Two Strikes: A Case Study of Consecutive St-Elevation Myocardial Infarctions (Stemi) in two Different Coronary Arteries.

An acute ST-elevation myocardial infarction (STEMI) followed by reinfarction within a short period of time is typically due to stent thrombosis. However, a STEMI caused by occlusion of one vessel followed by a repeat infarction due to occlusion of a different vessel which was seemingly innocent a few hours earlier is extremely rare. We present the case of a 61-year-old male with a past medical history of prediabetes, hyperlipidemia, tobacco use, and gastroesophageal reflux disease who presented to the emergency department with complaints of chest pain. His initial electrocardiogram (EKG) revealed ST elevation in leads II, III and aVF with reciprocal changes in leads I and aVL. He promptly underwent cardiac catheterization and had percutaneous coronary intervention with placement of two drug-eluting stents (DES) in the right coronary artery (RCA). At that time coronary angiography revealed 50% stenosis of the left anterior descending (LAD) artery and 60% stenosis of the second diagonal branch artery. Shortly after the procedure he was asymptomatic, and the post procedure EKG demonstrated resolution of the ST elevations. However, within 2 hours he developed chest pain and was found to have new ST elevations in the anterolateral leads. Repeat cardiac catheterization revealed patent RCA stents with subtotal occlusion of the LAD and another DES was placed. After the second procedure the patient remained hemodynamically stable, EKG changes resolved, and he was kept on eptifibatide infusion for 18 hours after which he was switched to dual antiplatelet therapy and ultimately discharged home. LEARNING POINTS: Physicians should promptly address the recurrence of symptoms following an initial ST-elevation myocardial infarctions (STEMI) and be proactive regarding follow-up with the appropriate investigations.Although recurrence of STEMI within a few hours is extremely rare, the first 2 weeks following an initial STEMI is a critical time and patients should be educated on symptoms that will require further evaluation.The mortality associated with early recurrent myocardial infarction is up to 50% in 5 years so these patients require strict outpatient follow-up and counseling to minimize risk factors.

Should Histoplasmosis be Screened for Before Initiation of Tumour Necrosis Factor Alpha Inhibitors?

Histoplasmosis is a soil-based dimorphic fungus endemic to the Midwest and Southeastern United States and is responsible for infection through inhalation of conidia. Infection is usually asymptomatic, as the fungal growth is contained by formation of granulomas. However, dissemination can occur in immunocompromised hosts due to the lack of optimal activity of interferon gamma, tumour necrosis factor alpha (TNF-alpha) and interleukin-17. There is a significant overlap between the symptomatology of histoplasmosis and granulomatosis with polyangiitis (GPA). We report a case of a 48-year-old female who presented with high-grade fever, worsening generalised weakness and tachycardia. She had a previous history of bilateral cavitary lung lesions for which she was evaluated at an outside facility. As her entire infectious investigation was negative and found to be positive for antineutrophil cytoplasmic antibody (ANCA), a diagnosis of GPA was made, and she was initiated on rituximab infusions 7 weeks prior to her presentation to our facility. Repeat infectious investigations at our facility were positive for (1-3)-ß-D-glucan test and urine histoplasma antigen. Prompt discontinuation of rituximab and initiation of systemic antifungal therapy led to clinical improvement. Based on this experience, we highlight the association of histoplasma with ANCA positivity along with the importance of closely monitoring these patients for possible clinical worsening after the initiation of TNF-alpha inhibitors, despite the negative infectious work-up. Also routine screening or pre-emptive therapy for histoplasmosis before the initiation of TNF-inhibitors is not recommended. LEARNING POINTS: Histoplasmosis is associated with ANCA positivity.Despite the negative investigations for histoplasmosis and criteria for GPA being met, patients should be closely monitored for possible clinical worsening after the initiation of immunosuppressive therapy, especially TNF-alpha inhibitors.Current guidelines are not recommending routine screening or pre-emptive therapy for histoplasmosis before initiation of TNF-alpha inhibitors.

Large Coronary Cameral Fistula to the Left Ventricle Presenting as Congestive Heart Failure.

