Hashir Kareem

Statin Induced Rhabdomyolysis with Non Oliguric Renal Failure: A Rare Presentation

Statins are safe, well tolerated, efficient and time tested drugs for the management of hypercholesterolemia, and thus play a cardinal role in the management of patients with heart disease. Although safe in clinical practice, they are associated with adverse effects, clinically the most important and most severe being muscle related complications/myotoxicity. Rhabdomyolysis, though rare, is the most severe form of myotoxicity. The US Food and Drug Administration (USFDA) adverse event reporting system reports rate of statin induced rhabdomyolysis at 0.3-13.5 cases per 1,000,000 patients. We present a case of a 74-year-old male who presented with an acute coronary syndrome and was initiated on atorvastatin. However, patient developed atorvastatin induced rhabdomyolysis, with non oliguric renal failure, which subsequently improved on cessation of medication.

Delayed Diagnosis of Left-Sided Diaphragmatic Hernia in an Elderly Adult with no History of Trauma.

Diaphragmatic Hernia (DH) is the herniation of abdominal contents into the thorax through a rent in the diaphragm. Acquired DH most commonly occurs following a blunt or penetrating trauma to the abdomen with former being common than the later. Very rarely DH can be spontaneous and be asymptomatic until its very extensive. A 78-year-old presented with breathlessness and chest pain of one month duration. There was dull note to percussion and absent breath sounds in left lower zone. Auscultation revealed bowel sounds in left infra-axillary and mammary area. Electrocardiogram and laboratory data suggested acute myocardial infarction. Coronary angiogram showed a triple vessel disease. Roentgenogram was simulating pneumonic consolidation but presence of air shadows was the thing against pneumonic consolidation. CT imaging of the thorax revealed an extensive left diaphragmatic hernia with viscera and left kidney as its contents. He was initially taken up for CABG and surgery for diaphragmatic hernia was planned at a later date. This case is important for its extensive nature and for its rarity as acquired DH rarely occurs spontaneously. Chest roentgenogram must be read cautiously in all such cases to look for this entity. Auscultation for bowel sounds in the thorax is a diagnostic clue.

Masquerading Bundle Branch Block: A Poor Prognostic Sign Revisited

Masquerading bundle branch block is a rare but important finding on the Electrocardiogram (ECG). It is an indication of severe and diffuse conduction system disease and usually indicates poor prognosis. The precordial leads show a Right Bundle Branch Block (RBBB) pattern while the limb leads resemble a Left Bundle Branch Block (LBBB). This finding on an ECG is almost invariably associated with severe underlying heart disease. It is extremely important to be aware of this finding as it is a marker of poor cardiac outcomes. We report the case of a 68-year-old gentleman, who presented with progressive dyspnoea on exertion over three months. ECG showed a broad QRS complex with a RBBB pattern on the precordial leads and a LBBB pattern on the limb leads (suggestive of masquerading bundle branch block). A coronary angiogram revealed severe Triple Vessel Disease (TVD). The patient was scheduled for an early Coronary Artery By-Pass Grafting Surgery. However, his clinical condition deteriorated and he died while awaiting the surgery.

Native Triple Valve Endocarditis as Complication of Post-Abortal Sepsis

Infective endocarditis (IE) is a highly morbid condition in pregnancy which poses both maternal and fetal risk. In majority of cases, endocarditis occurs only on single valve and usually occurs on valve with structural disease or prosthetic valve. Multi-valvular involvement is not common and so we report a case of native triple valve endocarditis as a complication of post abortal sepsis which was successfully treated medically.

Hammer in the Heart on Coronary Angiography

Here we report a 51-year-old female who presented for evaluation of dyspnoea on exertion and frequent palpitations since 1 month. Patient was diabetic and hypertensive and was on regular treatment. There was no history of fever, cough or pedal oedema. On general examination she had tachycardia, tachypnea and hypoxia on room air. Systemic examination showed grade 3 left parasternal heave and mid diastolic murmur at apex, additional sound (opening snap/tumour plop) was heard but was not able to be differentiated clinically. Chest roentenogram showed straightening of left heart border [Table/Fig-1]. [Table/Fig-1]: Chest roentgenogram PA view showing straightening of left heart border. Electrocardiogram showed atrial fibrillation, so possibility of mitral stenosis was considered. Trans thoracic echocardiogram (TTE) showed large (4*2.4 cm) left atrial mass found attached to inter atrial septum with cyst within prolapsing in and out of left ventricle causing dynamic mitral valve obstruction [Table/Fig-2] and [video-1] there was associated eccentric mitral regurgitation and severe pulmonary artery hypertension. Transoesophangeal echocardiography (TEE) showed the same findings. On coronary angiography LV myxoma was moving in and out of the LV simulating to and fro motion of hammer on left anterior oblique cranial view [video-2,3]. [Table/Fig-2]: Tran’s thoracic echocardiography apical four chamber view showing left atrial mass prolapsing into left ventricle. To the best of our knowledge, description of left atrial myxoma movement micmicking hammer in the heart was not reported previously. A study done by Vincelj J on 14 patients with atrial mass showed that TEE had 100% sensitivity and specificity in detecting them [1]. So diagnosis can be suspected by TTE and confirmed with TEE. Primary cardiac tumours are rare, 75% of them are benign and most of them are constituted by myxomas [2]. Myxomas occur most frequently in left atrium (93.5%) than in other regions [3]. Our patient had myxoma arising from inter atrial septum which is commonly seen. Once the suspicion of myxoma arises diagnosis can be made by TTE or TEE. Early diagnosis is required as it is not uncommon to see patients with signs of systemic embolisation as presenting symptom. Diagnosis of myxoma makes cause treatable and surgery is the treatment of choice with most series reporting an operative death rate of fewer than 5% [4]. As prognosis is good this possibility should always be suspected and ruled out with appropriate investigations. Our patient underwent successful resection and histopathology was consistent with myxoma. Post excision patient was symptomatically better and undergoing cardiac rehabilitation.

Cardiac Dysfunction in Patients with Sepsis, Severe Sepsis and Septic Shock

Aims: Patients with severe sepsis and septic shock often exhibit significant cardiovascular dysfunction. We designed the study with an aim to determine the severity of cardiac dysfunction in the different group of sepsis patients. Study Design: Single-center,cross-sectional study Place and Duration of Study:The study was carried out atof Cardiology, Kasturba

‘A dancing ball in the heart’: false tendon of the left ventricle simulating a mass lesion

A 44-year-old man presented to us with a history of chest discomfort since 3 days and pain and swelling of the left lower limb. There was no history of dyspnoea, palpitations or syncope. He was a smoker but not a diabetic or hypertensive. Cardiovascular examination was normal. ECG showed inverted T waves in lateral leads. An echocardiogram was performed which showed regional wall motion abnormality in the left anterior descending artery territory with good biventricular function. There was no evidence of pulmonary embolism. A large band-like structure with a fleshy calcific centre was noted in the left ventricular cavity. Troponin T levels were mildly elevated but all other blood investigations were normal. Venous Doppler showed evidence of deep vein thrombosis involving the left lower limb. He was taken up for a coronary angiogram in view of his ECG and echocardiogram findings. The angiogram did not reveal any significant coronary artery disease. However, fluoroscopy of the heart …