Waqas Javed Siddiqui

Left Renal Vein Compression Syndrome: Cracking the Nut of Clinical Dilemmas – Three Cases and Review of Literature

Case series Patient: Female, 36 • Female, 41 • Female, 36 Final Diagnosis: Left renal vein compression syndrome Symptoms: Hematuria Medication: — Clinical Procedure: Percutaneous intervention • nephrectomy Specialty: Nephrology Objective: Unusual clinical course Background: The term nutcracker phenomenon (NCP) elucidates anatomical structure and hemodynamics, whereas nutcracker syndrome (NCS) refers to clinical manifestations. We present three cases of similar clinical features of hematuria and flank pain with different clinical outcomes. Care Report: Case 1: A 36-year-old Caucasian female with a past medical history (PMH) of HIV infection presented for evaluation of hematuria. Computed tomography (CT) without contrast showed pelvic venous congestion and narrowing of the extra-renal left renal vein (LRV). After the failure of conservative management, renal auto-transplantation was attempted but failed because of extensive venous collateral; the patient subsequently required a total hysterectomy due to recurrence of symptoms. Case 2: A 41-year-old Caucasian female with extensive PMH presented with chronic abdominal pain. A CT scan of the abdomen and pelvis showed pelvic venous congestion. The patient underwent angioplasty and stent placement of the LRV. Subsequently, a left ovarian vein embolization was performed. On follow-up visits, her symptoms improved. Case 3: A 36-year-old female with PMH of HIV infection, gastroesophageal reflux disease, and hypertension presented with hematuria and flank pain. Her venogram revealed 1 mm Hg pressure gradient across stenosis, suggestive of LRV hypertension. Over the months of her follow-up after discharge, her hematuria gradually decreased from daily to intermittent non-daily frequency, without any intervention. Conclusions: The treatment of NCS includes observation, percutaneous angioplasty, open or endovascular surgery, or nephrectomy. In patients younger than 18 years of age, the best option is a conservative approach with observation for at least two years, as approximately 75% of patients have complete resolution of hematuria.

Reduced Stroke After Transcatheter Patent Foramen Ovale Closure: A Systematic Review and Meta-analysis

Background: Recent randomized control trials (RCTs) have suggested benefit with transcatheter patent foramen ovale (PFO) closure plus antiplatelet therapy over medical treatment alone for secondary stroke prevention. Material and Methods: Data sources: we searched PubMed and Ovid MEDLINE from the inception until November 10, 2017 for RCTs comparing TPFO closure to medical therapy in patients with a PFO and a history of cryptogenic stroke. Results: Five RCTs with 3,627 patients (TPFO closure = 1,829 versus medical therapy =1,798) were included. There was a decreased number of post‐TPFO closure strokes compared to the medical therapy arm; 53 versus 80 strokes (odds ratio [OR] = 0.61, CI: 0.39‐0.94, P = 0.03, I2 = 17%). Transient ischemic attacks occurred in 43 patients after TPFO closure versus 60 patients in the medical therapy group (OR = 0.80, CI: 0.53‐1.19, P = 0.26, I2 = 0%). There was a higher incidence of atrial fibrillation in the TPFO closure group, which occurred in 75 patients, compared to 12 patients in the medical therapy group (OR = 5.23, CI: 2.17‐12.59, P = 0.0002, I2 = 43%). There was a trend toward a decreased number of neuropsychiatric events in the TPFO closure closure group compared to the medical therapy group; 42 versus 67 neuropsychiatric events (OR = 0.71, CI: 0.48‐1.06, P = 0.09, I2 = 0%). Conclusions: TPFO closure plus antiplatelet therapy is superior to medical therapy in patients with a PFO and cryptogenic stroke. PFO closure is associated with new‐onset atrial fibrillation and a trend toward reduced neuropsychiatric events.

