Lohit Garg

Levamisole/Cocaine Induced Systemic Vasculitis and Immune Complex Glomerulonephritis

Levamisole is an antihelminthic and immunomodulator medication that was banned by the USFDA in 1998. It has been increasingly used to adulterate cocaine due to its psychotropic effects and morphological properties. Adverse reactions including cutaneous vasculitis, thrombocytopenia, and agranulocytosis have been well described. Despite systemic vasculitis in this setting, renal involvement is uncommon. We report here a case of ANCA positive systemic vasculitis with biopsy proven immune complex mediated glomerulonephritis likely secondary to levamisole/cocaine. A 40-year-old Caucasian male with no past medical history presented with 3-week history of fatigue, skin rash, joint pains, painful oral lesions, oliguria, hematuria, worsening dyspnea on exertion, and progressive lower extremity edema. He had a history of regular tobacco and cocaine use. Lab testing revealed severe anemia, marked azotemia, deranged electrolytes, and 4.7 gm proteinuria. Rheumatologic testing revealed hypocomplementemia, borderline ANA, myeloperoxidase antibody, and positive atypical p-ANCA. Infectious and other autoimmune workup was negative. Kidney biopsy was consistent with immune mediated glomerulonephritis and showed mesangial proliferation and immune complex deposition consisting of IgG, IgM, and complement. High dose corticosteroids and discontinuing cocaine use resulted in marked improvement in rash, mucocutaneous lesions, and arthritis. There was no renal recovery and he remained hemodialysis dependent.

The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices — A meta-analysis

BACKGROUND Left ventricular assist devices (LVADs) and implantable cardioverter defibrillators (ICD) are each known to improve mortality in patients with advanced congestive heart failure (CHF). If ICDs contribute to improved survival specifically in recipients of LVADs is currently unknown. AIM To evaluate the impact of presence of ICD on mortality in continuous flow LVAD recipients. METHODS A meta- analysis of available literature was performed. PubMed, Embase and Google Scholar databases were searched for studies that compared mortality in continuous flow LVAD patients with ICDs (new implantation or no de-activation) and without ICDs (including de-activation of existing implant). Pooled analysis using a fixed effects model was used for outcomes of interest. RESULTS We included 3 observational studies for a total of 292 patients (203 (69.5%) with ICD versus 89 (30.5%) without ICD). The presence of an active ICD was not associated with improved survival [OR 0.63, 95% CI 0.33-1.18; p=0.15]. In bridge to transplantation [BT] patients (224 patients, 149 with ICD versus 75 without ICD), an active ICD was not associated with a higher probability of survivzal [OR 1.47, 95% CI 0.78-2.76; p=0.23]. There was no difference in the occurrence of severe right ventricular dysfunction or failure between two groups [OR 0.78, 95% CI 0.42-1.47; p=0.45]. The risk of LVAD related complications were similar [OR 0.68, 95% CI 0.35-1.31; P=0.25]. CONCLUSION This meta-analysis demonstrates that there is no survival benefit with ICD in heart failure patients supported with continuous flow LVAD. There is an urgent need of large-scale randomized trials to specifically address this issue.

Atrial fibrillation and chronic kidney disease requiring hemodialysis — Does warfarin therapy improve the risks of this lethal combination?

INTRODUCTION Warfarin therapy for stroke prevention is recommended for patients with AF, but its value in patients with chronic kidney disease on HD is unknown. METHODS The anticoagulation regimens of patients with a prior history of AF hospitalized for initiation of chronic HD, and of patients receiving chronic HD who had a new diagnosis of AF between 2009 and 2012 were reviewed. Exclusions were renal transplant, peritoneal dialysis, rheumatic valve disease, prosthetic heart valve, GI bleeding, malignancy with chemotherapy in last 6months or still undergoing treatment, a history of AF ablation, a history of ICD implantation, or those receiving warfarin for non-AF indications. RESULTS Among 302 patients included in the study, 119 (39%) were prescribed warfarin and 183 (61%) were not. The two groups were similar regarding demographics, and prevalence of comorbidities including diabetes, heart failure, coronary artery disease, hypertension, use of antiplatelet agents and prior stroke. Warfarin use did not lower risk for ischemic stroke (HR 0.93; 95% CI 0.49-1.82, P=0.88) or improve overall survival (HR 1.02; 95% CI 0.91-1.15, P=0.62), but trended toward higher risk of bleeding complications (HR 1.53; 95% CI 0.94-2.51, P=0.086) after adjusting for potential confounders. CONCLUSION Warfarin use was not associated with reduction in stroke risk or mortality in patients with AF on chronic HD, but trended toward greater bleeding risk. The benefit of warfarin therapy in these patients may be outweighed by its risks.

