Enterohemorrhagic Escherichia coli: trigger for small vessel vasculitis.

We describe the case of a 19-year-old woman who presented with abdominal pain, vomiting, and a palpable purpuric rash. The patient subsequently developed dysentery and was found to have an infection from Shiga toxin-producing Escherichia coli. The patient also met diagnostic criteria for IgA vasculitis (also known as Henoch Schönlein purpura) but had negative immunofluorescence biopsies of the rash. The patient was treated with steroids and achieved recovery. To our knowledge, this is the first documented case of IgA vasculitis in the setting of an enterohemorrhagic E. coli infection. This case highlights an atypical presentation of IgA vasculitis and the need to include small vessel vasculitis as a differential diagnosis when treating patients of all ages.

Readmissions among People Living with HIV Admitted for Hypertensive Emergency.

OBJECTIVES: People with human immunodeficiency virus (HIV) are at an increased risk of developing cardiovascular diseases. Hypertensive emergency (HTNE), a complication of hypertension with potentially serious health implications, has high healthcare utilization. We attempted to determine the association between HIV status and risk for 30-day readmission after index hospitalization for HTNE. METHODS: We used the Nationwide Readmissions Database to identify all of the admissions during 2010-2017 with a primary discharge diagnosis of HTNE. Admissions were stratified by HIV status and comparisons were made with the χ2 test. We investigated predictors of all-cause 30-day readmission via multivariable logistic regression. RESULTS: A total of 612,854 hospitalizations with a primary discharge diagnosis of HTNE were identified, and 4115 (0.7%) were HIV positive. There was a total of 43,937 (7.16%) 30-day readmissions, and the rate was higher in regard to positive HIV status (29.8% vs 15.0%; P < 0.001). Renal failure was the most frequent reason for HIV readmissions and the second most frequent reason for non-HIV readmissions (15.6% vs 10.3%; P < 0.001). In contrast, heart failure was the most frequent reason for non-HIV readmissions and the second most frequent reason for HIV readmissions (10.3% vs 11.9%; P = 0.234). There was a higher median cost for HIV readmissions in comparison to non-HIV readmissions ($7660 vs $7490; P < 0.001). Finally, HIV was attributed to 40.6% increased odds of readmission after adjusting for pertinent clinical and demographic factors (P < 0.001). CONCLUSIONS: HIV-positive status is associated with an increased risk for 30-day readmission after index hospitalization for HTNE.

Sex differences in mortality and 90-day readmission rates after transcatheter aortic valve replacement: a nationwide analysis from the USA.

AIMS: To assess gender differences in in-hospital mortality and 90-day readmission rates among patients undergoing transcatheter aortic valve replacement (TAVR) in the USA. METHODS AND RESULTS: Hospitalizations for TAVR were retrospectively identified in the National readmissions database (NRD) from 2012 to 2017. Gender based differences in in-hospital mortality and 90-day readmissions were explored using multivariable logistic regression models. During the study period, an estimated 171 361 hospitalizations for TAVR were identified, including 79 722 (46.5%) procedures in women and 91 639 (53.5%) in men. Unadjusted in-hospital mortality and 90-day all-cause readmissions were significantly higher for women compared with men (2.7% vs. 2.3%, P = 0.002; 25.1% vs. 24.1%, P = 0.012, respectively). After adjusting for baseline characteristics, women had 13% greater adjusted odds of in-hospital mortality [adjusted odds ratio (aOR): 1.13, 95% confidence interval (CI): 1.02-1.26, P = 0.017], and 9% greater adjusted odds of 90-day readmission compared with men (aOR: 1.09, 95% CI: 1.05-1.14, P < 0.001). During the study period, there was a steady decrease in-hospital mortality (5.3% in 2012 to 1.6% in 2017; Ptrend < 0.001) and 90-day (29.9% in 2012 to 21.7% in 2017; Ptrend < 0.001) readmission rate in both genders. CONCLUSION: In-hospital mortality and readmission rates for TAVR hospitalizations have decreased over time across both genders. Despite these improvements, women undergoing TAVR continue to have a modestly higher in-hospital mortality, and 90-day readmission rates compared with men. Given the expanding indications and use of TAVR, further research is necessary to identify the reasons for this persistent gap and design appropriate interventions.

