Timothy R. Larsen

Hyperacute drug-induced hepatitis with intravenous amiodarone: case report and review of the literature

Amiodarone is a benzofuran class III antiarrhythmic drug used to treat a wide spectrum of ventricular tachyarrhythmias. The parenteral formulation is prepared in polysorbate 80 diluent. We report an unusual case of acute elevation of aminotransaminase concentrations after the initiation of intravenous amiodarone. An 88-year-old Caucasian female developed acute hepatitis and renal failure after initiating intravenous amiodarone for atrial fibrillation with a rapid ventricular response in the setting of acutely decompensated heart failure and hepatic congestion. Liver transaminases returned to baseline within 7 days after discontinuing the drug. Researchers hypothesized that this type of injury is related to liver ischemia with possible superimposed direct drug toxicity. The CIOMS/RUCAM scale identifies our patient’s acute hepatitis as a highly probable adverse drug reaction. Future research is needed to understand the mechanisms by which hyperacute drug toxicity occurs in the setting of impaired hepatic perfusion and venous congestion.

Prevalence of Masked Hypertension in African Americans

Masked hypertension (MH), the presence of normal office blood pressure (BP) with elevated ambulatory pressure, has been shown to correlate with organ damage. Population‐based studies from Europe and Asia estimate a prevalence of 8.5% to 15.8%. Two small studies in African Americans estimate a prevalence >40%. Therefore, the authors utilized ambulatory BP monitoring (ABPM) to identify the prevalence of MH in our African American population. Pressure was recorded every 30 minutes while awake and every 60 minutes while asleep. Patients with 24‐hour average BP ≥135/85 mm Hg, awake average BP ≥140/90 mm Hg, or asleep average BP ≥125/75 mm Hg had MH. Seventy‐three participates had valid data. The mean age of the patients was 49.8 years, mean body mass index was 31.1, and 39 patients (53%) were women. Thirty‐three patients (45.2%) had MH. Patients with MH had higher clinic systolic BP and trended toward higher BMI values. The authors corroborated the high prevalence of MH in African Americans. ABPM is critical to diagnose hypertension in African Americans, particularly in those with high‐normal clinic pressure and obesity.

A forgotten devil; Rupture of mitral valve papillary muscle.

Summary Background: Papillary muscle rupture is one of the catastrophic mechanical complications following myocardial infarction. Rupture leads to acute mitral valve regurgitation, pulmonary edema, and cardiogenic shock. Survival is dependent on prompt recognition and surgical intervention. Cases Report: We present two cases where acute myocardial infarction was complicated by papillary muscle rupture resulting in severe mitral regurgitation and cardiogenic shock. In both cases rupture occurred within one week of infarction. Both patients did not receive coronary revascularization; one patient presented late after the onset of chest pain, the other patient percutaneous revascularization attempted and was not successful. Both patients suffered an inferior wall infarction. Echocardiogram demonstrated severe mitral regurgitation with a jet directed posteriorly. In both cases rupture of the posteromedial papillary muscle resulted in flail of the anterior mitral valve leaflet, thus serving as a reminder that both the anterior and the posterior leaflets attach to both papillary muscles. Conclusions: While one case had a good outcome, the other reinforces the fact that this is a very serious complication requiring prompt recognition and treatment.

Acute warfarin toxicity: An unanticipated consequence of amoxicillin/clavulanate administration

Patient: Male, 53 Final Diagnosis: Acute Warfarin toxicity Symptoms: — Medication: Warfarin Clinical Procedure: — Specialty: Hematology Objective: Unusual clinical course Background: Warfarin remains the most common anticoagulant in the management of thromboembolic diseases. However, its extensive drug interaction requires frequent monitoring and dose adjustments. Almost all antibiotics, including penicillins, have the potential to interact with warfarin causing either under or over anticoagulation which increases the risk for thrombus formation and significant bleeding respectively. Case Report: A 53-year-old Caucasian male with a history of protein C deficiency and recurrent intravascular thrombosis developed a dental abscess. He was treated with amoxicillin/clavulanate 500/125 mg twice daily and referred to a dentist. He developed significant bleeding after tooth extraction. INR was 20.4. He received fresh frozen plasma and vitamin K with resolution of bleeding. Conclusions: While rare, clinically significant prolonged prothrombin time and potentially life threatening bleeding can occur when amoxicillin/clavulanate is concomitantly administered with warfarin. Prompt recognition and intervention is necessary to avoid life threatening complications from warfarin-amoxicillin/clavulanate interaction.

A Lethal Case of Influenza and Type 5 Cardiorenal Syndrome

Interactions between the heart and kidneys have been labeled as the cardiorenal syndrome (CRS). Type-5 CRS describes a disease that simultaneously damages both organs. With severe infection, systemic inflammatory mediators (TNF-α and IL-1β) cause wide-spread endothelial dysfunction, cellular apoptosis, and depressed organ function. Impaired myocardial function promotes worsening renal function and vice versa, leading to a dangerous positive feedback loop. Influenza viruses cause both myocardial and kidney injury, presumably through an immune-mediated mechanism. Herein we present a lethal case of influenza, resulting in acute type V cardiorenal syndrome.

Frequency of fluid overload and usefulness of bioimpedance in patients requiring intensive care for sepsis syndromes.

