Apoorva Jayarangaiah

Marijuana Induced Myocarditis: A New Entity of Toxic Myocarditis

Marijuana is the most common drug of abuse in the United States. Marijuana has more than 460 active chemical compounds including δ-9- tetrahydrocannabinol (THC). It acts via the CB1 and CB2 receptors that are distributed in various tissues in the body. Marijuana is known to cause tachycardia, bradycardia, hypertension, to decrease time angina, myocardial infarction and cardiac arrest. Till date, four cases of myocarditis/perimyocarditis associated with marijuana use have been reported. In one such case, it led to the development of heart failure in a young male patient. It is not clear if marijuana in and of itself causes myocarditis/perimyocarditis or if the etio-pathogenesis is actually related to the contaminants in marijuana such as pesticides and heavy metals. We hereby present a young male who with myocarditis related to marijuana use. Clinicians should have suspicion for myocarditis or perimyocarditis in patients presenting with chest pain following marijuana use.

Marijuana Induced Type I Brugada Pattern: A Case Report

Marijuana is the most common drug of abuse in the United States. Marijuana acts on cannabinoid receptors CB1, CB2 and another distinct endothelial receptor. Marijuana is known to cause tachycardia, hypotension and hypertension. Various arrhythmias including atrial fibrillation, atrial flutter, II degree AV block, ventricular fibrillation, ventricular tachycardia, asystole and brugada pattern associated with marijuana use have been reported. We here present an interesting case of Type I Brugada pattern in electrocardiography (ECG) in a 36 year old healthy African American male who presented after smoking four joints. Urine toxicology test proved marijuana use. Acute coronary syndrome was ruled out, coronary angiogram revealed normal coronaries, 2D echocardiogram showed no evidence of structural heart disease. Upon resolution of Brugada pattern in ECG, procainamide challenge performed in electrophysiology laboratory did not induce Brugada pattern. Patient was asked to return to hospital if he developed fever that did not resolve with antipyretics. Further studies are required to to understand the effect of marijuana on cardiac ion channels.

Rapid Progression of Heart Failure in a Patient with Idiopathic Inflammatory Myopathy

Idiopathic inflammatory myopathy (IIM) is a rare autoimmune myopathy that includes polymyositis, dermatomyositis, inclusion body myositis and autoimmune necrotizing myositis. Cardiac involvement was considered a rare occurrence in IIM however, recent reports suggests that cardiac involvement is a common feature and portends poor prognosis as it is usually encountered in advanced disease. IIM leads to myocarditis with subsequent development of myocardial fibrosis, cardiac conduction system disease and cardiomyopathy resulting in both systolic and diastolic heart failure. Conduction abnormalities such as first, second and third degree atrioventricular blocks, right and left bundle branch blocks associated with IIM have been reported. We present a case of a 44-year-old woman with biopsy proven-IIM whose left ventricular ejection fraction (LVEF) and electrocardiogram (ECG) were recorded as normal two years prior. On presentation to our hospital ECG revealed atrial tachycardia and 2D echocardiogram revealed heart failure with reduced ejection fraction (20-30%). Patient quickly progressed to complete heart block. A cardiac resynchronization therapy-defibrillator (CRT-D) insertion was planned but patient succumbed to sepsis.

The Utility of Endoscopic Ultrasound–Guided Brachytherapy in Liver Metastasis: A Case Report and Review of the Literature

Endoscopic ultrasound guided brachytherapy (EGBT) has been reported to be useful in certain malignancies including esophageal and pancreatic cancers. Percutaneous or surgical placement of radioactive seeds into the liver secondaries (brachytherapy) has been done successfully, however, the utility of EGBT in liver metastasis remains largely unclear. In this case report, we demonstrate the safety, efficacy and feasibility of EUS guided brachytherapy (EGBT) in liver metastasis secondary to leiomyosarcoma.

Esophago-pericardial Fistula Induced Community Acquired Methicillin Resistant Staphylococcus Aureus (CA-MRSA) Cardiac Tamponade - A Rare Case Report and Literature Review

Community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infection is a matter of public health concern. The incidence of community acquired Staphylococcus aureus (CA-MRSA) is rising. To date only 12 cases of CA-MRSA pericarditis and seven cases of esophageal cancer related purulent pericarditis have been reported. We here present a 54 year old woman who presented with cardiac tamponade that was noted to be purulent and in whom esophagopericardial fistula secondary to squamous cell esophageal cancer was discovered subsequently. Purulent pericardial fluid subsequently grew MRSA. Patient succumbed despite appropriate management with antibiotics.

A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use

Cocaine is a commonly abused illicit drug in the United States. The complex effects of cocaine on the conduction system of the human heart has not been completely understood. Cocaine acts as a sympathomimetic by inhibition of reuptake of neuronal catecholamines, leading mostly to tachyarrhythmias on presentation. However, cocaine also exerts other effects on the conduction system including sympathomimetic, sino-bradycardic as well as local anesthetic properties. While Multiple cases of atrioventricular (AV) conduction blocks including first degree AV block, Mobitz type I and third degree AV blocks have been previously reported, we hereby present the first case report of cocaine- induced Mobitz type II second degree AV block. This case occurred in a 55 year old woman who presented with retrosternal chest pressure and tested positive for cocaine abuse as documented by urine toxicology test. Patient spontaneously converted to normal sinus rhythm the following day post admission to the hospital. Cocaine is known to inhibit sodium channels and thus has been known to decrease SA node automaticity and conduction via AV node. Electrophysiology studies have previously confirmed cocaine mediated delay in impulse conduction and repolarization. Though rare, physicians should be aware of the possibility of bradyarrhythmias associated with cocaine abuse in order to apply standard therapy such as pacemaker in the event of non-resolution of this serious arrhythmia.

Brugada Pattern in Diabetic Ketoacidosis: A Case Report and Scoping Study

Brugada syndrome is a rare cardiac arrhythmia which is associated with right bundle branch block pattern (RBBB) and ST-segment elevation in right precordial leads. SCNA5 mutation is the most common genetic abnormality associated with Brugada syndrome. Brugada pattern not related to genetic mutations has been previously reported in the setting of fever, metabolic conditions, lithium use, marijuana and cocaine abuse, ischemia and pulmonary embolism, myocardial and pericardial diseases. Multiple isolated cases of Brugada pattern associated with diabetic ketoacidosis (DKA) have been previously reported. We here present a case of type 1 Brugada pattern in a 23 year-old-male who presented with DKA. Brugada pattern in DKA is attributed to acidosis and multiple electrolyte abnormalities including hyperkalemia which alter ion channel expression in the heart thus leading to Brugada pattern which subsequently resolved with treatment of DKA. In such patients, Brugada pattern is not reproducible on procainamide induction cardiac electrophysiology study (EPS). Our scoping study demonstrates male predominance 20/22 cases of (DELETE this highlighted area) Brugada pattern in DKA, a finding that is consistent with prevalence of this disease among males.