ST-elevation myocardial infarction in nonagenarians: A nationwide analysis of trends and outcomes in the United States.

OBJECTIVE: To assess ST elevation myocardial infarction (STEMI) trends and outcomes in nonagenarians undergoing primary percutaneous coronary intervention (pPCI) compared to medical management. BACKGROUND: Although nonagenarians (age greater than 90 years) represent the fast-growing age decade of the US population, limited evidence is available regarding trends and outcomes of treatment strategies for STEMI in this population cohort. METHODS: We performed a retrospective analysis using the National Inpatient Sample (NIS) database to identify nonagenarians presenting with STEMI and treated with either pPCI or medical management. In-hospital mortality, in-hospital complications, length of stay and in-hospital costs were analyzed. RESULTS: Between 2010-2017, 41,042 STEMI hospitalizations were identified in nonagenarians, of which 11, 155 (27.2%) included pPCI whereas 29, 887 (72.8%) included medical management. STEMI hospitalizations among nonagenarians decreased over the study period. Overall unadjusted in-hospital mortality was 21.6%, and the hospitalizations that included pPCI had significantly lower mortality compared to the medical management (13.6% vs. 24.5%, p < .001). After adjusting for baseline characteristics, hospitalizations that included pPCI had 42.1% lower odds of in-hospital mortality (adjusted OR: 0.58, 95% CI: 0.50 to 0.67, p < .001). Altogether, in-hospital cardiac, bleeding and vascular complications, length of stay and in-hospital costs were higher in pPCI hospitalizations. CONCLUSION: In nonagenarians, STEMI mortality is high, but pPCI is associated with superior outcomes compared to medical management alone. Therefore, pPCI can be considered an acceptable treatment strategy in this population.

Impact of Acquired Thrombocytopenia on Cardiovascular Outcomes in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis.

BACKGROUND: Acquired thrombocytopenia (aTP) is associated with a high frequency of bleeding and ischemic complications in patients undergoing percutaneous coronary intervention (PCI). Herein, we report a meta-analysis evaluating the adverse effects of aTP on cardiovascular outcomes and mortality post-PCI. METHODS: A literature search was performed using PubMed, Embase, Cochrane and, clinicaltrials.gov from the inception of these databases through October 2019. Patients were divided into two groups: 1) No Thrombocytopenia (nTP) and 2) Acquired Thrombocytopenia (aTP) after PCI. Primary endpoints were in-hospital, 30-day and all-cause mortality rates at the longest follow-up. The main summary estimate was random effects Risk ratio (RR) with 95% confidence intervals (CIs). RESULTS: Seven studies involving 57,247 participants were included. There was significantly increased in-hospital all-cause mortality (HR 10.73 [6.82-16.88]), MACE (HR 2.96 [2.24-3.94]), major bleeding (HR 4.78 [3.54-6.47]), and target vessel revascularization (TVR) (HR 7.53 [2.8-20.2]), in the aTP group compared to the nTP group. Similarly, aTP group had a statistically significant increased incidence of 30-day all-cause mortality (HR 6.08), MACE (HR 2.77), post-PCI MI (HR 1.98), TVR (HR 5.2), and major bleeding (HR 12.73). Outcomes at longest follow-up showed increased incidence of all-cause mortality (HR 3.98 [1.53-10.33]) and MACE (HR 1.24 [0.99-1.54]) in aTP group, while there was no significant difference for post-PCI MI (HR 0.94 [0.37-2.39]) and TVR (HR 0.96 [0.69-1.32]) between both groups. CONCLUSIONS: Acquired Thrombocytopenia after PCI is associated with increased morbidity, mortality, adverse bleeding events and the need for in-hospital and 30-day TVR.