Impact of Hyoscine Bromide Use on Polyp Detection Rate During Colonoscopy: A Systematic Review and Meta-Analysis

Background Colorectal cancer (CRC) is a leading cause of death worldwide. Polyp detection rate (PDR) and adenoma detection rate (ADR) are key focus in endoscopic research for CRC screening and prevention. Use of anti-spasmodic agents during colonoscopy to help identify adenomas and polyps has remained a controversial topic. Hyoscine butyl bromide (HBB) is the most commonly used anti-spasmodic agent in patients undergoing colonoscopy. Some randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine use of HBB for polyp and adenoma detection rates. Methods We conducted a systematic search in PubMed and MEDLINE from inception until February 10, 2018, for studies which compared HBB with placebo. We used RevMan version 5.3 for analysis. Procedural end-points were polyps, adenomas, and advanced adenoma detection rates, mean number of polyps detected and cecal intubation time. Results We included seven RCTs with 2,588 patients in our analysis. A total of 1,301 patients were randomized to HBB arm and 1,287 to the placebo arm. There was no significant difference in the primary outcome of polyp detection rate, 654 in HBB group vs. 616 in the placebo group, (odds ratio (OR) = 1.11, confidence interval (CI) = 0.93 - 1.34, P = 0.25). There was no difference in secondary outcomes of adenoma detection rate, 430 in HBB group vs. 396 in the placebo group, (OR = 1.06, CI = 0.89 - 1.26, P = 0.51), advanced adenoma detection rate, 92 in HBB vs. 95 in placebo group (OR = 0.95, CI = 0.70 - 1.30, P = 0.76), mean number of polyps detected (point estimate = 0.12, CI = 0.00 - 0.23, P = 0.05), adenomatous polyps (OR = 0.84, CI = 0.39 - 1.81, P = 0.65) and cecal intubation time (point estimate = 0.73, CI = -1.98 - 0.52, P = 0.25) between the two groups. Conclusions The use of HBB in patients undergoing colonoscopy does not appear to improve polyp or adenoma detection rates. It showed a non-significant trend of increased mean number of polyps detected with HBB.

Meta-Analysis comparing outcomes and need for renal replacement therapy of Transcatheter aortic valve implantation versus surgical aortic valve replacement

Acute kidney injury (AKI) is commonly associated with aortic valve replacement. Surgical aortic valve replacement (SAVR) is a known risk factor for AKI but little is known about the short- and long-term effects of transcatheter aortic valve implantation (TAVI). The purpose of our analysis is to identify the short- and long-term effect of TAVI on renal outcomes. We searched Medline and PUBMED from January 1, 2000 to November 6, 2017 for randomized control trials (RCTs) comparing TAVI to SAVR in patients with severe aortic stenosis. Three hundred sixty-nine trials were identified, 6 RCTs were included in our analysis. RevMan version 5.3 was used for statistical analysis. Heterogeneity is calculated using I2 statistics. Primary outcomes were AKI within 30 days and 1 year of TAVI, and requirement for renal replacement therapy. We included 5,536 patients (2,796 in TAVI and 2,740 in SAVR arm) from 6 RCTs. Baseline characteristics were similar. There was reduced incidence of AKI at 30 days of TAVI compared with SAVR, 57 versus 133 (odds ratio [OR] 0.40, confidence interval [CI] 0.28 to 0.56, p <0.00001, I2 = 7%) with no difference at 1 year (OR 0.65, CI 0.32 to 1.32, p = 0.23, I2 = 76%) and need for renal replacement therapy OR 0.95, CI 0.50 to 1.80, p = 0.87, I2 = 0%). Permanent pacemaker was more frequent in the TAVI arm compared with SAVR arm, 379 versus 110, (OR 3.75, CI 1.67 to 8.42, p = 0.001, I2 = 89%). In conclusion, TAVI is associated with a reduction in AKIs at 30 days despite the exposure to contrast and higher incidence of new permanent pacemaker placement.

Syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) as an initial presenting sign of non small cell lung cancer-case report and literature review

Association of SIADH with malignancy was first reported in 1957, when it was described in two patients with bronchogenic carcinoma. While the association with small cell lung cancer (SCLC) is well known, that with non small cell lung cancer (NSCLC) has been rarely reported. We report a case of 70 year old male who was found to have hyponatremia secondary to SIADH. Radiological tests revealed right hilar lung mass with mediastinal adenopathy. Bronchoscopic biopsy revealed non-small cell lung cancer of type squamous cell. Magnetic resonance imaging (MRI) of brain showed metastatic lesions, thereby confirming diagnosis of metastatic lung cancer. Paraneoplastic syndromes occur in 10% of lung cancer cases and they represent a group of disorders related to secretion of functional polypeptides or hormones from tumor cells. SIADH is more commonly described in conjunction with small cell lung cancer but there are a few case reports describing its occurrence after initiation of therapy for NSCLC such as radiation and chemotherapy. The mechanism for this phenomenon is not known. Unlike infectious causes, hyponatremia as initial presentation is an uncommon feature of malignancy-associated SIADH. In the lung cancer population, hyponatremia has been identified as a negative prognostic factor in hospitalized patients and those with advanced-stage disease. Malignancy should be a consideration in the diagnostic evaluation of SIADH, irrespective of the time of presentation.

Adenocarcinoma of the lung presenting as thrombotic thrombocytopenic purpura

Acquired thrombotic thrombocytopenic purpura (TTP) usually presents as severe microangiopathic hemolytic anemia (MAHA) and thrombocytopenia in a previously healthy individual. It occurs in approximately three in one million adults and 1 in 10 million children annually. The incidence is increased in females and blacks. Diagnosing TTP and initiating therapy with plasma exchange is a must to avoid preventable complications. Acquired thromotic microangiopathy has been linked to collagen vascular diseases, use of certain medications, organ transplants, infections, pregnancy and cancer. We report a rare case of a 56-year-old African American male diagnosed with TTP who found to have an asymptomatic adenocarcinoma of the lung. Prompt cancer management resulted in completed remission of the thrombotic microangiopathy.

Ventricular septal defect: early against late surgical repair

Ventricular septal defect (VSD) is a rare complication of right ventricular infarction (RVI) which is associated with significant mortality, if not treated appropriately. It typically occurs within the first 10–14 days after myocardial infarction. Surgical repair has been shown to reduce in-hospital mortality from 90% to 33–45%. Early surgical VSD repair has also been associated with high 30-day operative mortality of 34–37%. Furthermore, after an acute MI the friable myocardium enhances the risk of recurrent VSD with early surgical repair. We present a case of a middle-aged woman who developed VSD after an RVI. Her surgical repair was delayed by 2 weeks due to development of Staphylococcus aureus bacteremia. During this period, she was managed medically and later on underwent percutaneous repair with an amplatzer VSD occluder device. Keeping this patient encounter in mind, we would like to emphasize on the limited recommendations available for early against late surgical repair of VSD.

Vegetation Attached to the Left Interatrial Septal Surface at the Congenital Location of the Foramen Ovale: A Rare Occurrence

Patient: Male, 57 Final Diagnosis: Infective endocarditis vegetation attached to the congenital foramen ovale location Symptoms: Dysuria • fatigue • fever Medication: — Clinical Procedure: Trans thoracic echocardiography • trans esophageal echocardiography • redosternotomy Specialty: Cardiology Objective: Rare disease Background: Non-valvular mural infective endocarditis (IE) is a rare bacterial growth on cardiac walls. Several risk factors have been reported. Echocardiography is an important diagnostic modality for diagnosing vegetation attached to the intracardiac walls. Case Report: We present the case of a 57-year-old man admitted with Staphylococcus aureus bacteremia due to an infected tunnelled hemodialyses catheter. Transthoracic echocardiogram did not show any abnormality, but transesophageal echocardiogram (TEE) revealed a 1.7×0.8 cm mobile echo-density attached to the surface of the interatrial septum in the left atrium, where the foramen ovale (FO) exists in utero. The patient was transferred to another facility for re-do sternotomy cardiac surgery, where these findings were confirmed intraoperatively. A biopsy of the mass was taken, which confirmed it to be a vegetation attached to the FO. Conclusions: We report the first case in the literature of vegetation attached to the surface of the interatrial septum in the left atrium at the congenital location of the foramen ovale. There have been no previously reported cases in the literature with such novel imaging findings.