Giant-Cell Aortitis-Induced Acute Aortic Insufficiency: An Underestimated Etiology.

BACKGROUND Acute aortic insufficiency can be secondary to multiple conditions, including infective endocarditis, aortic root pathologies (eg, dissection, aortitis), or traumatic injury. Aortitis involves a broad spectrum of disorders characterized by inflammatory changes in the aortic wall. This pathology can be subsequently classified depending on its etiology into inflammatory and infectious causes. Large-vessel vasculitis (giant-cell arteritis, Takayasu arteritis, and IgG4-related vasculitis) is the most common non-infectious causes of aortitis. Giant-cell aortitis usually lacks the classic clinical findings of giant-cell arteritis such as headache, visual symptoms, or jaw claudication, which can be a diagnostic challenge. However, clinicians should have a high index of suspicion, since this pathology can evolve into potentially life-threatening conditions, including aortic aneurysm, aortic wall rupture, and aortic acute dissection. CASE REPORT We present a case of a 76-year-old woman who presented to the Emergency Department (ED) with shortness of breath associated with orthopnea, paroxysmal nocturnal dyspnea, and mild productive cough with white sputum. A transthoracic echocardiogram demonstrated reduced left ventricular ejection fraction, dilated left ventricle, and severe aortic insufficiency. Cardiac catheterization revealed mild non-obstructive coronary arteries and severe aortic regurgitation. The surgical pathology report of the portion of the aorta was consistent with giant-cell aortitis. CONCLUSIONS In this article, we present a case of giant-cell aortitis as an unusual etiology of acute aortic insufficiency, which is most probably under-detected in clinical practice. In addition to describing the case, we aim to highlight the importance of proper ascending aorta evaluation in patients presenting with new-onset aortic regurgitation and heart failure to prevent associated morbidity and mortality.

Portal Vein Thrombosis Associated With Fusobacterium nucleatum Bacteremia: A Rare Abdominal Variant of Lemierre's Syndrome.

Lemierre's syndrome is a rare but potentially severe complication of bacterial infections that usually affects previously healthy adolescents and young adults. It commonly presents as septic thrombophlebitis of the internal jugular vein and bacteremia following a recent oropharyngeal infection. The most commonly isolated organisms are Fusobacterium necrophorum, followed by Fusobacterium nucleatum and other anaerobes. Atypical Lemierre's syndrome is characterized by thrombophlebitis at sites distant from the head and neck veins and is far less encountered than typical Lemierre's syndrome. Here, we present a case of an elderly African American female with pylephlebitis, a rare abdominal variant of Lemierre's syndrome with extensive portal vein, splenic vein, and mesenteric vein thrombosis following perforated diverticulitis and resultant F. nucleatum bacteremia. She demonstrated complete recovery following appropriate long-term intravenous antibiotics and anticoagulation. This case calls attention to the re-emergence of the rare manifestation of this forgotten disease and highlights improved outcomes with prompt recognition and early treatment.

Pericardial Cyst, A Rare Incidental Finding in an Uncommon Location: A Case Report.

A pericardial cyst is one of the rare causes of mediastinal masses. Most of the cases are secondary to congenital incomplete fusion of the pericardial sac. More than two-thirds of the cases are present in the right cardiophrenic angle, and the left cardiophrenic angle is the second most common location. In our study, we illustrated an incidental finding of the pericardial cyst in a patient who presented with nonspecific symptoms and was found to have a left-sided cardiophrenic pericardial cyst, which is only found in about 20% of the cases. A CT scan and echocardiogram confirmed the diagnosis of a 4.39-centimeter cyst with no signs of complications like tamponade or pericarditis. As the patient's symptoms resolved, outpatient follow-up with serial echocardiogram was advised. Through this report, we aim to raise awareness of the importance of further investigation for nonspecific symptoms like atypical chest tightness and differentiating simple pericardial cysts from other pericardial lesions. Based on the symptoms, size, and compression effect of the cyst, management may vary from serial echocardiogram to aspiration or surgical resection.

Levine's Sign Points to Spontaneous Coronary Artery Dissection in a Healthy Young Male.

