Ragesh Panikkath

Antibiotic‐induced Cardiac Arrhythmias

This review aims to clarify the underlying risk of arrhythmia associated with the use of macrolides and fluoroquinolones antibiotics. Torsades de pointes (TdP) is a rare potential side effect of fluoroquinolones and macrolide antibiotics. However, the widespread use of these antibiotics compounds the problem. These antibiotics prolong the phase 3 of the action potential and cause early after depolarization and dispersion of repolarization that precipitate TdP. The potency of these drugs, as potassium channel blockers, is very low, and differences between them are minimal. Underlying impaired cardiac repolarization is a prerequisite for arrhythmia induction. Impaired cardiac repolarization can be congenital in the young or acquired in adults. The most important risk factors are a prolonged baseline QTc interval or a combination with class III antiarrhythmic drugs. Modifiable risk factors, including hypokalemia, hypomagnesemia, drug interactions, and bradycardia, should be corrected. In the absence of a major risk factor, the incidence of TdP is very low. The use of these drugs in the appropriate settings of infection should not be altered because of the rare risk of TdP, except among cases with high-risk factors.

Idiopathic intracranial hypertension: ongoing clinical challenges and future prospects.

Idiopathic intracranial hypertension (IIH) is an uncommon disorder characterized by increased intracranial pressure without radiological or laboratory evidence of intracranial pathology except empty sella turcica, optic nerve sheath with filled out cerebrospinal fluid spaces, and smooth-walled nonflow-related venous sinus stenosis or collapse. This condition typically affects obese women. The incidence of IIH is increasing with the rising prevalence of obesity. Persistent headache is the most common symptom. Visual impairment is a serious complication that may not be recognized by the patients. This paper reviews clinical manifestations, diagnostic challenges, and current treatments of IIH in adults. Various imaging modalities have been studied on their validity for detection of IIH and papilledema. This review also includes new studies on medical, surgical, and interventional management of this condition. Acetazolamide and topiramate are the only two medications that have been studied in randomized controlled trials about their efficacy in treatment of IIH. In patients who have severe visual impairment or progressive visual deterioration despite medical management, surgical or interventional treatment may be considered. The efficacy and complications of cerebrospinal fluid diversion, optic nerve sheath fenestration, and endovascular venous stenting reported in the last 3 decades have been summarized in this review. Finally, the prospective aspects of biomarkers and treatments are proposed for future research.

Cardiac Repolarization Abnormalities Among Patients With Various Stages of Chronic Kidney Disease

Patients with chronic kidney disease (CKD) are at increased risk of life‐threatening cardiovascular arrhythmias. Although these arrhythmias are usually secondary to structural heart diseases that are commonly associated with CKD, a significant proportion of cases with sudden cardiac death have no obvious structural heart disease. This study aims to explore the relationship of cardiac repolarization in patients with CKD and worsening kidney function.

Indications and Appropriateness of Inferior Vena Cava Filter Placement

Background:Several professional societies have published guidelines for the placement of inferior vena cava (IVC) filters. The authors wanted to determine how frequently patients in their hospital had IVC filters placed based on current indications and to compare guidelines published by the American College of Chest Physicians (ACCP) and the Society of Interventional Radiologists (SIR). Methods:The authors performed a structured review of the medical records of 180 patients identified by International Classification of Diseases, Ninth Revision, codes who had IVC filter placement at their hospital between July 1, 2007, and June 30, 2012. Indications for placement were based on current recommendations from the ACCP and SIR. Results:These patients had a mean age of 62.4 ± 15.7 years and included 96 men and 84 women. One hundred forty patients had a history of deep venous thrombosis, pulmonary emboli or both. One hundred seven patients had permanent filters inserted, 34 had retrievable filters inserted and 39 had an unknown type of filter inserted. Forty-one patients (22.7%) had no definite indication for IVC filter insertion based on SIR guidelines, and 72 (40%) had no definite indication based on ACCP guidelines. There was a good agreement between the ACCP guidelines and the SIR guidelines when indications were categorized. Only one retrievable filter was removed. Conclusions:Twenty to forty percent of the patients with IVC filter insertions in their hospital had no definite indication documented in the medical record. A performance improvement activity to evaluate the use of IVC filters, such as a dedicated clinic, may be useful.

Chest Pain and Diarrhea: A Case of Campylobacter Jejuni-Associated Myocarditis

BACKGROUND Diarrhea and chest pain are common symptoms in patients presenting to the emergency department (ED). However, rarely is a relationship between these two symptoms established in a single patient. OBJECTIVE Describe a case of Campylobacter-associated myocarditis. CASE REPORT A 43-year-old man with a history of hypertension presented to the ED with angina-like chest pain and a 3-day history of diarrhea. Electrocardiogram revealed ST-segment elevation in the lateral leads. Coronary angiogram revealed no obstructive coronary artery disease. Troponin T rose to 1.75 ng/mL. Cardiac magnetic resonance imaging showed subepicardial and mid-myocardial enhancement, particularly in the anterolateral wall and interventricular septum, consistent with a diagnosis of myocarditis. Stool studies were positive for Campylobacter jejuni. CONCLUSIONS Campylobacter-associated myocarditis is rare, but performing the appropriate initial diagnostic testing, including stool cultures, is critical to making the diagnosis. Identifying the etiology of myocarditis as bacterial will ensure that appropriate treatment with antibiotics occurs in addition to any cardiology medications needed for supportive care.

