Cardiovascular Magnetic Resonance Imaging Phenotypes and Long-term Outcomes in Patients With Suspected Cardiac Sarcoidosis.

Importance: In patients with sarcoidosis with suspected cardiac involvement, late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging (CMR) identifies those with an increased risk of adverse outcomes. However, these outcomes are experienced by only a minority of patients with LGE, and identifying this subgroup may improve treatment and outcomes in these patients. Objective: To assess whether CMR phenotypes based on left ventricular ejection fraction (LVEF) and LGE in patients with suspected cardiac sarcoidosis (CS) are associated with adverse outcomes during follow-up. Design, Setting, and Participants: This cohort study included consecutive patients with histologically proven sarcoidosis who underwent CMR for the evaluation of suspected CS from 2004 to 2020 with a median follow-up of 4.3 years at an academic medical center in Minnesota. Demographic data, medical history, comorbidities, medications, and outcome data were collected blinded to CMR data. Exposures: CMR phenotypes were identified based on LVEF and LGE presence and features. LGE was classified as pathology-frequent or pathology-rare based on the frequency of cardiac damage features on gross pathology assessment of the hearts of patients with CS who had sudden cardiac death or cardiac transplant. Main Outcomes and Measures: Composite of ventricular arrhythmic events and composite of heart failure events. Results: Among 504 patients (mean [SD] age, 54.1 [12.5] years; 242 [48.0%] female and 262 [52.0%] male; 2 [0.4%] American Indian or Alaska Native, 6 [1.2%] Asian, 90 [17.9%] Black or African American, 399 [79.2%] White, 5 [1.0%] of 2 or more races (including the above-mentioned categories and Native Hawaiian or Other Pacific Islander), and 2 [0.4%] of unknown race; 4 [0.8%] Hispanic or Latino, 498 [98.8%] not Hispanic or Latino, and 2 [0.4%] of unknown ethnicity), 4 distinct CMR phenotypes were identified: normal LVEF and no LGE (n = 290; 57.5%), abnormal LVEF and no LGE (n = 53; 10.5%), pathology-frequent LGE (n = 103; 20.4%), and pathology-rare LGE (n = 58; 11.5%). The phenotype with pathology-frequent LGE was associated with a high risk of arrhythmic events (hazard ratio [HR], 12.12; 95% CI, 3.62-40.57; P < .001) independent of LVEF and extent of left ventricular late gadolinium enhancement (LVLGE). It was also associated with a high risk of heart failure events (HR, 2.49; 95% CI, 1.19-5.22; P = .02) independent of age, pulmonary hypertension, LVEF, right ventricular ejection fraction, and LVLGE extent. Risk of arrhythmic events was greater with an increasing number of pathology-frequent LGE features. The absence of the pathology-frequent LGE phenotype was associated with a low risk of arrhythmic events, even in the presence of LGE or abnormal LVEF. Conclusions and Relevance: This cohort study found that a CMR phenotype involving pathology-frequent LGE features was associated with a high risk of arrhythmic and heart failure events in patients with sarcoidosis. The findings indicate that CMR phenotypes could be used to optimize clinical decision-making for treatment options, such as implantable cardioverter-defibrillators.

Stung to the Heart.

A 48-year-old woman with a history of scorpion sting was admitted with cardiogenic shock. Electrocardiogram showed ventricular tachycardia which reverted with magnesium sulphate after failed attempts with electrical cardioversion. Postcardioversion electrocardiogram showed Brugada pattern. (Level of Difficulty: Advanced.).

'Gym Tonic' and Quadriparesis.

We report a case of acute onset quadriparesis which occurred after consumption of some drugs which were illicitly prescribed to our young patient by his gym instructor. The deadly concoction of so-called gym-tonic (Cyproheptadine and dexamethasone) led to hypokalaemic paralysis in our patient.

Preintensive care: Thrombolytic (streptokinase or tenecteplase) in ST elevated acute myocardial infarction at peripheral hospital.

