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Objective To explore the clinical effect and safety of Suhexiang Pills () in the treatment of patients with tachycardia after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Methods A total of 138 patients with tachycardia after SARS-CoV-2 infection admitted to eight hospitals such as 971st Hospital of the PLA Navy, Changzhou Second People's Hospital, Xuzhou First People's Hospital, Henan Provincial People's Hospital, Henan Chest Hospital from February 2023 to March 2023 were randomly divided into control group and treatment group, with 87 patients in the treatment group and 51 in the control group. Patients in the control group were po administered with betaloc, once a day, and the initial dose was 23.75 mg, adjusted in time according to the patient's heart rate. Patients in the treatment group were po administered with Suhexiang Pills, 1 pill/time, twice daily. Patients in two groups were treated for 7 d. The clinical efficacy of the two groups was observed, and the heart rate and cardiac function indexes, RR interval, blood oxygen saturation and adverse reactions were compared between the two groups before and after treatment. Results After treatment, the total effective rate of the treatment group was 98.85%, and the total effective rate of the control group was 90.20%, and the difference between the two groups was statistically significant (P < 0.05). After treatment, heart rates were significantly decreased in both groups (P < 0.05), and the heart rates of the treatment group were significantly better than those of the control group (P < 0.05) on the 7th day of treatment. After treatment, the level of left ventricular ejection fraction (LVEF) in both groups was significantly higher than that before treatment (P < 0.05), and there was statistical difference between the treatment group and the control group (P < 0.05). The levels of left ventricular end diastolic dimension (LVEDD) and left ventricular end-systolic diameter (LVESD) in the treatment group significantly decreased than that before treatment (P < 0.05), and there was no statistical difference compared with the control group (P > 0.05). After treatment, the maximum RR interval in both groups reached the normal range on the third day, and the treatment group was significantly better than the control group (P < 0.05). Blood oxygen saturation of the treatment group was significantly increased on the 7th day of treatment compared with before treatment (P < 0.05), but there was no statistical significance between the two groups (P > 0.05). There was no significant difference in the total incidence of adverse events between the two groups (P > 0.05). Conclusion Suhexiang Pills decrease heart rates in patients with tachycardia after SARS-CoV-2 infection, which was equivalent to the effect of western medicine, and can protect heart, improve heart function to a certain extent.Copyright © 2023 Editorial Office of Chinese Traditional and Herbal Drugs. All rights reserved.
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Clinical data and follow-up of a case of congenital disorder of glycosylation type Ia (CDG-Ia) combined with dilated cardiomyopathy admitted to the Department of Cardiology, Children's Hospital of Nanjing Medical University were analyzed retrospectively.The 5-year-old female patient was admitted in December 2016 due to recu-rrent shortness of breath for 2 months.Clinical symptoms and signs included repeated attacks of shortness of breath, physical retardation, malnutrition, binocular esotropia, multiple episodes of hypoglycemia, hepatosplenomegaly, hypotonia and other multi-system damages.Cardiac echocardiography suggested the feature of dilated cardiomyopathy, including the significant enlargement of the left ventricle, and decreased systolic function.Genetic testing revealed a compound heterozygous mutation in the PMM2 gene, and as a result, the patient was diagnosed as CDG-Ia.The patient's condition improved after symptomatic treatments such as Cedilanid, Dopamine, Dobutamine, Furosemide, as well as support treatments like myocardium nutrition, blood sugar maintenance, liver protection, etc.After discharge, the patient was given oral Digoxin, Betaloc, Captopril and diuretics, and hypoglycemia-controlling agents.The patient was followed up every 3-6 months.After more than 2 years of follow-up, the heart function and heart enlargement gradually returned to normal.During the Corona Virus Disease 2019 outbreak, self-withdrawal continued for 2 months.Re-examinations showed decreased cardiac function and enlarged left ventricle again.Medications were resumed again, and the patient was followed up closely.This case report suggested that CDG-Ia may be associated with dilated cardiomyopathy, and the cardiac phenotype may be improved by symptomatic supportive treatment.Copyright © 2021 by the Chinese Medical Association.
