A rare case of central post-stroke pain in a patient with migraine and lacunar infarcts in the medulla oblongata

Studies about headaches associated with acute ischemic stroke in patients suffering from migraine were limited, and therefore we present a clinical case of central post-stroke pain (CPSP) in a 47-year-old woman with migraine and lacunar infarcts in the medulla oblongata and also possible mechanisms of CPSP in patients with migraine. Magnetic resonance imaging of the brain revealed lacunar infarction in the medulla oblongata on the right (vertebral artery basin) and a single focus of gliosis in the parietal lobe on the right. Magnetic resonance angiography of cerebral vessels showed the fetal type of structure of both posterior cerebral arteries. This clinical case is a complex clinical situation of a combination of secondary headaches (post-stroke) in a patient with a primary headache (migraine), which was successfully treated by the combined administration of first-line drugs for the treatment of neuropathic pain in a patient with lacunar infarcts in the medulla oblongata. The treatment of CPSP is a difficult task due to the insufficiently unexplored mechanisms of development, the most effective approaches are those aimed at reducing the increased excitability of neurons.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.

Sars-Cov-2 and Mrna Vaccine-Associated Recurrent Pericarditis Treated with Rilonacept

Background While rare, pericarditis is associated with both acute infection by SARS-CoV-2 as well as the Moderna mRNA-1273 vaccine. The interleukin-1 (IL-1) blocking drugs show promise in cases unresponsive to traditional therapy. Rilonacept is a fusion protein IL-1 alpha and beta cytokine trap which binds and inactivates circulating IL-1. The FDA approved it for the treatment of recurrent pericarditis in 2021. Case A 35-year-old man presented complaining of progressively worsening sharp chest pain aggravated by supine positioning, fatigue, and intermittent low-grade fever two weeks after a booster dose of the mRNA-1273 vaccine. His only past medical history was persistent tachycardia following SARS-CoV-2 infection in early 2020, now well controlled with a metoprolol tartrate. Acute pericarditis was diagnosed by history and echocardiography which showed a small pericardial effusion and enhancement of the pericardium. He was treated successfully with high-dose ibuprofen. Four months later, the patient presented with similar symptoms and echocardiography results following SARS-CoV-2 infection. He was prescribed indomethacin, colchicine, and pantoprazole. The patient returned after two weeks and reported his symptoms were unchanged. Decision-making In this setting of recurrent pericarditis, the standard treatment was ineffective despite a good previous response. Rilonacept was instead initiated. He received a 320 mg dose and reported resolution of symptoms after four days. The patient continued taking rilonacept 160 mg subcutaneously once weekly, and three months later he was again diagnosed with PCR-confirmed acute symptomatic SARS-CoV-2 infection. He continued to take rilonacept weekly and at a follow-up eight weeks after recovering, he reported no recurrence of pericarditis symptoms. Conclusion This case shows that rilonacept is an effective treatment for SARS-CoV-2 and mRNA vaccine-associated pericarditis, and implies that cytokine dysregulation is a significant contributor to its pathogenesis. Furthermore, the case suggests that rilonacept may prevent recurrence of pericarditis in a susceptible individual acutely diagnosed with SARS-CoV-2Copyright © 2023 American College of Cardiology Foundation

Cardiac Angiosarcoma Presenting as Recurrent Pericardial Effusion and Constrictive Pericarditis

Background Malignancy accounts for 15-20% of moderate to large pericardial effusions. Among these, cardiac angiosarcomas are extremely rare. Case A 30-year-old male presented with dyspnea and fatigue, 9 months after COVID-19 infection. He had sinus tachycardia (117 beat/min). Chest X-ray showed cardiomegaly. Echocardiogram demonstrated a large circumferential pericardial effusion with right ventricular collapse. Decision-making Pericardiocentesis yielded 850 ml of bloody fluid, with symptomatic relief. He was discharged on colchicine and indomethacin with a presumptive diagnosis of post-viral pericarditis. A month later, he had recurrent symptoms and re-accumulation of large circumferential effusion. CT chest revealed multiple pulmonary nodules and bilateral pleural effusions. He underwent subxiphoid pericardial window and pleural biopsy. Fluid analysis and biopsy results were inconclusive. Over 3 weeks, he had worsening symptoms, despite a daily pericardial drain output of ~200 ml. Repeat echocardiogram showed loculation of the effusion with signs of constrictive pericarditis. He underwent pericardiectomy. Pathology revealed cardiac angiosarcoma. FDG PET scan showed thoracic metastasis. Anakinra was initiated. Conclusion Idiopathic and post-viral etiologies are the most common causes of pericardial effusion. Although rare, cardiac angiosarcoma should be on the differential diagnosis for recurrent pericardial effusion. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Primary Cardiac Lymphoma with an Aggressive Hostile Take-Over