BACKGROUND: Coronary artery disease is a major cause of death in India. Sudden death preceded by chest pain is due to acute myocardial infarction. Villagers are aware and afraid of chest pain. Majority of chest pain victims attend the primary physician in golden hours. Hence, primary doctors can play important role for early thrombolysis and salvage the myocardium from irreversible injury. This study determined year mortality in a patient who received the rapid thrombolysis at primary care hospital (streptokinase or tenecteplase) at rural setting. SETTING: Peripheral General Hospital Mahad on Mumbai-Goa highway. PATIENTS AND METHODS: Patients with typical chest pain with electrocardiogram showed ST segment elevated myocardial infarction (STEMI) with or without risk factors admitted from 2005 to march 2016 were studied. Details clinically studied: time interval between chest pain to hospital, hospital to needle time, reperfusion and arrhythmias. Time required for regression of elevated ST segment, a response to thrombolytic (streptokinase or tenecteplase) therapy, is studied. RESULTS: Total 244 patient reported with chest pain of these 35 cases brought dead with history of chest pain and convulsive moment before they died. Of these, 209 patients had acute STEMI. Of these, 162 received streptokinase (STK) and 47 received tenecteplase (TNP)]. Analysis of STK Vs TNP patients 18 (11.11%) versus 3 (6.38%) (P = 0.361) died during the treatment. Around 17 (18.49%) vs 5 (10.63%) (P = 0.941) did not show signs of reperfusion, respectively. Re infarction occurred during hospitalization 3 (2.5%) versus 3 (6.38%) (P = 0.094) cases. Around 12 (7.40%) versus 0% (P = 0.072) died at the end of 12 months of thrombolytic therapy. CONCLUSION: Thrombolysis of STEMI within golden hours improved the reperfusion. However, 1-year fatality is significance with streptokinase as compared with tenecteplase.

Pathophysiology of dilatation of pupils due to scorpion and snake envenomation and its therapeutic value: Clinical observations.

Dilated nonreacting pupils are routinely taken as a sign of irreversible brain damage. Alpha-receptor stimulation (scorpion sting) and presynaptic acetylcholine receptor blocker (krait bite) may result in dilation of pupils without involvement of the brain. This study was aimed to clinically evaluate the response of pupils in scorpion sting and krait bite. Victims of scorpion sting and krait bite were chosen from Raigad district. Scorpion sting and krait bite cases were admitted to hospital and were clinically evaluated in detail regarding neurological manifestations. Both cases had nonreacting dilation of pupils, complete neurological recovery accompanied with reverse of pupillary size and its response to light. In scorpion sting and krait bite poisoning, dilated nonreacting pupils are not the signs of irreversible brain damage.

Rabies: A Novel Clinical Presentation.

Rabies is a fatal disease. Saliva of a rabid dog is a rich source of rabies virus. We report a patient who suffered of rabies, who was infected by abrasion caused by the nails of a rabid dog. Dogs often lick their nails and thereby transfer the rabies virus-contaminated saliva to their claws. Despite treatment in our Intensive Care Unit and application of various pharmacological antidotes, we were unable to prevent the fatal outcome.

Premonitory signs and symptoms of envenoming by common krait (Bungarus caeruleus).

Between January 2005 and August 2011 141 victims of krait bite poisoning were admitted to the general hospital at Mahad. Clinical signs and symptoms preceding the development of neuroparalysis were analyzed. Fifty-six percent of patients were male. A total of 140 victims reported between midnight and 05:00. Patients awoke in the night due to abdominal colic (85%) and chest pain (72%). Patients gave a history of vomiting (42%), sweating (17%) and excessive salivation (35%). On arrival at hospital, 78% cases had dysphasia with pooling of saliva, 89% had heaviness in both eyelids and ptosis; 12.5% of patients died on the way to hospital while 13.47% died during treatment. In total, 74.46% recovered, and of these 48% needed artificial ventilation. The sudden onset of abdominal colic and vomiting in a person sleeping on the floor without a mosquito net led to neuroparalysis due to krait bite poisoning.