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Introduction: Retroperitoneal fibrosis (RPF) is a rare disease which can be primary (idiopathic) or secondary to drugs, tumors or infections. We are reporting the first case of RPF causing renal atrophy, renal artery stenosis and renovascular hypertension associated with SARS-CoV2. Method(s): A 37-year-old female nurse presented to her PCP with a new-onset of hypertension. She had recovered from severe SARS-CoV2 infection merely two months ago. Physical examination was remarkable for BP 170/110 mmHg, HR 88 beats/min, BMI of 31 alongside trace pitting edema. Initial lab data showed her creatinine to be 1.1mg/dl and ultrasound of her kidneys showed an atrophied right kidney with a size of 7.8 cm while the left kidney was 11.6 cm. An ultrasound KUB of that same time showed that the size of the right kidney was 10.4 cm and left 11.5 with normal renal parenchyma. She was started on amlodipine 10 mg and valsartan 160 mg per day. Two weeks later she was referred to a nephrologist when her creatinine was increased to 3.1 mg/dl. Renovascular hypertension secondary to right renal artery stenosis or thrombus was suspected. Autoimmune & hypercoagulable work up was negative. CT angiogram showed an ill-defined, poorly enhancing retroperitoneal soft tissue thickening draping the mid abdominal aorta, the origin of SMA, and bilateral renal arteries which terminated above the aortoiliac bifurcation. This, RPF, involved segment of 8.6 cm of the mid and lower abdominal aorta, causing moderate narrowing of proximal SMA, short segment narrowing of proximal left main and accessory renal artery, and diffuse long segmental narrowing of the right main renal artery. RPF encasement of right renal artery lead to poor right renal nephrogram and atrophic kidney. (Figure no A: Abdominal contrast-enhanced computed tomographic (CT) scan showing the encasement of the both renal arteries by the retroperitoneal fibrosis (RPF).Figure no B : Renal angiogram showing the renal artery stenosis on right side) Acute kidney injury (AKI) was initially thought to be due to angiotensin receptor blockade in the setting of bilateral renal artery stenosis. Valsartan was swapped for metoprolol and the serum creatinine levels decreased to 1.5 mg/dl in two weeks. Prednisone was started for RPF at a dose of 60 mg per day with a slow taper over 4 months. Over the next 8 weeks, creatinine became normal and blood pressure was controlled with amlodipine 2.5 mg/day. Subsequently at 4 months her creatinine was 1.0 mg/dl and she was off all anti-hypertensive drugs. A repeat CTA after 6 months showed that there was significant reduction in RPF. Atrophic right kidney was noted without any significant interval change. RPF, renal artery stenosis, renovascular hypertension and right renal atrophy was strongly suspected to be associated with SARS-Cov2 since none of these were identified prior to her suffering from SARS-CoV2. Result(s): [Formula presented] [Formula presented] Conclusion(s): To our knowledge, this is the first case of RPF associated with SARS-CoV-2 causing renovascular hypertension and renal atrophy. Local and systemic production of IL-6, TGF- beta and Th2 cytokines has been demonstrated in idiopathic RPF and pulmonary fibrosis due to SARS-CoV2. The presumptive pathogenesis could involve SARS-Cov2 induced release of IL-6 and other cytokines which can activate B cells and fibroblasts. No conflict of interestCopyright © 2023
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Objectives: We present a case of a 38-year-old male with no known comorbidities who presented with incessant focal atrial tachycardia complicated by tachycardia-mediated cardiomyopathy and COVID-19 infection. He successfully underwent 3D Cardiac Mapping + radiofrequency ablation of the right superior pulmonary vein. Material(s) and Method(s): Results: A 38-year-old male presented with persistent palpitations and tachycardia associated with heart failure symptoms. On work up, 12 L-ECG showed sustained focal atrial tachycardia with heart rate (HR) ranges 170-190 bpm with positive p-wave axis in lead I, II, III, AVF and upright in lead V1. He was initially started on HR-lowering medications and given electrical synchronized cardioversion which were both unsuccessful. A week later, patient developed COVID-19 pneumonia and subsequently completed isolation as per local government protocol. During the course of admission, a POCUS echocardiogram was done which showed a newly depressed left ventricular ejection fraction (EF) of 22% compared to a previous 44% two weeks earlier. Hence, patient eventually underwent successful 3D-mapping and radiofrequency ablation of the right super pulmonary vein via transseptal approach. He was then successfully discharged with Metoprolol 200 mg twice daily alongside with other heart failure medications. Conclusion(s): Development of COVID-19 infection can run the risk of worsening and clinical decompensation among patients with incessant tachyarrhythmia and there are still no established data regarding the safety of doing radiofrequency ablation post-COVID-19 infection. This case report illustrates doing a successful radiofrequency frequency ablation post-COVID-19 infection in a patient who developed incessant atrial tachycardia.