Background Primary cardiac lymphoma (PCL) is an extranodal lymphoma involving only the heart and/or pericardium. PCL accounts for 2% of primary cardiac tumors and 0.5% of extranodal lymphomas. Its diagnosis is usually delayed due to rarity and non-specific findings. Case A 77-year-old man with Alzheimer dementia, atrial fibrillation on apixaban, and COVID-19 illness 3-weeks prior, who presented to the hospital with diffuse abdominal discomfort, fatigue, anorexia, and hypoactivity. Patient was tachycardic and normotensive with pronounced jugular venous distention, non-collapsing with respiration. ECG revealed sinus tachycardia, first degree atrioventricular (AV) block and chronic LBBB. Cardiac troponins were mildly elevated without significant delta. An abdominopelvic CT revealed an incidental, large pericardial effusion (PE). Bedside echocardiogram confirmed a large hemodynamically significant PE as well as a mass-like echogenicity encasing and infiltrating the pericardium and myocardium at the basal aspect of the right ventricle free wall. Decision-making In view of recent COVID-19 infection, he was started on indomethacin and colchicine for suspected viral or neoplastic pericarditis. Pericardiocentesis drained 900ml of amber to serosanguineous fluid with quick hemodynamic improvement. Fluid analysis was non-diagnostic for neoplasia. Subsequently, he developed symptomatic bradycardia with an intermittent complete AV block with junctional escape rhythm, transitioning to a second-degree AV block after removal of beta-blocker. Awaiting permanent pacemaker implant, he developed ventricular fibrillation with sudden cardiac death that required prolonged unsuccessful ACLS. Autopsy revealed an extensive infiltrative tumor, predominantly right-sided, consistent with primary cardiac B-cell lymphoma. Conclusion PCL should be part of the working diagnosis in patients presenting with a pericardial effusive process in combination with a right sided myocardial mass. Early cardiac MRI/PET scan or biopsy should be considered when the diagnosis is not certain. Prompt diagnosis could allow for treatment that potentially prolongs survival.Copyright © 2023 American College of Cardiology Foundation

Unsuspecting Adult Case of Rhinovirus Pleuropericarditis

Rhinoviridae are the most common cause of upper respiratory tract infections, especially in children, and often referred to as “the common cold”. Symptoms are usually mild, nasopharyngeal in nature;they have, however, been implicated in cases of infantile viral pericarditis. Its role in the presentation of adult viral pericarditis remains unclear. We present the case of a 45-year-old male with a past medical history of pre-diabetes, hyperlipidemia and hypertension with complaints of severe left-sided chest pain that worsened with movement and coughing but improved when lying supine. Two weeks prior to presentation, he had developed an intermittent cough, treated with antibiotics and steroids. On presentation to the ED, the patient was afebrile but hypotensive to 80/52 mmHg, tachycardic to 116 BPM, hypoxic to 88% on room air, improving to 91% with 3L nasal cannula. Physical examination was notable for wheezing and egophony. Laboratory findings were concerning for WBC 19.97x10-3/uL, Hgb 13.4 g/dL, CRP 176 mg/L, Ferritin 772 ug/L, D-dimer 3.70 ug/mL FEU;procalcitonin 0.2 ng/mL and troponin <0.015 ng/mL. Respiratory viral panel revealed negative COVID-19 test but positive for rhinovirus/enterovirus. Electrocardiogram showed sinus tachycardia. Chest computed tomography demonstrated moderate pericardial effusion, ground glass attenuation of the lungs bilaterally with moderate left pleural effusion and reflux of contrast into the hepatic veins, suggestive of right heart failure. Echocardiogram demonstrated small to moderate pericardial effusion. The patient was admitted with the diagnosis of acute rhino/enteroviral-associated pleuropericarditis. Broad-spectrum antibiotics, prednisone, colchicine and indomethacin were commenced. Upon clinical stabilization of his condition, steroids were discontinued and he was discharged home with close follow-up. While rhinovirus has been associated with infantile viral pericarditis, it is implicated in pneumonia and COPD exacerbations in adults but rarely reported as a cause of adult pericarditis. A case-control study of adults diagnosed with acute idiopathic pericarditis had an independent association with an upper respiratory tract infection or gastroenteritis in the month preceding pericarditis diagnosis but did not delineate causative viruses. Therefore in cases of unknown causes of viral pericarditis, thorough history is vital. Steroids as part of the treatment algorithm for pleuropericarditis management has long been debated. Older literature has not favored the use of steroids due to high recurrence rate. However, Perrone et al refuted this point, noting that low-dose steroids with gradual tapers have equal efficacy and recurrence rates as compared with NSAIDs/colchicine. Therefore, steroids may be a reasonable option for patients with contraindications to NSAIDs/colchicine.