ABSTRACT
Here, we report a case of hereditary hyperhomocysteinemia presenting as dilated cardiomyopathy which was successfully diagnosed using a combination of point-of-care ultrasonography (POCUS) and echocardiogram (ECHO). A 39-year-old Caucasian male with a family history of homocystinuria and early deaths in adult male members from cardiovascular disease presented with complaints of purplish discoloration and 4/10 pain in bilateral feet along with severe nausea/vomiting for the last two days. Physical examination was significant for tachycardia, low normal mean arterial pressures, dry mucous membranes, right basilar crepitations, S3 gallop with holosystolic murmur along with peripheral cyanosis, and pitting edema. Laboratory examination revealed leucocytosis, elevated d-dimers, high anion gap metabolic acidosis secondary to worsening renal function, elevated liver enzymes, hyperhomocysteinemia, elevated B-type natriuretic peptide, and troponins along with low protein C and S. Electrocardiogram demonstrated left axis deviation with abnormal QRS-T angle and intraventricular conduction delay with a QRS duration of 133 ms. Bedside POCUS and ECHO revealed marked left ventricular dilatation with an ejection fraction of 10% and mitral regurgitation. Computed tomography angiography of the chest and abdomen was positive for partial left subclavian vein thrombus with extensive collateral formation and right-sided pleural effusion. The patient was started on anticoagulants and promptly transferred to a tertiary care center for left ventricular assist device placement. Hyperhomocysteinemia can present with atypical heart failure symptoms, and early usage of bedside POCUS and interpretation of findings in the context of family history are imperative for a successful diagnosis.
ABSTRACT
The results of long-term administration of leuprolide acetate (LA) depot in a 52-yr-old Asian elephant bull (Elephas maximus) for control of musth are presented. Twelve injections were administered for 6 yr during our interpretation of early musth or "premusth." Intervals between musth periods during the study varied from 2 to 34 mo. Blood samples, drawn weekly, were assayed for serum testosterone concentrations; mean levels were 11.78 +/- 1.97 nmol/L throughout the first 26 mo of the study, 7.28 +/- 1.28 nmol/L during the following 21 mo, and 0.45 +/- 0.035 nmol/L in the last 34 mo of this study. Early musth signs ceased within 3 days of drug administration after 10 of 12 injections. The mean serum testosterone concentrations were significantly decreased by the last 34 mo of the study. The results suggest leuprolide is a suitable alternative for controlling or preventing (or both) musth in captive Asian elephants, although permanent reproductive effects may occur. Zoos and wildlife conservation institutions could benefit from the use of LA in Asian elephants to increase the male availability in captivity, consequently ensuring genetic diversity and the perpetuation of the species.
