An Unusual Case of Heart Failure: Sometimes When You Hear Hoof Beats You Should Think of Zebras.

This case describes a 74-year-old male who was hospitalized with hyponatremia and worsening systolic and new diastolic heart failure. Workup showed low voltage QRS complexes on electrocardiogram and new diastolic dysfunction on echocardiogram. Because of this clinical scenario amyloidosis was suspected. ATTR amyloidosis was confirmed without doing an invasive endocardial biopsy by the use of immunofixation studies and Technetium 99 PYPm scan, and abdominal fat pad biopsy. The types and manifestations of amyloidosis in general and cardiac amyloidosis, in particular, are reviewed as well as the diagnostic test available to the clinician to confirm this diagnosis.

A Curious Case of Encephalopathy in a Hospitalized Patient: Round Up the Unusual Suspects.

This case describes a 52-year-old female who developed encephalopathy after being hospitalized with sepsis from a recently placed Permcath. A grade two decubitus ulcer was also a potential source of infection. Cefepime and Vancomycin were empirically begun, and the patient improved hemodynamically and clinically. She developed encephalopathy on day six of hospitalization. When the Cefepime was discontinued the encephalopathy promptly resolved. The causes of hospital acquired encephalopathy and potential difficulties in making this diagnosis are discussed with special emphasis on Cefepime induced encephalopathy.

An unusual case of metastasis to the left side of the heart: a case report.

INTRODUCTION: Cardiac metastases are found in six to 20% of autopsies of patients with malignant neoplasm. The most common neoplasms that metastasize to the heart are malignant melanoma, lymphoma, and leukemia, but the relative numbers are greater with breast and lung cancers, reflecting the most common incidence of these cancers. CASE PRESENTATION: A 60-year-old Hispanic man presented to our hospital after being transferred from an outside hospital for workup and evaluation of an adrenal mass of the abdomen and pelvis, found on computed tomography. His chief complaint upon admission was altered mental status. Physical examination was unremarkable. He was alert and oriented and had a dry and non-erythematous oropharynx, and bilateral diffuse wheezing on lung examination. Computed tomography of the chest showed multiple hypodense lesions in the left ventricular myocardium, suggestive of metastases. There were also tiny sub-centimeter nodular densities in the right upper and lower lobes. Adrenal glands contained hypodense lesions, which showed characteristic adenocarcinomatous malignant cells. CONCLUSION: Cancers which have metastasized to the heart are found in six to 20% of patients with malignant neoplasms. The right side of the heart is more commonly involved in metastasis. This study is unusual in that a tumor of an unknown primary origin had metastasized to the left side of the heart.

Medical qualification of a commercial spaceflight participant: not your average astronaut.

BACKGROUND: Candidates for commercial spaceflight may be older than the typical astronaut and more likely to have medical problems that place them at risk during flight. Since the effects of microgravity on many medical conditions are unknown, physicians have little guidance when evaluating and certifying commercial spaceflight participants. This dynamic new era in space exploration may provide important data for evaluating medical conditions, creating appropriate medical standards, and optimizing treatment alternatives for long-duration spaceflight. CASE: A 57-yr-old spaceflight participant for an ISS mission presented with medical conditions that included moderately severe bullous emphysema, previous spontaneous pneumothorax with talc pleurodesis, a lung parenchymal mass, and ventricular and atrial ectopy. The medical evaluation required for certification was extensive and included medical studies and monitoring conducted in analogue spaceflight environments including altitude chambers, high altitude mixed-gas simulation, zero-G aircraft, and high-G centrifuge. To prevent recurrence of pneumothorax, we performed video-assisted thoracoscopic pleurodesis, and to assess lung masses, several percutaneous or direct biopsies. The candidate's 10-d mission was without incident. CONCLUSION: Non-career astronauts applying for commercial suborbital and orbital spaceflight will, at least in the near future, challenge aerospace physicians with unknowns regarding safety during training and flight, and highlight important ethical and risk-assessment problems. The information obtained from this new group of space travelers will provide important data for the evaluation and in-flight treatment of medical problems that space programs have not yet addressed systematically, and may improve the medical preparedness of exploration-class missions.

Total parenteral nutrition associated crystalline precipitates resulting in pulmonary artery occlusions and alveolar granulomas.

This case report describes total parenteral nutrition (TPN) -associated crystalline precipitates occluding the pulmonary artery branches in a Crohn's disease patient who survived. These precipitates caused focal vascular disruptions and alveolar granulomas. High-resolution CT (HRCT) scan demonstrated a diffuse ground-glass appearance. Pulmonary function tests showed severe ventilatory defects, arterial hypoxemia, and decreased oxygen saturations. Energy dispersive x-ray analysis (EDAX) of the patient's lung biopsy and expectorant demonstrated similar patterns, supporting crystal migration into the alveoli. Treatment included broad-spectrum antibiotics, anticoagulation, corticosteroids, and daily pulmonary toilet. The patient required continuous supplemental oxygen for two months and then was able to use it intermittently. This patient survived widespread pulmonary vascular occlusions secondary to precipitation and crystallization of TPN solution, with moderately severe residual deficits in exercise tolerance and chest x-ray abnormalities. This case underscores the importance of surveillance and recognition and of TPN-associated complications by health care workers.

Pathologic features of Mycobacterium kansasii infection in patients with acquired immunodeficiency syndrome.

CONTEXT: Mycobacterium kansasii is a slow-growing photochromogenic mycobacterium that may infect patients with human immunodeficiency virus (HIV) late in the course of acquired immunodeficiency syndrome (AIDS). The clinical features of pulmonary and extrapulmonary infections have been described in the literature; however, the pathology of infection has not been adequately addressed. OBJECTIVE: This report describes the pathologic features of 12 cases of M kansasii infection in patients with AIDS. DESIGN: The medical records, autopsy protocols, cytologic material, and histologic material from patients with AIDS and concomitant M kansasii infection at a tertiary-care medical center during 1990-2001 were reviewed. RESULTS: Twelve cases were identified, 6 by autopsy, 5 of which were diagnosed postmortem. Four of the 12 cases had cytologic material and 4 cases had histologic biopsies available for review. Pulmonary infection was most common (9/12), and all patients in whom thoracic lymph nodes were assessed showed involvement (7/7). Abdominal infection was less frequent, with only 1 of 6, 2 of 6, and 2 of 6, demonstrating liver, spleen, and abdominal lymph node infection, respectively. Isolated infections without documented pulmonary infection included brain abscess (n = 1), ulnar osteomyelitis (n = 1), and paratracheal mass (n = 1). Cytologic and histologic material showed a wide range of inflammatory reactions, including granulomas with and without necrosis, neutrophilic abscesses, spindle-cell proliferations, and foci of granular eosinophilic necrosis. The M kansasii bacillus was characteristically long, coarsely beaded, and frequently showed folded, bent, or curved ends. Intracellular bacilli were randomly or haphazardly distributed within histiocytes. CONCLUSION: Mycobacterium kansasii infection produces predominantly pulmonary infection in late-stage AIDS with a high incidence of thoracic lymph node involvement and a much lower incidence of dissemination to other sites. Infection is manifest as a wide variety of inflammatory reactions on cytology and histology; however, the characteristic appearance of the bacillus on acid-fast bacilli stain and its intracellular arrangement in histiocytes can allow a presumptive identification.