Gastroduodenal artery aneurysm - an extremely rare but insidious cause of abdominal pain: a case report.

An arterial aneurysm is a localized weakening of the artery wall that results in pathological dilatation. All intra-abdominal artery aneurysms are labeled as visceral artery aneurysms (VAA), apart from the aorto-iliac artery aneurysms. VAA´s are rare, gastroduodenal artery aneurysms (GDAA), constituting 1.5% of visceral artery aneurysms. A woman in her early 80s´ presented with chronic epigastric pain, weight loss, and nausea. Conservative management was unsuccessful. Imaging revealed a GDAA, prompting endovascular coil embolization. Subsequent evaluation confirmed Polyarteritis Nodosa (PAN), treated with rituximab. The report underscores the diagnostic challenges, emphasizing the need for a multidisciplinary approach using imaging and angiography. GDAA's potential life-threatening rupture necessitates prompt intervention, as illustrated in this case. The rare association with PAN, although infrequent, underscores the importance of considering underlying etiologies in multiple visceral aneurysms. Early diagnosis and intervention are pivotal for this uncommon yet potentially lethal condition.

Arrhythmogenic Left Ventricular Cardiomyopathy Associated With a Phospholamban Gene Mutation in a Young Female: A Case Report and Literature Review.

Arrhythmogenic cardiomyopathy (ACM) is a myocardium disease characterized by phenotypic features of myocardial scarring due to fibrofatty myocardial replacement often associated with global or regional ventricular dysfunction. For years after arrhythmogenic right ventricular cardiomyopathy (ARVC) was first described, the left ventricle (LV) was generally considered normal or minimally involved. In recent years, however, LV involvement has been recognized. It usually presents with early-on arrhythmias more than heart failure symptoms compared to dilated cardiomyopathy. It can be right ventricular, biventricular, or left ventricular. The underlying pathophysiology involves either desmosomal or non-desmosomal mutations. Phospholamban (PLN) mutation is one of those and is associated with more severe arrhythmias and SCD. Primary prevention with ICD implantation should be considered in these patients, even the ones with an ejection fraction greater than 35%. In addition, if such patients progress to Stage D heart failure, they need to be evaluated for advanced heart failure therapies.

Pembrolizumab-Induced Broken Heart Syndrome, Pneumonitis, and Hypophysitis Occurring Concurrently; A Deadly Triad.

Immune checkpoint inhibitors are novel medications used to treat a wide range of solid organ tumors and work by stimulating the cellular immune response. With their increasing use, more and more multiorgan side effects are reported in the literature. Prompt recognition of these findings is vital for the safe clinical use of these agents. Most side effects are immune-mediated injury, and the treatment involves stopping the ICI drug and systemic steroids. We report a case of a 72-year-old female treated with pembrolizumab monotherapy for non-small cell lung cancer. She presented for dyspnea and generalized weakness after the second session of pembrolizumab. She was found to have a triad of Takotsubo cardiomyopathy, hypophysitis, and pneumonitis. The patient was discharged home on steroids and heart failure treatment with the discontinuation of further sessions of pembrolizumab.

Heart Failure Associated With Mycoplasma Pneumoniae Infection, A Case and Review of Literature.

Mycoplasma pneumoniae is well known to cause pulmonary infection. However, it often has extrapulmonary manifestations as well. We diagnosed and treated a 41-year-old female who presented with symptoms of pneumonia along with multisystem involvement, including rash, acute hepatitis, and new onset heart failure that improved with steroids and doxycycline. Subsequent guideline-directed medical therapy for non-ischemic cardiomyopathy (NICM) coincided with the complete recovery of the left ventricular function in three months. We also did a brief literature review with similar prior reported cases.

A Rare Association: Non-ST Elevation Myocardial Infarction (NSTEMI) Secondary to Respiratory Syncytial Virus (RSV) Infection.

We present a case report on a rare association between non-ST elevation myocardial infarction (NSTEMI) and respiratory syncytial virus (RSV) infection in a patient with no traditional risk factors for cardiovascular disease (CVD) including a family history of premature coronary artery disease (CAD). While RSV is commonly known for its respiratory manifestations, it has been increasingly recognized as a cause of significant morbidity and mortality in adults, particularly those with underlying comorbidities. However, the association between RSV infection and NSTEMI, especially in patients without traditional risk factors, remains relatively unexplored. Our case involves a 31-year-old healthy adult who presented with progressive exertional chest pain and flu-like symptoms. Electrocardiogram (EKG) changes and elevated troponin levels indicated NSTEMI. Laboratory tests confirmed RSV infection. Angiography revealed significant coronary artery disease requiring percutaneous coronary intervention. This case highlights the need for healthcare professionals to be aware of the potential cardiovascular (CV) complications associated with RSV infection, even in patients without traditional risk factors. It expands our understanding of viral respiratory infections as potential triggers for acute coronary syndromes (ACS) and emphasizes the importance of considering RSV infection in the differential diagnosis of NSTEMI, especially in young otherwise healthy individuals. Further research is warranted to explore the underlying mechanisms and develop preventive strategies for RSV-related cardiovascular complications.