Guideline-directed therapy for sepsis calls for early fluid resuscitation. Often patients receive large volumes of intravenous fluids. Bioimpedance vector analysis (BIVA) is a noninvasive technique useful for measuring total body water. In this prospective observational study, we enrolled 18 patients admitted to the intensive care unit for the treatment of sepsis syndromes. Laboratory data, clinical parameters, and BIVA were recorded daily. All but one patient experienced volume overload during the course of treatment. Two patients had >20 L of excess volume. Volume overload is clinically represented by tissue edema. Edema is not a benign condition, as it impairs tissue oxygenation, obstructs capillary blood flow, disrupts metabolite clearance, and alters cell-to-cell interactions. Specifically, volume overload has been shown to impair pulmonary, cardiac, and renal function. A positive fluid balance is a predictor of hospital mortality. As septic patients recover, volume excess should be aggressively treated with the use of targeted diuretics and renal replacement therapies if necessary.

Systemic Embolization from an Unusual Intracardiac Mass in the Left Ventricular Outflow Tract

Endocarditis can affect any endocardial surface; in the vast majority of cases, the cardiac valves are involved. It is exceedingly rare to develop infective endocarditis on the endocardium of the left ventricular outflow tract due to the high velocity of blood that traverses this area. Herein, we present a rare case of left ventricular outflow tract endocarditis that likely occurred secondary to damage to the aortic valve leaflets (from healed prior aortic valve endocarditis) causing a high velocity aortic valve regurgitant jet that impinged upon the interventricular septum which damaged the endocardium and resulted in a fibrotic “jet lesion.” This fibrous jet lesion served as a nidus for bacterial proliferation and vegetation formation. The high shear stress (due to high blood flow velocity through the left ventricular outflow tract) likely promoted the multiple embolic events observed in this case. Our patient was successfully treated with aortic valve replacement, vegetation resection, and antibiotics.

Assessing the Prevalence of Mechanical Dyssynchrony with Activity in Patients with Low Ejection Fraction and Narrow QRS at Rest

Introduction: Cardiac Resynchronization Therapy (CRT) improves hemodynamics, symptoms, and overall mortality in patients with advanced heart failure (HF) and ventricular electrical dyssynchrony (QRS duration >120 msec). Previous studies have shown that mechanical dyssynchrony (MD) may be present in up to 45% of patients with advanced HF and QRS duration <120 ms at rest. We determined whether activity induces MD in patients with QRS duration <120 msec. Methods: A total of 47 consecutive patients with left ventricular ejection fraction (LVEF) ≤ 30%, New York Heart Association (NYHA) class II-IV HF, and a QRS complex 65 msec from peak systolic activation of the septal wall to the lateral wall of the left ventricle. Minnesota living with heart failure questionnaire (MLWHFq), EF and NYHA class were assessed to determine risk factors for exercise induced MD. Results: Of the 47 patients, MD occurred in 11 patients (23%) at rest and 5 patients (13%) at exercise. The mean time to peak systolic velocity in the rest and exercise dyssynchrony groups was 105 ± 32 msec and 124 ± 29 msec respectively, compared with 45 +/- 15 msec in patients not experiencing dyssynchrony. No patients experienced electrical dyssynchrony with activity. EF, NYHA class or MLWHF questionnaire were not predictive. Conclusion: MD with activity is not uncommon in patients with HF and a narrow QRS. MD should consider including patients with exercise induced MD as this population otherwise may go ignored. Additionally, patients with pre-existing electrical dyssynchrony who develop MD with exercise may benefit from optimization of their device settings to meet the potential hemodynamic challenge rendered by increased physical activity and heart rate.

A missed malignant right coronary artery anomaly detected post-cardiac event in an adult patient.

Aims: We present this case to raise awareness of this unusual presentation of a malignant anomalous right coronary artery arising from the left coronary cusp in a patient older than 50 years. We describe a useful imaging modality and discuss therapy. Presentation of the Case: We report a case of a 63-year-old male with an interarterial coursing right coronary artery arising from the left coronary cusp with a history of a mechanical aortic valve replacement. The patient presented to our emergency department after being resuscitated from a cardiac arrest and later had a normal coronary angiogram. High suspicion of his right coronary artery angulation, he underwent a computed tomography with angiogram that revealed his anomalous course and anatomy. Discussion: We discuss the importance of coronary artery anomaly detection in the young at risk population (athletics), pathophysiology, diagnostic modalities, and treatment recommendations. Surgical revascularization has been advocated in malignant coronary anomalies, however, the lack of large randomized clinical trials for patients older than 50year-old left this topic controversial. Medical therapy augmented with implanted cardioverter defibrillator (ICD) was utilized in this case. Medical management could be considered in centers that don’t have surgical experience or in adult patients who are a Case Study British Journal of Medicine & Medical Research, 4(1): 501-509, 2014 502 poor surgical candidate because of other comorbidities or life expectancy. Conclusion: Computed tomography with angiogram seems to be the best noninvasive modality to delineate coronary course and anatomy. There is a need for randomized clinical trials to determine the best management of anomalies arising from opposite sinus with an interarterial course in adults >50-year-old.

Myocardial Infarction in a Young Female with Palindromic Rheumatism: A Consequence of Negative Remodeling

Palindromic rheumatism is a rare disease associated with systemic inflammation. Negative or constrictive coronary artery remodeling is typically not seen until the 7th or 8th decade of life. We report a case of a young female with palindromic rheumatism who suffered a non-ST segment elevation myocardial infarction secondary to a flow-limiting lesion that demonstrated negative remodeling by intravascular ultrasound (IVUS).