Hemasri Tokala

Left ventricular noncompaction and myocardial fibrosis: a case report

Background Left ventricular noncompaction (LVNC) is a rare congenital abnormality. It is currently classified as a genetic cardiomyopathy and results from early arrest of endomyocardial morphogenesis. The pathophysiology of left ventricular dysfunction, which becomes apparent beyond the 4th decade of life, is unclear. Case report We report a case of 60-year-old woman who presented with shortness of breath and showed noncompacted endocardium on echocardiography. Cardiac catheterization and viral studies were unremarkable. Histology revealed endomyocardial fibrosis without disarray. She was subsequently diagnosed with LVNC and treated with medications. Discussion Cardiologists and other physicians should be aware of LVNC due to its high likelihood of misdiagnosis and associated high complication rates. Early diagnosis, intervention and screening among family members can decrease the morbidity and mortality associated with LVNC.

HER2 status in elderly women with breast cancer

OBJECTIVES HER2 (human epidermal growth factor receptor 2) is an important biomarker in breast cancer, but its prevalence in elderly women is not well established. Previous studies reported HER2 status based on either immunohistochemistry (IHC) or fluorescent in situ hybridization (FISH) interchangeably. However, the tests may give discordant results. We report the prevalence of HER2 amplification in elderly women using only FISH. MATERIALS AND METHODS We retrospectively identified women 65 years and older undergoing core biopsy, lumpectomy or mastectomy for primary breast malignancy at a single institution between 2009 and 2011. Data collected included age, histopathological type, hormone receptor status, and HER2 status. Descriptive statistics were performed using SAS Software, Version 9.2. RESULTS One hundred fifty-eight women were included in the study. Most had invasive ductal carcinoma (74.7%), and were positive for either estrogen (ER) or progesterone (PgR) receptors (82.3% and 70.0%, respectively). Only 17% were negative for both ER and PgR; 11.4% were triple negative. Nineteen samples (12.0%) were positive for HER2. In univariate analyses, hormone receptor and HER2 status did not vary with age. When stratified by age, 60% of women with hormone receptor/HER2 positive tumors were younger than 70 years, compared with 22.2-33.3% of women in other subgroups. The difference was not statistically significant (p=0.20). CONCLUSION This study adds to the knowledge of the biology of breast cancer in elderly women. Triple negative tumor incidence was similar to that previously reported for women under 70 years old, but HER2 positive tumors were less common. Additional prospective studies are needed to confirm our findings.

Metformin and Angiogenesis in Cancer-Revisited

Several clinical studies demonstrated that diabetic patients treated with metformin were less likely to develop vascular complications, independent of glycemic control. It was also demonstrated that the large variety of metformins vascular actions can be seen in nondiabetic conditions. Metformin has an interesting potential to treat vascular dysfunction and tumor angiogenesis in conditions beyond diabetes. Since metformins use in cancer as a single antiangiogenic agent appears to be a therapeutic disappointment, the use of the drug as part of combination anticancer modality represents a therapeutic challenge. The normalization of vascular dysfunction as a new therapeutic strategy may provide better delivery of conventional anticancer agents to the tumor and disrupted tumor environment. In this review, we will outline the available information from the literature regarding metformin and tumor angiogenesis and suggest eventual experimental and clinical approaches.

Sudden Cause of Cardiac Death—Be Aware of Me: A Case Report and Short Review on Brugada Syndrome

Introduction. Brugada syndrome accounts for about 4% of sudden cardiac deaths (SCD). It is characterized by an ST-segment elevation in the right precordial electrocardiogram (EKG) leads. Case Presentation. We describe a 39-year-old healthy Caucasian man who was admitted to the intensive care unit after being cardioverted from ventricular fibrillation (VF) arrest. His past history was significant for an episode of syncope one month prior to this presentation for which he was admitted to an outlying hospital. EKG during that admission showed ST elevations in V1 and V2 leads, a pattern similar to Type 1 Brugada. A diagnosis of Brugada syndrome was missed and the patient had a cardiac arrest a month later. We discuss a short review of Brugada syndrome and emphasize the need to look for it in patients presenting with SCD and malignant arrhythmias. Conclusion. Physicians should always consider Brugada syndrome in the differential diagnosis of ST-segment elevation in anterior precordial leads of EKG and associated VT/VF. Although more than 17 years have passed since the first case was reported, increased awareness of this syndrome is needed to identify patients with EKG changes and treat them accordingly to prevent incidence of (SCD) and its deleterious complications.

Antipsychotic Therapy-Induced New Onset Diabetic Ketoacidosis.

Atypical antipsychotics are very widely used for various psychiatric ailments because of their less extrapyramidal side effects. Various reports of disturbances in glucose metabolism in the form of new onset diabetes mellitus, exacerbation of preexisting diabetes mellitus, diabetic ketoacidosis, hyperosmolar nonketotic coma, acute pancreatitis, and increased adiposity have been reported. We present a case of new onset diabetic ketoacidosis in a patient without a history of glucose intolerance who was being treated with olanzapine for bipolar disorder. He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. He was discontinued off of his olanzapine and started on resperidol for his bipolar disorder. Over the course of 6 months, the patient was discontinued off of his insulin and has been doing well on his follow-up appointments. This case highlights the necessity of close blood glucose monitoring of patient on atypical antipsychotic medications irrespective of their diabetic status.