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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
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Background Phospholamban (PLN), an inhibitor of sarcoplasmic reticulum (SR) Ca2+-ATPase, is a regulator of Ca2+ release during excitation-contraction coupling. We present a case of recurrent polymorphic ventricular tachycardia (PMVT)/ventricular fibrillation (VF) due to a PLN mutation. Case 38 year-old male presents after resuscitation following VF arrest. An ICD was implanted. Seven years later, he presented with VF storm requiring ventricular assist device support and he underwent catheter ablation of PVC triggers of VF arising from the moderator band. Because he had an ECG that was concerning for early repolarization syndrome, he was placed on quinidine and metoprolol. After an episode of VT in 2020 in the setting of COVID infection, whole genome sequencing was obtained and identified a pathogenic PLN mutation. PLN L39Ter has been associated with dilated and hypertrophic cardiomyopathy as well as sudden death. The patient has a history of normal left ventricular function and wall thickness by echocardiography. Decision-making Given the involvement of PLN on SR handling of Ca2+, flecainide may be a more effective therapy for the treatment of PMVT/VF in this patient. Conclusion PLN mutations have been associated with cardiomyopathies. This case illustrates a patient with the pathogenic PLN L39X variant with short-coupled PMVT with no imaging evidence of structural heart disease. Whether a more targeted therapy such as flecainide may be more effective in this patient remains to be determined. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Background: The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup provides a weak conditional recommendation in support of hemodialysis (HD) for select patients with severe phenytoin poisoning. Despite this recommendation, the HD clearance of phenytoin is poorly studied. We present a patient who developed phenytoin toxicity that was treated with hemodialysis and report on the efficacy of phenytoin removal during HD. Case report: An 87-year-old man with epilepsy who was maintained on a stable dose of 300mg phenytoin extended-release daily was admitted to the hospital for treatment of Coronavirus Disease 2019 and congestive heart failure. On hospital day 14, the patient had a gradual onset of depressed mental status with hypothermia (nadir 35 degrees Celsius). At this time, he had a rising total blood phenytoin concentration (peak 49.3 mcg/mL [therapeutic 10-20mcg/mL] with an albumin of 3.8 g/dL [normal 3.4-5.4 g/dL]). The patient's other medications included furosemide, aspirin, atorvastatin, digoxin, doxycycline, metoprolol tartrate, and warfarin;he was also receiving albumin and crystalloid for hypovolemia (albumin nadir on hospital day 14: 2.5 g/dL). Free phenytoin concentrations were not available. Alternate etiologies of hypothermia (endocrine, infectious) were excluded. The Poison Control Center was consulted and recommended HD because of the concern for prolonged coma, as per EXTRIP guidelines. The patient received three sessions of HD over a period of 6 days at 2.5-3 h per session using an F160 Optiflux membrane filter (Fresenius Medical Care, Waltham, MA, USA), with a blood flow rate of 350mL/min and a dialysate flow rate of 700mL/min. After the first session of HD (2.5 h) on hospital day 21, his hypothermia resolved and his phenytoin concentration fell from 39.2mcg/mL to 34.2 mcg/mL with only mild improvement in his mental status. After 6 days (hospital day 27), his phenytoin concentration decreased to 19.5 mcg/mL and his mental status normalized. Effluent from the first HD session had phenytoin concentrations below the limit of detection (0.50mcg/mL). Thus, no greater than 52mg of phenytoin was removed during a 2.5-h session of hemodialysis. Discussion(s): The reason for the sudden increase in blood phenytoin concentrations in this patient is unclear in the absence of drug-drug interactions or dosing changes to the phenytoin. Although uncommonly reported, patients with phenytoin toxicity can experience hypothermia. In this case, the patient's hypothermia resolved during HD, although it is unclear if this was related to changes in phenytoin concentration or (more likely) direct extracorporeal warming via the HD machine. If the patient's phenytoin clearance from the first session were extrapolated to subsequent sessions an estimated maximum of 166.4mg of phenytoin would be removed in 8 total hours of HD, which is far less than previously reported phenytoin clearances on the order of grams. This difference may be related to the use of high cutoff dialysis membranes in prior studies, which are not routinely used. Conclusion(s): Although HD rapidly resolved this patient's hypothermia, a minimal amount of phenytoin was recovered in the patient's dialysate. Prior studies suggesting consequential clearance and efficacy of phenytoin removal by extracorporeal treatment may not apply to routine HD methods. Further studies on the utility of extracorporeal treatment for phenytoin toxicity are needed.
