Cardiogenic and obstructive shock: primary laryngeal synovial sarcoma with cardiac metastasis.

A man in his 20s with a history of laryngeal synovial sarcoma presented with dyspnoea. Imaging revealed a large right ventricular (RV) mass, which was resected, and histological analysis indicated synovial sarcoma recurrence. Within 1 month of RV mass resection, the tumour progressed with paratracheal metastasis. The lumen was nearly obliterated, and right ventricular outflow tract (RVOT) obstruction led to rapid deterioration with mixed cardiogenic and obstructive shock. We present a rare case of primary laryngeal synovial sarcoma metastasising to the heart.

Aortic Thrombosis and Ischemic Stroke With Hemorrhagic Conversion in a Patient With Remote COVID-19 Infection: A Treatment Dilemma.

Coronavirus disease 2019 (COVID-19) is primarily known to affect the lungs; however, several studies indicate that it can be a multisystem disease. There is documentation detailing different sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients affected with this virus have been seen to develop a hypercoagulable state leading to systemic thrombosis in some cases or embolism leading to catastrophic outcomes in others. Data regarding anticoagulation in these patients is limited. Further research needs to be carried out for management and prophylaxis for patients with COVID-19 at risk of aortic thrombosis.  We present a case of a middle-aged man with multiple comorbidities and remote COVID-19 infection who came to the emergency room with signs and symptoms worrisome for a cerebrovascular accident (CVA). Brain imaging revealed multiple cortical infarcts suggestive of a cardioembolic etiology. During his hospitalization, he underwent a transesophageal echocardiogram (TEE) that showed a 1x1 cm mobile thrombus in the distal descending aorta. Laboratory workup was negative for any hypercoagulable condition; it was thought that this patient might have a hypercoagulable state post-COVID-19 infection. After a thorough risk vs. benefit discussion, patient was started on apixaban. He remains alive and is doing well in a recent follow-up in our clinic.

Epipericardial Fat Necrosis: A Concise Review of Literature.

Epipericardial fat necrosis (EFN) is an inflammatory process that occurs in the mediastinal fat surrounding the heart. It is a rare cause of acute chest pain and mimics more ominous clinical conditions such as acute coronary syndrome, aortic dissection, and pulmonary embolism. Clinicians are often not familiar with this condition due to its infrequent occurrence, and traditional textbooks of medicine and cardiology have not covered this topic adequately. In the past, EFN had been managed primarily with thoracotomy and surgical excision. This has changed with advances in imaging techniques and their more frequent utilization. Computed tomography (CT) of the chest is essential for the diagnosis of EFN as it allows for the evaluation of the nature and precise location of the lesion. Magnetic resonance imaging helps to differentiate EFN from other mediastinal fatty lesions such as lipomas or liposarcomas. The clinical presentation of acute chest pain along with CT findings of the encapsulated fatty pericardial lesion is adequate for diagnosis. Our review describes the emerging role of imaging in diagnosis and change in management over the last few years.

Outcomes after transcatheter aortic valve replacement in cancer survivors with prior chest radiation therapy: a systematic review and meta-analysis.

BACKGROUND: Cancer survivors with prior chest radiation therapy (C-XRT) frequently present with aortic stenosis (AS) as the first manifestation of radiation-induced heart disease. They are considered high-risk for surgical valve replacement. Transcatheter aortic valve replacement (TAVR) is as an attractive option for this patient population but the outcomes are not well established in major clinical trials. The authors performed a systemic review and meta-analysis of clinical studies for the outcomes after TAVR in cancer survivors with prior C-XRT. METHODS: Online databases were searched from inception to April 2020 for studies evaluating the outcomes of TAVR in patients with and without C-XRT. We analyzed the pooled estimates (with their 95% confidence intervals) of the odds ratio (OR) for the all-cause mortality at 30-day and 1-year follow-ups, 4-point safety outcomes (stroke, major bleed, access-related vascular complications and need for a pacemaker), a 2-point efficacy outcome (mean aortic valve gradient and left ventricular ejection fraction) and worsening of congestive heart failure (CHF). Four studies were included following 2054 patients with and without prior C-XRT exposure (164 patients and 1890 patients respectively). RESULTS: The C-XRT group had similar 30-day mortality compared to the control group (OR 1.29, 95% CI 0.64 to 2.58, p = 0.48). The 1-year mortality was higher in the C-XRT group (OR 1.97, CI 1.15 to 3.39, p = 0.01). Apart from higher congestive heart failure (CHF) exacerbation in the C-XRT group (OR 2.03, CI 1.36 to 3.04, p = 0.0006), TAVR resulted in similar safety and efficacy outcomes in both groups. CONCLUSION: TAVR in the C-XRT group has similar 30-day mortality, safety, and efficacy outcomes compared to the control group; however, they have higher 1-year mortality and CHF exacerbation. Including an oncologist to the cardiology team who considers cancer stage in the decision-making process and applying additional preoperative scores such as frailty indices may refine the risk assessment for these patients. The quality of analyzed data is modest, warranting randomized trials to assess the true benefits of TAVR in these patients.

