Wing-Hing Chow

Epithelioid hemangioendothelioma of the brain.

Epithelioid hemangioendothelioma is a recently described vascular neoplasm characterized by epithelioid tumor cells and borderline biologic behavior. Its four principal sites of occurrence are the soft tissue, liver, lung, and bone. We report a case of primary cerebral epithelioid hemangioendothelioma in a 4-month-old male infant. The tumor consisted of loose aggregates of epithelioid cells with a focal cordlike or bridging-branching pattern, supported in a fibromyxoid stroma. The tumor cells displayed frequent intracytoplasmic vacuoles. Immunohistochemically, the tumor cells showed positive staining for Ulex europaeus agglutinin, vimentin, and cytokeratin. The tumor pursued an indolent clinical course. The patient was alive 28 months after initial presentation, but he was left with a severe neurological deficit because of the location and growth of the tumor.

Amiodarone-Induced Thyrotoxicosis Is a Predictor of Adverse Cardiovascular Outcome

BACKGROUND Amiodarone-induced thyrotoxicosis (AIT) is a clinical condition that is notoriously difficult to manage; the relative risk of adverse cardiovascular events in these patients compared with euthyroid patients is largely unknown. OBJECTIVE We compared the clinical characteristics and major adverse cardiovascular events (MACE) in AIT and euthyroid patients. METHOD Patients at a tertiary referral center who had been prescribed amiodarone for at least 3 months were retrospectively analyzed. Baseline clinical characteristics, laboratory parameters, and outcome events were evaluated. MACE was defined as cardiovascular mortality, myocardial infarction, stroke and heart failure, or ventricular arrhythmias that required hospitalization. RESULTS A total of 354 patients (61.8 +/- 14.1 yr; 64.7% male) with a mean follow-up of 48.6 +/- 26.7 months were studied. AIT, euthyroid status, and amiodarone-induced hypothyroidism were identified in 57 (16.1%), 224 (63.3%), and 73 (20.6%) patients, respectively. No differences in baseline clinical characteristics were observed between AIT and euthyroid patients. Nonetheless AIT patients demonstrated a higher MACE rate (31.6 vs. 10.7%, P < 0.01), mostly driven by a higher rate of ventricular arrhythmias that required admission (7.0 vs. 1.3%, P = 0.03). Cox-regression multivariate analysis revealed that AIT (hazard ratio 2.68; confidence interval 1.53-4.68; P < 0.01) and left ventricular ejection fraction less than 45% (hazard ratio 2.52; confidence interval 1.43-4.42; P < 0.01) were independent predictors of MACE. CONCLUSION In patients prescribed long-term amiodarone therapy, occurrence of AIT is associated with a 2.7-fold increased risk of MACE. Regular and close biochemical surveillance is thus advisable to identify and treat this high-risk group of patients.

Anticoagulation instability with life-threatening complication after dietary modification.

Anticoagulation instability due to a change in intake of vitamin K after dietary modification was observed in 2 patients on long-term oral anticoagulants. One patient developed diffuse bruises treated conservatively with fresh frozen plasma transfusion and the other had a thrombosed aortic prosthesis which required emergency operation. To prevent such complications, dietary modification especially with food rich in vitamin K should be undertaken with care in patients on long-term oral anticoagulants.

Adverse effect of topical methylsalicylate ointment on warfarin anticoagulation: an unrecognized potential hazard.

The adverse effect of topical methylsalicylate ointment on warfarin anticoagulation is studied in 11 patients. All patients had an abnormally elevated international normalized ratio after significant usage of topical methylsalicylate ointment as obvious from both the clinical history and a positive blood level of salicylate. Out of the 11 patients, 3 had bleeding manifestation; 2 with bruises and 1 with gastrointestinal bleeding. It is concluded that topical methylsalicylate ointment should be prescribed with care to patients on warfarin and excessive usage is to be avoided since potentially dangerous drug interaction could occur.

