Type B Aortic Dissection Masquerading As Acute Pyelonephritis: Think Beyond Measures.

Aortic dissection (AD) is a life-threatening medical emergency with a high mortality rate if misdiagnosed; therefore, an urgent and precise diagnosis is crucial for prompt treatment. This article presents a rare case report of AD with an atypical clinical presentation that led to delayed diagnosis and a complicated clinical course. Herein, we aim to contribute to the existing literature by providing insights into the varied presentations of AD and offering valuable lessons for clinicians faced with similar diagnostic scenarios. A 64-year-old female with an extended history of hypertension and other comorbidities presented to the emergency department with a one-day duration of right-sided loin pain and fever. Her blood investigations demonstrated evidence of leukocytosis and high c-reactive protein (CRP) levels. She was preliminarily treated as a case of acute pyelonephritis since, initially, clinical and radiographic evidence did not yield an alternative diagnosis. Despite antibiotics, her condition deteriorated, and her urine output became less than 0.5 mL/kg/hour for six consecutive hours. Additionally, the obtained urine culture was negative on the third day of admission, which made the medical team repeat her history taking and clinical examination, revealing a previously overlooked weight loss. This red flag prompted the medical team to conduct thorough chest and abdominal imaging studies in search of any hidden malignancy, especially when her thyroid function test returned normal. Surprisingly, a contrast-enhanced abdominal CT scan demonstrated an infarcted right kidney by thromboembolism that originated from the partially obstructive thrombus in the proximal abdominal aorta, which was later confirmed to be a type B AD by a CT angiogram. A multidisciplinary team guided her treatment, which included carefully controlling her blood pressure, using anticoagulants, and closely monitoring the patient. The take-home messages of this case report underscore the critical importance of recognizing atypical clinical presentations of AD, overcoming diagnostic challenges through comprehensive approaches, tailoring treatments to individual patient needs, and advocating for a multidisciplinary and patient-centered approach to enhance overall clinical outcomes.

Elderly Patient With Hematological and Neurological Manifestations of Undetermined Origin: A Diagnostic Dilemma of Pernicious Anemia.

Pernicious anemia (PA) is a chronic inflammatory destructive disease of parietal cells of predominantly the gastric fundus. It leads to vitamin B12 (cobalamin) deficiency secondary to a deficiency of intrinsic factors. Despite the medical advances nowadays, diagnosing PA can be challenging. This report highlights a neglected case of PA with ongoing subacute combined degeneration of the cord (SCDS) in an elderly patient. An 86-year-old lady with multiple comorbidities was referred to the hematology outpatient clinic for refractory anemia for the last two months. At first, her general practitioner (GP) treated her as a case of anemia of chronic disease but without improvement. Her initial clinical assessment revealed hematological and neurological manifestations of undetermined origin, including global weakness, hypertonia, and hyperreflexia with sensory deficits, especially in the lower limbs. On investigation, the hemoglobin level was 9 g/dL with high indirect bilirubinemia and lactate dehydrogenase (LDH). Despite the normal mean corpuscular volume (MCV) and peripheral blood smear, positive anti-intrinsic factor and parietal cell antibodies tests were subsequently reported, suggesting the diagnosis of PA. As a result, she was commenced on lifelong parenteral cobalamin replacement therapy. On follow-up visits of three months, she illustrated a clinical recovery in fatigability and paranesthesia. As expected, the laboratory parameters revealed a rise in hemoglobin level (11 g/dL) and serum vitamin B12 (418 pg/mL). However, she remained bedridden with spastic limbs. Clinicians should have a high index of suspicion since PA is a rare disease with variable clinical presentations. The optimal management approach is by a multidisciplinary care team of internists, neurologists, gastroenterologists, and hematologists.

Effects of Ramadan Intermittent Fasting on the Severity of ß-Thalassemia Major Patients.

