Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Direct oral anticoagulants (DOACs), such as apixaban, are used for the prevention and management of thromboembolic diseases. Here, we present a case of a 72-year-old African American woman who presented to the hospital with shortness of breath and precordial chest pain for three days. The patient was diagnosed with volume overload associated with the progression of chronic kidney disease (CKD) and subsequently admitted to the hospital. Since the patient failed to adequately respond to diuretics, hemodialysis was initiated. During the hospital stay, she developed paroxysmal atrial fibrillation. Along with amiodarone, apixaban was started for primary stroke prophylaxis. Within 72 hours, the patient developed worsening chest pain. An echocardiogram revealed a large pericardial effusion with cardiac tamponade. She was taken for an emergent open pericardial window placement to relieve cardiac tamponade, where 600 mL of blood was drained. Considering the timeline of the development of a large bloody pericardial effusion following initiation of apixaban, spontaneous hemorrhagic cardiac tamponade attributed to the use of apixaban was diagnosed. The patient was eventually taken off all anticoagulants. In considering potential mechanisms, impaired hepatic and renal metabolism of apixaban could be factored in this case. In addition, CKD can increase bleeding risk, due to platelet dysfunction and impaired interaction of von Willebrand factor with GPIIb-IIIa. Moreover, renal secretion of apixaban is mediated by p-glycoprotein and amiodarone is an inhibitor of this protein. Although extremely rare, spontaneous hemorrhagic cardiac tamponade can occur with the use of DOACs, such as apixaban. Prompt recognition and urgent treatment remain keys to avoiding adverse patient outcomes.

Extra-pulmonary Cutaneous Sarcoidosis Presenting With Granulomatous Cranial Lesions and Cardiac Complications: A Case Report

Sarcoidosis is a non-caseating granulomatous disorder affecting multiple organs. Although the lungs are the most common site of presentation, extra-pulmonary manifestations involving the skin and heart can occur. Sarcoidosis affecting skull bone is uncommon and involvement of skin, heart, and skull bone all together, without pulmonary manifestations, is extremely rare. We report a 63-year-old Caucasian woman with a past history of cutaneous sarcoidosis and granulomatous skull bone lesions who presented with recurrent syncope. An ambulatory cardiac monitor detected intermittent high-grade atrioventricular block and cardiac MRI confirmed the diagnosis of cardiac sarcoidosis. This case represents an extremely unique journey of sarcoidosis and suggests potential consideration for cardiac sarcoidosis screening in patients with a history of extra-cardiac manifestations.

Cocaine-Induced Ascending Aortic Thrombus

Aortic thrombosis without coexisting atherosclerosis is uncommon. Sometimes, aneurysms or dissections can predispose to thrombus in the abdominal or thoracic aorta. However, ascending aortic thrombus in a non-aneurysmal, non-atherosclerotic aorta is a rare occurrence. Although arterial thrombosis has been linked with its use, cocaine-associated thrombus of the ascending aorta has been rarely described. We report a young man with regular use of cocaine presenting with constant, burning, left-sided chest pain. He was found to have a large thrombus in a structurally normal ascending aorta. Medical management with therapeutic anticoagulation was started. Despite an interruption of anticoagulation treatment for two months due to non-compliance, the man survived. This unique case highlights the importance of various vascular complications associated with cocaine use, their early recognition, and their treatment.

Phenazopyridine-Induced Methemoglobinemia: A Case Report

Methemoglobinemia is a condition caused by increased methemoglobin, a reduced form of hemoglobin, in the blood. This causes the molecules to bind oxygen more tightly and decreases their ability to release that oxygen to tissue. Most cases of methemoglobinemia are acquired and occur either in pediatric populations or in individuals with predisposing conditions. This report illustrates a case of an otherwise healthy 31-year-old patient presenting to the emergency department with cyanosis of the hands and mouth and an O2 saturation of 78% after taking increased doses of the over-the-counter medication phenazopyridine. A "chocolate-brown" color of her arterial blood, and increased methemoglobin levels of 20.2%, confirmed the diagnosis of methemoglobinemia. She was treated with both methylene blue and ascorbic acid, and her oxygen saturation and serum chemistry returned to normal levels within a few hours. The case highlights the importance of discussing the dosage of all over-the-counter medications with patients and recognizing the signs and symptoms of methemoglobinemia.

Role of autopsy surgeon in determination of time since death in criminal cases

Importance of determination of time since death is very important for the investigating agencies, autopsy surgeons and legal authorities in criminal cases or when a foul play is suspected behind a death. There are many variabilities and probabilities in determination process but the following points are to be read and analysed carefully so that it can be easier to ascertain the time since death: History and circumstances of death; somatic and molecular signs of death; emptying time of stomach and state of digestion of food in the stomach; biochemical investigations, etc. The individual points are narrated in a nutshell in this article.

Common Medicolegal Problems Faced by Medical Officers of Armed Forces Medical Services

Many a times medical officers of Armed Forces Medical Services face problems concerning policy as well as policy matters la connection with their medico-legal duties and responsibilities. This is particularly so with hospital administrators, pathologists and surgeons. Over and above, the lack of Army Orders and DG Memoranda on this topic makes one feel at a loss. The consequences of mistakes committed while performing medicolegal duties may include strictures from the courts. This article tries to list the common medicolegal problems encountered by medical officers of Armed Forces Medical Services working at different levels and in different capacities, and provides solutions for the same.

POST MORTEM DIAGNOSIS OF EARLY MYOCARDIAL INFARCTION

Acute Myocardial Infarction as a cause of death is diagnosed in many cases of sudden death based on the indirect evidence of critical narrrowing (75%) of one or more coronary arteries. Microscopic evidence of infarction is seen in H & E stained sections only if the person has survived for a minimum period of 6 hours after sustaining fatal ischaemic attack. In this study we have used two laboratory methods for visualisation of infarcts of lesser 'age', viz.-Triphenyl Tetrazolium Chloride (TTC) Macro Test and Acridine Orange Fluorescence Study. The former is a gross staining procedure which can reveal infarcts of 5-6 hours age, while the later is UV Fluorescent microscopic examination capable of detecting infarcts of 2 hours age. Although these procedures are well accepted ones, the aim of this article is to induce Forensic Pathologists to incorporate these tests in the study protocol of all sudden death cases with the aim of 'visualising' the infarct rather than basing the diagnosis on indirect evidence of critical narrowing of Coronaries.

Gender bias torture in place of work

Gender bias torture specially sexual harassment of women at the work place is now a hard reality, the ultimate form of control that repressed men, especially those in position of authority, can have today. They are generally being allowed to get away with it. Mainly because women are fearful and totally unorganized, managements are complacent and the law takes much too long to work if it ever does. Global picture is horrifying. Child abuse, women abuse and even some men are sexually abused. The fear of loss of job, hostility at work and social stigma still prevent women from complaining about sexual harassment. It has been recognized as human rights violation by the Supreme Court which has even drawn up legally binding guidelines directing employers to implement preventive and remedial measures in the work place.