Rosuvastatin Use Implicated in the Drug Reaction with Eosinophilia and Systemic Symptoms.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a life-threatening drug-induced hypersensitivity reaction that is most closely associated with antiepileptics and antibiotics. While cases of DRESS are rare, here we present a case of DRESS in an adult male following administration of rosuvastatin who presented with fevers, generalized rash, and facial fullness. Vitals on presentation were temperature 102oF, pulse 95/min, blood pressure 95/47 mmHg, and respiratory rate of 14/min. His physical examination revealed scleral icterus, generalized blanching maculopapular rash, facial fullness, and right upper quadrant tenderness. Laboratory investigations found hemoglobin 10 gm/dl, white blood cell count 16.0 K/uL, peripheral eosinophil count 1,700 K/uL, alkaline phosphatase 2,501 U/L, aspartate transaminase 620 U/L, alanine transaminase 680 U/L, total bilirubin 13.2 mg/dl with a direct component of 9 mg/dl, blood urea nitrogen 66 mg/dl, creatinine 5.20 mg/dl, glomerular filtration rate 8 ml/min, and immunoglobulin E level 623 IU/mL. Serology for viral hepatitis, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 was negative. Computed tomographic scan of chest, abdomen, and pelvis showed generalized lymphadenopathy. Over the next week, the patient deteriorated clinically with worsening transaminitis and oliguric acute renal failure requiring renal replacement therapy. As per the European Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR), the probability of rosuvastatin-induced DRESS syndrome was scored as "definite." He was treated with systemic and topical glucocorticoids leading to a gradual improvement in his symptoms. Skin biopsy was suggestive of DRESS syndrome as well. Since DRESS carries such a significant risk of mortality between 10% and 20%, DRESS must be recognized and treated as soon as symptoms present. Clinicians should also be aware that statins, one of the most commonly prescribed drugs, are also a potential cause DRESS.

Pharmacological and Non-pharmacological Strategies for Volume Overload in Acute Decompensated Congestive Heart Failure: A Review Article.

The epithet of acute decompensated heart failure (ADHF) is volume overload. ADHF is associated with a rising number of hospital admission for volume overload. Medication non-compliance, excessive salt intake, comorbidities, and/or disease progression can attribute to volume overload. Heart failure (HF) therapy has innovated during the past few decades, but diuretics have been the mainstay of treatment. Diuretics are vital even though these drugs stimulate the renin-angiotensin-aldosterone system (RAAS) and lead to adaptive responses like diuretic resistance, neurohormonal activation, and worsening renal function that may be inimical. There has been a thriving interest in cutting-edge strategies to manage volume overload in ADHF. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) guidelines advocate pharmacological and non-pharmacological interventions to treat volume overload in ADHF patients. Ultrafiltration (UF) is, therefore, an emerging stand-in therapy of interest for treating volume overload in ADHF patients. This review article epitomizes available clinical data on the use of diuretics and UF in ADHF patients and identifies challenges for each approach.

Distribution of gastric carcinoma in an area with a high prevalence of Helicobacter pylori.

BACKGROUND/AIMS: South Asia is an enigma for gastric cancer (GC) because it is a low risk region with a high prevalence of Helicobacter pylori (H. pylori) infections. We evaluated the trend of GC clinical presentation and risk factors in patients with dyspeptic symptoms. MATERIALS AND METHODS: The medical records of patients, coded by the international classification of diseases (ICD-10-CM, 2015, Diagnosis Code C16.9) for malignancies of stomach diagnosed by esophagogastroduodenoscopy (EGD) and histopathology, were studied. RESULTS: 394 GC cases with a mean age of 54±15 years, range of 18 to 88, were analyzed. 256 (65%) were male. Distal non-cardiac and cardiac tumors were 302 (77%) and 92 (23%) cases, respectively. The WHO classification of GC defined 222 (56%) cases as intestinal type adenocarcinoma, 68 (17%) cases as signet ring cell carcinoma (SRC), 62 (16%) cases as diffuse type and 42 (11%) cases as B cell non-Hodgkin lymphoma. The co-morbid conditions associated with GC were H. pylori infection (positive in 246 (62%) cases), diabetes mellitus type 2 (in 90 (23%) cases), and cigarette smoking (in 94 (24%) cases). Of the male patients, 88 (34%) (p<0.001) were smokers. Body mass index was abnormal in all age groups and in both sexes. Cardiac regions for GC were more common in the 46- to 60-year old age range and in males. Diffuse GC was seen in all age groups but there were significantly more common in the 18- to 45-year old age range. Gastric non-Hodgkin's lymphoma was seen at an early age of 18-45 years in 14(12%) and a later of 61-88 years in 20 (15%). CONCLUSION: Intestinal type GC is common at all ages but SRC and diffuse GC are more common in patients less than 50 years old. SRC and diffuse GC were not specific to the elderly in our study population.