Chikezie Alvarez

Spontaneous pneumomediastinum in a healthy young female: A case report and literature review

Spontaneous pneumomediastinum (SPM) is an uncommon finding in young adults presenting usually without any comorbidities or an underlying pathology. It is most commonly due to alveolar rupture in the setting of an inciting event such an underlying asthma, barotrauma, valsalva maneuver, or esophageal rupture. Individuals can have varying presentations, from chest pain, dyspnea and dysphagia, to anxiety, weakness, or facial and neck swelling. The majority of patients have subcutaneous emphysema on examination and can have abnormal laboratory findings such as an elevated C-reactive proteins and leukocytosis. Diagnostic modalities used include chest x-ray, CT scan, ultrasound and barium swallow or esophagram. Majority of individuals and treated conservatively with rest, analgesia and oxygen administration. The prognosis of SPM is usually good with resolution within several days in most cases and the recurrence rate is very low. We report the case of a 22-year-old female presented with SPM diagnosed by chest x-ray and chest CT scan who was treated conservatively with subsequent spontaneous resolution.

Reduced Stroke After Transcatheter Patent Foramen Ovale Closure: A Systematic Review and Meta-analysis

Background: Recent randomized control trials (RCTs) have suggested benefit with transcatheter patent foramen ovale (PFO) closure plus antiplatelet therapy over medical treatment alone for secondary stroke prevention. Material and Methods: Data sources: we searched PubMed and Ovid MEDLINE from the inception until November 10, 2017 for RCTs comparing TPFO closure to medical therapy in patients with a PFO and a history of cryptogenic stroke. Results: Five RCTs with 3,627 patients (TPFO closure = 1,829 versus medical therapy =1,798) were included. There was a decreased number of post‐TPFO closure strokes compared to the medical therapy arm; 53 versus 80 strokes (odds ratio [OR] = 0.61, CI: 0.39‐0.94, P = 0.03, I2 = 17%). Transient ischemic attacks occurred in 43 patients after TPFO closure versus 60 patients in the medical therapy group (OR = 0.80, CI: 0.53‐1.19, P = 0.26, I2 = 0%). There was a higher incidence of atrial fibrillation in the TPFO closure group, which occurred in 75 patients, compared to 12 patients in the medical therapy group (OR = 5.23, CI: 2.17‐12.59, P = 0.0002, I2 = 43%). There was a trend toward a decreased number of neuropsychiatric events in the TPFO closure closure group compared to the medical therapy group; 42 versus 67 neuropsychiatric events (OR = 0.71, CI: 0.48‐1.06, P = 0.09, I2 = 0%). Conclusions: TPFO closure plus antiplatelet therapy is superior to medical therapy in patients with a PFO and cryptogenic stroke. PFO closure is associated with new‐onset atrial fibrillation and a trend toward reduced neuropsychiatric events.

Coronary Slow-Flow Phenomenon as an Underrecognized and Treatable Source of Chest Pain: Case Series and Literature Review

Background. Coronary slow-flow phenomenon (CSFP) is characterized by delayed distal vessel opacification of contrast, in the absence of significant epicardial coronary stenosis. CSFP has been reported as a cause of chest pain and abnormal noninvasive ischemic tests and is often underrecognized. Material and Methods. Charts and angiographic records from our institution were reviewed to identify 15 consecutive patients who were diagnosed with CSFP from January 2016 to January 2017. Results. Of the 15 patients (4 females and 11 males) studied, the mean age was 59.1 years (range = 45-86 years); all had left ventricular ejection fraction >45% and without significant valvular stenosis/regurgitation. The indication for coronary angiography for all 15 patients was chest pain with abnormal noninvasive tests. Of the 11 patients who underwent previous coronary angiograms, all revealed prior evidence of CSFP. None of these patients were on calcium channel blockers (CCBs) or long-acting nitroglycerin agents before angiography. Intracoronary CCBs were effectively utilized to alleviate the angiographic finding (improvement in Thrombolysis in Myocardial Infarction frame count) in all 15 patients. Oral CCBs were started with subsequent improvement in all 15 patients (mean follow-up time = 13.6 months). Conclusion. Coronary slow-flow should be a diagnostic consideration in patients presenting with chest pain and abnormal noninvasive ischemic testing with nonobstructive epicardial vessels. CSFP remains underrecognized, and the specific standard of care for treatment has not been established. In each of the 15 cases, intracoronary nifedipine resolved the angiographic manifestation of coronary slow-flow. Furthermore, in follow-up, all patients improved symptomatically from their chest pain after oral CCBs were initiated.

