Sinus Venosus Atrial Septal Defect: A Challenging Diagnosis

Sinus venosus atrial septal defect (SVASD) is a rare adult congenital heart disease which permits shunting of blood from the systemic to the pulmonary circulation and is commonly associated with anomalous pulmonary venous return.

We report a case of a 27-year-old man with a history of premature birth and unilateral cryptorchidism who was admitted for syncope. Electrocardiogram (ECG) demonstrated atrial fibrillation (AF)and S1Q3T3 pattern along with an incomplete right bundle branch block. Transthoracic echocardiography (TTE) suggested the presence of right ventricular pressure and volume overload and severe right ventricular and right atrial enlargement. The agitated saline study was negative suggesting no inter-atrial communication. Transesophageal echocardiography (TEE) demonstrated a superior SVASD and raised the possibility of an anomalous pulmonary venous connection. Chest computed tomography identified the right superior pulmonary vein connection to the superior vena cava.

The diagnosis of SVASD poses multiple challenges from the variety of symptoms to the selection of appropriate imaging and the complexity of surgical treatment. 

Post-Cholecystectomy Mirizzi Syndrome: A Case Report and Review of the Literature

Patient: Female, 44

Final Diagnosis: Post-cholecystectomy Mirizzi syndrome

Symptoms: Abdominal pain • nausea • vomiting

Medication: Tramadol • hydromorphone • prochlorperazine

Clinical Procedure: US • MRCP • ERCP• choledochoscopy

Specialty: Gastroenterology and Hepatology

Use of Guideline-Directed Medical Therapy in Patients With ST-Elevation Myocardial Infarction

Introduction ST-elevation myocardial infarction (STEMI) is a serious manifestation of coronary artery disease and remains a significant contributor to morbidity and mortality worldwide. To reduce the risk of recurrent cardiovascular disease (CVD) events, the American College of Cardiology (ACC) and American Heart Association (AHA) recommend the use of five classes of medications after acute coronary syndrome (ACS). The purpose of this study was to evaluate whether STEMI patients admitted to our community hospital were discharged on optimal medical therapy based on the latest AHA/ACC guidelines. Methods A retrospective, single-center electronic medical records review was conducted at our community hospital between July 2017 and December 2018. Patients included in the study were admitted to our hospital through the emergency department as STEMI alerts. We reviewed the discharge prescriptions and assessed compliance with the medication regimen endorsed by AHA/ACC, which includes aspirin, P2Y12 inhibitors, β-blockers, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and statins. Results A total of 147 patients were included in our study. The mean age of our study population was 62 ± 12.48 years. 97.2% of all patients with STEMI underwent coronary angiography. Hypertension (65.9%) was the most common comorbidity followed by hyperlipidemia (54.42%), diabetes mellitus (29.25%), and history of coronary artery disease (CAD) (24.48%). Among patients with successful reperfusion, 87.4% of the patients received the combination of four guideline-directed medical therapy (GDMT) (comprising dual antiplatelet therapy, a β-blocker, and a statin) and 57% were discharged on five guideline-directed medical treatment (the combination of dual antiplatelet therapy, a β-blocker, an ACEIs or an ARB, and a statin). Conclusion Optimal secondary prevention medications are known to be effective in reducing the risk of repeat ischemic events in ACS. This study demonstrated that adherence to GDMT in our community-based hospital study is better compared to prior studies but remained suboptimal. Potential strategies to improve adherence to guidelines are necessary.

A Case of Rheumatoid Arthritis and Paget Disease of Bone

Patient: Male, 74

Final Diagnosis: Rheumatoid arthritis (RA)

Symptoms: Joint pain • joint swelling

Medication: —

Clinical Procedure: —

Specialty: Rheumatology

Brain Natriuretic Peptide and Troponin T in Patients With Acute Pulmonary Embolism and Grade 3 Obesity: A Retrospective Analysis

Introduction The interpretation of brain natriuretic peptide (BNP) and Troponin T (TnT) in patients with obesity is very challenging. The applicability of these biomarkers as prognostic indicators of increased mortality in pulmonary embolism (PE) in patients with Grade 3 obesity has yet to be determined. Methods To investigate whether the combination of BNP and TnT may help to identify patients at low risk for short-term mortality, we assessed 92 patients admitted with the diagnosis of PE and Grade 3 obesity. The study endpoint was all-cause mortality at 30 days. Results The negative predictive value (NPV) of these tests combined is 98.8%; however, we were not able to detect a statistically significant difference between the patients who had a BNP < 100 pg/mL and TnT < 0.03 ng/mL and the other individuals who had either BNP ≥ 100 pg/mL or TnT ≥ 0.03 or both. The mortality rate was 5.43% within 30 days of the diagnosis. The logistic regression analysis using BNP and troponin as continuous variables identified BNP (p < 0.005) as an independent predictor for 30 days mortality. Receiver operating characteristic (ROC) analysis determined that a BNP level of 684 pg/mL was the cutoff level to predict mortality in the population studied. Conclusions Our results support that BNP and TnT levels retain an excellent NPV among patients with PE and Grade 3 obesity. BNP testing could be an independent predictor of high-risk patients in this population. The low incidence of all-cause mortality in this study (5.43%) is primarily explained by the more frequent use (9.75%) of systemic or catheter-based thrombolysis associated with a lower rate of major bleeding compared to the general population.

