A Rare Differential of Epistaxis.

Glomus tympanicum is a type of glomus tumor that affects the middle ear, located at the auricular branch of the vagus nerve. Glomus tumors, in general, are rare, slow-growing tumors and may not require surgery in some patients. It can be challenging to manage due to its hypervascularity, location, and advanced stage of diagnosis. Although glomus tympanicum commonly presents with pulsatile tinnitus and conductive hearing loss, it presented in our patient with large-volume hemoptysis and epistaxis, requiring urgent diagnostic and therapeutic interventions. We highlight the unique presentation of a 48-year-old female with sudden onset large-volume hemoptysis and epistaxis, leading to the discovery of a hypervascular glomus tympanicum in the right middle ear, identified via MRI. On arrival, her vitals were within normal limits, and a physical examination was pertinent for the obvious ongoing bleeding from her mouth. The examination revealed increased respiratory effort and bilateral crackles. Laboratory values were pertinent for hemoglobin of 11.8 g/dl. Ear examination revealed a large, vascular-appearing mass filling the right ear. An MRI of the face and neck showed an avidly enhancing 3.7 cm x 1.8 cm x 1.2 cm mass within the right middle ear and mastoid cavity, extending into the external auditory canal and through the eustachian tube into the nasopharynx. The mass was inseparable from the lateral border of the internal auditory canal in the petrous canal. Due to concern for glomus tympanicum, the patient underwent urgent embolization and subsequent tumor resection. Considering our patient initially presented large-volume hemoptysis, there was concern for alveolar hemorrhage. However, as she had no increased oxygen requirement, there was suspicion of massive epistaxis mistaken for hemoptysis. Due to large volume epistaxis, she underwent urgent embolization as resection could have been challenging due to increased vascularity. It is important to remember that massive epistaxis may not present with blood in the anterior nares, thereby delaying diagnosis and management. Furthermore, probing such tumors should be avoided as it may lead to life-threatening bleeding.

Lenvatinib-associated hemoperitoneum in a patient with primary angiosarcoma of the breast.

We highlight the risk of lenvatinib drug toxicity when high-risk anatomic regions are affected by angiosarcoma.

3-Year Post-Transcatheter Aortic Valve Replacement (TAVR) Restenosis: A Rare Complication.

The pathophysiology of aortic valve stenosis is degenerative and calcific. It may be exacerbated by atherosclerotic processes characterized by lipid accumulation and inflammation. When the stenosis gets hemodynamically severe, the valves would need to be replaced. They could be replaced using mechanical or bioprosthetic heart valves. Balloon-expandable (BE) transcatheter heart valves (THVs) were compared to the self-expanding (SE) THVs and it was found that the rate of bioprosthetic valve failure was low over a five-year period. We present the case of a 70-year-old female who presented with worsening shortness of breath three years after transcatheter aortic valve replacement and was found to have early valve degeneration.

Cardiogenic Shock in a Patient With 4G/4G PAI Polymorphism and MTHFR A1298C Mutation.

Myocardial infarction (MI) remains a common cause of morbidity and mortality. Although many well-known risk factors exist, the association between inherited thrombophilia disorders and acute MI is not well described. Here, we present a case of a 75-year-old male with known 4G/4G PAI-1 polymorphism, methylenetetrahydrofolate reductase (MTHFR) mutation, and peripheral artery disease (PAD) post stent placement who presented with cardiogenic shock in the setting of acute MI with no prior significant cardiac history.

Pulmonary Renal Syndrome in ANCA-Negative Vasculitis.

Below we highlight a rare case of anti-neutrophil cytoplasmic antibody (ANCA)-negative vasculitis, unique in its own right, as the diagnosis was hard to make and the respiratory decline rapid, with the patient going from a 23% fraction of inspired oxygen (FiO2) on admission to 100% FiO2 within four days for what was initially presumed to be community-acquired pneumonia. Precise data on the incidence or prevalence of ANCA-associated vasculitis are lacking. However, a 20-year population-based study in the United States found that, of 58 incident cases, 9% were ANCA-negative. We present the case of a 69-year-old Egyptian male with worsening shortness of breath who was found to have elevated inflammatory markers and an ANCA-negative panel and was later diagnosed with ANCA-negative vasculitis. By highlighting this case, we aim to increase awareness and point out the need to keep the disease high on the list of differential diagnoses in order to allow for timely intervention. Though there isn't a lot of data available on definitive treatment or the disease itself, there are studies that point to rituximab, cyclophosphamide, plasmapheresis, and hemodialysis as useful interventions for treatment.

Sustained Ventricular Tachycardia Presenting As Gastrointestinal (GI) Symptoms.

Ventricular arrhythmias (VAs) are among the most common cardiac rhythms seen among patients. Patients presenting with frequent, sustained ventricular tachycardia (VT) pose a dilemma for clinicians due to the constant risk of sudden cardiovascular compromise. Ventricular tachycardia, which is commonly seen in patients with defects in cardiac anatomy, has been associated with an increased risk of sudden death. A previous myocardial scar from a previous myocardial infarction remains the most common cause of sustained monomorphic VT (SMVT) in patients with structural cardiac disease. Studies have shown that implantable cardioverter-defibrillators (ICDs) can be used for primary prevention in patients with ischemic or nonischemic cardiomyopathy whose ejection fraction remains below 35% despite guideline-directed medical therapy. It can also be used for secondary prevention of sudden cardiac death in patients who have had a VT or ventricular fibrillation (VF). Identifying individuals at risk for developing deleterious VTs who will benefit from ICD placement for prevention has been the objective of many large studies in recent years. We present a case of clinical importance involving the use of ICD in the primary prevention of mortality from sustained ventricular arrhythmias.

Plasmapheresis vs Conventional Insulin Therapy in Hypertriglyceridemia-Induced Acute Pancreatitis.

Hypertriglyceridemia is a rare yet firm etiology of pancreatitis, with an incidence of 2-4% in the general population. The etiology of hypertriglyceridemia itself consists of both primary and secondary causes. We discuss the case of a 37-year-old female with a strong family history of hypertriglyceridemia (primary cause) along with daily alcohol consumption (secondary cause) who initially presented to the emergency department with tingling and numbness of her bilateral upper extremities, bilateral lower extremity cramping and spasm and pins, and needles sensation in all extremities. She was found to have acute pancreatitis (AP) as a cause of hypocalcemia with elevated triglycerides of 5,823 mg/dl responsive to plasmapheresis combined with insulin drip. We explore the pathophysiology of hypertriglyceridemia-induced acute pancreatitis and the different modalities used to treat it which are still largely debated. The choice of therapy has been influenced by the cost, perceived effectiveness, and availability.