Thirty-Day Readmissions After Left Ventricular Assist Device Implantation in the United States: Insights From the Nationwide Readmissions Database

Background: Early readmissions contribute significantly to heart failure–related morbidity and negatively affect quality of life. Data on left ventricular assist device (LVAD)–related 30-day readmissions are scarce and limited to small studies. Methods and Results: Patients undergoing LVAD implantation between January 2013 and November 2014 who survived the index hospitalization were identified in the Nationwide Readmissions Database. We analyzed the incidence, predictors, causes, and costs of 30-day readmissions. Of 2510 LVAD recipients, 788 (31%) were readmitted within 30 days. Length of index hospitalization ≥31 days (hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.07–1.50) and female sex (HR, 1.19; 95% CI, 1.01–1.42) were associated with a higher risk of 30-day readmission, whereas private insurance (HR, 0.83; 95% CI, 0.70–0.99), pre-LVAD use of short-term mechanical circulatory support (HR, 0.53; 95% CI, 0.29–0.98), and discharge to a short-term hospital facility (HR, 0.41; CI, 0.21–0.78) were associated with a lower risk. Cardiac causes accounted for 23.8% of readmissions: heart failure (13.4%) and arrhythmias (8.1%). Noncardiovascular causes accounted for 76.2% of readmissions: infection (30.2%), bleeding (17.6%), and device-related causes (8.2%). Mean length of stay for readmission was 10.7 days (median, 6 days), and average hospital cost per readmission was

Gastrointestinal complications associated with catheter ablation for atrial fibrillation

34 948±2457. Conclusions: Early readmissions are frequent after LVAD implantation even in contemporary times. Preimplant identification of high-risk patients, and a protocol-driven follow-up using a multidisciplinary approach will be needed to reduce readmissions and improve outcomes.

Hypermucovirulent Klebsiella pneumoniae: An Emerging Threat in the United States

Atrial fibrillation is the most common arrhythmia in the United States. With the ageing population, the incidence and prevalence of atrial fibrillation are on the rise. Catheter ablation of atrial fibrillation is a widely accepted treatment modality in patients with drug refractory symptomatic paroxysmal or persistent atrial fibrillation. The close proximity to the left atrium posterior wall makes the thermosensitive esophagus a potential site of injury during catheter ablation of AF leading to various gastrointestinal complications. The major gastrointestinal complications associated with catheter ablation include atrioesophageal fistula, gastroparesis, esophageal thermal lesions and esophageal ulcers. Multiple studies, case reports and series have described these complications with various catheter ablation techniques such as radiofrequency, cryoenergy and high frequency focused ultrasound energy ablation. This review addresses the gastrointestinal complications after AF ablation procedures and aims to provide the clinicians with an overview of clinical presentation, etiology, pathogenesis, prevention and management of these conditions.

CARDIAC THROMBOSIS IN ACUTE ANTERIOR MYOCARDIAL INFARCTION: EVALUATION OF HOSPITAL MORTALITY, THROMBOEMBOLISM AND BLEEDING

CLINICAL PRESENTATION A 73-year-old white woman with a medical history of hypertension and diabetes presented with complaints of pain and progressive worsening of vision in her left eye for 3 days. She also noted fever and chills for 1 day. She denied eye trauma, headache, neck pain, neck stiffness, numbness, or weakness in her hands or legs. She said the right eye was normal. She denied travel outside the country. On presentation, she was afebrile, and the eye examination showed conjunctival injection with a 1-mm hypopyon in the left eye. Proptosis was present, and intraocular pressure was elevated. The remainder of the examination was unremarkable. Laboratory evaluation revealed elevated white blood cell count at 12.8 billion/L. Hemoglobin A1c was 8.4. Endophthalmitis was considered, and intravitreal antibiotics were administered. Vitreal fluid was sent for culture. The vitreal culture grew hypermucovirulent phenotype of K. pneumoniae. The urine culture grew the same organism, whereas blood cultures were negative. An ultrasound of the abdomen did not reveal any evidence of liver or kidney abscess, and the transthoracic echocardiogram revealed no vegetations. She was initially started on linezolid and levofloxacin. These drugs were subsequently replaced with ciprofloxacin. She eventually had to undergo enucleation because of her poor response to intravitreal and systemic therapy with evidence of progressive infection and severe pain. Multiple purulent pockets were identified during surgery that were drained adequately.

