Atypical presentation of spontaneous splenic rupture secondary to Epstein-Barr virus infection.

We present a case of atraumatic splenic rupture secondary to Epstein-Barr virus (EBV) infection in a woman in her early 50s. The patient initially presented with sepsis secondary to pneumonia but then developed abdominal pain and distension. CT revealed splenic rupture with a significant perisplenic hematoma. Laboratory tests confirmed an EBV infection. Owing to frailty, she underwent fluoroscopy-guided splenic artery embolisation. This case highlights the rare risk of splenic rupture following EBV infection, even in the absence of typical symptoms of infectious mononucleosis.

Hydrocortisone-induced symptomatic sinus bradycardia.

Steroids are commonly prescribed medications that have a wide range of adverse effects. Bradycardia is one of the rare but significant side effects of steroid use, and only a few cases have been reported with bradycardia as a side effect. In this report, we present a case of a woman in her early 50s who developed severe symptomatic sinus bradycardia following high-dose administration of intravenous hydrocortisone, initiated for acute exacerbation of Crohn's disease. Her symptoms entirely resolved after discontinuation of the steroid. This case highlights the importance of obtaining baseline ECG and cardiac monitoring in patients treated with pulsed high-dose steroids.

Use of transthoracic echocardiography in the evaluation of chest pain: illustrative cases and review of recent guidelines.

Chest pain (CP) is a very common presentation with a wide range of differential diagnoses, including life-threatening conditions, which need to be considered, diagnosed and treated urgently. Cardiac CP accounts for less than one-third of causes. Echocardiography is a valuable non-invasive tool that can help in diagnosing and treating patients presenting with CP. National Institute for Health and Care Excellence (NICE), European Society of Cardiology (ESC) and American Heart Association (AHA) guidelines state that echocardiography can help in the diagnosis of acute coronary syndromes and also in ruling out other serious conditions. We present three cases where transthoracic echocardiography (TTE) was essential in assessing patients, making the correct diagnosis and offering the right treatment. This article emphasises the importance of using TTE in assessing patients with CP and hopes to promote its consideration in day-to-day practice.

Direct oral anticoagulants: integration into clinical practice.

The introduction of direct oral anticoagulants (OACs) for the treatment and prevention of thromboembolic disease represents a shift from the traditional vitamin K antagonist-based therapies, which have been the mainstay of treatment for almost 60 years. A challenge for hospital formularies will be to manage the use of direct OACs from hospital to outpatient settings. Three direct OACs-apixaban, dabigatran and rivaroxaban-are widely approved across different indications, with rivaroxaban approved across the widest breadth of indications. A fourth direct OAC, edoxaban, has also completed phase III trials. Implementation of these agents by physicians will require an understanding of the efficacy and safety profile of these drugs, as well as an awareness of renal function, comedication use, patient adherence and compliance. Optimal implementation of direct OACs in the hospital setting will provide improved patient outcomes when compared with traditional anticoagulants and will simplify the treatment and prevention of thromboembolic diseases.

Infective endocarditis with co-existent acalculous cholecystitis: a rare but important association.

The authors present the case of an otherwise healthy retired male who presented with a history of fevers, rigors and right upper quadrant abdominal pain. Although haematological, biochemical and radiological investigations supported a diagnosis of acalculous cholecystitis, the underlying cause was not obviously apparent and the patient's clinical condition deteriorated rapidly over the course of a few hours despite appropriate medical treatment. Repeat clinical examination was consistent with acute pulmonary oedema in association with a new murmur throughout the whole of the cardiac cycle. Transthoracic echocardiography revealed the presence of severe aortic regurgitation, a presumptive diagnosis of infective endocarditis was made and medical therapy adjusted. Shortly after, the patient suffered a cardiac arrest and an attempt at resuscitation was unsuccessful. Postmortem examination revealed the presence of aortic valve cusp rupture secondary to bacterial endocarditis in addition to gallbladder appearances consistent with acute acalculous cholecystitis.

False positive cardiac troponin elevation due to heterophile antibodies: more common than we recognise?

A 53-year-old woman was admitted with non-exertional chest pain and elevated cardiac troponin I (cTnI) without dynamic changes of ischaemia on the ECG. She had recently undergone coronary angiography which had shown normal coronary vessels. Repeat angiography on this admission was again unremarkable. Samples of blood were sent for analysis using different troponin assays and demonstrated chronic basal elevation of cTnI while simultaneous assay for troponin T (cTnT) remained normal. Subsequent testing revealed the presence of heterophile antibodies interfering with the troponin I assay leading to a false positive result.