Guramrinder Singh Thind

Malignant hypertension as a rare cause of thrombotic microangiopathy

Malignant hypertension can occasionally be associated with microangiopathic haemolytic anaemia. A 38-year-old male presented with nausea, vomiting, loss of appetite and oliguria for 2 weeks. He was diagnosed with hypertensive emergency with cardiac and renal dysfunction. Interestingly, further workup was diagnostic for the presence of thrombotic microangiopathy (TMA): haemoglobin =12.7 g/dL, indirect bilirubin =2.0 mg/dL, haptoglobin ≤6 mg/dL, platelet count =121 000/μL and schistocytes on peripheral smear. At the outset, the cause of TMA was unclear. Patient denied having diarrhoea, making haemolytic uremic syndrome less likely. A normal ADAMTS13 activity test ruled out thrombotic thrombocytopaenic purpura. Malignant hypertension induced TMA was highest on the differential and plasma exchange was deferred. Renal biopsy revealed features of TMA and malignant nephrosclerosis. Patient eventually became dialysis dependent. Aggressive blood pressure control was obtained with multiple medications.

Recent advances in the understanding of endothelial barrier function and fluid therapy

Elucidation of the structural basis of endothelial barrier function and the study of transcapillary fluid exchange dynamics are areas of active research. There has been significant enhancement in our understanding of the ultrastructural basis of endothelial barrier function. The role of glycocalyx has received special attention. Experimental evidence has called for a revision in the classic Starling principle of transcapillary exchange. The glycocalyx model provides a potential structural mechanism for the revised Starling principle. This knowledge can provide the framework for understanding the volume expansion effect of fluid therapy and the physiological basis of fluid therapy.

May-Thurner Syndrome as a Rare Cause of Paradoxical Embolism in a Patient with Patent Foramen Ovale

May-Thurner syndrome is an underrecognized anatomical variant that can lead to increased propensity for venous thrombosis in the lower extremities. We present a case of a 67-year-old female who presented with transient ischemic attack. Initial workup including CT scan of the head, MRI scan of the head, and magnetic resonance angiogram of the head and neck was unremarkable. A transthoracic echocardiogram with bubble study was also normal. Subsequently, a transesophageal echocardiogram was performed that revealed a patent foramen ovale with right-to-left shunt. Lower extremity duplex venous ultrasound showed no evidence of deep vein thrombosis. However, magnetic resonance venogram of the pelvis showed compression of the left common iliac vein just after its origin suggestive of May-Thurner syndrome. Hence, May-Thurner syndrome was recognized as the probable source of paradoxical embolism causing transient ischemic attack in this patient.

Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva

A 77-year-old woman with multiple risk factors for coronary artery disease, was referred for left heart catheterisation after abnormal dobutamine stress test, revealing anterior and anterolateral hypokineses. Coronary angiogram revealed a large, dominant right coronary artery (figure 1A), originating from the right coronary cusp along with underdeveloped anomalous left coronary system. Left main artery was absent. Left anterior descending artery (LAD) was originating from right coronary cusp posteriorly (figure 1B), while the left circumflex artery (LCx) from the same cusp anteriorly (figure 1C). Probably the small calibre …

Single coronary artery with bicuspid aortic valve

A 45-year-old man with known history of coronary artery disease and bicuspid aortic valve (BAV) (figure 1) was admitted for worsening symptoms of angina. Coronary angiogram showed single coronary artery arising from the left cusp, trifurcating into right coronary artery, left anterior descending (LAD) and left circumflex artery (LCx) (figure 2). No course of the left main coronary artery between the aortic root and the pulmonary artery was …

Anomalous origin of the coronary artery from the pulmonary artery in a 33-year-old man

A 33-year-old man, without prior history of coronary artery disease, was referred to a catheterisation laboratory with a diagnosis of non-ST elevation myocardial infarction. Coronary angiogram showed a dilated, dominant right coronary artery of normal origin with multiple collaterals draining to the left coronary system (figure 1A,B) and a coronary ‘steal’ phenomenon into the pulmonary artery (PA). Left main coronary artery (LMA) was not visualised on contrast injection into the aortic root (figure 1B). Ventriculogram showed ejection fraction of 40%–45% and anterior wall hypokinesis. Subsequent three-dimensional heart computer tomogram revealed anomalous …

Rare case of massive bilateral chylothorax

We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann’s procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient’s respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.

A case of congenital coronary-pulmonary fistulas presenting as spontaneous mediastinal haemorrhage.

Coronary artery fistulas are rare anomalous vascular connections between coronary arteries and a cardiac chamber or a central vessel, without an intervening capillary bed. Coronary-pulmonary fistulas are a distinct subset of coronary artery fistulas. We present the case of a previously healthy 63-year-old-man who presented with chest pain and was found to have mediastinal haemorrhage. Upon further investigations, he was found to have multiple coronary-pulmonary fistulas with pseudoaneurysm formation in three of the fistulas. Two of these pseudoaneurysms showed inflammatory changes indicative of recent bleed. These were determined to be the source of the mediastinal bleeding and patient’s initial presentation. The patient was managed medically after obtaining multiple expert opinions from various institutions.

A case of acyclovir neurotoxicity presenting with atypical cerebrospinal fluid findings

An 82-year-old man with a history of end-stage renal disease presented with progressively worsening confusion and somnolence for the past 4–5 days. The patient was diagnosed with herpes zoster by his primary care physician 5 days ago and was started on a course of valacyclovir 1 g three times a day (dose not adjusted for renal impairment). A lumbar puncture was performed and cerebrospinal fluid (CSF) studies revealed 37 white blood cells (WBCs)/hpf (100% monocytes), protein 64 mg/dL and glucose 52 mg/dL. He was started on ceftriaxone, ampicillin and acyclovir. MRI of the brain was done and was unremarkable. Acyclovir-induced encephalopathy was high on differential, but his CSF findings were concerning for viral encephalitis. Nonetheless, all antimicrobials were discontinued and he was scheduled for a 5-hour dialysis session. The very next day, he showed immense improvement and eventually recovered completely. CSF PCR tests for both herpes simplex virus and varicella zoster virus came back negative.

Hiding in plain sight: a case of chronic disseminated histoplasmosis with central nervous system involvement.

A 64-year-old man presented with gradual onset of confusion, ataxia and 25-pound weight loss over 3 months. MRI of the brain revealed two enhancing cerebellar lesions suspicious for metastases. Positron emission tomography-CT showed enhancement of cervical and axillary lymph nodes. Left axillary lymph node biopsy showed no evidence of malignancy but instead showed fungal organisms morphologically consistent with Histoplasma spp. Disseminated histoplasmosis with central nervous system involvement was suspected. Further history revealed that the patient had been having subjective fever for the past several months. He has had mild pancytopenia for about 2 years, which had not been further evaluated. Additionally, he had an oesophagogastroduodenoscopy 3 months prior to admission, which had shown granulomatous gastritis. Subsequently, the diagnosis of disseminated histoplasmosis was confirmed by serological testing and bone marrow biopsy. The patient was started on liposomal amphotericin B. Unfortunately, the patient had a catastrophic stroke and was transitioned to comfort care measures.