Pancoast-Tobias Syndrome: A Unique Presentation of Lung Cancer

A 65-year-old man with 50 pack-year smoking history presented to the emergency department for evaluation of upper back and right shoulder pain secondary to a fall. Physical examination was notable for anisocoria with a constricted left pupil (miosis), mild ptosis of the left eyelid, and bilateral shoulder pain, right more than left, with both passive and active movements. Chest computed tomography identified a soft tissue mass at the left lung apex with extension into the pleural surface, associated with destructive osseous changes of the right scapula, adjacent ribs, and thoracic vertebral bodies. Imaging of the brain revealed multiple masses suspicious of metastatic brain lesions. Biopsy of the right supraclavicular lymph node revealed lung tissue adenocarcinoma and negative Kirsten rat sarcoma viral oncogene homolog (K-Ras), epidermal growth factor receptor (EGFR), B-raf proto-oncogene (BRAF), C-ros oncogene 1 (ROS1), and anaplastic lymphoma kinase (ALK) rearrangement. Recognizing Pancoast syndrome in patients with significant smoking history, anisocoria, and shoulder pain is crucial for identifying the underlying etiology and expediting the treatment.

A Growing Mandate in American Medicine: Teaching Our Internal Medicine Residents About Healthcare Administration and Leadership

Leadership training during residency is essential for the successful development of contemporary physicians. Creating a curriculum for healthcare leadership and administration for internal medicine residents is particularly challenging due to the heterogeneity of leadership curricula across programs, the emphasis on individual advancement rather than collective leadership, and the scarcity of published research on the topic. A healthcare administration and leadership rotation for medical residents is a valuable experience that emphasizes the importance of contextualizing education on leadership and building relationships to achieve organizational goals.

Trapped in the Bowel

Intussusception in adults is a rare condition and is usually associated with organic disease. It has been implicated for 1% of all bowel obstructions. Clinical presentation can be non-specific and the rarity of the classic triad of abdominal pain, vomiting, and currant jelly stools contributes to late diagnosis and treatment. A 95-year-old lady presented to the emergency department for evaluation of nausea, vomiting, and a two-month history of intermittent diarrhea, which had been worsening for a few days prior to admission. On examination, the abdomen was soft but tender on deep palpation, with audible bowel sounds. No organomegaly or costovertebral angle (CVA) tenderness was appreciated. CT abdomen revealed a long segment of the colon with a loop within loop appearance from the proximal transverse colon to the distal descending colon, consistent with intussusception. The patient was taken to the operating room where local exploration using laparoscopy revealed complete telescoping and intussusception of terminal ileum into the distended ascending and transverse colon and the patient underwent right hemicolectomy. The signs and symptoms of intussusception among the elderly are very non-specific and include nausea, vomiting, change in bowel habits, and gastrointestinal bleeding. Since the classic triad of symptoms (abdominal pain, vomiting, and currant jelly stools) is rarely observed, timely diagnosis and management become a challenge for clinicians. Literature suggests that up to 90% of adults with intussusception present with ongoing abdominal pain. Especially in outpatient settings, patients presenting with intermittent abdominal pain that resolves quickly with simple analgesia should be promptly evaluated. This case illustrates that the rarity of incidence and non-specific clinical presentation are potential barriers towards timely diagnosis and treatment of intussusception among adults, especially the elderly population. Keeping a low threshold for prompt evaluation using appropriate imaging modalities can help overcome this challenge and help reduce the surgical burden.

May-Thurner Syndrome: A Suspicion That Led to an Incidental Discovery

May-Thurner syndrome (MTS)/Iliac vein compression syndrome is characterized by left iliac vein stenosis secondary to compression by the right common iliac artery against the fifth-lumbar vertebra. It increases the incidence of deep venous thrombosis (DVT). We had a 43-year-old female presenting with left leg swelling and was found to have extensive DVT provoked by a long history of travel. Because of the extension of her thrombus, a catheter-guided thrombectomy (CDT) was planned and findings of MTS were identified incidentally. She had an endovascular stent placed and was discharged on long-term anticoagulation.