A new ECG criterion to identify takotsubo cardiomyopathy from anterior myocardial infarction: role of inferior leads

With the exception of contrast-enhanced cardiovascular magnetic resonance imaging, clear distinction of takotsubo cardiomyopathy from anterior wall myocardial infarction cannot be achieved currently by simple and noninvasive tests. The aim of this study was to examine the role of inferior ECG leads in distinguishing these two conditions. From January 2004 to June 2006, eight female patients suffering from takotsubo cardiomyopathy were identified by the Mayo Clinic criteria. The clinical and ECG features were compared with 27 consecutive sex- and age-matched patients with anterior wall myocardial infarction admitted to the Coronary Care Unit within the same period. The observed ECG features were then verified with that of 62 published cases of takotsubo cardiomyopathy. Takotsubo cardiomyopathy patients had similar left ventricular ejection fraction (35.0% ± 5.7% vs 38.2% ± 6.4%, P = 0.829), lower peak creatinine kinase level (461 ± 330 U/l vs 2723 ± 1826 U/l, P = 0.020), more ST-segment elevation in the inferior leads (50% vs 7.4%, P = 0.016), and virtually no ST-segment depression in inferior leads (0% vs 48.2%, P = 0.015) compared with patients who had anterior wall myocardial infarction. ST-segment elevation of ≥1.0 mm in lead II had 62.5% sensitivity and 92.6% specificity in detecting takotsubo cardiomyopathy. The observed ECG characteristics were comparable with those in the literature. In patients who present with anterior wall myocardial infarction, the absence of ST-segment depression or ST-segment elevation in inferior leads, especially if the ST-segment in lead II ≥ III, is highly suggestive of takotsubo cardiomyopathy.

Fatal massive upper respiratory tract haemorrhage: an unusual complication of localized amyloidosis of the larynx.

Localized amyloidosis of the larynx is usually described as a non-bleeding lesion. We report a patient with localized laryngeal amyloidosis who developed a massive upper respiratory tract haemorrhage and died. This potentially fatal complication of localized amyloidosis of the larynx merits recognition as the disease could be controlled in most instances by surgical excision of the amyloid deposit.

Modified crush technique with double kissing balloon inflation (sleeve technique): A novel technique for coronary bifurcation lesions

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3–5 mm of proximal stent segment into the main vessel. At the same time, a size‐matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side‐branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.

Percutaneous balloon mitral valvotomy in pregnancy using the inoue balloon catheter

Percutaneous balloon mitral valvotomy (PBMV) using the Inoue balloon catheter was performed successfully in 2 patients with severe mitral stenosis refractory to medical treatment during pregnancy. Because of its unique design and ease of manipulation, we recommend the Inoue balloon catheter for performing PBMV in selected patients with mitral stenosis during pregnancy, as procedure and fluoroscopy times can be significantly shortened.

Diffuse Aortitis Complicating Behcet’s Disease Leading to Severe Aortic Regurgitation

Cardiovascular complications are uncommon in Behçets disease, but are frequently the cause of morbidity and mortality. Venous and peripheral arterial involvement have been well documented, but involvement of the proximal aorta has rarely been described. This report details a Chinese patient with Behçets disease. Diffuse aortitis led to proximal aortic dilatation and severe aortic regurgitation necessitating aortic valve replacement. Histopathology of the aorta revealed features similar to those observed in other systemic diseases with aortic involvement.

Monomorphic epithelioid variant of malignant myoepithelioma of the parotid gland: cytologic features in fine needle aspiration (FNA)

Neoplastic cells with myoepithelial differentiation are fairly common in tumours of salivary glands, both benign and malignant. However, benign salivary gland neoplasms composed exclusively of myoepithelial cells are not common, and malignant myoepithelioma or myoepithelial carcinoma of the salivary gland is rare. Malignant myoepithelioma has been defined as a rare malignant epithelial tumour composed of atypical myoepithelial cells with increased mitotic activity and aggressive growth. Histologically, myoepithelial cells may assume a spindle, plasmacytoid or epithelioid appearance. Accordingly, the histology of malignant myoepithelioma may consist of a monotonous or mixed population of spindle, plasmacytoid and epithelioid myoepithelial cells. In reported cases, spindle cells were the commonest cell type, plasmacytoid cells were second in frequency, while epithelioid cells were the least commonly encountered. In this report, we describe the cytological features of a distinctive case of malignant myoepithelioma, the monomorphic epithelioid variant, of the parotid gland, correctly suspected on FNA. The diagnosis was subsequently confirmed by histological, immunohistochemical and ultrastructural examination of surgically excised specimen. The differential diagnoses on FNA cytology are discussed.