A 56-year-old African American female was under evaluation for coronary artery disease by a cardiologist due to her complaints of intermittent chest pain. She underwent an outpatient echocardiogram and was found to have an ejection fraction of 20-25% with global left ventricular hypokinesis. Due to this finding along with her ongoing chest pain, she was referred to the emergency department for further evaluation. Her electrocardiogram showed changes suggestive of ischaemia and her cardiac troponins were mildly elevated, so she underwent an urgent cardiac catheterisation. The angiography confirmed the reduced ejection fraction and global left ventricular hypokinesis, but also demonstrated a large coronary cameral fistula (CCF) extending from the first septal branch into the left ventricle. She was then diagnosed with non-ischaemic cardiomyopathy and heart failure with reduced ejection fraction secondary to the CCF. In this report, we illustrate a frequently encountered clinical scenario in which a patient presented with chest pain and EKG findings indicative of ischaemic cardiomyopathy. The patient also had several risk factors for coronary artery disease, however further investigation revealed an alternative diagnosis. LEARNING POINTS: A description of rare coronary anomalies adds to the fund of medical knowledge and can guide physicians to make evidence-based decisions regarding its management.Increasing description of coronary cameral fistula will alert clinicians to suspect it as a cause for worsening heart failure and as a treatable cause of non-ischaemic cardiomyopathy.

Triple Vessel Coronary Artery Disease Identified in a 21-Year-Old Female.

Premature coronary artery disease (CAD) is characterized by the presence of symptomatic atherosclerosis in the coronary circulation in males below the age of 55 and females below the age of 45. We present the case of a 21-year-old female with a past medical history of heart failure with preserved ejection fraction, poorly controlled diabetes mellitus, essential hypertension, nephrotic syndrome, dyslipidemia, and class I obesity who presented with complaints of worsening bilateral lower extremity edema and exertional shortness of breath. Given her physical examination findings and laboratory investigations, a diagnosis of heart failure exacerbation was made. Echocardiography revealed a significant change in ejection fraction from three months earlier, and thus, she underwent a nuclear stress test. She was found to have fixed perfusion defects in the inferior wall. A diagnostic left heart catheterization identified severe triple vessel disease affecting the left anterior descending, left circumflex, and right coronary arteries. The patient and her family opted against coronary artery bypass grafting, and she was discharged to pursue high-risk intervention as an outpatient. This case highlights the importance of strict regulation of modifiable risk factors for CAD even in teenagers and young adults as her disease process likely began several years prior to the ultimate development of triple vessel CAD.

Right atrial thrombus leading to pulmonary embolism in a patient with dermatomyositis and COVID-19 managed with FlowTriever device thrombectomy.

A woman in her late 40s presented with complaints of shortness of breath, right-sided pleuritic chest pain and diffuse myalgias. She was diagnosed with deep vein thrombosis (DVT) 3 weeks earlier and had been compliant with her oral anticoagulation therapy. Investigations revealed a pulmonary embolism (PE) involving the right distal pulmonary artery on a CT angiogram of the chest. She was also found to have an incidental SARS-CoV-2 (COVID-19) infection and an elevated creatine kinase value. Anticoagulation with intravenous heparin was initiated according to the DVT/PE protocol. The following morning, a medium-sized mobile mass was identified in her right atrium on performing a transthoracic echocardiogram. Due to concerns of embolisation of the mass which could result in obstruction, right ventricular strain and ultimately haemodynamic instability, a thrombectomy was performed using the FlowTriever device under transthoracic echocardiography guidance. The right atrial mass was successfully removed and the patient was transitioned to another oral anticoagulant agent. On discharge, a muscle biopsy was performed and aided in the diagnosis of dermatomyositis and the patient received intravenous Ig, steroids and methotrexate.

Left Ventricular Noncompaction in Concomitance With Heroin Use Disorder.

Left ventricular noncompaction (LVNC) is a rare congenital condition defined by the presence of prominent trabeculations in the myocardial layer of the left ventricle. The clinical presentation is varied as some patients are asymptomatic and others have symptoms of decompensated heart failure, arrhythmias, or thromboembolism. We present the case of a 42-year-old female with a past medical history of asthma and substance use disorder who presented to the Emergency Department following a syncopal event. The patient had used heroin intranasally, following which she became unresponsive for several minutes. Her husband witnessed the event and initiated chest compressions. When examined by emergency medical services (EMS), she had a palpable pulse and was given naloxone. The patient underwent further evaluation and was admitted for the treatment of aspiration pneumonia. Throughout her hospital stay, she complained of chest pain with musculoskeletal characteristics, likely secondary to chest compressions. However, due to the persistence of pain, she had further cardiac evaluation done. Her electrocardiography (EKG) revealed a normal sinus rhythm with no acute ischemic changes. Her echocardiography revealed left ventricular apical trabeculations with normal systolic and diastolic function, in line with the diagnosis of LVNC. Upon discharge, she was extensively counseled to abstain from substance use and to follow up with cardiology for a cardiac event monitor. Given her initial syncopal event and high-risk substance use behavior, she would benefit from close follow-up for the presence of arrhythmias.