Statins and New Onset Diabetes Mellitus.

Statins have become one of the forefront medications in the prevention of cardiovascular morbidity and mortality in the 21st century. Apart from lowering low density lipoprotein-C (LDL-C), statins also play an important role in atherosclerotic plaque stabilization and regression. In the last two decades, there is growing evidence that statins have the potential to cause new onset diabetes mellitus (NODM). This is more pronounced in those with preexisting risk factors of developing diabetes. While several theories have been postulated, the exact mechanism behind the diabetogenic effect of statins remains unknown. Although NODM is associated with the use of statins, the overall benefits statins provide in terms of cardiovascular disease prevention far outweigh the effects of glycemic profile worsening.

Frequency of Acute Kidney Injury in Patient Receiving Piperacillin - Tazobactam: A Hospital-based Study from Qatar.

BACKGROUND: several studies have been reported piperacillin-tazobactam (TAZ / PIPC)-associated AKI with various frequencies. The aim of this study was to determine the frequency of TAZ/PIPC- associated AKI among our patients and to identify the risk factors for this clinical entity. METHODS: this retrospective cross-sectional study was conducted at Hamad General Hospital; it involved adult patients who were admitted from January 2017 to December 2017. RESULTS: we involved 917 patients, of whom 635 (69.25%) were males and 282 (30.75%) were females. The mean age of the patients was 52 (SD 19) years, and 98 (10.7%) patients were diagnosed with AKI. The patients with AKI were significantly older than without AKI [59.71 (SD 19.79) versus 51.06 (SD 18.67); P <0.001]. After TAZ/PIPC initiation, the mean creatinine level in the AKI group was higher than the mean creatinine level in the non-AKI group, [158.91 (SD 81.93) versus 66.78 (SD 21.42); P<001]. The mean time of onset of AKI after PIPC/TAZ initiation was 4.46 (SD 3.20) (1-12 days). AKI was significantly associated with low mean serum albumin (P<0.001), high mean fasting blood glucose (P<0.001), coronary artery diseases (P<0.001), heart failure (P<0.001), liver diseases (P=0.047), diabetes mellitus (P=0.021) and hypertension (P<0.001). The in-hospital mortality was significantly higher in the AKI group [38.78% versus 5.13% in the non-AKI group; P<0.001], and only advanced age and heart failure were found as independent risk factors for TAZ/PIPC-associated AKI. CONCLUSION: TAZ/PIPC was significantly associated with AKI. Advanced age and heart failure were identified as independent risk factors for TAZ/PIPC-associated AKI.

The Role of Anticoagulation in Post-COVID-19 Concomitant Stroke, Myocardial Infarction, and Left Ventricular Thrombus: A Case Report.

BACKGROUND Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects the lungs but can involve any organ. The medical community is struggling to cope with the critical illness associated with the disease. On top of that, patients who have recovered from COVID-19 have presented with complications such as thrombotic episodes in various organs both during and after being infected with SARS-CoV-2. A COVID-19-associated prothrombotic state has been mentioned in multiple recent research articles. The role of anticoagulants is debatable, because even after receiving them prophylactically, many patients have experienced thrombotic episodes. The situation, therefore, represents a challenge to the medical community. CASE REPORT We report on a COVID-19-associated prothrombotic state in a 65-year-old man with no history of comorbid illness. Initially, he presented with right-sided weakness and was found to have had an acute ischemic stroke. Urgent imaging after the stroke revealed changes on electrocardiography that were remarkable for left bundle branch block. The patient's elevated cardiac enzyme levels correlated with a silent acute myocardial infarction (MI). His echocardiogram revealed a left ventricular (LV) thrombus. He was managed with a multidisciplinary approach involving Neurology, Cardiology, and Medicine. CONCLUSIONS COVID-19-associated prothrombotic episodes involving arterial and venous systems have been reported in the literature. But concomitant stroke, acute MI, and LV thrombus rarely have been documented. The role of prophylactic or therapeutic anticoagulation is still unclear because even when patients are on these drugs, they continue to develop thrombotic episodes. Indeed, further studies are required to develop a standard management plan for what can be a fatal situation.