BACKGROUND: ß-thalassemia major (ß-TM) is an inherited autosomal recessive disorder manifested by the hemoglobin ß chain synthesis alteration. It is a lifelong illness with a scope of a wide range of complications. Many kinds of literature evaluated the effect of Ramadan intermittent fasting (RIF) on different medical conditions. However, there are no precise guidelines regarding its effect on patients with ß-TM. METHODS: A retrospective cohort study was conducted on ß-TM patients who visited the hereditary blood disorder center at Al Karama Teaching Hospital in Baghdad. Accordingly, six parameters were used to evaluate the effect of RIF on ß-TM patients before, during, and after Ramadan. These parameters include hemoglobin level, frequency of transfusion, aspartate aminotransferase (AST) level, alanine aminotransferase (ALT) level, left ventricular ejection fraction % (EF%), and spleen size. All of these details, including the demographic characteristics of age, gender, history of splenectomy, and body mass index (BMI) were retrieved from the patient's medical records after confirming their fasting through one-to-one interviews. This study aimed to fill the gap and investigate the possible effect of RIF on the severity of ß-TM. RESULTS: A total of 184 ß-TM patients were enrolled in this study. The mean duration of fasting was 25.2±2.18 days. More than half (110) of the patients were females (59.8%). Whereas, the mean age was 24.8±3.5 years. One-third of the patients (65) had a splenectomy (35.3%) and more than two-thirds had normal BMI. The initial parameters used to score the severity of ß-TM were evaluated separately. As a result, the hemoglobin level remained steady without any statistical significance during the three months. In addition, the frequency of blood transfusion and the spleen size carried the same result. Although the lowest median and range of liver enzymes were recorded during Ramadan, they were statistically insignificant compared to pre and post-fasting. Moreover, the left ventricular EF% was insignificant regardless of the patient's history of heart disease. CONCLUSION: This study revealed that RIF does not seem to affect the severity of ß-TM if the patients proceed with fasting. However, further studies in more countries with a bigger sample size are recommended to confirm these findings.

Thyrotoxic Cardiomyopathy Unveiled: Insights From a Compelling Case Report.

Thyrotoxicosis is a clinical condition characterized by inappropriately elevated thyroid hormone levels in the bloodstream, leading to systemic effects on the body. In fact, the thyrotoxic state has tight regulatory control over the cardiovascular system through genomic and non-genomic mechanisms. This study highlights a rare presentation of thyrotoxic cardiomyopathy (TCM), which, to the best of our knowledge, is one of the very few case reports involving heart failure with preserved ejection fraction (HFpEF) and only atrial involvement, compared to the previous literature. A 37-year-old female presented to the outpatient clinic with abdominal distention and neglected signs and symptoms consistent with thyrotoxicosis for a year. Investigations revealed high N-terminal pro-b-type natriuretic peptide (NT-proBNP) levels of 1788 pg/mL. Cardiac MRI and trans-thoracic echocardiogram (TTE) revealed bilateral atrial dilatation, a left ventricular ejection fraction (LVEF) of 60%, and diastolic dysfunction. Additionally, severe free-flowing tricuspid and mitral valve regurgitation were observed, with no evidence of pericardial effusion or ventricular abnormalities. Therefore, a diagnosis of TCM was suspected and eventually confirmed by excluding other differential diagnoses. Besides a diffuse goiter on ultrasonography, the thyroid panel test revealed low thyroid-stimulating hormone (TSH) levels of <0.01 mIU/L, a free thyroxine T4 of >100 pmol/L, and positive anti-thyroid peroxidase (TPO) and TSH receptor antibodies. Accordingly, a team of endocrinologists, cardiologists, and internists managed the patient with anti-thyroid medications alongside symptomatic treatment. A few days later, she was discharged in good condition, and a follow-up visit was arranged with the endocrinology and cardiology clinics. It is crucial to maintain a high level of suspicion to detect and treat TCM promptly, and a multidisciplinary approach should ideally be employed. This is not only important for the prevention of but also reversing potentially life-threatening cardiovascular complications.

Mid-Term Results of Fenestrated Endovascular Repair after Prior Open Aortic Reconstruction.

This study aims to assess the mid-term results of fenestrated endovascular aneurysm repair (FEVAR) for the treatment of proximal aortic pathology after previous open surgical repair (OSR). All patients with a previous history of OSR of an abdominal aortic aneurysm undergoing a FEVAR procedure between October 2010 and November 2021 were included. The endpoints of the study were technical success, mortality, target vessel patency and reinterventions during follow-up. Thirty-five patients (34 male, mean age 72.9 ± 7 years) were included. The median interval from the primary surgery to the FEVAR procedure was 136 months (range 47-261). The indication for treatment was a para-anastomotic aneurysm in 18 (51%) patients and a true aneurysm due to progression of disease in 17 (49%) patients. Technical success was achieved in 33 (94%) patients. There was one (3%) early death due to postoperative bleeding from a renal artery. Estimated survival at 12, 24 and 36 months was 89.1% ± 6%, 84.4% ± 7.3% and 84.4% ± 7.3%, respectively. There was no aneurysm-related mortality. One (3%) target vessel occluded during follow-up and three (9%) patients underwent late reinterventions. In conclusion, FEVAR is a safe and effective alternative for the endovascular treatment of para-anastomotic aneurysms/pseudoaneurysms after OSR showing high technical success, low mortality and morbidity, and good mid-term outcomes.

