Sushilkumar Satish Gupta

Curious case of extraskeletal myxoid chondrosarcoma

Extraskeletal myxoid chondrosarcomas (EMC) are a rare entity of soft tissue tumors that have slow growth with metastatic potential. We discuss here a case of EMC presenting with right upper extremity pain and hemoptysis. Computed tomography scans chest showed diffuse metastatic numerous lung nodules bilaterally. Biopsy confirmed the diagnosis of the tumor. Chemotherapy was a bigger challenge for our patient due to sparse research and data in the literature about the disease.

Asymptomatic large aortic root thrombus after left ventricular assist device implantation detected by cardiac computed tomography.

A 65-year old male with past medical history of non-ischemic cardiomyopathy, heart failure with reduced ejection fraction of 5e10% and chronic atrial fibrillation on anticoagulation, was admitted to our hospital due to repeated episodes of flash pulmonary edema. After the patient was medically stabilized, a left ventricular assist device (LVAD) Thoratec HeartMate II was implanted as destination therapy. Anticoagulation was initiated the following day, but subsequently suspended for 24 hours due to lower gastrointestinal bleeding. Heparin-induced thrombocytopenia (HIT) was ruled by negative HIT antibody and serotonin reactive assay. An echocardiogram did not identify any complication in the immediate postoperative period. Per local protocol, gated cardiac computed tomography (CT) was performed, which showed a large thrombus (4.5 2.5 cm) in the aortic root (Panel A, arrowhead) involving the left and non-coronary sinuses, in close proximity to the left main coronary ostium (Panel B, arrow), and extending into the sinotubular junction and tubular aorta (Panel C). Pulmonary embolism was also detected in the distal right main pulmonary artery and proximal right upper lobar artery (Panel D, asterisk). Due to high operative risk, the patient was managed medically and discharged in hemodynamically stable conditions. The patient has been followed as an outpatient for more than a year without any clinical events.

Right Ventricular Infarction

Coronary Heart Disease is a leading cause of morbidity and mortality worldwide. A great amount is known about left ventricular myocardial infarction. It was not until much later (1974) that right ventricular myocardial infarction was studied as a separate entity. Isolated right ventricle myocardial infarction is rare. Around one-third of patients with acute infero-posterior ST-segment elevation myocardial infarction, will present with concomitant right ventricular infraction. The aim of this paper is to review the literature on the importance of early recognition of right ventricular infarction, clinical presentation, pathophysiology, diagnostic evaluation, differential diagnosis, treatment, complications and prognosis.

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review

Background: Acute alcohol intoxication has been associated with cardiac arrhythmias but the electrocardiogram (ECG) changes associated with acute alcohol intoxication are not well defined in the literature. Objective: Highlight the best evidence regarding the ECG changes associated with acute alcohol intoxication in otherwise healthy patients and the pathophysiology of the changes. Methods: A literature search was carried out; 4 studies relating to ECG changes with acute alcohol intoxication were included in this review. Results: Of the total 141 patients included in the review, 90 (63.8%) patients had P-wave prolongation, 80 (56%) patients had QTc prolongation, 19 (13.5%) patients developed T-wave abnormalities, 10 (7%) patients had QRS complex prolongation, 3 (2.12%) patients developed ST-segment depressions. Conclusion: The most common ECG changes associated with acute alcohol intoxication are (in decreasing order of frequency) P-wave and QTc prolongation, followed by T-wave abnormalities and QRS complex prolongation. Mostly, these changes are completely reversible.

Clinical significance of atrial kick

A 68-year-old man with a history of diabetes mellitus type II, hypertension and active smoking was transferred to our hospital from a nearby hospital for coronary artery bypass graft (CABG) surgery after suffering a complicated inferior wall myocardial infarction (IWMI). Post the initial angioplasty, the patient developed in-stent thrombosis and became hypotensive with a systolic blood pressure < 90 mmHg. After hemodynamic stability was achieved he was transferred to our hospital. During his stay, the cardiac monitor showed fluctuations in his blood pressure with a drop in systolic blood pressure by 10 to 15 mmHg and diastolic blood pressure by 10 mmHg when he developed atrioventricular (AV) dissociation during an idioventricular rhythm. Atrial kick, the fourth phase of ventricular diastole in the cardiac cycle is where the atria contributes to the ventricular end diastolic volume by atrial contraction. The significance of the atrial kick in the hemodynamics of the patient was captured on the cardiac monitor during the patients stay in the cardiac intensive care unit.

A comparison between two types of indwelling pleural catheters for management of malignant pleural effusions

Background Malignant pleural effusion (MPE) is a common cause of quality of life deterioration in patients with advanced cancer. Management options include chemical pleurodesis with a sclerosing agent such as doxycycline or talc powder, surgery, and also the placement of tunneled indwelling pleural catheters (IPCs). Two different IPC types are mostly used in the USA. Methods We conducted a single-center retrospective study with the objective to compare the efficacy and safety profiles of two IPC systems. Patients with a diagnosis of malignancy, who received IPCs by the interventional radiology department of our hospital from January 2013 to March 2015, were identified in the local database and a chart review was performed to record characteristics and outcomes. Patients without a diagnosis of malignancy or with pleural effusions of cardiac origin were excluded from the study. Results We identified 27 patients with a median age of 59.0 years. Eighty patients received Aspira catheter while nine patients received PleurX catheter, and seven patients achieved spontaneous pleurodesis. The median length of stay (LOS) was 9 days for the Aspira group (AG), as compared to 13 days for the PleurX group (PG) (overall median LOS was 10 days; range, 2-62 days). The rate of catheter-related complications (pain, obstruction, loculations, infection, hemorrhage) was 39% (seven patients) for the AG and 33% (three patients) for the PG (overall ten patients, 37%). Conclusions In our study, outcomes and safety were similar for patients receiving either type of IPC, Aspira or PleurX.

