Alain Waked

Reverse Takotsubo Cardiomyopathy in the Setting of Anaphylaxis Treated with High-dose Intravenous Epinephrine

BACKGROUND Takotsubo cardiomyopathy is seen, though rarely, in anaphylaxis treated with epinephrine. Stress cardiomyopathy is most likely to occur in middle-aged women. The underlying etiology is believed to be related to catecholamine release in periods of intense stress. Catecholamines administered exogenously, and those secreted by neuroendocrine tumors (e.g., pheochromocytoma) or during anaphylaxis have been reported to cause apical ballooning syndrome, or takotsubo syndrome. However, reverse takotsubo stress cardiomyopathy is rarely seen or reported in anaphylaxis treated with epinephrine. OBJECTIVES To report a case illustrating that high-dose intravenous epinephrine can trigger stress cardiomyopathy, and that the risk is heightened with inappropriate dosing in the treatment of anaphylaxis. CASE REPORT We report a rare case of iatrogenic reverse takotsubo syndrome in a young woman who was inappropriately treated with high-dose intravenous epinephrine for mild anaphylaxis. CONCLUSION Inappropriately high doses of intravenous epinephrine can trigger stress cardiomyopathy. Emergency physicians should be familiar with the diagnosis, grading, and appropriate treatments of anaphylaxis to avoid this unnecessary complication.

Acute hepatitis in a woman following excessive ingestion of an energy drink: a case report

IntroductionThe consumption of energy drinks has increased significantly. We report the case of a patient who presented to our hospital with jaundice, abdominal pain, and markedly increased liver transaminases likely due to the increased consumption of an energy drink. To the best of our knowledge, this is the first case report in the literature linking the development of acute hepatitis to the consumption of an energy drink.Case presentationA 22-year-old Caucasian woman presented to our hospital with epigastric pain, nausea, vomiting, and low-grade fever. She had been drinking 10 cans of an energy drink daily for two weeks prior to presentation. Her physical examination revealed mild epigastric tenderness. Her initial blood tests revealed elevated alanine aminotransferase, aspartate aminotransferase, and total bilirubin. A computed tomographic scan of the abdomen and pelvis was normal, and the patient was discharged to home. She returned to the Emergency Department of our hospital with worsening pain and new-onset jaundice. This time her physical examination revealed epigastric tenderness and icteric sclera. Her aspartate aminotransferase, alanine aminotransferase, and international normalized ratio were markedly elevated. Further radiological studies were non-specific, and she was admitted to our hospital with a diagnosis of acute hepatitis. Her viral serology and toxicology screens were negative. The patient was treated supportively and was discharged after resolution of her symptoms and a marked decrease in her liver enzymes.ConclusionThe development of acute hepatitis in this patient was most likely due to the excessive ingestion of an energy drink, and we speculate that niacin was the culprit ingredient.

Acute complication due to impella 2.5 device (superficial femoral artery thrombosis): managed successfully with novel aspiration thrombectomy catheter (pronto v3).

The Impella recover LP 2.5 is a percutaneous left ventricular assist device (LVAD) recently approved for use in patients undergoing high risk percutaneous coronary intervention (PCI) and also in cases of cardiogenic shock. There is limited evidence available in literature about its safety, especially with regards to the incidence of local vascular complications, their management and long-term implications. We report here the first case of a serious local vascular complication—superficial femoral artery thrombus formation during Impella recover LP 2.5 use in a high risk PCI which was managed successfully with novel aspiration thrombectomy catheter (Pronto V3), which in itself is the first reported use of Pronto V3 in such a vascular complication.

Left Atrial Appendage Lipoma: An Unusual Location of Cardiac Lipomas

Cardiac lipomas are benign neoplasms of the heart and accounts for 8.4% of all primary tumors. They can occur sporadically at any age with no sex preference. The tumor originates mostly in the subendocardium and subepicardium but very rarely within the myocardium. Clinically this tumor is asymptomatic and found incidentally in the vast majority of cases. On occasion large lesions can lead to mechanical obstruction and pericardial effusions if located in the epicardium. Although lipomas can occur at different atrial or ventricular locations, it was never reported at the level of the left atrial appendage (LAA). Usually a mass in the LAA represents a thrombus, however there are few case reports of LAA tumors mainly representing fibroelastomas, myxomas, hemangiomas, and malignant tumors. To our knowledge there are no reported cases of left atrial appendage lipomas (LAAL) in the medical literature. We report the first case of LAAL discovered incidentally on transesophageal echocardiogram during off pump coronary artery bypass grafting. (Echocardiography 2011;28:E91‐E93)

Prosthetic aortic valve abscess producing intermittent right coronary artery compression.