Subcutaneous Implantable Cardioverter-Defibrillator Lead Dislodgement Masquerading as Left Shoulder Pain.

Implantable cardioverter-defibrillators (ICDs) have demonstrated efficacy in the prevention of sudden cardiac death secondary to cardiac arrhythmias in eligible patients. Complications with the subcutaneous ICD (S-ICD) are rarer than with the transvenous ICD but do still exist. Our patient presented four weeks after the insertion of S-ICD with complaints of left shoulder pain radiating to the chest wall and swelling over the S-ICD site. He was initially treated for rotator cuff injury and subacromial impingement syndrome but upon obtaining chest radiography was found to have a lead displacement traversing the splenic flexure of the colon. The patient was managed by a treatment team involving cardiology, surgery, and infectious disease and underwent S-ICD removal, exploratory laparotomy with splenic flexure mobilization, and completion of a four-week antibiotic course ultimately leading to reimplantation of S-ICD.

Protein S Deficiency and COVID-19: A Brutal Combination Leading to Acute Submassive Bilateral Pulmonary Embolism.

Protein S deficiency is a form of inherited thrombophilia that occurs due to low levels of or improper function of protein S. The role of protein S is to inactivate procoagulant factors, and a deficiency results in an increased risk of thrombotic events. The coronavirus disease 2019 (COVID-19) infection has also been studied to increase the risk of venous thromboembolism (VTE) due to an interplay of several mechanisms. However, the risk of VTE in patients affected by both of these disease processes simultaneously has not been thoroughly studied, and so recommendations regarding routine screening and prophylaxis of VTE have also not been established. We discuss the case of a 46-year-old woman with a past history of protein S deficiency and a recent COVID-19 infection who presented with complaints of shortness of breath. Upon examination, she was found to be hypoxic and tachycardic. A computed tomography angiography of the chest was done and revealed acute submassive bilateral pulmonary embolism with right heart strain and pulmonary infarcts. She was initially treated with intravenous heparin and later transitioned to oral anticoagulation for a minimum of six months.

Varicella Zoster Meningitis in a Young, Immunocompetent Patient Despite Initiation of Antiviral Therapy.

Varicella zoster virus (VZV) reactivation, also known as herpes zoster is common in older adults and immunocompromised individuals and often causes a painful, vesicular rash limited to a dermatomal distribution. On occasion, it can lead to various neurological complications as well. Here we present the case of a young, immunocompetent male in his 20's with a history of primary varicella infection who presented with complaints of a painful rash in the S3-S4 dermatomal distribution. Despite being initiated on the standard oral antiviral dose for two days, he developed a headache and neck stiffness. He was diagnosed with VZV meningitis through the lumbar puncture and cerebrospinal fluid polymerase chain reaction (PCR) assay analysis. The patient reported significant improvement in symptoms following intravenous acyclovir and was discharged with additional oral valacyclovir at a higher-than-standard dosage. Our case highlights that even in relatively low-risk patients, physicians must maintain a high level of clinical suspicion for the complications of VZV reactivation even after beginning the oral antiviral medication.

Unveiling of Type B Lactic Acidosis From Systemic Lupus Erythematosus-Associated B-cell Lymphoma: A Fatal Oncology Emergency.

Type B lactic acidosis is a rare oncological emergency usually associated with leukemia and lymphoma but also with solid malignancies. It can often go unrecognized as a possible source of lactic acidosis, leading to a delay in treatment. We review a 56-year-old woman with systemic lupus erythematosus and generalized lymphadenopathy being evaluated for underlying malignancy who presented with dyspnea, fatigue, and hematemesis. The patient was hemodynamically unstable and had severe lactic acidosis, leukocytosis, electrolyte derangements, multiple organ damage, and worsening diffuse lymphadenopathy. She was initially treated for septic shock due to acalculous cholecystitis on imaging with antibiotics and a cholecystostomy. The latter was complicated by a liver laceration requiring explorative laparotomy and open cholecystectomy, during which an excisional biopsy of the omental lymph node was done and confirmed B-cell lymphoma with marked plasmacytic differentiation. Her lactic acidosis never fully cleared despite surgery, and the refractory nature of it despite appropriate treatment of septic shock confirmed the diagnosis of type B lactic acidosis from underlying B-cell lymphoma. Chemotherapy was deferred due to the acuity of the condition. She continued to deteriorate despite aggressive management and was transitioned to comfort measures only per family request, following which she passed away. Type B lactic acidosis should be suspected in oncology patients without clinical evidence of ischemia who are not responding to fluid resuscitation and appropriate treatment of septic shock. Prompt recognition and early initiation of antineoplastic agents should be considered, when possible, to prevent adverse outcomes.