Recurrent Transient Ischemic Attacks in a Patient with Multiple Pacemaker Leads.

Venous complications-specifically, stenosis and thrombosis-are both well-known complications of transvenous implantation of pacemakers and defibrillators. Although they are a well-recognized phenomenon, these complications are rarely of clinical significance. One of the most concerning complications is the development of superior vena cava (SVC) syndrome. Studies have found that the incidence of SVC syndrome varies from 1 in 3,100 to 1 in 650 patients. The azygos-hemiazygos venous system is the most commonly observed collateral. We report a case of a 71-year-old female patient who presented with stroke-like symptoms during the injection of agitated saline bubbles while performing an echo and was found to have an unusual venous collateral circulation formed as a result of brachiocephalic and SVC obstruction from multiple pacemaker leads. Our patient's clinical presentation was extremely unique, and we did not find any cases during our literature search reporting a similar presentation. Multiple collaterals formed between the brachiocephalic and subclavian veins, and bilateral pulmonary veins in our patient allowed the injected air bubbles from the venous system to reach the left side of the heart and eventually the cerebrovascular system, resulting in these transient ischemic attacks. These attacks eventually resolved as the air bubbles were dissolved and washed away by the continuous blood flow. It is advisable to monitor the patient for possible venous stenosis and SVC syndrome after any device insertion during regular device follow-up appointments.

Pharmacological options for Candida albicans Endocarditis at the roadblock with irrecoverable prosthetics and drug interactions: a case report and review of literature.

BACKGROUND: Candidemia is the fourth most common nosocomial bloodstream infection. Endocarditis from candidemia is a rare but possibly fatal complication. The efficacy of amphotericin and echinocandins for induction and azoles for suppression has been well studied. Source control of infection, including removal of foreign bodies, remains the cornerstone for the success of any antifungal therapy. CASE PRESENTATION: We are describing a case of a 63-years old patient with multiple comorbidities who developed candidemia secondary to Candida albicans. The prospect of curing the fungemia was made difficult by prosthetic devices, including prosthetic heart valves, intracardiac defibrillator, and inferior vena filter, which could not be extracted due to poor cardiovascular status and higher postoperative mortality risk. Combination therapy with amphotericin and 5-Flucytosine (5FC) was used with the first recurrence. Suppression with fluconazole was contraindicated due to prolonged corrected QT (QTc) interval. Isavuconazole was employed for chronic lifelong suppression. CONCLUSION: Retaining prosthetics in higher surgical risk patients presents us with unique clinical and pharmacological challenges regarding breakthrough infections, drug interaction, and side effects from prolonged suppressive therapies.

Rare Case of Reversible Pulmonary Arterial Hypertension Secondary to Cyclophosphamide and Doxorubicin Chemotherapy.

Pulmonary arterial hypertension (PAH), characterized as a resting mean pulmonary artery pressure greater than 25 mmHg, is due to the narrowing of the pulmonary arteries, which can be idiopathic, inherited, or drug-related. Alkylating agents, including cyclophosphamide, are a risk factor for developing the pulmonary veno-occlusive disease. Drug-induced PAH is extremely rare. A 59-year-old female with newly diagnosed invasive ductal carcinoma of the right breast and high-grade ductal carcinoma in situ of the left breast was initiated treatment with doxorubicin and cyclophosphamide. About one week after receiving the first cycle, the patient developed worsening lower extremity edema and shortness of breath. She was then hospitalized, and a transthoracic echocardiogram and coronary angiogram revealed PAH. The team then changed the breast cancer treatment regimen to Taxol and carboplatin, and PAH was resolved in a follow-up echocardiogram after five months. This report has described the first case of PAH directly related to cyclophosphamide and doxorubicin. It is imperative to promptly recognize this rare but important side-effect as early diagnosis and response can potentially reverse the disease progression.

An Unusual Case of Hemorrhagic Pleuropericarditis After COVID-19 Vaccination.

As coronavirus disease 2019 (COVID-19) vaccines are being increasingly administered worldwide, subsequent side effects, such as myocarditis, pericarditis, and myopericarditis, are becoming increasingly more common. Our case describes a 64-year-old male who developed chest pain and shortness of breath one week after receiving the Moderna (Cambridge, Massachusetts) COVID-19 mRNA vaccine. He was found to have a large, left-sided pleural effusion and a small pericardial effusion. The patient underwent thoracentesis and video-assisted thoracoscopic procedure with chest tube placement, which drained bloody pleural and pericardial fluid. He was treated with a course of colchicine. Subsequent imaging revealed the resolution of pericardial and pleural effusions, along with the resolution of symptoms.

Normal Saline Versus Low Chloride Solutions in Treatment of Diabetic Ketoacidosis: A Systematic Review of Clinical Trials.

