Shuvendu Sen

Convulsive Syncope Induced by Ventricular Arrhythmia Masquerading as Epileptic Seizures: Case Report and Literature Review

It is important but difficult to distinguish convulsive syncope from epileptic seizure in many patients. We report a case of a man who presented to emergency department after several witnessed seizure-like episodes. He had a previous medical history of systolic heart failure and automated implantable converter defibrillator (AICD) in situ. The differential diagnoses raised were epileptic seizures and convulsive syncope secondary to cardiac arrhythmia. Subsequent AICD interrogation revealed ventricular tachycardia and fibrillation (v-tach/fib). Since convulsive syncope and epileptic seizure share many similar clinical features, early diagnosis is critical for choosing the appropriate management and preventing sudden cardiac death in patients with presumed epileptic seizure.

Coccidioidomycosis and Blastomycosis: Endemic Mycotic Co-Infections in the HIV Patient

Opportunistic fungal infections including aspergillosis species, candida species, and fusarium can be found in HIV-infected patients. Disseminated diseases due to endemic mycoses including histoplasmosis, coccidioidomycosis, and blastomycosis are all being reported among HIV patients who reside in the known endemic areas. However, in the non-endemic areas, or due to the rarity of these pathogens, it might be difficult to recognize these unfamiliar disease presentations. We report a patient with HIV who had dual infections with endemic mycotic infections of coccidioidomycosis and blastomycosis, as he had a brief stay in the endemic area.

A Rare Silent Killer: Right Atrial Metastasis of Thyroid Hürthle Cell Carcinoma

Hürthle cell carcinoma (HCC) is a variant of a follicular carcinoma with a tendency to higher frequency of metastases and a lower survival rate. However, intracavitary cardiac metastases from thyroid HCC are extremely rare. We describe the case of a 57-year-old female with thyroid HCC, 5 years after total thyroidectomy, who presented with dyspnea associated with hypoxia and hypotension. The computed tomography angiogram showed extensive pulmonary embolism and a 6-cm right atrial mass while the lower-extremity deep vein thrombosis studies were negative. This patient received a cardiac thrombectomy using cardiopulmonary bypass support. However, intraoperatively, we found out that the mass was from the mediastinum, directly extending into the heart and clearly unresectable since it effaced at least 1/3 of the right atrial wall. The core biopsy of the mass confirmed that it was metastatic poorly differentiated HCC of thyroidal origin. The patient eventually died of respiratory failure due to a massive pulmonary embolism. For cancer patients with unexplained dyspnea, cardiac metastases should be considered regardless of anticoagulation prophylaxis, especially when there is no deep vein thrombosis in the lower limbs. Early recognition of intracavitary cardiac metastases may help in providing prompt treatment and improving the prognosis.

How Early Can Pancreatic Cancer Be Recognized? A Case Report and Review of the Literature

The early symptoms of pancreatic cancer are often very vague. They may precede the diagnosis by years and go unrecognized. This makes pancreatic cancer one of the cancers with the worst survival rates. The progression rate of the early phase might be slower than previously thought. Here, we report a case where symptoms, including thromboembolism and new-onset diabetes mellitus, preceded the diagnosis of pancreatic cancer by 6 years or longer. The awareness of the early symptoms of pancreatic cancer is required for being vigilant and further diagnostic tests. A simple clinical model utilizing certain risk factors and symptoms for pancreatic cancer will help stratify the patients for further screening tests.

Cocaine-Induced Delayed Myocardial Infarction Complicated by Apical Thrombus

It is well demonstrated in the literature that cocaine use has been well linked to the formation of various forms of acute and chronic cardiovascular problems including but not limited to acute coronary syndromes. However, cocaine has been commonly associated with coronary vasospasms and less commonly with myocardial infarction and the formation of atrial thrombus. Through this case presentation, we illustrate the findings of a 35-year-old gentleman with history of cocaine use presenting with acute coronary syndrome and complicated by thrombus formation. Furthermore, through this report, we illustrate in a patient with no other risk factors and at a young age, how chronic cocaine use or even a history of usage may result in complications even weeks after its consumption.