Hospital Utilization and Mortality Post-electrical Cardioversion in Patients With Atrial Fibrillation in a Community Hospital

Background Electrical cardioversion (EC) is a procedure that restores normal sinus rhythm in patients with atrial fibrillation (AF). Data on post-EC outcomes relative to the success of inpatient EC is limited. Methods This is a retrospective study of patients admitted for AF who underwent inpatient EC from January 1, 2017, to January 1, 2021. We collected demographics and clinical, biochemical, and echocardiographic parameters that impact the success of EC. Outcome events were 30-day readmissions and mortality. Results Our study included 54 unique patients who either had EC in the emergency room or as part of their hospital admission course for atrial fibrillation. Most patients were men with an average age of 70 years with traditional risk factors for cardiovascular disease including heart failure, coronary artery disease, and chronic kidney disease. The group who had unsuccessful cardioversion was older than those in the ineffective EC. Mortality at 30 days (p < 0.01), 1 year (p < 0.01), and 30-day readmission rate (p < 0.01) were higher in patients with unsuccessful EC. Conclusion A predictive model for successful EC remains difficult to establish. Patients with unsuccessful in-hospital EC are at high risk for mortality and readmission at 30 days and require a comprehensive pre-discharge multidisciplinary approach and prioritized and individualized post-discharge integrated care.

Warfarin-Induced Skin Necrosis Despite Enoxaparin Bridging Therapy

Skin necrosis is a rare albeit severe complication of warfarin use for anticoagulation, resulting in significant morbidity and mortality. Here, we present the case of a 58-year-old woman who developed erythema and pain in her left leg two weeks after initiation of warfarin therapy with concomitant early administration of heparin for a deep vein thrombosis and pulmonary embolism. Subsequently, the erythema progressed to skin necrosis, and a diagnosis of warfarin-induced skin necrosis (WISN) was suspected. Warfarin was discontinued, and unfractionated heparin was commenced. The simultaneous presence of eosinophilia pointed toward an associated drug-related hypersensitivity reaction. Dexamethasone was added to the medication regimen. The patient was discharged on a factor Xa inhibitor and prednisone.

Recognizing WISN is crucial in patients receiving anticoagulation. The diagnosis can be particularly challenging in cases when bridging anticoagulation has been previously completed. Early diagnosis and drug discontinuation are critical to ensuring a favorable prognosis. Steroids may also play a role in the treatment of this condition if an associated drug hypersensitivity is identified.

"D" is for Dilemma

Immunoglobulin D (IgD) monoclonal gammopathy is a rare subtype of multiple myeloma (MM) associated with a worse prognosis compared with other variants of MM. A 61-year-old man with no known past medical history presented with complaints of abdominal pain, nausea, and vomiting for three weeks. Physical examination revealed mild epigastric tenderness. Laboratory data demonstrated a significantly elevated creatinine with minimal proteinuria and small abnormality in the gamma fraction. Ultrasound of the kidneys described normal-sized kidneys. Serum-free light chains and immunofixation were consistent with IgD kappa monoclonal gammopathy. Kidney biopsy revealed cast nephropathy. Bone marrow biopsy was remarkable for sheets of CD 38+ plasma cells comprising approximately 80% of the marrow cells. Recognizing the atypical presentation of IgD MM is crucial to facilitate early diagnosis and management and improve the prognosis of this subtype of MM.

Hospital Utilization for Patients With Cirrhosis and Severe Ascites in a Model of Outpatient Paracentesis by Interventional Radiology

BACKGROUND

 Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care.

METHODS

This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test.

RESULTS

Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation.

CONCLUSION

In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.

The Great Mimicker: Cutaneous Metastatic Melanoma Presenting as a Non-resolving Pleural Effusion

Although melanoma starts as a local disease, it can metastasize to other sites of the body including the lung, brain, liver, and intestines. However, pleural involvement is a rare presentation. Here, we present a case of a 57-year-old man with a history of stage IIA cutaneous melanoma, that relapsed 3 years after cutaneous resection, presenting with a non-resolving pleural effusion. Pleural fluid analysis was consistent with an exudative effusion, and pleural biopsy confirmed metastatic melanoma. The patient was treated with dual therapy of ipilimumab and nivolumab, as per National Comprehensive Cancer Network guidelines, with good response. Thus, we recommend having a high index of clinical suspicion for metastatic pleural melanoma when a patient with a history of cutaneous melanoma presents with a non-resolving pleural effusion.