Gastric Sarcoidosis: A Rare Clinical Presentation

Gastrointestinal (GI) sarcoidosis is a very rare disease, which clinically presents along with systemic disease or as an isolated finding. Gastric sarcoidosis is the most common form of GI sarcoidosis. Symptomatic gastric sarcoidosis is rare and only few case reports have been described in the literature with well-documented histological evidence of noncaseating granulomas. We present an interesting case of gastric sarcoidosis in a 39-year-old Caucasian man with symptoms of epigastric pain and profound weight loss. His endoscopic gastric mucosal biopsies revealed noncaseating granulomas consistent with gastric sarcoidosis. Treatment with oral steroids alleviated his symptoms with no recurrence in 2 years. Gastric sarcoidosis should be considered in patients with history of sarcoidosis and GI symptoms.

An Unusual Cause of Altered Mental Status in Elderly—Acute Cerebellitis: A Case Report and Review

Acute cerebellitis is a rare diagnosis found mostly in the pediatric population. The etiology, in most instances, is unknown. We describe the case of a 61-year-old woman who presented with acute mental status changes, signs of cerebellar dysfunction, and MRI findings of acute cerebellitis. A brief review of the existing literature and comparison of our case with previous reports are also presented.

A different type of dominoes in the stomach

Ingestion of foreign bodies is one of the common causes of emergency department visits. History, physical examination, and noninvasive imaging such as plain radiography and computer tomography scan can guide us regarding the type and location of the ingested foreign body. Most of the patients can be managed conservatively but few may need endoscopic evaluation and treatment.

Solitary lesion in magnetic resonance imaging: tumor versus multiple sclerosis.

CLINICAL PRESENTATION Atypical solitary lesions seen on magnetic resonance imaging (MRI) in multiple sclerosis (MS) are a diagnostic challenge, especially large demyelinating lesions known as tumefactive lesions. These lesions mimic neoplasm. A 56-yearold, right-handed, previously healthy Caucasian man presented with persistent left facial droop. He had similar symptoms 10 days ago, which was treated as Bell palsy. At this visit, he had more pronounced left-sided weakness, left facial droop and dysarthric speech. His strength was 3/5 on the left side with accentuated reflexes including positive Babinski reflex. Right sided examination was normal. Computed tomography scan of the head demonstrated an area of hypoattenuation within the right hemisphere. MRI of the brain (Figure 1A and 1B, sagittal view) showed a 2.5 2.6-cm T1 hypointense (panel A)/T2 hyperintense (panel B) mass (white arrow) within the posterior right frontal lobe involving the right precentral gyrus (motor cortex) with patchy peripheral enhancement without mass. There was no focal lesion in the spinal cord. Analysis of the cerebrospinal fluid revealed a slight increase in protein 54 mg/dL (15–45 mg/dL) along with elevated oligoclonal bands 13 ( 4 bands) and myelin basic protein 17 ng/mL (0.00–1.10 mn/dL). Workup for infection and malignancy was negative. He refused brain biopsy. He was diagnosed with tumefactive MS and was treated with steroids in addition to physical therapy. He recovered well and was discharged home. MRI at 6 months and 1 year revealed regression of the lesion (Figure 1C) along with no recurrence of symptoms. Tumefactive demyelinating lesions are generally more than 2 cm, well-demarcated, open-ring enhancing lesions with sparse mass effect and edema.1,2 In our case, neoplastic process was much less likely because of the lack of associated vasogenic edema, and the morphology of enhancement strongly suggested demyelination. We conclude that tumefactive MS should always be considered for differential diagnosis of a solitary demyelinating lesion on MRI mimicking a tumor.

New onset hypertension-rare intimal variant fibromuscular dysplasia

Fibromuscular dysplasia (FMD) involving the renal arteries commonly presents as hypertension secondary to renal artery stenosis. Atypical patterns involving intima are rare and contribute to less than 10% cases of FMD. We present a relatively uncommon case of new onset hypertension in a 30-year-old woman resulting from intimal variant FMD involving the left renal artery. Renal duplex ultrasonography and angiography showed stenosis of the left renal artery consistent with intimal variant FMD. Percutaneous transluminal angioplasty of the stenotic lesion was successfully performed. Following angioplasty, her blood pressure was normalized. Renovascular hypertension secondary to FMD involving intimal layer is rare and requires a high index of clinical suspicion. Renal duplex ultrasonography is the recommended initial test of screening for renal artery stenosis in appropriate patients. The standard selective renal angiography, intravascular ultrasound, along with or without hemodynamic assessment should be utilized when renovascular intervention is contemplated. Percutaneous transluminal angioplasty is the mainstay of treatment for those who meet the criteria of intervention.