Korosh Sharain

Does cardiac rhythm monitoring in patients with elevated troponin levels lead to changes in management

Background: We sought to identify the frequency of arrhythmias in patients with elevated cardiac troponin levels and without ST-segment elevation myocardial infarction or a primary arrhythmia, and to determine whether detection of an arrhythmia leads to management changes. Methods: A review of 1381 consecutive patients admitted from the emergency department for rhythm monitoring with an elevated cardiac troponin T (cTnT) level was performed. Patients admitted to an intensive care unit and those with an initial primary arrhythmia were excluded. Troponin values were obtained on admission, at 3 hours and at 6 hours. Electronic medical records and all rhythm recordings were reviewed for documentation of an arrhythmia and any changes in management. Results: An arrhythmia was detected in 26% of the 330 patients who met the inclusion criteria. Those with arrhythmias had higher rates of coronary artery disease and prior percutaneous coronary intervention (p = 0.02 and p = 0.01, respectively). Those with arrhythmias had higher mean cTnT values compared to those without arrhythmias (p = 0.02 at 3 hours and p = 0.006 at 6 hours) even after controlling for a discharge diagnosis of acute coronary syndrome. Changes in management in response to the detection of arrhythmias were infrequent (6.3%) and usually included only changes in medication doses. Conclusions: Patients admitted with an elevated cTnT level to a non-intensive care unit rhythm-monitored bed without ST-segment elevation myocardial infarction or primary arrhythmia have a high incidence of arrhythmias; however, changes in management are infrequent.

Mycoplasma pneumonia-associated mucositis.

We present a case of a young man with severe mucositis following an upper respiratory tract infection limited to the ophthalmic and oral mucosa while sparing the rest of the skin, genitalia and perianal regions. Investigations revealed that the mucositis was a rare extrapulmonary manifestation of Mycoplasma pneumoniae infection. He had progressive vision-threatening symptoms despite antibiotics and best supportive care and thus was treated with intravenous corticosteroids, immunoglobulins, temporary ocular amniotic membrane grafts and tarsorrhaphy. The patient made an almost complete recovery over 6 weeks.

Incidental IVC tumor thrombus found on echocardiographic work-up for systolic murmur leading to new diagnosis of renal cell carcinoma

A 55-year-old female with Hashimoto’s thyroiditis and hyperlipidemia was evaluated by her endocrinologist for an enlarging goiter. Her blood pressure was 138/72 mmHg and heart rate 87 bpm. On examination, the patient was noted to have a II/IV systolic murmur over the left sternal border that was not present one year prior; therefore, a transthoracic echocardiogram was obtained to evaluate the murmur. The echocardiogram showed minimal aortic valve sclerosis and no other valvular abnormalities; however, there was a large mass extending into the inferior vena cava (IVC) and right atrial (RA) junction consistent with a tumor thrombus. Further evaluation with contrast-enhanced computed tomography (CT) scan of the chest, abdomen, and pelvis demonstrated a 9 × 8 × 9-cm heterogeneous mass involving the mid and lower pole of the right kidney consistent with renal cell carcinoma (RCC) (Fig. 1a). Additionally, the large tumor thrombus was identified in the IVC–RA junction (Fig. 1b). She underwent right radical nephrectomy and IVC thrombectomy with transesophageal echocardiographic guidance (Fig. 1c). Figure 1d shows the surgical specimen. Pathology demonstrated a grade II/IV clear cell RCC with negative margins. Seven years after diagnosis, the patient was found to have pulmonary nodules on routine screening, which were biopsied and positive for RCC. She underwent right upper lobectomy and right lower lobe wedge resection. After 14 years of follow-up, she is without evidence of disease progression. Discussion

Symptoms of Atrial Fibrillation

Atrial fibrillation (AF) is the most common clinically significant arrhythmia and is associated with significant morbidity and mortality. Symptoms linked to atrial fibrillation are variable and commonly include palpitations, dyspnea, chest pain, or an incidental electrocardiographic finding. Other less common presentations include anxiety or depression. Understanding the many possible presenting signs and symptoms of atrial fibrillation is critical when evaluating patients in the short stay unit as they can be associated with other commonly coexisting cardiac conditions such as heart failure. Long-term clinical outcomes based on rate versus rhythm control are similar; therefore, an individualized treatment approach directed at symptoms may be most beneficial. The objectives of this chapter are to describe the wide range of symptoms associated with atrial fibrillation, to review the proposed mechanisms responsible for these symptoms, to list atrial fibrillation symptom scoring tools, and to summarize targeted symptom management strategies.

RECURRENT SYNCOPE AS A PRESENTATION OF SYSTEMIC MASTOCYTOSIS

Syncope is one of the most common referrals to the cardiology clinic. Obtaining a detailed history is paramount when evaluating the broad differential diagnosis for syncope. We describe a case of recurrent syncope caused by systemic mastocytosis diagnosed after taking a careful history. A 47-year-

A challenging case of progressive enteritis.

Question: A 21-year-old man was transferred to our institution from an outside hospital for a 4-week history of worsening diffuse colicky abdominal pain, nausea, vomiting, and nonbloody loose stools. His symptoms began several days after starting ciprofloxacin for scrotal pain and swelling, diagnosed as epididymitis. He described a 15-pound weight loss during this time period. On initial admission to the outside hospital, physical examination was only significant for moderate diffuse abdominal tenderness. Laboratory findings included leukocytosis (20.9/mm with neutrophilia), but a normal hemoglobin, platelet count, creatinine, and urinalysis. Computed tomography (CT) of the abdomen demonstrated jejunal wall thickening. Further workup including stool cultures for pathogens, Clostridium difficile polymerase chain reaction, antinuclear antibody, antineutrophil cytoplasmic antibody, and tissue transglutaminase antibody were all negative. Repeat imaging of the abdomen several days later owing to continued abdominal pain demonstrated extension of the bowel wall thickening into the ileum as well as mesenteric lymphadenopathy. He underwent exploratory laparotomy with resection of 20 cm of inflamed jejunum. Pathology revealed mucosal ulcerations with evidence of acute inflammation. He was initiated on total parenteral nutrition and intravenous corticosteroids; however, his abdominal pain persisted, and he was transferred to our institution. On arrival, he was noted to have a papular rash with secondary excoriations symmetrically distributed on his chest and elbows, which started the day before transfer (Figure A). CT enterography showed diffuse small bowel wall thickening (Figure B). Biopsies of the skin lesions were obtained (Figure C). A new proteinuria was also noted. What does the skin biopsy show? What is the most likely diagnosis? Is his initial complaint of scrotal pain pertinent to the diagnosis or a red herring? Look on page 514 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.