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Background and Aim: The European Medicines Agency has approved mRNA vaccines developed by Pfizer/BioNTech and Moderna for the vaccination of adolescents against the SARS-CoV-2 infection. Cases of myocarditis and pericarditis have been described as rare postvaccination complications. We describe the Latvian experience with adolescents suffering from myocarditis following COVID-19 vaccination. Method(s): From June to December 2021 four cases consistent with postvaccination myocarditis were admitted to the Children's Clinical University Hospital, which is the only centre with special-ized paediatric cardiology care in Latvia. The Pfizer/BioNTech vaccine had been used in all. An ECG, Holter monitoring and ECHO was done, HS Troponin I levels checked, the most common infectious causes of myocarditis were excluded, and a cardiac MRI was performed in all cases. Result(s): Case 1: 12-year-old girl, developed chest pain on postvac-cination day Nr 4 (PVD4) after the 1st dose. Holter monitoring revealed rare non-sustained ventricular tachycardia (NSVT), ECHO showed moderate mitral insufficiency, and a hyperecho-genic papillary muscle, troponin level peaked at 5339 pg/ml (PVD6), MRI (PVD 7) showed widespread myocardial oedema, transmural fibrosis. Symptoms resolved in 1 day, metoprolol suc-cinate and lisinopril were prescribed. Mitral insufficiency persists 5 months later. Case 2: 15-year-old boy, developed chest pain after the 2nd dose on PVD2 and lasted for 7 days, he was admitted on PVD11 with a peak troponin level of 19pg/ml. MRI (PVD15) showed widespread myocardial oedema. Metoprolol succinate was prescribed. Case 3: 15-year-old boy, developed chest pains on the day of the 1st dose and persisted for 35 days, he was admitted on PVD24 with peak troponin level 15ng/ml. MRI (PVD29) showed mild myocardial oedema, myocardial and pericardial fib-rosis. Case 4: 13-year-old boy, developed chest pain on PVD2, which lasted for 65 days, he had an episode of syncope. Holter monitoring showed frequent PVCs, and NSVT, on PVD34 tro-ponin level was 2,5pg/ml. The child received a course of NSAIDs and was referred to us on PVD68. MRI (PVD69) revealed wide-spread myocardial oedema, fibrosis, and pericarditis. Methylprednisolone was given, and betaxolol was prescribed. Conclusion(s): Our case series show that some cases of postvaccination myocarditis develop complications requiring long-term treatment.
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SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo
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SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Point of care ultrasonography (POCUS) uses an ultrasound technique that helps physicians augment physical examination findings and guide clinical decision-making at the bedside. We present a case that became a watershed moment for internal medicine residents at Abington Jefferson Hospital to use POCUS for every patient with atrial flutter/fibrillation with RVR prior to initiating diltiazem drip. CASE PRESENTATION: A 73-year-old male presented to the emergency department with complaints of palpitations. He was tachycardic with a heart rate in the 150s, and his rhythm was irregular. His basic labs were normal;an electrocardiogram investigation showed that he was experiencing an atrial flutter with 2:1 and 3:1 blocks. Chest X-ray was clear. He was given IV metoprolol 10 mg twice without achieving rate control and then started on a diltiazem drip, which initially improved his heart rate to 70s with rhythm changing to atrial flutter with 4:1 block. However, he started to become hypoxic, requiring intubation and then hemodynamically unstable, requiring initiation of pressors. Postintubation CXR indicated bilateral diffuse pulmonary edema and vascular congestion. Subsequently, he had Pulseless electrical activity (PEA) arrest. Return of spontaneous circulation (ROSC) was achieved after 3 minutes of chest compression and one round of epinephrine injection. Transthoracic echocardiogram showed an ejection fraction of 10%. He had a right heart catheterization which showed a CI of 1.7 and elevated PCWP and RVP. He was started on milrinone for ionotropic support and needed norepinephrine, vasopressin and phenylephrine to sustain his blood pressure. DISCUSSION: Atrial flutter and fibrillation are routinely seen arrhythmias in hospital settings. Patients with irregular rhythm who are in rapid ventricular rate and normotensive are often given IV metoprolol few times and then started on a diltiazem drip if RVR continues. Diltiazem not only decreases heart rate (negative chronotropic) but also decreases ventricular squeeze (negative ionotropic). It is contraindicated in patients with reduced ejection fraction. Patients’ ejection fraction values are not always known, especially if they have never had a transthoracic echocardiogram in the past or prior records are not available. POCUS helps physicians and residents to access and estimate LV function quickly and augments clinical decision making at the bedside. CONCLUSIONS: Internal Medicine Residents at Abington Hospital have made it a part of their protocol to always perform bedside ultrasonography in patients with atrial flutter/fibrillation with rapid ventricular rate before initiating diltiazem drip to prevent further avoidable cardiogenic shocks. Reference #1: Fey H, Jost M, Geise AT, Bertsch T, Christ M. Kardiogener Schock nach bradykardisierender Therapie bei tachykardem Vorhofflimmern : Fallvorstellung einer 89-jährigen Patientin [Cardiogenic shock after drug therapy for atrial fibrillation with tachycardia : Case report of an 89-year-old woman]. Med Klin Intensivmed Notfmed. 2016 Jun;111(5):458-62. German. doi: 10.1007/s00063-015-0089-9. Epub 2015 Oct 6. PMID: 26440099. Reference #2: Bitar ZI, Shamsah M, Bamasood OM, Maadarani OS, Alfoudri H. Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU. J Cardiovasc Imaging. 2021 Jan;29(1):60-68. doi: 10.4250/jcvi.2020.0138. PMID: 33511802;PMCID: PMC7847790. Reference #3: Murray A, Hutchison H, Popil M, Krebs W. The Use of Point-of-Care Ultrasound to Accurately Measure Cardiac Output in Flight. Air Med J. 2020 May-Jun;39(3):218-220. doi: 10.1016/j.amj.2019.12.008. Epub 2020 Jan 14. PMID: 32540116. DISCLOSURES: No relevant relationships by Fnu Aisha No relevant relationships by Lucy Checchio No relevant relationships by Ans Dastgir No relevant relationships by Shravya Ginnaram No relevant relationships by Syeda Hassan No relevant relationships by Chaitra Janga No relev nt relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Binod Poudel No relevant relationships by Shreeja Shah
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Chronic lymphocytic leukaemia is a haematological malignancy that occurs due to an increased proliferation of mature B lymphocytes. It is considered to be the most common leukaemia in adults. Hyponatremia is commonly seen in such patients. This case report is about a 75-year-old male, who presented with giddiness, followed by altered sensorium. However, the patient had no motor weakness or sensory loss. Initially, a diagnosis of posterior circulation stroke was made but Magnetic Resonance Imaging (MRI) brain did not show associated signs. The routine investigations showed highly elevated total leukocyte count and hyponatremia. The patient was worked up for malignancy and diagnosed with Chronic lymphocytic leukaemia. Oncology reference was taken and treated with tablet Ibrutinib. On discharge, the patient's mentation improved, and he is on regular follow-up.