Levine's sign is a universal sign of ischemic chest pain, defined as an individual holding a clenched fist over the chest that has a low sensitivity but is relatively specific for ischemia. Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic and a very unusual cause of acute myocardial infarction.In literature, it has been more common in young women, postpartum, or with fibromuscular dysplasia. Strenuous exercise is a rare cause of SCAD. We describe a case of a healthy 46-year-old Hispanic male who presented to ER after his morning gym session. The initial EKG was unremarkable. However, due to Levine's sign, a repeat EKG was done and showed hyperacute T waves with J-point elevation in the anterior leads. An immediate coronary angiogram revealed a spontaneous coronary artery dissection in the mid-left anterior descending artery (LAD) segment. Given the resolution of the chest pain and thrombolysis in myocardial infarction (TIMI) 3 flow, no intervention was done. The patient was managed medically with an uneventful recovery. In the current times, with the advent of high sensitivity troponin along with other rapid multimodality imaging techniques, the importance of physical signs and symptoms like Levine's sign has diminished. Yet, they still remain a vital part of patient evaluation. Additionally, SCAD is uncommon in males. However, this patient was consuming energy booster powder that may have predisposed him to the SCAD. In our opinion, Levine's sign still has high clinical value in the right context. We also postulate that energy booster supplements may have serious deleterious cardiovascular effects, and large studies are necessary to understand their full effects on the cardiovascular system.

Successful Utilization of Life-saving Extra-Corporeal CO2 Removal in Catastrophic Status Asthmaticus: A Case Report.

Acute asthma exacerbations can be severe and life-threatening. In some cases, standard interventions and management do not result in reversal of bronchoconstriction. It is crucial to detect patients with impending respiratory failure and escalate management to invasive mechanical ventilatory support and, in refractory cases, interventions like extracorporeal membrane oxygenation (ECMO). This technique is not frequently utilized but has proven to be effective in settings of resistant status asthmaticus. We describe a Case of respiratory distress secondary to asthma exacerbation, which rapidly devolved into status asthmaticus. It was resistant to all standard and off-label management modalities, which necessitated the use of veno-venous extracorporeal CO2 removal (VVECCO2R). ECMO was utilized in our case with great success. In this article, we aim to raise awareness of the importance of VVECCO2R in the treatment of refractory status asthmaticus and the difficulties that prevent widespread implementation of the technique across healthcare facilities.

A Rare Neurological Presentation Post-Cardiac Catheterization.

Unilateral Isolated oculomotor nerve palsy is a rare neurological complication after cardiac catheterization. Concomitant thalamus and midbrain infarction secondary to embolic events involving the artery of Percheron after cardiac catheterization have been reported in the literature. However, isolated midbrain infarction is a rare neurological deficit. Here, we present the case of a patient who presented with mild left-sided ptosis, binocular diplopia, and partially impaired left eye adduction two hours after cardiac catheterization. Brain magnetic resonance imaging revealed a focal area of restricted diffusion within the midbrain tegmentum, confirming this rare brainstem stroke.

Serratia marcescens Endocarditis.

Infective endocarditis (IE) secondary to Staphylococcus aureus and streptococcus species comprises the majority of cases in literature with Gram negative bacterial insults occurring infrequently. Serratia marcescens is a Gram negative bacillus which is classified as motile, non-lactose fermenting, and a facultative anerobe. The presumed risk factor for the development of S. marcescens IE is intravenous drug use (IVDU). We report two cases of IE causes by S. marcescens: first case describes IE of tricuspid and aortic valve requiring surgical intervention further complicated by epidural abscess. The second case was associated with renal and splenic infarct. These cases highlight the severity and complicated nature of S. marcescens IE. Given S. marcescens IE has been infrequently described in the literature, we believe that our cases are worth reporting to contribute to the present incidence and management of S. marcescens IE.

SARS-CoV-2 Associated With Pneumothorax: A Case Report and Literature Review.

SARS-CoV-2 has created universal disarray since its outbreak in 2019. Emergent measures were taken worldwide to mitigate the morbid outcomes of the pandemic. Multiple organ systems have been shown to be negatively impacted secondary to the heightened inflammatory response to the novel virus. In this report, we focus on the respiratory system. The novel virus impact on the respiratory system has been well documented, leading to acute respiratory distress syndrome. Here, we present a case of a patient with no risk factors for pneumothorax (smoking, underlying lung disease, prior history of pneumothorax, age, family history) who was found to be SARS-CoV-2 positive and developed a significant pneumothorax requiring transfer to the intensive care unit.

Endocarditis caused by Bartonella Quintana, a rare case in the United States.

