to the advent of antiretroviral therapy (ART). With the widespread use of ART, its incidence has significantly declined. Immune reconstitution inflammatory syndrome (IRIS) is an immune dysregulation phenomenon that reveals itself clinically as paradoxical deterioration after the commencement of ART in HIV infected patients. It has a wide variety of clinical manifestations. However, hematologic involvement is rare. Here, we present a very rare case of IRIS associated thrombocytopenia. With this case we intend to create mindfulness of the possibility of IRIS being one of the explanations for thrombocytopenia. 

Infective Endocarditis Presenting as Bilateral Orbital Cellulitis: An Unusual Case

Orbital cellulitis is a severe and sight-threatening infection of orbital tissues posterior to the orbital septum. The most common causes of orbital cellulitis are rhinosinusitis, orbital trauma, and surgery. Infective endocarditis (IE) is a systemic infection that begins on cardiac valves and spreads by means of the bloodstream to peripheral organs. Septic emboli can spread to any organ including the eyes and can cause focal or diffuse ophthalmic infection. Ocular complications of IE classically include Roth’s spots, subconjunctival hemorrhages, chorioretinitis, and endophthalmitis. IE as a cause of orbital cellulitis has been described by only one author in the literature. Here, we present a very rare case of bilateral orbital cellulitis caused by IE. Through this case, we aim to create awareness of the potential for serious ocular complications in IE and provide an overview of the management.

Lidocaine-Induced Systemic Toxicity: A Case Report and Review of Literature

For the past 50 years, local anesthetics such as lidocaine have been commonly used in various clinical settings. Its use is not just limited to anesthesia and surgery but is also frequently utilized in internal medicine and in primary care setting for bedside procedures. Despite its widespread use, most physicians are not familiar with the life-threatening manifestations of lidocaine toxicity and its treatment. Our case demonstrates a successful resuscitation after cardiac arrest in a healthy 33-year-old female with systemic lidocaine toxicity after she received lidocaine as a local anesthetic. Our goal is to educate general internists and primary care physicians of the possible hazards of lidocaine use. We also aim to create mindfulness of the symptoms of lidocaine toxicity and the use of intravenous lipid emulsion as an antidote.

Chylous Ascites in Systemic Lupus Erythematosus: A Diagnostic Challenge

Systemic lupus erythematous (SLE) is a chronic inflammatory disease of unknown etiology. It can affect nearly any organ. Gastrointestinal (GI) involvement in SLE is frequent but is mostly related to medication side effects and concomitant infections. Chylous ascites is a rare form of ascites that is milky appearing due to the high concentration of triglycerides. Chylous ascites as a complication of SLE is atypical. Our case highlights an extremely rare presentation of chylous ascites in SLE as an initial manifestation of the disease itself, posing diagnostic and therapeutic challenges. Through this case, we aim to raise awareness of SLE as a rare but reversible cause of chylous ascites.

Importance Of Thorough Physical Examination: A Lost Art

Several recent studies have described a deterioration in physical examination skills among modern physicians. Reasons hypothesized for this change are improvements in technology and time constraints. Poor physical exam skills are a noteworthy threat to patient safety as they can lead to incorrect as well as missed diagnoses, causing delays in timely implementation of life-saving treatments. Here, we present a case of extensive acute embolic strokes secondary to infective endocarditis. The patient was initially misdiagnosed as having Bell’s palsy due to incorrect physical examination. Through this case, we highlight the importance of management guided by a thorough history and physical examination to minimize diagnostic errors. 

Pancreatitis in the Setting of Vaso-occlusive Sickle Cell Crisis: A Rare Encounter

Acute pancreatitis is a common cause of acute abdominal pain. Gallstones and alcohol abuse account for the majority of the cases. Pancreatic ischemia is an uncommon but established cause of pancreatitis associated with connective tissue diseases, vasculitis, and shock. Our case highlights a rare case of vaso-occlusive crisis (VOC) in a patient with sickle cell (SC) disease leading to pancreatitis. Treatment remains largely conservative but exchange transfusion may be the therapy of choice in severely hypoxic patients or in patients with high pre-treatment hemoglobin S levels.