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CASE: The patient is a 66-year-old male presenting with progressive ambulatory dysfunction and lower extremity weakness that began ten days ago. Notably, the patient was admitted to the hospital two months prior with similar complaints. At that time, he was diagnosed with transverse myelitis after MRI showed a spinal cord lesion concerning for demyelination at T3-T4. The patient was treated with IV steroids and discharged. Neurology impression at time of discharge was transverse myelitis possibly related to Covid vaccination two weeks prior to admission. The patient states he was doing fine after initial discharge before recurrence of his progressive weakness and difficulty walking that led to the current admission. He denies fever, chest pain, abdominal pain, and bladder/ bowel incontinence. The patient is a former smoker and denies current alcohol or drug use. Past medical history includes WPW status post ablation, stable thoracic aortic aneurysm, peripheral neuropathy secondary to past alcohol abuse, osteoarthritis, GERD, and anxiety. Family history is remarkable for cancer, coronary artery disease, and diabetes in his father. Medications include metoprolol, tamsulosin, pantoprazole, olanzapine, and venlafaxine. Neurological exam is positive for atrophy and decreased vibratory sensation in bilateral lower extremities. His gait is not assessed due to safety concerns, but the patient notes he has begun using a cane to assist with ambulation. Otherwise, physical exam is unremarkable. Imaging studies include MRI showing T3-T4 hyperintensity, as seen during previous admission two months prior. Labs including ANA, rheumatoid factor, SPEP, CSF studies, and AQP-4 were negative. After an unrevealing workup, the patient experienced symptomatic improvement with IV steroids and was discharged home. IMPACT/DISCUSSION: Our case illustrates a clinical picture of Covid-19 vaccine-related transverse myelitis, a rare but serious complication of the vaccine. The prolonged course of this patient's complications is concerning, although the benefit of receiving the vaccine remains unquestionable. Furthermore, although the timing of symptom onset and vaccination suggests a relation, there are other diagnoses that could explain the presentation and further research is needed regarding vaccine-related side effects. This case emphasizes the importance of maintaining a high index of suspicion for neurological issues of unclear etiology following recent Covid-19 vaccination despite their rare occurrence. CONCLUSION: Teaching points: Diagnostic criteria for transverse myelitis includes sensory, motor, or autonomic dysfunction attributable to spinal cord, no evidence of cord compression, bilateral symptoms with clear sensory level, and inflammation defined by CSF analysis, elevated IgG, or MRI enhancement. Neurological complications of the Covid vaccine include general symptoms such as headache, fever, and fatigue, Bell's palsy, encephalomyelitis, myelitis, and cerebral venous sinus thrombosis.