Bartonella quintana is a relatively rare cause of endocarditis in the United States (USA). Historically it was linked with trench fever, but cardiac involvement seems to be more prevalent recently. There are some known risk factors associated with Bartonella quintana endocarditis such as human immunodeficiency virus (HIV) infection, alcoholism, homelessness and poor hygiene. We report a case of 37-year-old African man, with culture negative endocarditis, emboli and rising B. quintana and B. henselae IgG titers. B. quintana DNA was subsequently detected from the mitral valve sample with 16S rRNA gene and ribC primer sets. Eventually, blood culture for B. quintana was positive after 21 days. Patient was successfully treated with doxycycline and gentamicin. There have been a few cases of B. quintana endocarditis in the USA and most of them were associated with HIV infection, homelessness or alcoholism. The case reported here highlights the importance of high clinical suspicious for Bartonella species in blood culture negative endocarditis in the USA in appropriate setting and will help to increase awareness among physicians for early diagnosis and treatment.

Symptomatic central nervous system tuberculoma, a case report in the United States and literature review.

Intracranial tuberculoma is one of the rare central nervous system manifestations of Mycobacterium tuberculosis (MTB), seen in only 1% of tuberculosis patients. It can manifest as single or multiple lesions, most commonly located in the frontal and parietal lobes. Clinical features are similar to any space-occupying lesion in the brain and can present in the absence of MTB symptoms in other parts of the body. In this article, a 69-year-old immunocompetent man, with history of treated latent tuberculosis infection (LTBI) was reported. He presented with multiple joint arthralgias, weight loss, odd behavior, forgetfulness, intermittent fevers and syncope. Brain imaging revealed numerous enhancing intra-parenchymal lesions in cerebral and cerebellar hemispheres. Patient was successfully treated with anti-tuberculosis medications and corticosteroids, with clinical improvement on future follow ups. High clinical suspicion for tuberculoma as a differential diagnosis of any brain lesion, even in immunocompetent patients in low MTB prevalence countries, can result in early diagnosis and successful clinical outcomes.

Renal capsule for augmentation cystoplasty in canine model: a favorable biomaterial?

PURPOSE: To evaluate effectiveness of canine renal capsule for augmentation cystoplasty. MATERIALS AND METHODS: Ten adult dogs participated in this study. After induction of anesthesia each animal underwent bed side urodynamic study, bladder capacity and bladder pressure was recorded. Then via mid line incision abdominal cavity was entered, right kidney was identified and its capsule was dissected. Bladder augmentation was done by anastomosing the renal capsule to the bladder. After 6 months bed side urodynamic study was performed again and changes in bladder volume and pressure were recorded. Then the animals were sacrificed and the augmented bladders were sent for histopathology evaluation. RESULTS: Mean maximum anatomic bladder capacity before cystoplasty was 334.00±11.40cc which increased to 488.00±14.83cc post-operatively (p=0.039). Mean anatomic bladder pressure before cystoplasty was 19.00±1.58cmH2O which decreased to 12.60±1.14cmH2O post-operatively (p=0.039). Histopathology evaluation revealed epithelialization of the renal capsule with urothelium without evidence of fibrosis, collagen deposits or contracture. CONCLUSIONS: Our data shows that renal capsule is a favorable biomaterial for bladder augmentation in a canine model.

Renal capsule for augmentation cystoplasty in canine model: a favorable biomaterial?

ABSTRACT Purpose: To evaluate effectiveness of canine renal capsule for augmentation cystoplasty. Materials and Methods: Ten adult dogs participated in this study. After induction of anesthesia each animal underwent bed side urodynamic study, bladder capacity and bladder pressure was recorded. Then via mid line incision abdominal cavity was entered, right kidney was identified and its capsule was dissected. Bladder augmentation was done by anastomosing the renal capsule to the bladder. After 6 months bed side urodynamic study was performed again and changes in bladder volume and pressure were recorded. Then the animals were sacrificed and the augmented bladders were sent for histopathology evaluation. Results: Mean maximum anatomic bladder capacity before cystoplasty was 334.00±11.40cc which increased to 488.00±14.83cc post-operatively (p=0.039). Mean anatomic bladder pressure before cystoplasty was 19.00±1.58cmH2O which decreased to 12.60±1.14cmH2O post-operatively (p=0.039). Histopathology evaluation revealed epithelialization of the renal capsule with urothelium without evidence of fibrosis, collagen deposits or contracture. Conclusions: Our data shows that renal capsule is a favorable biomaterial for bladder augmentation in a canine model.