The alien hand syndrome.

A 77-year-old woman presented with the complaint of observing her left hand moving without her knowledge while watching television. Her left hand stroked her face and hair as if somebody was controlling it. These movements lasted only half an hour but on recovery, she had left hemiparesis. Alien hand syndrome as the presentation of cardioembolic stroke is extremely rare but can be terrifying to patients.

Multilobar lung infiltrates after exposure to dust storm: the Haboob Lung Syndrome.

Dust-associated pneumonia has been known to have occurred in the Dust Bowl era (1930s) in the southern plains of the US. However, this entity is currently not recognized, and there are no case reports or literature about this from the US despite the presence of occasional dust storms (also known as the haboob). We report 4 cases of multilobar infiltrates/pneumonia in healthy people within a few days of unprotected exposure to a dust storm. This entity presents with dyspnea and severe desaturation. The clinical details of patients are given in the Table. Two of the 4 patients needed ntubation and one expired. Although dust has been proposed to impair the ciliary otility and cause increased chance of infections, the blood nd sputum cultures obtained from these patients were sterle. The exact mechanism of bilateral lung infiltrates in these atients is not clear, although a superimposed infection after nhalation of dust could still be the reason. Dust has been mplicated in causation of lung disease in the literature. ang et al, in a 9-year retrospective study from Taipei, reported increased rates of hospitalization for pneumonia on the days with sandstorms and those immediately following it compared with the days without sandstorms. Al Eskan disease, “Desert Storm pneumonitis,” is a condition first described in 1992 among US veterans exposed to the fine sand dust of the Central and Eastern Saudi Arabian peninsula. Korényi-Both et al reported that the fine Saudi sand ust ( 1 micron in size) triggered a hyperergic lung conition, which was aggravated by some organic pathogenic omponents, leading to opportunistic lung infections. In an elegant prospective study among 320,143 male Swedish construction workers, exposure to inorganic dust was found to cause increased mortality in infectious pneumonia, especially lobar and pneumococcal pneumonia. Wu et al reported the effects of dust on 7 first esponders who were exposed to it during the collapse of

The Association of Alpha-Blockers and 5-Alpha Reductase Inhibitors in Benign Prostatic Hyperplasia With Fractures

Background:Alpha-blockers and 5-alpha reductase inhibitors are common drugs used to treat benign prostatic hyperplasia (BPH), a prevalent problem in older men associated with significant morbidity and cost. Data regarding how these medications affect skeletal health and fracture risk remain scarce. Methods:Studies were identified by searching PubMed, EMBASE, the Cochrane library and Thomson Reuters Web of Knowledge. Studies involving BPH patients that reported odds ratio (OR) estimates with 95% confidence intervals (CIs) for the association between fractures and exposure to 5-alpha reductase inhibitors or alpha-blockers were included. Pooled ORs were calculated using the random-effects model. Results:Three studies addressed fracture risk in patients exposed to 5-alpha reductase inhibitors (21,366 fracture cases). Four studies addressed fracture risk in patients exposed to alpha-blockers (22,051 fracture cases). The pooled OR for fractures with 5-alpha reductase inhibitor use was 0.9 (95% CI = 0.7–1.1). For hip/femur fractures with 5-alpha reductase inhibitor use, the pooled OR was 0.8 (95% CI = 0.7–1.0). The pooled OR for fractures with alpha-blockers was 1.1 (95% CI = 0.9–1.3). There was significant statistical heterogeneity among studies for alpha-blockers. Conclusions:In patients with BPH, exposure to 5-alpha reductase inhibitors was not associated with change in fracture risk. The 5-alpha reductase inhibitors may have a small protective effect against hip/femur fractures although this was not statistically significant. Although alpha-blockers were not associated with change in fracture risk, caution is required when interpreting the results as significant heterogeneity was present.

Mach band sign: an optical illusion.

The chest radiograph of a 63-year-old woman who was found unresponsive was concerning for pneumopericardium, but lacked the other corroborative features suggestive of pneumopericardium. None of the follow-up chest radiographs showed evidence of air around the heart. The radiolucent shadow that mimicked pneumopericardium in this case was due to an artifact known as Mach band sign, an illusion created by lateral inhibition in the light receptors in the retina.

I lost weight, but I became weak and cannot walk--a case of nutraceutical (T3)-induced thyrotoxic periodic paralysis.

Thyrotoxic periodic paralysis (TPP) is a rare reversible cause of paralysis and cramping. TPP is usually precipitated by common causes of thyrotoxicosis such as Grave disease or multinodular goiter. TPP precipitated by exogenous triiodothyronine (T3) intake is an extremely rare occurrence with only 3 cases reported to date. We now report a 24-year-old healthy manual laborer who developed quadriparesis during a period of rest after heavy exertion and carbohydrate intake. He had severe hypokalemia (potassium level 1.9 mmole/L). Correction of his hypokalemia reversed the paralysis without rebound hyperkalemia. After a detailed history review, he reported that he had been consuming nutraceuticals containing T3 for 1 month to lose weight, and laboratory studies confirmed factitious T3 toxicosis. There was no evidence of renal or gastrointestinal potassium wasting. This episode of TPP was the first manifestation of thyrotoxicosis in this patient, and avoidance of T3 intake prevented more episodes.