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Background: Dysgeusia is a distortion of taste sensation. Etiologies can include medications and Covid-19, among others. Dysgeusia may lead to appetite loss which is nonspecific and can have multiple causes, including major depressive disorder (MDD) (Coulter, 1988). Although post-marketing data revealed no association between nifedipine and dysgeusia (Ackerman, 1997), case reports of dysgeusia from nifedipine exist (Ackerman, 1997). We present a case of nifedipine-induced dysgeusia mistaken for depression. Case Report: A 42-year-old man with hypertension and diabetes was admitted to the hospital following right thalamocapsular and intraventricular hemorrhages. Hypertension was managed with metoprolol, lisinopril, nifedipine, and chlorthalidone. Levetiracetam was started for seizure prophylaxis. Medications included pantoprazole, simethicone, transdermal lidocaine, insulin, metformin, docusate, senna, and subcutaneous heparin. Psychiatric consultation was requested out of concern that appetite loss indicated depression. The day before psychiatric evaluation, mirtazapine 15 mg at bedtime for mood and appetite was started. Nifedipine 90 mg daily had been started 9 days prior to his first complaint of decreased appetite. The patient reported feeling disconnected from his family and “sad" for ∼10 years, complaining that family members “talk behind his back.” He was otherwise without paranoia. He denied insomnia, anhedonia, hopelessness, poor concentration, suicidal ideation, homicidal ideation, guilt, mania, or hallucinations. He reported poor appetite due to epigastric discomfort and bad taste to foods. Covid-19 testing was not yet widely available. No other signs or symptoms suggestive of Covid-19 were present. Although alert and fully oriented, concentration was impaired with sometimes tangential thought processes. Affect was full without depression. A diagnosis of adjustment disorder was made. The psychiatry team suspected nifedipine-induced dysgeusia and advised discontinuing nifedipine. Appetite improved two days later. Discussion: This case highlights the importance of considering alternative causes of nonspecific symptoms of depression, including decreased appetite, that may have non-psychiatric causes. Dysgeusia is widely recognized as a symptom of Covid-19. Other causes, including medications may be underrecognized and amenable to intervention. Conclusion: It would be helpful to consider medication side-effects as potential causes for taste distortion alongside psychiatric diagnoses, and COVID-19. References: 1. Coulter DM: Eye pain with nifedipine and disturbance of taste with captopril: a mutually controlled study showing a method of post marketing surveillance BMJ 1988;296: 1086–8. 2. Ackerman BH, Kasbekar N: Disturbances of taste and smell induced by drugs. Pharmacotherapy 1997;17(3):482-96.
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Introduction: Hydroxychloroquine is used for the treatment of malaria, rheumatoid arthritis and lupus erythematosus. In 2020, hydroxychloroquine was also repurposed for the treatment of COVID-19. Although current evidence does not encourage the use of hydroxychloroquine to treat COVID-19, its therapeutic and prophylactic use against COVID-19 is still investigated in clinical trials. Despite being in clinical use for more than 60 years, its clinical pharmacology is not well understood. Hydroxychloroquine is metabolized into three active metabolites, but the key metabolizing enzymes have not been unambiguously identified. Moreover, little is known about the inhibitory effects of hydroxychloroquine on cytochrome P450 (CYP) enzymes. Objectives: This study aimed to investigate the CYP metabolic and inhibitory profile of hydroxychloroquine and its three metabolites in vitro. Methods: Hydroxychloroquine metabolism was studied in human liver microsomes (HLM) and recombinant CYP enzymes using substrate depletion and CYP-selective inhibitors. The inhibitory effects of hydroxychloroquine and its metabolites on nine CYP enzymes were also determined in HLM, using automated probe substrate cocktail assays. Results: Based on screening experiments, CYP3A4, CYP2D6 and CYP2C8 were the key enzymes involved in hydroxychloroquine metabolism in vitro. Although the intrinsic clearance (CLint) value of hydroxychloroquine depletion by recombinant CYP2D6 (0.87 μl/min/pmol) was more than 10-fold higher than that by CYP3A4 (0.075 μl/min/pmol), scaling of the recombinant data to HLM level resulted in similar CLint values for CYP2D6 and CYP3A4 (11 and 14 μl/min/mg) because of the much greater abundancy of CYP3A4 than that of CYP2D6. The scaled HLM CLint of CYP2C8 was 5.7 μl/min/mg. Data in HLM with CYPselective inhibitors also suggested relatively equal roles for CYP2D6 and CYP3A4 in hydroxychloroquine metabolism, and a smaller contribution for CYP2C8. In CYP inhibition experiments, hydroxychloroquine and its three metabolites were direct CYP2D6 inhibitors (50% inhibitory concentration IC50 18-135 μM), while all metabolites were CYP3A timedependent inhibitors (IC50 12-117 μM, IC50 shift 2.2-3.4-fold). CYP2D6 inhibition explains the reported clinical drug-drug interaction between hydroxychloroquine and the CYP2D6 substrate metoprolol. The present data, together with the inhibitors' estimated intracellular hepatocyte concentrations, were successfully used in a static model to predict the fold increase in metoprolol AUC (predicted: 2.3- 2.8-fold, observed: 1.65-fold). Conclusion: The present study unambiguously demonstrates that hydroxychloroquine is metabolized mainly by CYP2D6, CYP3A4 and CYP2C8 in vitro. Moreover, hydroxychloroquine and its three metabolites are CYP2D6 reversible inhibitors, and hydroxychloroquine metabolites are CYP3A time-dependent inhibitors. The current data can be used in static and physiologically-based pharmacokinetic models to predict hydroxychloroquine drug-drug interaction potential, as shown with the successful prediction of hydroxychloroquine - metoprolol drug-drug interaction. (Table Presented).
