RESUMO
In this case report, we describe a 55-year-old female patient with worsening exertional dyspnea who is referred to the cardiology department, due to the appearance of worsening pulmonary vascular disease on computed tomography (CT) of the chest. Previous transthoracic echocardiograms (TTE) identified right ventricle enlargement, but no other structural abnormalities. She completed cardiac magnetic resonance (CMR) imaging, which identified a large secundum atrial septal defect (ASD). She subsequently underwent surgical planning and correction of the lesion with improvement of her symptoms. This case and a growing body of literature support the use of CMR as an alternative imaging modality for the diagnosis of congenital heart disease (CHD).
RESUMO
Baroreflex failure is a rare cause of syncope and labile blood pressures. Here, we present a case of baroreflex failure in a patient with history of nasopharyngeal cancer, status-post neck radiation. A 76-year-old male presented from an outside facility for possible pacemaker placement as he was found to have symptomatic third-degree atrioventricular (AV) block. The AV block resolved following discontinuation of the patient's his verapamil. The patient then developed labile blood pressures. A work-up for secondary causes of hypertension was negative, but due to the patient's neck radiation history, it was suggested that the labile blood pressures were due to baroreflex failure. We then started the patient on clonidine and other nonpharmacological interventions. The blood pressure was maintained after these treatments and on follow-up, the labile blood pressures had resolved. Our case demonstrates that baroreflex failure can be managed without any invasive intervention by performing frequent blood pressure measurements along with medication management.
RESUMO
BACKGROUND: Lyme disease is an infection that is estimated to affect over 300,000 people in the United States annually. Typically, it presents with erythema migrans (EM), an annular rash at the site of tick attachment, within 3 to 30 days of inoculation. Untreated patients may progress to early disseminated disease. A further complication, Lyme carditis is rare but may occur several weeks later. It commonly manifests as a variable atrioventricular (AV) conduction block, with a high-grade AV block occurring in only 1% of untreated patients. This case demonstrates an unusually early presentation of Lyme carditis with complete heart block. CASE PRESENTATION: A 21-year-old male was transferred from an outside emergency department (ED) for possible pacemaker placement due to symptomatic third-degree AV block. Four days earlier the patient presented to the outside ED with fever, chills, and unrecognized EM on his right neck. He was discharged with antipyretics, but no antibiotic therapy. On the day of transfer, he returned with persistent fevers, EM now on his trunk and upper extremities, lightheadedness, and substernal chest pressure. An electrocardiogram revealed the third-degree AV block leading to transfer. Upon arrival, the patient was promptly diagnosed with Lyme carditis. Pacemaker implantation was deferred, and intravenous (IV) ceftriaxone was initiated. Within 48 hours his third-degree AV block improved to a first-degree block. By this time, his EM had also resolved. He was discharged with oral doxycycline and a 30-day event monitor, which ultimately showed persistent first-degree AV block. CONCLUSIONS: This case reinforces a unique presentation of Lyme carditis. Disseminated EM and Lyme carditis may present concurrently within 2 weeks of tick attachment. Early recognition and treatment is important for preventing progression to disseminated infection. Lyme-associated AV block will reverse within 48 to 72 hours of initiating IV antibiotic therapy and will not require pacemaker implantation. Lyme carditis should be considered in patients without heart disease who present with any degree of AV block.
