A Chest Pain Conundrum: Dapsone-Induced Methemoglobinemia in a Heart Transplant Patient.

We present the case of a 39-year-old male with a past medical history of orthotopic heart transplantation who presented with chest pain and dyspnea on exertion. He was diagnosed with dapsone-induced methemoglobinemia toward the end of his hospital course, and his condition clinically improved with the discontinuation of the offending agent. This case highlights the importance of medication review and history-taking. Clinicians should be mindful of dapsone-induced methemoglobinemia, especially when encountering patients with dyspnea and a history of dapsone intake.

Combined zinc and vitamin B6 deficiency in a patient with diffuse red rash and angular cheilitis 6 years after Roux-en-Y gastric bypass.

A 39-year-old woman with a history of Roux-en-Y gastric bypass (RYGB) surgery and alcohol use presented with a confluent erythematous rash involving the perineum spreading outward to the abdomen, thighs and lower back. She had angular cheilitis and glossitis. The rash was painful and blistering in scattered areas. She was hypotensive and appeared to be in septic or hypovolemic shock at presentation. Serum levels of zinc and vitamin B6 were critically low and biopsy of her rash returned suggestive of a nutritional deficiency as its source. The rash slowly improved over the following 2 weeks with oral zinc and vitamin B6 replacement. The body rash resembled that of infants born with inherited defects in zinc transporters, referred to as acrodermatitis enteropathica (AE). This case may represent an acquired case of AE in the setting of prior RYGB.

Incorporation of the HEART Score Into a Low-risk Chest Pain Pathway to Safely Decrease Admissions.

Chest pain can be a challenging complaint to manage in the emergency department. A missed diagnosis can result in significant morbidity or mortality, whereas avoidable testing and hospitalizations can lead to increased health care costs, contribute to hospital crowding, and increase risks to patients. The HEART score is a validated decision aid to identify patients at low risk for acute coronary syndrome who can be safely discharged without admission or objective cardiac testing. In the largest and one of the longest studies to date (N = 31,060; 30 months), we included the HEART score into a larger, newly developed low-risk chest pain decision pathway, using a retrospective observational pre/post study design with the objective of safely lowering admissions. The modified HEART score calculation tool was incorporated in our electronic medical record. A significant increase in discharges of low-risk chest pain patients (relative increase of 21%; p < 0.0001) in the postimplementation period was observed with no significant difference in the rates of major adverse cardiac events between the pre and post periods. There was a decrease in the amount of return admissions for 30 days (4.65% fewer; p = 0.009) and 60 days (3.78% fewer; p = 0.020). No significant difference in length of stay was observed for patients who were ultimately discharged. A 64% decrease in monthly coronary computed tomography angiograms was observed in the post period (p < 0.0001). These findings support the growing consensus in the literature that the adoption of the HEART pathway or similar protocols in emergency departments, including at large and high-volume medical institutions, can substantially benefit patient care and reduce associated health care costs.

Genetic characterization of esocid herpesvirus 1 (EsHV1).

Blue spot disease, believed to be caused by esocid herpesvirus 1 (EsHV1), has been observed in wild northern pike Esox lucius in a number of cold-water locations, including the northern USA, Canada, and Ireland. In the spring of 2014, a northern pike was caught in Wisconsin displaying the characteristic bluish-white circular plaques on the dorsum and fins. Microscopic examination of hematoxylin and eosin-stained sections of the proliferative cutaneous lesions revealed a focally extensive abundance of panepidermal, megalocytic keratinocytes with karyomegaly. Enlarged nuclei stained basophilic, and an abundance of coarse eosinophilic granules were observed in the expanded cytoplasm. Transmission electron microscopy revealed aggregates of enveloped virus particles with electron-dense, hexagonal nucleocapsids surrounded by a uniformly staining ellipsoidal tegument layer within cytoplasmic vacuoles of megalocytic epidermal cells. More than 7000 bp of the EsHV1 genome were sequenced from infected skin tissues. Phylogenetic and phenetic analyses, based on the partial DNA-dependent DNA polymerase and terminase gene sequences, revealed EsHV1 forms a novel branch within the family Alloherpesviridae as the sister group to the clade that includes members of the genera Ictalurivirus and Salmonivirus. The gross, microscopic, and ultrastructural lesions reported in our study were identical to previous reports of blue spot disease in northern pike; however, here we provide the first molecular evidence supporting EsHV1 as a new species in the family Alloherpesviridae.