Fenestrated and branched stent grafts for the treatment of post-dissection thoracoabdominal aortic aneurysms.

The present study aims to analyze fenestrated/branched endovascular aneurysm repair (F/BEVAR) in the treatment of post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs). Focus is given on indication, anatomic suitability, device planning, and clinical outcomes. PD-TAAAs present with additional challenges in F/BEVAR. These include true lumen compression and visceral arteries originating from the false lumen. These technical challenges limited the use of F/BEVAR in PD-TAAAs to a few institutions in the beginning, but the good results reported with this approach have led to an increase in its use in a growing number of centers. Our current single-center experience includes 75 patients treated with F/BEVAR for a PD-TAAA between October 2010 and October 2021. Technical success was achieved in 74 cases (98.7%). Two patients (2.6%) died in the first 30 postoperative days. Ten patients (13.3%) had postoperative symptoms of spinal cord ischemia: 9 (12%) with transient limb weakness and 1 (1.3%) with permanent paraplegia. There was only 1 death (1.3%) related to the aneurysm during follow-up. Mean ± SD estimated primary patency rates of the target vessels at 12, 24, and 36 months were 97.9% ± 1%, 96.1% ± 1.6%, and 95.2% ± 1.9%, respectively. The estimated freedom from re-intervention rates at these time points were 81.4% ± 5.3%, 56.9% ± 7.3%, and 53.9% ± 7.5%, respectively. In conclusion, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results with regard to mortality and morbidity. The additional technical challenges posed by PD-TAAAs need to be considered to prevent complications and decrease the high rate of re-interventions.

Bone Metastasis As the Initial Presentation of a Hidden Bronchogenic Carcinoma.

Primary malignant bone tumours are on the whole rare, while secondary bone tumours are much more common. Up to 40% of bone metastases are associated with lung cancer. This case report highlights a rare presentation of metastatic bone disease as the initial presentation of a primary lung malignancy and only very few cases were mentioned in literature with the same presentation of no clinical signs of the primary lung pathology, except for an unexpected radiological finding of a suspicious lung lesion. An 85-year-old gentleman presented with a progressive lower backache radiating to both lower limbs over a period of 4 weeks associated with difficulty in walking, significant weight loss, and decreased appetite. A skeletal survey showed only spondylolisthesis. However, no clinical improvement was noticed with conventional therapy. Examination of the respiratory, gastrointestinal, and genitourinary systems was normal. Ultrasonography of the abdomen and pelvis, and the findings of the colonoscopy did not add anything. During the third week of follow-up, the patient reported unbearable severe pain in the left arm. A plain radiograph revealed a pathological fracture of the humerus. Secondary bone metastasis was suspected. Although the patient was a non-smoker and there were no clinical signs of underlying lung disease, a simple plain chest radiograph, unexpectedly, showed a suspicious right lower lobe lesion. Therefore, a contrast-enhanced computerized tomography (CT) scan for the chest, abdomen, and pelvis was done which revealed a right lower lobe lesion of bronchogenic carcinoma with distant metastasis. Unfortunately, the patient died after 3 weeks of palliative therapy when he was admitted to the hospital with acute renal failure and septic shock. Bone metastases in lung cancer predict a poor prognosis and short-term survival. The diagnosis of such a challenging presentation requires a high index of suspicion. If the patient had been sent for a plain chest radiograph at first, lots of time and effort could be saved in reaching the diagnosis without the need for further sophisticated or invasive diagnostic procedures.

Limb Occlusion Rate after EVAR With Individualized Graft Limb Selection and a Liberal Protocol of Primary Relining.

BACKGROUND: This study analyses limb occlusion rates after endovascular aneurysm repair (EVAR) with a strategy including stent-graft limb selection and liberal primary stenting (relining) in anatomies at higher risk for occlusion with uncovered self-expandable or balloon-expandable stents. METHODS: All patients undergoing elective EVAR with a bifurcated stent-graft between January 2010-August 2018 were included. A protocol involving personalized stent-graft selection and liberal primary relining based on preoperative imaging was followed during the whole period. Primary endpoints were technical success and primary limb patency during follow-up. Secondary endpoints included mortality and limb reintervention rates. Risk factors associated to limb patency and reintervention rates were analyzed. RESULTS: Six hundred and fifteen patients (548 males; mean age 72.9 ± 9 years) were included. Overall technical success was 98.5% (606/615). One (0.16%) patient died during the first 30 days. Of the 1230 limbs, 96 (8%) were deemed at risk for occlusion in view of the anatomy, and primarily relined in 62 patients. Estimated primary limb patency at 6 months, 1 year and 3 years was 99.5 ± 0.2%, 99.2 ± 0.3% and 98.5 ± 0.5%, respectively. Freedom from limb-related reintervention at 6 months, 1 year and 3 years was 98.1 ± 0.4%, 97.4 ± 0.5% and 95.6 ± 0.7%, respectively. Only one (1%) of the 96 relined limbs occluded during follow-up. No differences were found in terms of patency or freedom from reintervention between limbs at risk that were primary stented and limbs without adjunctive stents. Gore Excluder stent-grafts presented better patency (Breslow P = 0.005) and lower reintervention rates (Breslow P = 0.001) than other devices during follow-up. Peripheral artery disease was also a risk factor for reintervention (Breslow P = 0.015). CONCLUSION: Liberal use of primary limb relining in patients with iliac anatomy at higher risk for occlusion appears to be a safe and effective strategy to preserve limb patency after EVAR. Gore Excluder graft limbs present better patency and lower reintervention rates than other stent-graft types.