Digestive system involvement and clinical outcomes among COVID-19 patients: A retrospective cohort study from Qatar.

BACKGROUND: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 virus most commonly presents with respiratory symptoms. While gastrointestinal (GI) manifestations either at presentation or during hospitalization are also common, their impact on clinical outcomes is controversial. Some studies have described worse outcomes in COVID-19 patients with GI symptoms, while others have shown either no association or a protective effect. There is a need for consistent standards to describe GI symptoms in COVID-19 patients and to assess their effect on clinical outcomes, including mortality and disease severity. AIM: To investigate the prevalence of GI symptoms in hospitalized COVID-19 patients and their correlation with disease severity and clinical outcomes. METHODS: We retrospectively reviewed 601 consecutive adult COVID-19 patients requiring hospitalization between May 1-15, 2020. GI symptoms were recorded at admission and during hospitalization. Demographic, clinical, laboratory, and treatment data were retrieved. Clinical outcomes included all-cause mortality, disease severity at presentation, need for intensive care unit (ICU) admission, development of acute respiratory distress syndrome, and need for mechanical ventilation. Multivariate logistic regression model was used to identify independent predictors of the adverse outcomes. RESULTS: The prevalence of any GI symptom at admission was 27.1% and during hospitalization was 19.8%. The most common symptoms were nausea (98 patients), diarrhea (76 patients), vomiting (73 patients), and epigastric pain or discomfort (69 patients). There was no difference in the mortality between the two groups (6.21% vs 5.5%, P = 0.7). Patients with GI symptoms were more likely to have severe disease at presentation (33.13% vs 22.5%, P < 0.001) and prolonged hospital stay (15 d vs 14 d, P = 0.04). There was no difference in other clinical outcomes, including ICU admission, development of acute respiratory distress syndrome, or need for mechanical ventilation. Drugs associated with the development of GI symptoms during hospitalization were ribavirin (diarrhea 26.37% P < 0.001, anorexia 17.58%, P = 0.02), hydroxychloroquine (vomiting 28.52%, P = 0.009) and lopinavir/ritonavir (nausea 32.65% P = 0.049, vomiting 31.47% P = 0.004, and epigastric pain 12.65% P = 0.048). In the multivariate regression analysis, age > 65 years was associated with increased mortality risk [odds ratio (OR) 7.53, confidence interval (CI): 3.09-18.29, P < 0.001], ICU admission (OR: 1.79, CI: 1.13-2.83, P = 0.012), and need for mechanical ventilation (OR: 1.89, CI:1.94-2.99, P = 0.007). Hypertension was an independent risk factor for ICU admission (OR: 1.82, CI:1.17-2.84, P = 0.008) and need for mechanical ventilation (OR: 1.66, CI: 1.05-2.62, P = 0.028). CONCLUSION: Patients with GI symptoms are more likely to have severe disease at presentation; however, mortality and disease progression is not different between the two groups.

Optic neuropathy as a presenting feature of vitamin B-12 deficiency: A systematic review of literature and a case report.

INTRODUCTION: Vitamin B12 (VitB12) deficiency rarely manifests with visual symptoms. Optic nerve damage in VitB12 deficiency is thought to be via degeneration. However, optic neuritis, though infrequent, has been reported secondary to VitB12 deficiency. MATERIAL AND METHODS: We conducted a systematic review of all the reported cases of VitB12 deficiency with optic nerve involvement in Pubmed, Cochrane, and Google Scholar any date up to September 6, 2020. We have discussed the findings and compiled the available information on ophthalmological manifestations of VitB12 deficiency. We aim to provide a unified knowledge about the evidence related to types of optic neuropathies reported to date secondary to VitB12 deficiency. We also present a case of bilateral optic neuritis secondary to VitB12 deficiency. PRESENTATION OF CASE: We present a 29-year-old previously healthy male with progressive, painful, bilateral, but asymmetric visual deterioration for forty-five days. A detailed history, examination, and laboratory workup were carried out. He was diagnosed as having optic neuritis secondary to VitB12 deficiency. He showed partial improvement with the replacement of VitB12. CONCLUSION: We suggest promptly identifying and replacing VitB12 in patients with optic neuritis with proven VitB12 deficiency to prevent permanent damage to the optic nerve. Patients with VitB12 deficiency should have a baseline fundoscopic exam to rule out subclinical optic nerve damage. Moreover, patients who present with visual disturbances should be screened for VitB12 deficiency, especially the vegan population.