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The prevalence of Pheochromocytoma in pat ient with hypertension is 0.1 -0.6%. These types of tumours are known for unpredictable perioperative course and hemodynamic instability. Various different drugs and anaesthesia techniques can be used to tackle these situations. Dexmedetomidine is emerged as newer agent with better hemodynamic stability, reducing requirement of other anaesthesia drugs, blunting of sympathoadrenal response in resection of Pheochromocytoma. We report four cases operated between January 2021 to June 2021.Preoperative preparation was done with α and β blockade. Dexmedetomidine was used during induction as 1 mcg/kg over 10 mins followed by 0.7mcg/kg/hr intraoperatively. Combination of Dexmedetomidine, Fentanyl, NTG, Isoflurane and Epidural analgesia was used. IF needed boluses of Esmolol and Labetalol were used during tumor manipulation. All the patients had an uneventful perioperative course. Dexmedetomidine with pre-operative α and β blockade reduce the need of other drugs intraoperatively and can be used as anaesthetic adjunct to maintain steady hemodynamic.
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Introduction: SARS-COV-2, causing the COVID-19 pandemic, had a disease spectrum affecting multiple organs since its emergence in 2019. There is an association between COVID-19 and thyroid disease. Multiple vaccines had been approved for SARS-COV-2. Despite their safety profile, adverse effects have been reported. An association between thyrotoxicosis after the vaccine has been reported. But COVID-19 vaccine is very rare to precipitate a thyroid storm. Case Description: 29-year-old gentleman, presented to Emergency Department (ED) complaining of shortness of breath for 5 days, increasing in severity. He had a cough with whitish sputum, no fever or chest pain. He had palpitations and 10 kg weight loss, for 6 months. Five days prior to the presentation he received the second dose of the BNT162b2 vaccine (Pfizer-BioNTech COVID -19 vaccine) Physical examination: the vital signs showed tachycardia 175 beat/minute with an irregular pulse, otherwise unremarkable, he was conscious alert and oriented to time place and person, there was bilateral mild exophthalmos and diffuse soft goiter. Chest exam showed bilateral coarse basal crackles. He has bilateral pitting edema of the lower limbs. Blood investigation was remarkable for TSH < 0.01 (0.3-4.5 mIU/L), FT3 12.6 (3.6-7.4 pmol/L), FT4 48.5 (11-23.5 pmol/L) and TSH receptor antibodies (TRAB) 34, Positive > 1.75 IU/L. Electrocardiography showed atrial fibrillation with a rapid ventricular response. Echocardiography showed reduced ejection fraction (40%) with moderate global hypokinesia. The patient was admitted under MICU care as thyroid storm (Bursh-Wartosfsky score 50/140) secondary to Graves’s disease and precipitated by COVID 19 vaccine. He was started on Propylthiouracil 200 mg every 4 hours, hydrocortisone 100 mg every 8 hours, Lugol’s solution 10 drops every 8 hours, cholestyramine 4 gm every 6 hours, and metoprolol 12.5 mg every 12 hours, the dose of metoprolol increased gradually to avoid worsening of heart failure. The patient’s condition was improving, he was switched from propylthiouracil to carbimazole 20 mg twice daily, and after a few days, he was stable and discharged home on carbimazole and metoprolol. The patient didn’t attend the endocrine clinic for follow-up as he traveled back to his home country. Discussion: The association between thyrotoxicosis and the COVID-19 vaccine is reported in the literature. Very rarely COVID-19 vaccine can precipitate thyroid storm in a patient with Graves’s disease. The immune system activation after the vaccine possibly leads to a decompensated state in this patient with existing hyperthyroidism.
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Introduction: SARS-CoV-2 causes COVID-19 disease which can affect multiple organs including the lungs, heart, gastrointestinal tract, kidneys, central nervous system, and the endocrine system. Subacute thyroiditis is commonly caused by viral etiologies and is emerging as a potential complication of COVID-19. We report herein a case of subacute thyroiditis following COVID 19 infection. Case Description: A 57-year-old gentleman known to have hypertension, hyperlipidemia, and reactive airway disease, presented to the Emergency Department (ED) 10 days after testing positive for SARS-CoV-2. He reported worsening shortness of breath, chest pain, increasing cough, generalized weakness, exercise intolerance, and decreased appetite. In the ED, he was hypoxemic (SpO2=93%), afebrile (T=36.9ºC) and hemodynamically stable (BP=120/76 mmHg, HR=88bpm). Otherwise, the rest of his physical exam was unremarkable. Chest X-Ray revealed COVID-19 associated pneumonia and his COVID PCR test was positive. He had elevated liver function tests (AST 588 U/L;ALT 933 U/L;AlkPhos 819 U/L) and electrolytes imbalance were noted. The patient was admitted and treated with a course of antibiotics and steroids. Labs also exhibited suppressed TSH at 0.164 mcUnits/mL (0.350 - 5.000 mcUnits/mL), elevated free T3 at 4.3 pg/mL (2.2 - 4.0 pg/mL) and free T4 at 2.2 ng/dL (0.8 - 1.5 ng/dL), and negative anti-thyroid peroxidase antibodies, anti-thyroglobulin and TSH receptor antibodies. Upon further investigation, he reported heat intolerance, excessive sweating, and occasional tremors. He denied any personal or family history of thyroid disease as well as any amiodarone consumption. Subacute thyroiditis was diagnosed. The home medication of Beta-blocker (metoprolol) was continued and cholestyramine 4g twice daily was added to his regimen. Symptoms and free T3 and T4 levels improved and were back to normal upon discharge. Four months later, in the outpatient setting, thyroid function tests remained normal. Discussion: COVID-19 can cause simultaneous inflammatory multi-organ damage. Our patient had COVID-19 associated pneumonia, liver injury and subacute thyroiditis. Non-thyroidal illness and steroid use may affect thyroid functions and lead to suppressed TSH. In such instances, we would expect the free T3 to be low, unlike our patient’s data. Due to the wide range of organ involvement and presenting symptoms associated with COVID-19, it is not uncommon to neglect some emerging conditions while focusing and treating the more life-threatening ones. Subacute thyroiditis is a commonly overlooked complication associated with COVID-19. Its presentation can range from being asymptomatic to a full-blown thyroid storm. Untreated hyperthyroidism can cause worsening hemodynamics in COVID-19 patients. Therefore, recognizing subacute thyroiditis in such patients may prevent more severe and serious sequelae.