61-year-old man with a history of aortic and mitral valve replacement was admitted with prosthetic valve nfective endocarditis after prolonged antibiotic therapy. lectrocardiogram showed no signs of myocardial ischmia. Transthoracic echocardiography showed a prosthetic ortic valve with vegetations. Preoperative coronary catheerization showed intermittent compression of the right oronary artery (Figs 1A and 1B; arrows). Intraoperative ransesophageal echocardiography showed an echolucent ass adjacent to the anterior part of sinus of Valsalva xpanding and contracting with the cardiac cycle (Figs A–C). This confirmed the cause of compression of the CA. (AB abscess cavity; AO aorta; AP prosthetic alve; PA proximal common pulmonary artery; SVC uperior vena cava; SV sinus of Valsalva; VG vegeta-

Lack of subjective tendency to bleed as clinical marker for aspirin resistance

The anti-platelet effect of aspirin (ASA) is widely proven to be effective in the prevention of fatal and non-fatal cardiovascular events in high risk patients. However, despite being on aspirin therapy, 10–20% of patients experience recurrent vascular events over a long period of time, thus the term ASA treatment failure. On the other hand, ASA resistance is commonly used to define the failure of aspirin to inhibit the thromboxane A2 production or the platelet aggregation at the laboratory level. The direct correlation between the laboratory and the clinical aspirin resistance has been shown previously. The demographic and the clinical markers of bleeding (through questionnaire) were collected in 114 patients on routine ASA treatment for cardiovascular events. The rapid platelets functional assay for aspirin was measured. The proportion, Fisher’s exact test, Spearman rho correlation, and cyclooxygenase-proportional univariate analysis were used. The statistical significance value was considered for p< 0.05. Out of 134 eligible patient, 114 (85%) agreed to participate in this study. ASA resistant was found in 13.8% in male as compared to 4.7% in female with p1⁄4 0.04. There was no significant correlation between ASA resistance and age, race, absence of mucocutaneous bleeding, smoking, diabetes, hypertension, kidney diseases, and other comorbidities. There is no clinical correlation to ASA resistance. However, ASA resistance is seen more with male gender. Further prospective studies to validate such correlation should be designed to eliminate the compliance confounder factor. The anti-platelet effect of aspirin is widely proven to be effective in the prevention of fatal and non-fatal cardiovascular events in high risk patients [1]. Aspirin (ASA) reduces the activation of platelets by irreversibly acetylating cyclooxygenase-1 [2–6]. However, despite being on aspirin therapy, 10–20% of patients experience recurrent vascular events over a long period of time [7]. Thus, the term ‘‘aspirin treatment failure’’ has been used to describe the occurrence of any atherothromboembolic ischemic events in compliant patients [8, 9]. On the other hand, the term ‘‘aspirin resistance’’ detected with laboratory tests is used to define the failure of aspirin to inhibit the thromboxane A2 production or the platelet aggregation and varies from 0.5% to 45% [10–12]. The direct correlation between the laboratory and the clinical aspirin resistance has been shown previously [13, 14], however, a clinical tool that predict ASA resistance is still lacking. The clinical implication of such simple tool will be of great benefit in preventing secondary cardiovascular events, since testing for aspirin resistance is expensive and not widely available. The goal of this project is to find any clinical marker that can predicts ASA resistance. Therefore, this project is designed to test the correlation between the ASA resistance testing and the absence of any mucocutaneous bleeding. To our knowledge, Clinical markers (through questionnaire) assessing for aspirin resistance has not been described yet. In an effort to find clinical markers that help in identifying aspirin resistant patients, we designed a pilot prospective cohort study. The study aim was to test aspirin resistance using rapid platelets functional assay for aspirin (RPFA-ASA) (VerifyNow aspirin by Accumetrics ) and correlate it with subjective mucocutaneous bleeding as reported by a selfdocumented questionnaire. As questionnaires are becoming an important tool in human research, we took several steps in developing a self-reporting questionnaire. Two groups involving different health care professional workers (physicians, nurses, administrative, and public health professionals) at Staten Island University Hospital and School of public health at State University of New York-Downstate, met on a weekly basis for 3 months to create and develop this questionnaire. At the end of this period, this questionnaire was presented to randomly chosen patients as a testing group. All questions,

Drug-eluting stent thrombosis after 2029 days of placement: longest ever reported interval between drug-eluting stent placement and very late thrombosis

In this era of very wide-spread use of percutaneous coronary intervention for the management of coronary artery disease, the appropriate duration of antiplatelet therapy after drug-eluting stent implantation still remains a subject of debate. Current recommendations from the American College of Cardiology/American Heart Association (2007) is to continue treatment with aspirin and clopidogrel for 1 year and then continue with aspirin only. However, cases of very late stent thrombosis (more than 12 months postimplantation) are being increasingly reported in literature. In this article we report a case of thrombosis as a result of drug-eluting stent placement after almost 67 months (2029 days), which to our knowledge, is the longest reported duration between the implantation of drug-eluting stent and occurrence of vascular event associated with very late stent thrombosis.

Erratum: Characteristics and outcomes of methicillin-resistant staphylococcus aureus surgical-site infections in patients with cancer: A case-control study (Annals of Surgical Oncology DOI: 10.1245/S10434-010-0923-5)

Department of Infectious Diseases, Infection Control and Employee Health, Unit 402, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY; Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Texas Health Science Center at Houston, School of Public Health, Houston, TX; Department of Infectious Diseases, Rizk Hospital, Beirut, Lebanon