Should We Rely on Screening Tests for Further Management Alone in Polymerase Chain Reaction Negative COVID-19 Patients? A Case Series.

Since the declaration of coronavirus disease 2019 (COVID-19) disease as a pandemic by the World Health Organization (WHO), it has been a challenge to the whole medical community. Researchers and clinicians have been trying to explain and explore its mechanism and pathophysiology to get a better understanding of this disease, as it has exhausted the healthcare resources and has impacted human life in general. Many tests have been developed including polymerase chain reaction (PCR) of the virus and rapid diagnostic testing in patients based on IgM/IgG serology. But owing to variable sensitivity and specificity of these tests, it has created a challenging situation to proceed with the further management plan. We are reporting a case series where we experienced the dilemma of diagnosing COVID-9 disease in our patients and further plan of care.

Isolated Bulbar Palsy: A Rare Presentation of Neurosarcoidosis.

Sarcoidosis, which is a non-caseating granulomatous chronic inflammatory disease, can affect virtually any organ system, including the central nervous system (CNS). Very rarely, patients may present solely with neurosarcoidosis. It commonly presents with unilateral or bilateral seventh nerve palsy. Rarely it can present as dangerous progressive bulbar palsy and is a diagnostic and clinical challenge. We present a case of sarcoidosis with a unique presentation of isolated bulbar palsy. A 38-year-old male presented to the emergency with a sudden onset of dysphonia followed by dysphagia for both solids and liquids for one week and 5 kg weight loss in two months. The rest of the CNS exam was unremarkable. On labs, he had hypercalcemia and suppressed parathyroid hormone (PTH) intact. Detailed radiological investigations, lab tests, and lymph node biopsy helped confirm the diagnosis of neurosarcoidosis. The patient did not respond to first-line steroid therapy and hence received intravenous immunoglobulin (IVIG) subsequently with adequate response and complete neurologic recovery, confirmed by a follow-up visit.

Myopericarditis Presenting as Acute ST-Elevation Myocardial Infarction with Atrioventricular Dissociation.

Myopericarditis, which is an inflammatory process involving the myocardium and pericardium, is not a rare condition encountered in cardiac emergencies. Rarely though, it can give an acute myocardial infarction picture on electrocardiogram (ECG), leading to urgent angiography. More rarely, it can be associated with atrioventricular (AV) dissociation, which is a condition of dyssynchrony of electrical activity between atria and ventricles. We present the case of a young female, who presented with severe chest pain, associated with ST elevation in anterior leads of ECG and raised troponins, necessitating urgent coronary angiography. Normal coronaries led to further evaluation, including cardiac magnetic resonance imaging, which established the diagnosis of myopericarditis. The patient had AV dissociation secondary to myopericarditis. With the treatment of myopericarditis and transvenous pacing, the patient stabilized and was subsequently discharged asymptomatic.

Cardiovascular Autonomic Neuropathy and its Association with Cardiovascular and All-cause Mortality in Patients with End-stage Renal Disease.

Background End-stage renal disease frequently leads to increased cardiovascular mortality. Cardiovascular autonomic neuropathy (CAN) may be predictive of cardiac arrhythmias and sudden cardiac death in patients with end-stage renal disease. Methods A total of 70 patients with end-stage renal disease were included in the study. The assessment of cardiac dysautonomia was based on the four standardized tests performed at the baseline and, again, at the end of the study. The criteria for CAN included at least two abnormal test results. Results Fifty of 70 patients completed the study and were followed-up after one year. Out of the 50 patients, 44 (88%) had CAN at baseline. Twelve (24%) patients died at the one-year follow-up. Sudden cardiac death was reported in seven out of 12 (58%) patients. All seven patients who died had high dysautonomia scores (three abnormal tests) at the baseline. There was a significantly higher percentage of patients with all four abnormal tests amongst patients who died of any cause (56% vs. 17%; RR 6.07, 95% CI 1.29-28.49; p-value 0.02) or due to sudden cardiac death (43% vs. 10.5%; RR 6.37, 95% CI 1.03-39.36; p-value 0.04). All five patients who did not have CAN at the baseline developed this abnormality on repeat testing after one year. Conclusion The prevalence of CAN in patients with end-stage renal disease on maintenance hemodialysis was significantly higher. CAN was an independent predictor of all-cause and cardiovascular mortality, which highlights it as a risk stratification tool in patients with end-stage renal disease.