Acute ischemic stroke as initial manifestation of undiagnosed iron deficiency anemia: case-report and literature review.

Cerebrovascular disease is the second leading cause of death in the United States in adults aged 65 years and older and is most commonly caused by atherosclerosis. More so, cryptogenic strokes account for one-third of all ischemic strokes. At the same time, iron deficiency anemia is prevalent worldwide and mostly affects females of childbearing age. Here we report a case of a 42-year-old female who presented with symptoms of acute ischemic stroke and was found to have severe iron deficiency anemia. After prompt investigation of other secondary causes, it was determined that her stroke was likely secondary to her iron deficiency anemia. Upon review of the literature, a few case reports showed an association between iron deficiency anemia and strokes in the adult population, but little evidence exists supporting a direct relationship between the two entities. In this case, we aim to evaluate the complex relationship between iron deficiency anemia and stroke and to define a new potential cause of ischemic stroke, which would have been considered earlier as cryptogenic. However, further studies in the future are warranted to validate our observation.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients with Cardiac Surgery: Meta-Analysis and Systematic Review of the Literature.

The number of patients with severe aortic stenosis (AS) and a history of prior cardiac surgery has increased. Prior cardiac surgery increases the risk of adverse outcomes in patients undergoing aortic valve replacement. To evaluate the impact of prior cardiac surgery on clinical endpoints in patients undergoing transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR), we performed a literature search using PubMed, Embase, Google Scholar, and Scopus databases. The clinical endpoints included in our study were 30-day mortality, 1-2-year mortality, acute kidney injury (AKI), bleeding, stroke, procedural time, and duration of hospital stay. Seven studies, which included a total of 8221 patients, were selected. Our study found that TAVR was associated with a lower incidence of stroke and bleeding complications. There was no significant difference in terms of AKI, 30-day all-cause mortality, and 1-2-year all-cause mortality between the two groups. The average procedure time and duration of hospital stay were 170 min less (p ≤ 0.01) and 3.6 days shorter (p < 0.01) in patients with TAVR, respectively. In patients with prior coronary artery bypass graft and severe AS, both TAVR and SAVR are reasonable options. However, TAVR may be associated with a lower incidence of complications like stroke and perioperative bleeding, in addition to a shorter length of stay.

Hypolipidemia contributing to the severity of sepsis triggered by influenza a virus: A case report.

Hypolipidemia, an increasingly diagnosed disorder, is defined as a low-density lipoprotein serum level of <50 mg/dL. Hypolipidemia can be asymptomatic. However, the effect of hypolipidemia on sepsis survival and severity is still to be identified. Multiple studies show the physiologic effects of cholesterol on the immune system, and other studies linked hypolipidemia to increased mortality and morbidity. In this case, we present a young patient admitted for severe sepsis, and he developed multiorgan failure. Workup revealed hypolipidemia. The patient recovered from sepsis with residual renal and cardiac injury. We hypothesized that hypolipidemia could be contributing to the increased morbidity in the patient, although further studies are needed to approve this hypothesis. What is unique about this case is that it sheds light on a commonly overlooked metabolic abnormality that plays a role in the body's response to infections and sepsis. RELEVANCE FOR PATIENTS: This case report presents a previously healthy young patient admitted for pneumonia who had a complicated course. Workup revealed hypolipidemia that can be contributing to the severity of his disease. This observation may lead to more studies to evaluate the relationship between lipoprotein level and disease severity which may change the management for patients with hypolipidemia, especially with the familial type.

Intracerebral Hemorrhage in a Patient with Untreated Rheumatoid Arthritis: Case Report and Literature Review.

Rheumatoid vasculitis (RV) occurs in patients with long-standing rheumatoid arthritis (RA) or high levels of immunological factors and can result in devastating cardiovascular (CV) events. Here we report a case of a 38-year-old male who presented with hypertensive emergency and intracerebral hemorrhage (ICH). In the literature, a few observational studies have indicated the association of RA with hypertension; however, little evidence exists supporting a direct relationship between RA and ICH. In this case, we attempted to evaluate the complex relationship between all of these factors and found that early detection and treatment of RA may be beneficial in reducing ICH; however, large studies in the future are warranted to validate our observation.