Pericardial Metastasis Induced Tamponade from Urothelial Carcinoma: A Rare Entity

Urothelial carcinoma in a few cases may result in cardiac metastasis. A rare presentation of this condition is its diagnosis as a result of cardiac tamponade. Tamponade is an unusual entity as a result of urothelial carcinoma and has only been reported in four cases. There have also been only a total of fifteen cases of cardiac metastasis from this form of malignancy. It is through this discussion that we emphasize the importance of early detection and monitoring of cardiac symptoms with the implementation of echocardiogram imaging. Although not feasible in all patients it may be considered in those presenting with cardiac and pulmonary symptoms. In this case we discuss the presentation of a 71-year-old gentleman with a history of urothelial carcinoma after cystectomy and while on chemotherapy presented with new onset atrial fibrillation and later was diagnosed with cardiac tamponade as a result of malignant metastasis.

Acute confusional state: A manifestation of toxoplasma and CMV co-infection in HIV patient

Context: When dealing with a patient with HIV that presents with an altered mental status, there are various infections and disease etiologies a physician has to rule out that may play a role in complicating the inherent complex nature of HIV. Toxoplasma gondii (T. gondii) and cytomegalovirus (CMV) affect a large part of the worlds population and lead to a varied and broad symptomatology depending upon the severity of HIV, the CD4 count and how early the infection is diagnosed. Case Report: We report an HIV+ patient in his early 50s and with a low CD4 count that presented with severe lethargy and confusion. Imaging studies that were performed after stabilizing the patient revealed a ring-enhancing lesion in the brain and after further testing, a diagnosis of reactivated T. gondii with co-infection with CMV was made. Patients infected with T. gondii that are already immune-compromised deteriorate rapidly and the disease diagnosis poses several challenges. Conclusion: Clinicians have to be extremely careful about making a prompt diagnosis and initiate treatment without delay before the infection takes a deadly toll on the patient. Since our patient was not on the required prophylactic medication to prevent infection with T. gondii, it was imperative to start treatment in a timely manner and to monitor the patient for any further decline in functioning.

The impact of the 2008-2009 economic recession on acute myocardial infarction occurrences in various socioeconomic areas of Raritan bay Region, New Jersey

Background: Psychosocial stress is one important risk factor for myocardial infarction. Aim: The study was to assess the impact of the 2008-2009 economic recession on myocardial infarction occurrences in different socioeconomic areas of Raritan Bay region, New Jersey. Materials and Methods: The patients, who were treated for acute myocardial infarction from January 2006 to June 2012, were grouped based on the average incomes of their residence districts in the Raritan Bay region. The Spearman Rank Correlation test was used to assess the correlation between the monthly occurrences of myocardial infarction and Dow Jones stock averages, as well as the correlation between the myocardial infarction occurrences and NJ State unemployment rates. Results: Among 1,491 cases that were identified, 990 cases resided in areas with income below the state average and 477 were from areas above the average. After the onset of the recession, the myocardial infarction occurrences trended up in the low-income area group but not in the high-income area group; and this increasing trend is correlated with the rise in NJ State unemployment rates but not with the changes in stock averages. Conclusion: Our findings suggest that unemployment contributed to an increased risk of myocardial infarction among the residents in low socioeconomic areas after the 2008-2009 economic recession.

A rare cause of acute abdomen: spontaneous dissection of the superior mesenteric artery.

Spontaneous superior mesenteric artery (SMA) dissection is a rare, but potentially fatal disease. Prompt diagnosis and treatment of SMA dissections result in a lower prevalence of intestinal infarction and mortality. In the current era, imaging techniques can promptly diagnose SMA dissection; however, no definitive guidelines have been established to treat this condition.

Severe Hypothyroidism-Induced Volvulus

Thyroid disorders have been found to be associated with multiple organ systems and thus have a broad spectrum of presenting symptoms and clinical conditions. Certain aspects of the gastrointestinal (GI) system have yet to be fully understood and documented. Hypothyroidism and even hyperthyroidism have been identified in patients with motility symptoms involving the GI tract. These symptoms can vary and can be a complication of undertreated or undiagnosed condition involving the thyroid. Unfortunately, the mechanism in which these hormones can impact intestinal motility remains poorly understood and not well documented. In this case report, we discuss the presentation of a 71-year-old female with poorly managed hypothyroidism presenting with significant abdominal distention and pain secondary to underlying volvulus formation. By better understanding the complications induced by hypothyroidism, physicians may be able to prevent further life-threatening outcomes with early management and intervention.