Bleeding heart: a case of spontaneous hemopericardium and tamponade in a hyperthyroid patient on warfarin.

We describe the case of an 81-year-old female, diagnosed with hyperthyroidism-related atrial fibrillation. Given her CHA2DS2VASc score of 3, she was started on warfarin for stroke prevention. One month later, she was admitted with cardiac tamponade. This tamponade was suspected to be secondary to hemopericardium, based on the elevated international normalized ratio (INR), drop in haemoglobin and the radiodensity (55 HU) of the pericardial effusion on CT. The patient was a Jehovah's witness who therefore initially refused measures for reversing coagulopathy. Given her coagulopathy and absence of imminent haemodynamic compromise, pericardiocentesis was deferred. Unfortunately, 1 day later, the patient deteriorated rapidly. By the time pericardiocentesis was performed and factor VIIa administered, the patient had already started developing multiple organ failure. She developed cardiac arrest and died 3 days after her admission. Only 10 cases of hemopericardium attributable to warfarin have previously been reported. In this report, we review the literature and also describe how hyperthyroidism most likely predisposed our patient to bleeding complications from warfarin.

Giant cell myocarditis: a life-threatening disorder heralded by orbital myositis.

A 40-year-old man with a history of orbital myositis (OM) presented to the emergency department with ventricular tachycardia requiring electrical cardioversion. Postcardioversion ECG showed right bundle branch block, while an echocardiogram revealed an ejection fraction of 20% and a dilated right ventricle. Cardiac MRI produced suboptimal images because the patient was having frequent arrhythmias. The rest of the work up, including coronary angiography, was unremarkable. Given the dilated right ventricle, we suspected arrhythmogenic right ventricular cardiomyopathy and discharged the patient with an implantable cardioverter-defibrillator. 1 week later, he was readmitted with cardiogenic shock; endomyocardial biopsy revealed giant cell myocarditis (GCM). To the best of our knowledge, this is the seventh case report of GCM described in a patient with OM. We recommend that clinicians maintain a high degree of suspicion for GCM in patients with OM presenting with cardiac problems.

The efficacy and tolerability of Levetiracetam as an add-on therapy in patients with startle epilepsy.

PURPOSE: To evaluate the efficacy and tolerability of Levetiracetam as an add-on therapy in patients with startle epilepsy (StEp). METHODS: Ten (7 males and 3 females) were enrolled in the study. LEV was started at 500mg bid, escalating over 1-2 weeks to maximal doses of 3000mg daily, based on seizure control and tolerance for 13-28 months. RESULTS: The onset of startle seizures in patients with StEp varied from birth to 11 years. Six in 10 patients gave good responses to the treatment. There were adverse effects in three patients. CONCLUSION: Many AEDs have been used by medically intractable patients with StEp for many years but the results were almost discouraging. It was observed that 60% of the patients gave good response to LEV. Advanced studies are required to indicate the efficiency of LEV which proved to be effective on animals with audiogenic seizures on reflex epilepsies.