West Nile virus encephalitis in a young immunocompetent female in Omaha Nebraska.

One of the most common cause of arbovirus encephalitis in the United States of America (USA) is West Nile virus (WNV). In immunocompetent hosts, 70-80% of infected individuals have subclinical disease. However, in less than 1% of people infected by WNV it can become fulminant neuroinvasive disease associated with neurological morbidity. Herein, we discuss a case of neuroinvasive WNV disease with non-specific symptoms in an immunocompetent young female in Omaha. Our patient survived the acute phase of WNV encephalitis but has extended recovery to daily functioning. We also reviewed literature on WNV cases in immunocompetent individuals and to the best of our knowledge only 3 cases have been reported to date. The difference between reported cases and our case is her younger age, bilateral upper and lower extremity paralysis, 30 day hospitalization with significant morbidity leading to a prolonged stay at rehabilitation facility with residual cognitive and gross motor impairment. Usually WNV is not considered a differential in immunocompetent individuals which leads to delay in diagnosis, management and therefore increases mortality and morbidity. Therefore purpose of our case report is to raise awareness of atypical presentations of WNV infection in immunocompetent individuals in non-endemic area to emphasize the importance of early diagnosis and management.

Transient Asymptomatic Sinus Bradycardia and Sinus Pauses with Bevacizumab: Case Report and Literature Review.

Systemic side effects of anti-cancer therapy remain a major limiting factor for patients, even with targeted therapy. Bevacizumab is an example of targeted cancer therapy which targets the vascular endothelial growth factor receptor (VEGFR) that has been approved for the treatment of various cancers and has been evaluated in metastatic urothelial carcinoma (MUC). We report a case of MUC on bevacizumab containing regimen who developed temporary asymptomatic sinus bradycardia with sinus pauses. That adverse event was thought to be related to the bevacizumab in her cancer regimen. Her Holter monitoring recording for a total duration of 28 days and 14 h after discharge did not show recurrence of sinus pauses. This case indicates the necessity for observation for the cardiac conduction defects as side effects in patients receiving bevacizumab, especially since they might be asymptomatic and transient.

Necrotizing Autoimmune myopathy: A case report on statin induced rhabdomyolysis requiring immunosuppressive therapy.

Statins can cause a wide spectrum of muscular adverse effects ranging from asymptomatic elevation of Creatine Kinase (CK), myalgia and exercise intolerance to rhabdomyolysis. Most of these effects generally resolve on stopping the medication. However, statins can be associated with a unique autoimmune myopathy wherein symptoms persist or even progress after statin discontinuation and require immunosuppressive therapy. The case presented is a 60-year-old woman who was on statin treatment for a period of 2 years. She developed muscle weakness with a limb girdle distribution. She had persistent elevation of CK even after discontinuation of statin therapy. EMG done revealed irritable myopathy and muscle biopsy showed necrosis without inflammation. She subsequently tested positive for anti-3-hydroxy-3-methylglutaryl-coenzyme A (anti-HMG CoA) antibody which is found to be present in patients with statin-associated necrotizing autoimmune myopathy. Patient was started on steroid without much improvement in her symptoms. After a month of follow up, her upper extremity strength was back but lower extremity continued to be weak which prompted us to start her on Methotrexate and Azathioprine. Like our patient, there are rare subgroup of patients with an immune-mediated necrotizing myopathy that does not improve after discontinuation of the drug and requires aggressive treatment with immunosuppressive agents. Awareness and early recognition of this disease is very important in patients who continue to have CK elevation and weakness after discontinuation of statin therapy.

A Rare Case of Isolated Left Ventricular Non-compaction in an Elderly Patient.