Ipilimumab as a Cause of Severe Pan-Colitis and Colonic Perforation

Ipilimumab is a human monoclonal antibody that functions as a cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitor that is used to treat malignant melanoma. Due to ipilimumab's removal of immune regulation, specifically through the inactivation of CTLA-4, it is commonly associated with inflammatory and autoimmune events. Gastrointestinal (GI) related immune-related adverse events such as diarrhea occur in 29% of patients with 7.6% of patients specifically suffering from colitis. We describe a case of colonic perforation with ipilimumab use. Our goal is to raise awareness and alert practicing gastroenterologists of this particular adverse effect.​ A 74-year-old male patient presented to the emergency department with complaints of hematochezia, abdominal pain and decreased appetite. The patient's past medical history included desmoplastic BRAF mutation negative melanoma with metastatic disease to the face, liver, and trigeminal nerve. He underwent his last treatment of ipilimumab three weeks prior to presentation. In total, the patient received four doses of 3 mg/kg of ipilimumab every three weeks. Since the initiation of ipilimumab, he reported diarrhea as its adverse effect, which was treated with tapering doses of prednisone one month at a time. Colonoscopy revealed mucosal ulceration and erosion in the rectum, sigmoid colon, and remaining descending colon up to the splenic flexure and cecum. After the colonoscopy, the patient became tachycardic, hypotensive and complained of sudden abdominal pain. A computed tomographic (CT) scan of the abdomen showed free intraperitoneal air. He was immediately taken to the operating room (OR) for an emergent laparotomy. In the operating room, perforations were noted at the splenic flexure and the cecum with large amounts of succus spilling from the perforations. The majority of the large bowel appeared cyanotic and dusky; consequently, a sub-total colectomy with terminal ileostomy was performed. After the procedure, the patient was started on antibiotics for severe peritonitis and admitted to the intensive care unit (ICU) with septic shock. His clinical status continued to deteriorate due to acute respiratory failure, nosocomial pneumonia, severe protein calorie malnutrition and coagulopathy from disseminated intravascular coagulation (DIC). The patient did not recover from his illness and died a few days later. It is imperative that physicians caring for patients receiving treatment with CTLA-4 inhibitors frequently monitor for and promptly treat possible immune-related adverse effects. For patients with ipilimumab-related colitis, prompt identification of symptoms and early treatment with steroids are crucial in preventing harmful or possibly fatal immune-related adverse events. Gastroenterologists should be wary of this adverse side effect in this high-risk population when performing colonoscopy and take necessary precautions.

Infective Endocarditis Presenting as Subarachnoid Hemorrhage: An Appeal for Caution

Spontaneous subarachnoid hemorrhage (SAH) as the presenting feature of infective endocarditis (IE) is rare. It has classically been described in association with the rupture of intracranial mycotic aneurysms (ICMA). Here we describe a very rare case of non-aneurysmal spontaneous SAH in a patient with IE. The patient originally presented with a headache and low-grade fever. Neuroimaging including computed tomography (CT) and magnetic resonance imaging (MRI) of the head revealed SAH. She was eventually diagnosed with streptococcus gallolyticus (formerly streptococcus bovis) IE. Through this case, we advocate consideration of the diagnosis of IE in patients with SAH so that there is timely recognition of this reversible but serious disease.

Giardia-filled Pancreatic Mass in a Patient With Recently Treated T-cell-rich B-cell Lymphoma

Giardia lamblia (G. lamblia)-filled pancreatic masses are a rarely reported entity. Furthermore, there are only a few case reports in literature on the association of these masses with cancer. We present a case of a G. lamblia-filled pancreatic cystic mass in a patient with a history of T-cell-rich B-cell lymphoma. The authors performed a PubMed search using (Medical Subject Headings) MeSH terms of pancreas, mass, Giardia, and lymphoma.  A 53-year-old male with past medical and surgical history of T-cell-rich B-cell lymphoma, status post R-CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab) therapy with positron emission tomography (PET) scan showing no residual disease, essential hypertension, and alcohol use disorder presented to the emergency department (ED) with epigastric pain and nausea for one week. Computed tomography (CT) scan of the abdomen showed a 2.3 cm hypodense pancreatic cystic mass. This was a new finding when compared to his prior abdominal imaging. Fine needle aspiration (FNA) biopsy of the mass showed lymphocytes, reactive atypical epithelial cells, and numerous organisms consistent with Giardia lamblia. He was treated with metronidazole 250 mg by mouth three times a day (TID) for five days. Follow-up magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) showed complete resolution of the pancreatic mass. There are only a few case reports on G. lamblia in the pancreas. The pathologist indicated sheets of numerous Giardia in the sample, making small bowel contamination less likely and G. lamblia aspirate from the pancreas more probable as the source. The authors hypothesize that this patient may have had chronic G. lamblia infection as a potential cause for the T-cell-rich B-cell lymphoma manifestation. The patient reported travel to an area with possible exposure to G. lamblia one year prior to presentation with the lymphoma. During that time he had increasing abdominal pain, intermittent chronic diarrhea, and weight loss. G. lamblia's mechanism of action has been theorized to involve induction of pro-apoptotic factors, intestinal barrier dysfunction, up-regulation of cell-cycle genes, and crypt hyperplasia.  The mechanism of action of pancreatic masses filled with G. lamblia and the association of G. lamblia and cancer is not completely understood. Further research is required to better understand these possible phenomena as it can help us better comprehend G. lamblia, its associations, and new cancer etiologies.