Single Center Experience with Endovascular Repair of Acute Thoracoabdominal Aortic Aneurysms.

PURPOSE: To investigate feasibility and outcomes of endovascular repair for acute thoracoabdominal aortic aneurysms (TAAA). MATERIALS AND METHODS: Data from a single center were retrospectively analyzed. Patients who underwent endovascular repair for acute TAAA between January 2010 and April 2020 were included. Perioperative and mid-term follow-up outcomes were analyzed. Survival, freedom from reintervention, and target vessel patency were calculated by Kaplan-Meier analysis. RESULTS: A total of 30 patients (18 men, 67.5 ± 6.9 years) underwent endovascular repair for acute symptomatic (n = 15) or contained ruptured (n = 15) TAAA. An off-the-shelf four-branched stent-graft (T-Branch) was used in 19 (63.3%) patients, a custom-made device (CMD) with expedite order in 5 (16.7%) patients, a CMD with short anticipated delivery time in 3 (10.0%) patients, and a CMD available in the hospital in 3 (10.0%) patients. Technical success was 90.0% (n = 27). Thirty-day mortality was 10% (n = 3). There was no complete persistent paraplegia, but one (3.3%) patient suffered permanent limb weakness. Estimated survival at 1 and 2 years was 86.3% ± 6.4%, and 82.3% ± 7.2%, respectively. Estimated freedom from reintervention at 1 and 2 years was 81.4% ± 7.6% and 73% ± 8.8%. Estimated target vessel patency at 1 and 2 years was 96.6% ± 2% and 92.6% ± 2.9%. CONCLUSION: Endovascular treatment of acute TAAA in this selected group of patients was associated with low early mortality and excellent mid-term survival. The off-the-shelf stent-graft option (T-Branch) was used in the majority of patients. Endovascular repair should be considered the first option for suitable acute TAAA.

Outcomes of fenestrated and branched endovascular aortic repair for chronic post-dissection thoracoabdominal aortic aneurysms.

BACKGROUND: Aneurysmal degeneration after acute dissection occurs in a significant proportion of patients. Fenestrated and branched stent-grafting (F/BEVAR) has been increasingly used to treat these post-dissection thoracoabdominal aortic aneurysms (PD-TAAA). The aim of this study was to report early and mid-term outcomes of F/BEVAR in PD-TAAA. METHODS: Retrospective single center analysis of a prospectively maintained database including all patients undergoing F/BEVAR for PD-TAAA between October 2010-February 2020. RESULTS: Fifty-five patients (45 males, mean age 66±10 years) were included. Technical success was achieved in all patients. Thirty-day mortality was two (3.6%) patients. Major perioperative complications were noted in nine (16.4%) patients including five (9.1%) with transient spinal cord ischemia (SCI) and one (1.8%) with permanent paraplegia. Mean follow-up was 24 months (1-76 months). Cumulative survival rates at 12, 24 and 36 months were 87±5.5%, 83.5±6.3% and 72.2±8.1%, respectively. Estimated freedom from reintervention at 12, 24 and 36 months was 82.2±6.7%, 60.1±9.2% and 55.9±9.5%, respectively. Main reasons for reintervention were endoleaks from target vessels and common iliac arteries. Estimated target vessel patency at 12, 24 and 36 months was 97.8±1.2%, 95.4±2.1%, and 94.1±2.4%, respectively. Mean aneurysm sac regression during follow-up was 7.9±7.1 mm, with complete false lumen thrombosis in 80% of patients. No ruptures occurred during follow-up. CONCLUSIONS: F/BEVAR for PD-TAAA is associated with low perioperative mortality and morbidity in a large volume endovascular center. Mid-term results demonstrate a high rate of aneurysm sac regression. Extended sealing with longer bridging stents for target vessels is recommended.