A 61-year-old male, with a history of emphysema, obstructive sleep apnea, and hypertension, presented to the emergency room with worsening shortness of breath over a three-month period. The patient also complained of orthopnea, paroxysmal nocturnal dyspnea, and progressively worsening lower limb swelling. On examination, the patient had jugular venous distension, bilateral lower extremity edema, and bibasilar crackles. The laboratory evaluation showed an elevated B-natriuretic peptide level and a normal troponin level. A transthoracic echocardiogram (TTE) showed a reduced left ventricular ejection fraction (LVEF) of 20%-25% with prominent hyper-trabeculations noted in the left ventricle, most prominent in the lateral and apical walls. These findings were concerning for left ventricular non-compaction (LVNC). The patient underwent left heart catheterization, which did not show obstructive coronary disease as a cause of his cardiomyopathy. The patient was managed with guideline-directed therapy for heart failure and was started on warfarin due to the increased risk of thromboembolism associated with LVNC. During his admission, he exhibited multiple episodes of nonsustained ventricular tachycardia and was subsequently evaluated by electrophysiology (EP). He was discharged home with a wearable cardioverter defibrillator with instructions to follow up with EP in three months for an evaluation of implantable cardioverter-defibrillator (ICD) placement for primary prevention.

Campylobacter jejuni and Pseudomonas coinfection in the setting of ulcerative colitis.

A 66-year-old woman presented with 2 days of fever and severe diarrhoea. She has a history of ulcerative colitis (UC), well controlled with medication. She also has a history of Ehlers-Danlos syndrome, infective endocarditis following aortic valve replacement and pulmonary embolism. She had complained of passing stool with traces of blood about 30 times per day. Stool testing for Clostridium difficile, routine culture and microscopy was done. She was started on ceftriaxone. CT scan revealed thick-walled colon consistent with UC flare. Flexible sigmoidoscopy showed active continuous colitis extending from the rectum to the proximal descending colon. Campylobacter jejuni was isolated from the stool and blood cultures yielded Pseudomonas aeruginosa. The antibiotic was transitioned to intravenous piperacillin/tazobactam and azithromycin followed by 2 weeks of intravenous cefepime. Her diarrhoea was controlled, and she was discharged for follow-up in 2 months.

Ureteritis Cystica: An Unusual Presentation in an Otherwise Healthy Female.

A 23-year-old, previously healthy female presented with lower abdominal pain and mildly elevated creatinine one month following a right ureter stent for non-specific ureteral thickening causing obstruction. On admission, computed tomography (CT) revealed moderate hydronephrosis of the left kidney that would require stent placement as well. During stent placement, it was noted that the gross appearance of the ureters resembled ureteritis cystica. Biopsies were taken and showed signs of chronic inflammatory changes consistent with this diagnosis. Interestingly, this patient had no obvious medical history suggesting a cause for this process. She had been otherwise healthy with no recurrent episodes of urinary tract infection, nephrolithiasis, or sexually transmitted infection. The patient was discharged symptom-free following stent placement and will follow with urology for future stent replacements and clinical monitoring.

Effectiveness of Thrombolytic Therapy in Acute Embolic Stroke due to Infective Endocarditis.

Objective. To identify the role of thrombolytic therapy in acute embolic stroke due to infective endocarditis. Design. Case report. Setting. University hospital. Patient. A 70-year-old male presented with acute onset aphasia and hemiparesis due to infective endocarditis. His head computerized tomographic scan revealed left parietal sulcal effacement. He was given intravenous tissue plasminogen activator with significant resolution of the neurologic deficits without complications. Main Outcome Measures. Physical examination, National Institute of Health Stroke Scale, radiologic examination results. Conclusions. Thrombolytic therapy in selected cases of stroke due to infective endocarditis manifesting as major neurologic deficits can be considered as an option after careful consideration of risks and benefits. The basis for such favorable response rests in the presence of fibrin as a major constituent of the vegetation. The risk of precipitating hemorrhage with thrombolytic therapy especially with large infarcts and mycotic aneurysms should be weighed against the benefits of averting a major neurologic deficit.