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Introduction: Covid 19 infection is a recent pandemic which has been linked numerous symptoms post recovery from acute illness. Inappropriate sinus tachycardia[IST] is one of the conditions seen in patients recovered from Covid 19 infection. Currently there is no effective treatment for IST. The present study compares the efficacy of Beta blockers and Ivabradine in controlling the heart rate in IST. Methods: A multi centric prospective study was carried out in 48 patients who developed Post COVID IST for a period of six months. The data was collected and analysed using appropriate statistical test for comparision of minimal, mean, and maximum heart rate at zero, three, and six months. RESULTs: The participants were divided into two random groups. Group A received Metoprolol 50 mg once daily and group B received Ivabradine 5 mg twice daily. Both the groups were followed and then their minimal, mean and maximal heart rate was recorded at zero, three and six months. Both the drugs were found to be effective in decreasing the heart rate with a p value of less than 0.05. Ivabradine was found to be superior than metoprolol in controlling mean heart rate over six months duration with a p value of less than 0.01.Ivabradine also had better effect than metoprolol in controlling maximal heart rate at three months with a p value of less than 0.01 and over six months with a p value of less than 0.001. Conclusion: Treatment of post COVID 19 IST with Ivabradine has shown to improve basal as well as mean heart rate and is more effective than Beta blocker for a long term use. It can be used as a better alternative to Beta blocker who developed its side effects or are intolerant to it. [ FROM AUTHOR] Copyright of Journal of Cardiovascular Disease Research (Journal of Cardiovascular Disease Research) is the property of Journal of Cardiovascular Disease Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
ABSTRACT
Background: The mRNA COVID vaccine is a rare cause of myocarditis in young patients. We describe a case of cardiogenic shock with extensive workup ruling out COVID vaccine induced myocarditis. Case: 42-year-old female who drinks 5 Monster energy drinks and 3-4 cups of coffee daily presented to the hospital with palpitations two weeks following her mRNA COVID vaccine. EKG showed atrial tachycardia with heart rates of 160 beats per minute. Adenosine and Lopressor were administered resulting in hemodynamic instability requiring norepinephrine. An echocardiogram showed dilated cardiomyopathy with ejection fraction of 15%. Right heart catheterization was performed, and the cardiac index was 1.22 L/min/m², systemic vascular resistance was 1918 dynes*sec*cm-5 and wedge pressure was 31 mm Hg. The patient was started on nitroprusside, furosemide, and milrinone drips and she began to improve. The patient was adamant the vaccine is what triggered her heart failure and extensive testing was performed to rule out COVID vaccine induced myocarditis. Workup showed normal coronary arteries and no evidence of infiltrative disease or myocarditis on cardiac MRI. The etiology was from tachycardia induced cardiomyopathy triggered by excessive stimulants and the patient had successful atrial tachycardia ablation of the right superior pulmonary vein. She was discharged on medical therapy for heart failure and advised to stop drinking energy drinks. Decision-making: Once the patient did not respond to the rate controlling agents an echocardiogram showed reduced ejection fraction. Right heart catheterization confirmed cardiogenic shock and nitroprusside and milrinone were started to help reduce afterload and improve contractility. Workup to exclude COVID induced myocarditis lead to the diagnosis of tachycardia induced cardiomyopathy and atrial tachycardia ablation was performed. Conclusion: We report a case of cardiogenic shock with workup diagnosing tachycardia induced cardiomyopathy induced from a combination of excessive monster energy drinks and coffee. She was treated successfully with afterload reduction, inotrope support, and atrial tachycardia ablation.