A Large Grade 5 Mobile Aortic Arch Atheromatous Plaque: Cause of Cerebrovascular Accident

Aortic atheromas (aortic atheromatous plaques) are defined by an irregular thickening of the intima ≥2 mm, and a complex plaque is defined as a protruding atheroma ≥4 mm with or without an attached mobile component. Stroke incidence is approximately 25% in patients with mobile plaques of the aortic arch and 2% in patients with quiescent nonmobile plaques. Antiplatelet agents, oral anticoagulants, and statins have been suggested in the management of atheromas. We present an 80-year-old male, with non-ST-segment elevation myocardial infarction (NSTEMI) and chronic dysarthria, found to have an acute cerebrovascular accident (CVA) secondary to embolism from a large 12 mm aortic arch plaque, treated medically with oral antiplatelet therapy, anticoagulation, and statin therapy.

Systolic heart failure in a patient with primary aldosteronism

A 53-year-old African man with a 25-year history of uncontrolled hypertension and systolic heart failure presented with an acute congestive heart failure exacerbation. He was found to have severe hypokalaemia, so additional testing was performed, and primary aldosteronism was confirmed. CT scan showed a 1.2×2.4 cm well-defined, homogeneous adenoma of the left adrenal gland. Adrenal vein sampling confirmed unilateral primary aldosteronism with lateralisation to the left adrenal gland. The patient was started on spironolactone and was referred to surgery for laparoscopic left adrenalectomy. Primary aldosteronism is associated with high cardiovascular morbidity and mortality due to activation of cardiac mineralocorticoid receptors. Studies suggest these negative effects can be reduced with early intervention and treatment. This case highlights the importance of investigating secondary causes of hypertension in young patients and the potential adverse cardiac effects of primary aldosteronism when it goes undiagnosed and untreated for years.

Meta-Analysis comparing outcomes and need for renal replacement therapy of Transcatheter aortic valve implantation versus surgical aortic valve replacement

Acute kidney injury (AKI) is commonly associated with aortic valve replacement. Surgical aortic valve replacement (SAVR) is a known risk factor for AKI but little is known about the short- and long-term effects of transcatheter aortic valve implantation (TAVI). The purpose of our analysis is to identify the short- and long-term effect of TAVI on renal outcomes. We searched Medline and PUBMED from January 1, 2000 to November 6, 2017 for randomized control trials (RCTs) comparing TAVI to SAVR in patients with severe aortic stenosis. Three hundred sixty-nine trials were identified, 6 RCTs were included in our analysis. RevMan version 5.3 was used for statistical analysis. Heterogeneity is calculated using I2 statistics. Primary outcomes were AKI within 30 days and 1 year of TAVI, and requirement for renal replacement therapy. We included 5,536 patients (2,796 in TAVI and 2,740 in SAVR arm) from 6 RCTs. Baseline characteristics were similar. There was reduced incidence of AKI at 30 days of TAVI compared with SAVR, 57 versus 133 (odds ratio [OR] 0.40, confidence interval [CI] 0.28 to 0.56, p <0.00001, I2 = 7%) with no difference at 1 year (OR 0.65, CI 0.32 to 1.32, p = 0.23, I2 = 76%) and need for renal replacement therapy OR 0.95, CI 0.50 to 1.80, p = 0.87, I2 = 0%). Permanent pacemaker was more frequent in the TAVI arm compared with SAVR arm, 379 versus 110, (OR 3.75, CI 1.67 to 8.42, p = 0.001, I2 = 89%). In conclusion, TAVI is associated with a reduction in AKIs at 30 days despite the exposure to contrast and higher incidence of new permanent pacemaker placement.