Traditionally, normal saline solution (NSS) has been the fluid of choice in diabetic ketoacidosis (DKA) patients, but the NSS is an acidic fluid and may lead to the delayed resolution of DKA. A systemic review search was conducted on PubMed, Embase, and Central Cochrane Registry to compare the efficacy of low chloride solutions with normal saline solution in DKA resolution. Randomized clinical trials with normal saline as a control arm and low chloride solutions as an intervention arm were included. Four studies were included in the analysis. The investigated outcomes, including time to resolution for DKA and duration of insulin infusion, varied depending on the endpoint were reported in the studies. Overall, balanced solutions were generally associated with faster correction of pH. The time to reach overall DKA endpoints was comparable in both groups. We concluded that crystalloid solutions may be used as an initial resuscitation fluid in the DKA population and may lead to earlier resolution of acidosis. More clinical trial data is required to reach statistical significance for the hypothesis.

An Unfortunate Case of Takotsubo Cardiomyopathy During Plasmapheresis for Myasthenia Crisis.

A literature review shows scarce reports of myasthenic crises (MC) complicated by Takotsubo cardiomyopathy (TC). This patient cohort (0.11%) has higher all-cause mortality and prolonged in-hospital course. We present a rare case of a 72-year-old man who developed cardiogenic shock post-plasmapheresis for myasthenia crisis. He became hemodynamically unstable and developed acute respiratory failure requiring intubation 30 minutes after completion of plasma exchange. Serum troponin peaked at 3.19 ng/mL while an emergent 12-lead electrocardiogram (EKG) showed new-onset diffuse ST-segment elevation. Hypokinesis of the entire apex, anterior septum, mid-and apical inferior septum, and mid-and apical inferior wall consistent with Takotsubo cardiomyopathy was seen on bedside echocardiogram. The patient received a continuous infusion of norepinephrine and vasopressin. The hospital course was complicated by multiorgan failure and eventual demise. This case highlights MC and the potential of plasma exchange therapy to induce TC.

Immune thrombocytopenic purpura and legionella infection: A case report highlighting the association.

Immune thrombocytopenic purpura (ITP) can be acquired or secondary to other drugs, infections, or autoimmune disorders. Legionella is a known intracellular organism that causes Legionnaire's disease and affects the lungs. Presented is the first case showing a direct association between Legionella and ITP. Our patient was a 61-year-old female with a past medical history of asthma whose clinical presentation was consistent with pneumonia secondary to Legionella. Her hospital course was complicated by critical bleeding with severe thrombocytopenia. She responded to antibiotics, steroids, and intravenous immunoglobulins (IVIG). Our case suggests an association between ITP and Legionella and emphasizes its timely diagnosis for appropriate treatment.

Circulating tumor DNA in blood: Future genomic biomarkers for cancer detection.

Cancer is characterized by Darwinian evolution and is a primary cause of mortality and morbidity around the globe. Over the preceding decade, the treatment of cancer has been markedly improved by many targeted therapies, but these treatments have given birth to new challenges and issues. Clonal evolution and tumor heterogeneity present a significant challenge in designing cancer therapies. Fortunately, these restrictions have been overcome by technological advancements allowing us to track both genetic and epigenetic aberrations. Cell-free circulating tumor DNA (ctDNA) analysis, or "liquid biopsy" from a blood sample, provides the opportunity to track the genetic landscape of cancerous lesions. This review focuses on ctDNA analysis as a noninvasive method and versatile biomarker for cancer treatment and technological advancements for ctDNA analysis. This method may able to cope with all the challenges associated with previous cancer therapies and has the potential to monitor minimal residual disease, tumor burden, and therapy response and provide rapid detection of relapse. However, there are many challenges that still need to be addressed. Future prognosis, diagnosis, and analysis of ctDNA require reproducibility and accuracy of results, which are not possible without the validation and optimization of procedures. Integrated digital error suppression has thus far shown promise in the detection of ctDNA in cancer.

HIV Diagnosis and Treatment through Advanced Technologies.

Human immunodeficiency virus (HIV) is the chief contributor to global burden of disease. In 2010, HIV was the fifth leading cause of disability-adjusted life years in people of all ages and leading cause for people aged 30-44 years. It is classified as a member of the family Retroviridae and genus Lentivirus based on the biological, morphological, and genetic properties. It infects different cells of the immune system, such as CD4+ T cells (T-helper cells), dendritic cells, and macrophages. HIV has two subtypes: HIV-1 and HIV-2. Among these strains, HIV-1 is the most virulent and pathogenic. Advanced diagnostic methods are exploring new ways of treatment and contributing in the reduction of HIV cases. The diagnostic techniques like PCR, rapid test, EIA, p24 antigen, and western blot have markedly upgraded the diagnosis of HIV. Antiretroviral therapy and vaccines are promising candidates in providing therapeutic and preventive regimes, respectively. Invention of CRISPR/Cas9 is a breakthrough in the field of HIV disease management.