Thyrotoxic Periodic Paralysis and Cardiomyopathy in a Patient with Graves’ Disease

Thyrotoxic periodic paralysis (TPP) and cardiomyopathy are two established complications of thyrotoxicosis. Emergent management is essential as TPP and cardiac events secondary to thyrotoxic cardiomyopathy can be fatal. We report a unique case of a patient with Graves’ disease presenting with symptoms secondary to both these complications. A 34-year-old Hispanic male, diagnosed with Graves’ disease, non-compliant with his medications, presented to the emergency room (ER) with complaints of generalized weakness, palpitations, chest pain and multiple episodes of nausea and vomiting for one day. On presentation, the patient was tachycardiac, had a systolic flow murmur and decreased motor strength in all extremities. Blood work showed a potassium of 1.8 millimoles per liter, cardiac troponin of 0.04 nanograms per milliliter and a thyroid panel consistent with hyperthyroidism. Electrocardiogram showed atrial flutter. In the ER, Propranolol, Propylthiouracil and Hydrocortisone were administered to prevent thyroid storm. Potassium was repleted, and the patient developed rebound hyperkalemia. He was given calcium gluconate, insulin, sodium polystyrene and admitted to the medical intensive care unit (MICU) for further management. Echocardiogram revealed severely decreased left ventricular systolic function and an ejection fraction of 26-30%. He was diagnosed with cardiomyopathy secondary to thyrotoxicosis. He was stabilized with Methimazole, Propranolol, Lisinopril and discharged on day nine with these medications and an outpatient follow-up appointment. Thyrotoxicosis can be life-threatening. This case shows a unique instance where a Hispanic patient presented with two complications of this phenomena. The pathogenesis of TPP involves increased responsiveness of the beta-adrenergic receptors, which leads to increased activity of the Sodium/Potassium (Na+/K+) ATPase pump and a transcellular shift of potassium into cells. The condition can resolve acutely with the administration of potassium. It is important to monitor the rate of potassium replacement as rebound hyperkalemia can occur, as this case demonstrates. Propranolol is an integral part of treatment as it is a beta-adrenergic receptor blocker and blocks the peripheral conversion of thyroxine (T4) to triiodothyronine (T3) in high doses. Thyrotoxic cardiomyopathy is one of the many cardiac complications that can be precipitated by Graves’ disease. One probable cause is the chronic tachycardia that patients with hyperthyroidism develop. Treatment entails managing the hyperthyroidism by starting the patient on beta blockers and anti-thyroid drugs or radioactive iodine uptake. Diuretics can be started to manage patients with heart failure. It is important to identify and treat the condition immediately to prevent grave complications.

Neisseria cinerea in a Post-splenectomy Patient: A Rare Potentially Fatal Bacteremia

Neisseria cinerea is a commensal which usually resides in the human respiratory tract. Very rarely, the organism finds its way into the bloodstream causing severe bacteremia. So far, very few cases of Neisseria bacteremia have been reported. We report a case of a 78-year-old male, post-splenectomy, who presented with high fever, cough and shortness of breath. The patient was initially managed for septic shock with fluid resuscitations, vasopressors and broad-spectrum antibiotics. Later, the blood cultures grew gram-negative coccobacilli, Neisseria cinerea. The patient was successfully treated with intravenous ceftriaxone. This is the first case ever of Neisseria cinerea bacteremia in a post-splenectomy patient and ninth case overall. This case illustrates that the physicians should maintain heightened awareness for Neisseria cinerea bacteremia in post-splenectomy patients.

Solitary Fibrous Tumor of Pleura Invading into the Left Atrium via Pulmonary Vein

A 67-year-old woman came to the hospital because of difficulty in breathing. After an initial clinical assessment, contrast-enhanced computerized tomography (CT) of the chest revealed a well-circumscribed heterogeneous mass arising from the pleura adjacent to the superior and medial left pulmonary artery. The mass was invading the pulmonary vein and entering the left atrium. Histopathology of the biopsy of the mass was suggestive of solitary fibrous tumor (SFT) of the pleura. The patient underwent pneumonectomy and resection of the left atrial mass with pericardial patch repair of the left atrium.

Splenic and kidney infarct: Sequelae of subacute Streptococcus mitis bacterial endocarditis

Infective endocarditis (IE) is caused due to the vegetation on the heart valves, myocardium wall, or the pacemaker leads. Vegetation is a lesion that appears as a consequence of successive deposition of platelets and fibrin on the endothelial surface of the heart. Colonies of microbes can be usually found under the vegetation. Heart valves are involved more frequently as compared to other places. Streptococcus miti s, formerly known as S. mitior, is a commensal of the oral flora, however, if there of loss of integrity of the mucous membrane, the infection may disseminate to the blood flow. We describe here a rare presentation of S. mitis, causing IE and its complications in an immunocompetent patient.