Bortezomib-Induced Cardiac Tamponade in a 49-Year-Old Man.

Proteasome inhibitors such as bortezomib and carfilzomib have been used effectively to treat patients who have certain hematologic malignancies. Proteasome activity is elevated in the heart, and potent inhibition results in accumulation of misfolded intracellular protein aggregates and apoptosis. Heart failure, conduction disturbances, and premature atherosclerosis have been associated with bortezomib therapy. We describe the case of a 49-year-old man who was taking bortezomib for graft-versus-host disease, when he developed cardiac tamponade and needed emergency pericardiocentesis. At that time, there was no evidence of graft-versus-host disease. To our knowledge, this is the first time that a pericardial effusion without underlying cardiac dysfunction has been reported in relation to bortezomib therapy. The diagnosis of pericardial effusion during bortezomib therapy, the absence of other causative agents-including graft-versus-host disease-and no recurrence of pericardial effusion after discontinuing bortezomib therapy suggest that bortezomib caused our patient's tamponade.

Lambl's excrescence, migrainous headaches, and "tiger stripes": puzzling findings in one patient.

Lambl's excrescences are mobile, thin, filiform structures that occur at sites of valve closure. Even though many clinicians consider them to be part of the normal aging process, evidence suggests an association between Lambl's excrescences and ischemic stroke, migrainous headaches, and acute coronary syndromes. As a thin filamentous structure, a Lambl's excrescence is better detected and characterized with transesophageal than with transthoracic echocardiography. Intracardiac oscillatory structures can also be seen as "tiger stripes" on spectral pulsed Doppler echocardiographic recordings. Herein, we present the case of a 68-year-old woman who had 3 concurrent enigmatic findings with unclear correlation: migrainous headaches, Lambl's excrescences, and the uncommon finding of "tiger stripes" on spectral Doppler echocardiography. We discuss the possible correlation between these 3 findings and review the available literature on Lambl's excrescences and tiger stripes.

May-Thurner syndrome in a 68-year-old woman after remote abdominal surgery.

May-Thurner syndrome, also called iliac vein compression syndrome, is a rare cause of left iliac deep vein thrombosis, which arises from pulsatile compression of the left common iliac vein by the right common iliac artery. The resultant endothelial damage and intraluminal spur formation can lead to iliac deep vein thrombosis and sudden-onset left-lower-extremity edema and pain. Patients typically present with May-Thurner syndrome in their 2nd to 4th decades of life. In chronic form, the syndrome can be debilitating because of venous claudication and stasis ulcers. Surgical approaches and endovascular interventions have been effective in the acute phase of the disease, and intravenous stents can resolve the manifestations of chronic venous compression. Anticoagulation alone is ineffective, and a consensus regarding the usage and duration of antiplatelet and antithrombotic therapy has not been established. We present the case of a 68-year-old woman with a remote history of abdominal surgery who presented with left-lower-extremity edema and pain. Magnetic resonance venography of the pelvic veins yielded a definitive diagnosis of May-Thurner syndrome. Catheter-directed thrombolysis and intravenous stent placement resolved her symptoms, and she was discharged from the hospital on anticoagulative therapy. A year later, she had no residual pain or edema, and the affected veins were patent with normal phasic flow and normal responses to compression and augmentation.