A unilateral hyperlucent lung - Swyer-James syndrome: A case report and literature review

Swyer-James-Macleod syndrome (SJMS) is a rare etiology of a unilateral hyperlucent hemithorax but an important one, which should be considered in any individual with such findings. Presentation usually occurs in adulthood with an asymptomatic history in many cases or with a history of childhood infections. Clinically, symptomatic patients may present with productive cough, dyspnea on exertion, hemoptysis, decreased exercise tolerance and recurrent pulmonary infections. Many individuals are asymptomatic only requiring conservative management. However, some patients may require surgical intervention. SJMS can be easily misdiagnosed and must be suspected for example, in any patient diagnosed with asthma who does not respond to therapy. We report a case of a 51-year-old African American male diagnosed with SJMS on the basis of his medical history, clinical presentation and x-rays and computed tomography chest scans findings.

Adenocarcinoma of Lung Presenting as Lambert-Eaton Myasthenic Syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is a paraneoplastic neuromuscular junction disorder. LEMS presents with muscular weakness and fatigability, mainly involving the proximal lower limbs. There are 2 types of LEMS depending on the etiology: paraneoplastic and idiopathic. The paraneoplastic form, which constitutes more than a half of the cases, is mostly associated with intrathoracic neoplasms. Most cases are seen in patients with small cell lung cancer; other subtypes of lung cancer are extremely rare. In this article, we report a case of LEMS as a rare association with adenocarcinoma of the lung.

Concurrent Primary Gastric and Pulmonary Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review

The primary pulmonary diffuse large B-cell lymphoma (PPDLBCL), a kind of non-Hodgkin’s lymphomas, itself is a rare entity. Its association with primary B-cell gastric lymphoma has not been established yet. Herein we present a case of PPDLBCL along with a literature review. This case is special and extremely rare as it has concurrent primary gastric B-cell lymphoma.

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use

Background The purpose of this study was to compare the outcome of Clostridium difficile infection (CDI) in patients on systemic steroids for various indications to patients not on steroids in term of disease severity, and associated morbidity and mortality. Methods We retrospectively reviewed records of all patients with CDI at our hospital from January 2011 to December 2016. Patients were evaluated for baseline characteristics, comorbidities, medications, disease severity, disease-related length of stay (LOS) from the diagnosis of CDI to discharge, need for surgical intervention, and disease-related mortality. Based on systemic steroids use, patients who were using steroids for different indications constituted the study population, and those with no steroids use were clustered as a control group. Results Of the 258 patients included, males were 127 (49%). Severe and severe-complicated CDI developed in 21/63 (33.3%) and 1/63 (1.6%) of patients on steroids (average daily dose of 20 mg), and in 73/195 (37.4%) and 5/195 (2.6%) of patients with no steroids use (P = 0.56 and P = 0.66, respectively). Surgical intervention was not required in the steroids group and 5/195 (2.7%) of patients not on steroids underwent bowel surgeries (P = 0.38). Mean LOS (days) was 11.6 ± 1.5 in the steroids group and 10.4 ± 0.7 in the no-steroids group (P = 0.4). CDI-related mortality occurred in 9/63(14.3%) of patients on steroids, and in 15/195 (7.7%) of patients not on steroids (P = 0.12; odds ratio (OR): 2; 95% confidence interval (CI): 0.8 - 4.8). Conclusion There was no significant difference in the severity of CDI, need for surgical interventions, disease-related LOS and mortality in systemic steroids users compared to patients not on steroids.