The Discovery of an Intracardiac Thrombus Following a Mild COVID-19 Infection: A Case Report and Review of Literature.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) is a viral disease that predominantly affects the respiratory system, but extrapulmonary manifestations have been increasingly reported over the course of the pandemic. Common extrapulmonary manifestations include the gastrointestinal, cardiovascular, and neurological systems, such as diarrhea, rashes, loss of smell/taste, myalgia, acute kidney injury, cardiac arrhythmias, or heart failure. COVID-19 infection is associated with an increased risk of thromboembolic events, especially in the setting of severe disease. We present a case of a 42-year-old female who recently tested positive for COVID-19 infection and presented to the clinic with complaints of palpitations that started after her diagnosis. An electrocardiogram done in the clinic showed sinus rhythm, and the patient was placed on an event monitor, which showed no evidence of tachyarrhythmia. A transthoracic echocardiogram (TTE) done as part of the workup showed a large thrombus in the right ventricular outflow tract attached to the ventricular side of the pulmonic valve. The patient was started on a therapeutic dose of apixaban at 10 mg twice a day (BID) for seven days and 5 mg twice a day afterward.

A rare presentation of spontaneous rupture of splenic vein aneurysm as cardiac arrest: A case report.

Splenic vein aneurysm (SVA) is a rare condition associated primarily with portal hypertension. This case highlights a potentially fatal, rare SVA complication in a young patient who presented in cardiac arrest, creating a diagnostic enigma in the emergency department until a POCUS revealed a possible underlying etiology.

Enlarging Liver Mass: Inflammatory Pseudotumor in a Patient With Polymyalgia Rheumatica.

Inflammatory pseudotumors of the liver are rare, non-neoplastic liver tumors. Due to the nonspecific clinical presentation, imaging features, and histopathological findings, they can mimic malignant tumors requiring invasive diagnostics. We present a case of a 61-year-old female patient with a history of type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and polymyalgia rheumatica who had initially presented with abdominal pain for 3 weeks. Further workup showed normal liver chemistries and tumor markers: AFP and CA 19-9. Magnetic resonance imaging (MRI) of the abdomen showed a segment 6 lesion measuring 4.1 × 4.0 × 3.7 cm. A liver biopsy then confirmed the diagnosis of an inflammatory pseudotumor of the liver with negative IgG4. On follow-up imaging, a rapid growth of this liver lesion was noted. Laparoscopy was done but did not show any distinct liver lesion. Follow-up imaging confirmed a decrease in the size of the mass. Interestingly, the patient had been on a higher dose of steroids for her polymyalgia rheumatic leading up to the follow-up imaging. This is the first case of an inflammatory pseudotumor of the liver in a patient with polymyalgia rheumatica. With this case, we would like to increase the awareness for inflammatory pseudotumors of the liver as a differential diagnosis of liver lesions in patients with underlying autoimmune disorders.

Management of Life-Threatening Bleeding in Patients With Mechanical Heart Valves.

Valvular heart disease is common in the United States, with a number of patients undergoing valve replacement procedures every year. The two types of valve prostheses include mechanical and bioprosthetic valves. Mechanical heart valves require lifelong anticoagulation with vitamin K antagonists like warfarin. The clinicians are often faced with the dilemma of major bleeding episodes such as intracranial hemorrhage or gastrointestinal bleeding in these patients. The management includes reversing warfarin-induced coagulopathy with vitamin K supplementation, fresh frozen plasma, or prothrombin complex concentrate (PCC), with PCC being the treatment of choice. With regard to the safe resumption of anticoagulation, guidelines are silent, and data is limited to case reports/series. This article reviews the present literature for the management of bleeding in patients with mechanical heart valves and the safe duration for holding off anticoagulation with minimal risk of valve thrombosis/thromboembolism.

Stent Embolization Mimicking Acute Myocardial Infarction.

Venous thromboembolism is associated with significant morbidity and mortality if left untreated. Anticoagulation is the cornerstone of treatment. Venous stents are a relatively newer entity that are increasingly being used to treat venous stenosis/occlusion. It is a safe procedure, but complications include vein rupture, arterial puncture, retroperitoneal bleeding, and in-stent thrombosis. Stent migration is a rare but potentially fatal complication. We present a case of venous stent embolization to the heart that presented as a non-ST segment elevation myocardial infarction.

Immunoglobulin G-4-Related Retroperitoneal Fibrosis.

Retroperitoneal fibrosis is caused by the replacement of normal retroperitoneal tissue with fibrosis. The majority of the cases are idiopathic, but some secondary causes include malignancy, infection, drugs, and radiotherapy. Immunoglobulin G-4 (IgG-4) related disease is a relatively newer disease and one of the rarer causes of retroperitoneal fibrosis. It usually involves the pancreas, lungs, kidneys, aorta lacrimal and salivary glands, or extrapancreatic bile duct. Elevated serum IgG-4 is the biomarker of the disease and its levels correlate with disease activity. High-dose glucocorticoid is the treatment of choice.

A Case of Recurrent Coronary Subclavian Steal Syndrome.

