Preeti A. Chandra

Cardiac tamponade caused by fracture and migration of inferior vena cava filter.

A 53-year-old male presented to the emergency room with acute cardiopulmonary compromise. Echocardiography revealed cardiac tamponade. The patient was taken emergently for surgery and a 28 gauge wire of 1.5 cm was retrieved from his right ventricle. A section had fractured from the inferior vena cava (IVC) filter and migrated to the right ventricle, causing perforation and tamponade. Very few cases of fractured IVC filters that have migrated to the heart, and even fewer cases causing cardiac tamponade, have been described. The risk factors that cause migration of IVC filters need to be further elucidated.

Rituximab is Useful in the Treatment of Felty's Syndrome

Feltys syndrome is regarded as a severe variant of rheumatoid arthritis (RA) that develops in less than 1% of patients with RA. It consists of a triad of RA, splenomegaly, and leukopenia, which tends to develop after a long course of RA. Treatment of neutropenia is mainly comprised of disease-modifying antirheumatic drugs including methotrexate, hydroxychloroquine, auronofin, penicillamine, glucocorticoids, and granulocyte monocyte colony stimulating factor. Recently, there has been a growing interest in the biologic agent rituximab in the treatment of Feltys syndrome. To our knowledge, only one previous case of rituximab being beneficial in the treatment of Feltys syndrome has been reported. We report the case of a 60-year-old man with Feltys syndrome in whom treatment with rituximab led to a sustained neutrophil response and marked symptomatic improvement in the form of decrease in the size of rheumatoid nodules and better pain control.

Pre-procedural Elevated White Blood Cell Count and Neutrophil-Lymphocyte (N/L) Ratio are Predictors of Ventricular Arrhythmias During Percutaneous Coronary Intervention.

AIMS The absolute white blood cell (WBC) count and neutrophil to lymphocyte (N/L) ratio are predictors of death/myocardial infarction in patients who have undergone coronary angiography. We hypothesized that a pre-procedural elevated WBC count and an elevated N/L ratio would be a predictor of development of significant ventricular arrhythmias in subjects undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS We retrieved the data for all patients developing ventricular arrhythmia during PCI between 1999 to 2009 from our cath lab database (from 30,798 records), a total of 70 patients (Group I), and tabulated their WBC counts and absolute neutrophil and lymphocyte counts as well as N/L ratios. We compared the data with a random group of age, gender, medications and pre-existing condition matched controls (n=70) (Group II). We also adjusted for amount of myocardium under jeopardy. Group I had a significantly higher total WBC count (means 14,344 Vs 6852; 95% CI; p=0.0004); neutrophil count (means 75.79% Vs 58.06%; 95% CI; p < 0.0001) and N/L ratio (means 3.79 Vs 1.56; 95% CI; p < 0.0001) [means compared with t test]. CONCLUSION Our data suggests a pre-procedural elevated WBC count, neutrophils and elevated N/L ratio are predictors of significant ventricular arrhythmias in patients undergoing percutaneous coronary intervention (PCI).

Tako-tsubo cardiomyopathy following electroconvulsive therapy.

A 70-year-old woman with extensive psychiatric history, including depression and bipolar disorder, and past medical history of mitral valve prolapse repair (3 years ago) was brought in from the psychiatry ward to the emergency department for evaluation of ECG changes following electroconvulsive therapy (ECT). ECG done after the procedure showed ST elevations in V2-V3 and new T-wave inversions in the precordial leads. Troponin level was 0.23 ng/ml. An echocardiogram revealed apical akinesis with segmental wall motion abnormalities and a decreased ejection fraction of 30-35%. Cardiac catheterization revealed clean coronaries. A repeat echocardiogram 6 weeks after the event showed a normal ejection fraction. A diagnosis of tako-tsubo cardiomyopathy was made. ECT causes a significant increase in bigeminy, trigeminy, and supraventricular tachycardia. ECT is associated with a low mortality rate; in the range of 0.01-0.1% and 75% of these are attributable to cardiovascular causes. To our knowledge, this is the first reported case of tako-tsubo syndrome immediately following electroconvulsive therapy.

Dronedarone-induced digoxin toxicity: new drug, new interactions.

Dronedarone is a relatively new antiarrhythmic drug approved for paroxysmal or persistent atrial fibrillation. Dronedarone can inhibit P-glycoprotein-mediated digoxin clearance and increase steady-state digoxin level 2.5 times. It is important to closely monitor plasma digoxin levels or administer a lower loading dose of digoxin in patients taking dronedarone concomitantly. We report a case of digoxin toxicity in a patient taking concomitant dronedarone as a result of interaction between digoxin and dronedarone.