Death during exercise testing in a patient with asymptomatic severe aortic stenosis

Left ventricular thrombus (LVT) is a well-known complication of acute myocardial infarction, most commonly seen in anterior wall ST-segment elevation myocardial infarction (STEMI). It is associated with systemic thromboembolism. The aim of this study is to evaluate the impact of LVT on in-hospital

Pheochromocytoma and stress cardiomyopathy: Insight into pathogenesis

Introduction: Patients with symptomatic severe aortic valve stenosis (As) experience short and long-term survival benefit with aortic valve replacement (AVr). Among patients with asymptomatic severe As (AsAs) current guidelines recommend exercise stress testing (Ett) as a safe and effective method to risk stratify patients and to assist with the timing of AVr. We discuss the course of disease in As, review the role of Ett and express concerns about the safety of performing stress tests in asymptomatic patients with severe As. case report: We describe the case of a 69-year-old male with left bundle branch block and AsAs who underwent Ett with echocardiographic imaging. We describe the details of the patient’s clinical, EcG and echo doppler parameters prior, during and following the test. Patient developed pulseless electrical activity during early recovery with eventual resuscitation and mechanical support. the patient did not survive due to continued deterioration in clinical status. conclusion: Despite being considered safe, Ett can unmask symptoms in AsAs and result in Mahek Shah1, Anuraj Sudhakaran1, Baburaj Aparna3, Muhammad Qasim2, Brijesh Patel2, Lohit Garg1, Bruce Feldman1 Affiliations: 1Division of Cardiology, Department of Medicine, Lehigh Valley Health Network, Allentown PA, USA; 2Department of Medicine, Lehigh Valley Health Network, Allentown PA, USA; 3Amritha Institutes of Medical Science and Research Center, Kochi, Kerala, India. Corresponding Author: Anuraj Sudhakaran, MD, 1250 S Cedar Crest Blvd, Suite 300, Allentown PA 18103 United States; Email: dranurajms@yahoo.com Received: 18 December 2017 Accepted: 13 February 2018 Published: 15 March 2018 caSe rePO Peer reviewed | OPen a ce S hemodynamic instability leading to death. A comprehensive registry of safety data is needed. clinical vigilance and physician supervision during stress testing may minimize the risk of serious adverse events.

The Influence of Pregnancy in Patients with Congenital Long QT Syndrome.

AIM To investigate the occurrence of cardiomyopathy (CMP) in a cohort of patients with histologically proven pheochromocytoma (pheo), and to determine if catecholamine excess was causative of the left ventricular (LV) dysfunction. METHODS A retrospective chart review spanning years 1998 through 2014 was undertaken and patients with a diagnosis of pheo confirmed with histopathologic examination were included. Presenting electrocardiograms and cardiac imaging studies were reviewed. Transthoracic echocardiography (TTE), ventriculography or single positron emission computed tomography imaging was evaluated and if significant abnormalities [left ventricular hypertrophy (LVH) or LV dysfunction] were noted in the pre operative period a follow up post-operative study was also analyzed. Multivariate analysis using logistic regression was used to investigate independent predictors for outcomes of interest, LV dysfunction and LVH. RESULTS We identified 18 patients with diagnosis of pheo confirmed on pathology. Mean age was 54.3 ± 19.3 years and 11 (61.1%) patients were females. 50% of such patients had either resistant hypertension or labile blood pressures during hospitalization, which had raised suspicion for a pheo. Cardiac imaging studies were available for 12 (66.7%) patients at the time of inclusion into study and preceding the adrenalectomy. 7 (58.3%) patients with a TTE available for review had mild or more severe LVH while 3 (25%) patients had LV dysfunction of presumably acute onset. In a multivariate analysis, elevated catecholamine levels as assessed by urinary excretion of metabolites was not an independent predictor of development of LV systolic dysfunction or of presence of LVH on TTE. Two female patients with a preceding history of hypertension had marked LV hypertrophy and systolic anterior motion of the mitral valve. Prolongation of the QTc interval was noted in 5 (27.8%) patients but no acute arrhythmias were observed in any patient. CONCLUSION This study adds to the growing body of literature on the predilection of patients with pheochromocytomas to develop non-ischemic CMP. Degree of catecholamine excess as measured by urinary secretion of metabolites did not predict the development of CMP but 2 of 3 patients developed CMP in the setting of significant acute physiologic stress. Our findings provide support to the proposed etiologic role of elevated catecholamines in TC and other stress induced forms of CMP, however, activation of a brain-neural-cardiac axis from acute stress and local release of catecholamines but not chronic catecholamine elevations are likely to be responsible in pheo related CMP.