Coronary subclavian steal syndrome (CSSS) is one of the rare complications of coronary artery bypass graft surgery (CABG). This phenomenon is a potential complication after left internal mammary artery (LIMA) to left anterior descending artery (LAD) CABG. A proximal stenosis of the left subclavian artery (SA) could cause retrograde flow from LIMA to left SA, which characterizes the mechanism of CSSS. We describe a unique case of recurrent CSSS in a 64-year-old female who presented with one month of exertional dyspnea and acute onset chest pain. She had an extensive coronary artery disease history with CABG 15 years prior to presentation and CSSS treated with left SA stent placement nine years later. She also underwent percutaneous intervention with stents placed in the saphenous vein graft. Although electrocardiogram, cardiac enzymes, and stress test did not show any evidence of acute ischemic changes, perfusion scan detected large areas of partially reversible ischemia. Cardiac catheterization was performed, which showed in-stent restenosis of the left SA and retrograde flow from the LIMA to the left SA indicative of recurrence of CSSS. Left SA arteriogram confirmed in-stent restenosis of the left SA, which was treated with balloon angioplasty and stent placement.

Contrast Extravasation Mimicking Subarachnoid Hemorrhage After Cardiac Catheterization.

Neurological complications after coronary angiography are rare but associated with significant mortality and morbidity. These include ischemic and hemorrhagic strokes, and transient ischemic attacks. Rarely, contrast media can cross the blood brain barrier causing transient neurological symptoms including confusion and seizures. On imaging, it can mimic a subarachnoid hemorrhage (SAH). Blood can be differentiated from contrast media using MRI. We present a patient who developed confusion after undergoing cardiac angiography and the initial CT of the brain showed SAH. However, MRI of the brain did not reveal any hemorrhage indicating contrast staining.

Double Vision: Isolated Third Cranial Nerve Palsy After Cardiac Catheterization.

Neurological complications after cardiac catheterization are rare. We report an unusual case of isolated third cranial nerve palsy in a 72-year-old male patient whose past medical history was significant for diabetes mellitus and coronary artery disease (CAD). He presented for elective cardiac catheterization for stable angina, which revealed multivessel CAD and no intervention was done. Two hours after the procedure, the patient suddenly started complaining of new-onset double vision in his left eye. Ophthalmologic exam revealed ptosis of the left eye lid, sluggish pupillary reflex and impaired adduction of the left eye along with exotropia of the left eye on primary gaze, all findings consistent with the left third nerve palsy. Rest of the neurological exam and neuroimaging (CT angiogram of head and MRI brain) were normal. Embolic phenomenon has been described as a possible mechanism in such patients leading to small vessel ischemic disease and cerebral microinfarction. Neuro-ophthalmologic complications after cardiac catheterization are rare but devastating for the patients. These should be recognized promptly, and patients should undergo neuroimaging to evaluate for any identifiable causes. These patients should be treated with aspirin and statin therapy and evaluated by ophthalmology for correction with prism lenses if symptoms persist.

A Rare Case of Ventilator-Associated Pneumonia Caused by Cupriavidus Pauculus.

Ventilator-associated pneumonia is a hospital-acquired infection that is commonly encountered in intubated patients in the intensive care unit (ICU). It is associated with significant morbidity and mortality. The causative organisms include gram-negative rods (Escherichia coli, Klebsiella pneumoniae, or Acinetobacter species) or gram-positive cocci (Staphylococcus aureus). Described here is a case of ventilator-associated pneumonia caused by a relatively unknown gram-negative bacterium, Cupriavidus (C.) pauculus that was successfully treated with intravenous cefepime.

The Sweet syndrome as a cutaneous manifestation of Crohn's disease.

Crohn's disease is an inflammatory bowel disease associated with many extraintestinal manifestations involving multiple organs, including the skin, eyes, liver, and joints. Classic Sweet's syndrome is a cutaneous manifestation of Crohn's disease, characterized by sudden onset of painful plaques or nodules of the skin associated with fever and neutrophilia. We present a case of classic Sweet's syndrome in a patient with well-controlled Crohn's disease.

Ethylene Glycol Poisoning with a Near-Normal Osmolal Gap: A Diagnostic Challenge.

Ethylene glycol is a colorless, odorless, sweet-tasting liquid commonly found in antifreeze, as well as in industrial agents. It is regarded as one of the toxic alcohols. Ethylene glycol poisoning usually occurs due to ingestion, and its toxicity is mediated by its metabolites, glycolic acid, and oxalate. These metabolites can cause neurological symptoms, gastrointestinal symptoms, and/or renal failure if not diagnosed and treated promptly. The diagnosis can be very challenging as the test used to detect ethylene glycol in the blood may not be readily available or due to an inaccurate history. The treatment of ethylene glycol poisoning consists of supportive care, sodium bicarbonate, and the use of an antidote (ethanol or fomepizole) which inhibits alcohol dehydrogenase and thereby prevents the formation of toxic metabolites. Patients with advanced poisonings may also require dialysis. The diagnosis is usually suggested by a high anion gap metabolic acidosis and an elevated osmolal gap in the setting of a suspected ingestion. Rarely, the osmolal gap may be close to normal which can delay the diagnosis or lead to a misdiagnosis. We report a case of ethylene glycol ingestion with a near-normal osmolal gap.