Intra-atrial tumor thrombi secondary to hepatocellular carcinoma responding to chemotherapy

Context: Hepatocellular carcinoma accounts for 1-2.5% of all cancer in America with extension to inferior vena cava and right atrium in 1-4% of the cases. Patients with advanced hepatocellular carcinoma invading the right heart are considered poor candidates for surgery. In the past, such patients had dismal prognosis due to complications like pulmonary embolism and sudden death. Case Report: Our patient was admitted with worsening jaundice, abdominal pain and significant weight loss. Abdominal ultrasound, elevated alfa feto-protein levels and computerized tomography pointed to the diagnosis of hepatocellular carcinoma. Transthoracic echocardiography demonstrated two masses in the right atrium with the base of masses extending from inferior vena cava into right atrium. The patient was diagnosed to have stage IV heptaocellular carcinoma. This is associated with dismal prognosis. But after being started on sorafenib, the tumor regressed considerably and was barely discernable on echocardiography performed a month later. Conclusion: Though aggressive surgical resection is the best therapeutic approach for hepatocellular carcinoma, it may not always be possible and in such cases combination of different therapeutic approaches such as chemotherapeutic agents, radiotherapy and chemoembolization may improve survival.

Protothecal Olecranon Bursitis: An Unusual Algal Infection

Prototheca is an achlorophyllic alga which rarely causes infections in humans and protothecal olecranon bursitis is remarkably rare. We report a case of a 76-year-old immunocompetent man presenting with pain and swelling of the right elbow secondary to protothecal infection. Initial cultures of the olecranon bursal aspirate revealed no growth; however, repeat aspiration after 2 months grew prototheca species on culture. Prototheca wickerhamii and Prototheca zopfii are the only 2 protothecal species known to cause human infections. Protothecal infection can manifest as skin infections, extremity infections, bursitis and very rarely as systemic infections. Treatment of protothecal infections remains controversial. Amphoterecin B, ketoconazole and fluconazole have been reported to yield a successful outcome. More recently, itraconazole has been found to be curative. Surgical excision of the bursa remains the definitive treatment. Our patient was treated with itraconazole with a favorable response.

Brugada syndrome unmasked by lithium.

A 38-year-old man was brought by emergency medical service after resuscitation following cardiac arrest. The patient was found pulseless with a wide complex tachycardia. The patient had bipolar disorder and was on lithium, lamotrigine, and ziprasidone. His electrolytes and lithium levels were normal. An electrocardiogram (EKG) was performed the next day and showed type 1 Brugada pattern. Lithium was held. Electrophysiologists made a diagnosis of drug-unmasked Brugada syndrome. Lithium can unmask Brugada syndrome through its ability to block sodium channels, even at subtherapeutic concentrations. Physicians need to be aware of this potentially fatal drug effect and should monitor EKGs of patients on lithium.

Disseminated tuberculosis secondary to adalimumab.

A 62-year-old woman with rheumatoid arthritis presented with fever (T-103.9°F). Vital signs and physical examination were normal. She was taking adalimumab, methotrexate, and prednisone for the past 9 months. Blood and urine cultures, human immunodeficiency virus, rapid plasma reagin, purified protein derivative, and cerebrospinal fluid test findings were negative. Computed tomography showed scattered 0.2-cm nodules in the lungs and innumerable subcentimeter lesions in the liver and spleen. Broad-spectrum antibiotics were started empirically. Liver biopsy findings revealed necrotizing granulomas and were negative for acid fast bacilli and fungi on staining. As the patient was persistently febrile despite antibiotics, the antibiotics were discontinued, and an antituberculous regimen including INH, ethambutol, and pyrazinamide was initiated empirically on day 40 of hospitalization. Fourteen days after liver biopsy, acid-fast bacilli grew in the tissue culture. Disseminated tuberculosis (TB) was diagnosed. Fever subsided after 1 week of anti-TB treatment. Antitumor necrosis factor alpha therapy in rheumatoid arthritis increases the risk of TB 5-fold. This is mostly as a result of reactivation of latent TB and commonly presents as disseminated TB. It usually occurs in the early stage of treatment. In our patient, the screening test results for TB before initiation of Adalimumab could have been falsely negative due to immunosuppression secondary to steroids. Our case emphasizes that current screening tests can miss latent TB especially in immunosuppressed patients. As it is difficult to diagnose TB with polymerase chain reaction and culture, histopathology should be sought early. Patients on antitumor necrosis factor alpha therapy presenting with fever of unknown origin should be considered for empirical anti-TB treatment regardless of microbiological and tissue diagnosis.

Direct renin inhibitor induced renal failure.

Aliskiren, a direct renin inhibitor, is a novel antihypertensive agent with placebo-like tolerability. The patient developed acute renal failure after addition of aliskiren to combination of diuretic, angiotensin-converting enzyme inhibitor and aldosterone antagonist. This case highlights the point that acute renal failure can occur as an adverse effect of aliskiren. Because there is no conclusive evidence about the safety of aliskiren when used in combination with multiple drugs that inhibit renin angiotensin aldosterone system, caution should be exercised while initiating this drug in patients already on combination of diuretic, angiotensin-converting enzyme inhibitor and aldosterone antagonist.