A rare case of right coronary artery dissection during routine left heart catheterization.

Percutaneous coronary intervention (PCI) is an effective method for coronary revascularization, however, alongside its benefits, it can be accompanied by complications. Catheter induced coronary artery dissection (CICAD) is rare and the consequences can be devastating if left untreated. The incidence has been reported to be as low as 0.1%. Also, propagation of the dissection to the aortic root remains uncommon. The mechanism of dissection is related to mechanical injury to the arterial wall during manipulation with the catheter or wire. It may also occur due to injection of contrast, stenting or balloon dilation. Timely recognition is important in these cases to facilitate optimal patient outcomes which is usually accomplished with stenting. Herein, we report a rare case of a 68-year-old female with multivessel coronary artery disease who presented for routine left heart catheterization and developed catheter induced right coronary artery (RCA) dissection with propagation towards the aortic root which was treated with stenting and watchful waiting.

Unveiling a Critical Subacute Complication: Right Apical Septum Pacemaker Lead Dislodgement Leading to Right Ventricular Perforation and Minimal Pericardial Effusion.

The implantation of cardiac pacing devices, such as pacemakers and implanted cardioverter-defibrillators (ICDs), has significantly improved patient outcomes in the treatment of a range of cardiac arrhythmias. Right ventricular (RV) pacing lead perforation is an uncommon but potentially dangerous complication that can occur despite technical breakthroughs. RV lead perforation, which can result in right ventricular perforation as well as possible pulmonary or vascular harm, is caused by the pacing lead breaking through the myocardial wall. Despite being rare, this complication warrants attention because of the risks for morbidity and mortality that are involved. We present a case of right ventricular perforation caused by a pacemaker lead and examine the nuances of RV lead perforation in this instance, including its prevalence, clinical presentation, diagnostic difficulties, and treatment strategies, illuminating the many factors to be taken into account while properly managing this issue.

Transverse Myelitis: An Adverse Reaction to Abatacept.

Immunotherapies are powerful disease-modifying agents in treating autoimmune diseases like rheumatoid arthritis (RA). However, their unique mechanisms of action confer a broad spectrum of immune-related adverse events (irAEs), which tend to be rare but complex, with significant risk for morbidity and mortality. We report a case of transverse myelitis in a patient with RA whose joint disease had been well-controlled with long-term intravenous abatacept. Suspicion of an unusual irAE in this elderly patient, whose neurologic symptomatology was gradual and protracted, prompted the discontinuation of abatacept and the rapid initiation of corticosteroid therapy. These interventions yielded a favorable clinical outcome for the patient. We must draw clinicians' attention to this rare but potentially consequential adverse drug reaction.

A Rare Occurrence of Spontaneous Coronary Artery Dissection in Elderly: Diagnostic Challenges and Clinical Implications.

Spontaneous coronary artery dissection (SCAD) is the ripping of the epicardial coronary artery wall without any trauma, coronary procedures, or rupture of atherosclerotic plaque. Intimal rip, intramural hematoma, and false lumen formation are the hallmarks of this disease, which may result in coronary blood flow obstruction and myocardial ischemia. The role of SCAD in acute coronary syndrome (ACS), and sudden death has come to light more and more, particularly in young females and those with few typical atherosclerotic risk factors. This study details a 65-year-old female with a history of hypertension, hyperlipidemia, asthma, and chronic kidney disease who presented with severe chest pain and elevated troponin levels. Upon investigation, spontaneous dissection of the left anterior descending artery (LAD) involving its mid and distal segments was identified. The present case highlights a rare occurrence of spontaneous coronary artery dissection (SCAD) in a demographic typically unaffected by the condition - females aged 65 years and over. The atypical presentation underscores the importance of reporting such cases to prevent oversight. This patient's case is particularly noteworthy as it deviates from the typical predisposing factors associated with SCAD, such as youth, pregnancy, or stressors. Additionally, the case is unique in that it presented both SCAD and imaging findings consistent with takotsubo cardiomyopathy, suggesting a complex cardiac pathology deserving of further study and consideration.

Black Cohosh: An Uncommon Culprit of Bradycardia in Postmenopausal Women.

The use of herbal supplements has become increasingly prevalent, with black cohosh (BC) gaining popularity for managing menopausal symptoms. However, reports of adverse effects associated with BC are limited. We present a case of bradycardia linked to prolonged BC ingestion. A 76-year-old postmenopausal woman who has been taking BC for years has had syncopal attacks multiple times during the past years associated with bradycardia with the heart rate dropping to 30 beats/minute with no identifiable cause. Discontinuation of BC resulted in a gradual resolution of bradycardia, highlighting a plausible association. There were no additional pharmacological or invasive interventions required.

Surviving the Storm: Cardiac Tamponade and Effusive Constrictive Pericarditis Complicated by Pericardial Decompression Syndrome Induced by COVID-19 Infection in the Setting of Newly Diagnosed Acute Myeloid Leukemia (AML).

Coronavirus disease 2019 (COVID-19)-induced pericarditis and pericardial myocarditis are common entities; however, the development of pericardial effusion post-COVID-19 infection has only been reported in about 5% of cases. Rapid and acute progression to pericardial tamponade is uncommon, and progression to effusive constrictive pericarditis (ECP) and pericardial decompression syndrome (PDS) is an even rarer phenomenon. We describe these phenomena in this report to raise awareness and aid clinicians in the early diagnosis and management of these conditions. We report a case of a 45-year-old female with a past medical history of recent COVID-19 infection, uncontrolled diabetes mellitus, and hypertension who presented with severe chest pain, which was determined to be acute pericarditis post-COVID-19 infection. The patient developed a large pericardial effusion leading to cardiac tamponade within one day of initial presentation. Urgent pericardiocentesis was performed but was complicated by rapid decompensation of the patient, which has been assumed to be ECP following pericardiocentesis and PDS.  Close monitoring of acute pericarditis with pericardial effusion is required in these patients for the early detection of cardiac tamponade, which requires urgent pericardiocentesis. Judicious post-pericardiocentesis follow-up is also required for the early diagnosis of conditions such as ECP and PDS. These cases are generally managed symptomatically, but in cases of severe ECP syndrome, pericardial stripping may be required.

Trends and Disparities in Cardiovascular Death in Sarcoidosis: A Population-Based Retrospective Study in the United States From 1999 to 2020.

BACKGROUND: Despite significant cardiac involvement in sarcoidosis, real-world data on death due to cardiovascular disease among patients with sarcoidosis is not well established. METHODS AND RESULTS: We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for data on patients with sarcoidosis aged ≥25 years from 1999 to 2020. Diseases of the circulatory system except ischemic heart disease were listed as the underlying cause of death, and sarcoidosis was stated as a contributing cause of death. We calculated age-adjusted mortality rate (AAMR) per 1 million individuals and determined the trends over time by estimating the annual percentage change using the Joinpoint Regression Program. Subgroup analyses were performed on the basis of demographic and geographic factors. In the 22-year study period, 3301 cardiovascular deaths with comorbid sarcoidosis were identified. The AAMR from cardiovascular deaths with comorbid sarcoidosis increased from 0.53 (95% CI, 0.43-0.65) per 1 million individuals in 1999 to 0.87 (95% CI, 0.75-0.98) per 1 million individuals in 2020. Overall, women recorded a higher AAMR compared with men (0.77 [95% CI, 0.74-0.81] versus 0.58 [95% CI, 0.55-0.62]). People with Black ancestry had higher AAMR than people with White ancestry (3.23 [95% CI, 3.07-3.39] versus 0.39 [95% CI, 0.37-0.41]). A higher percentage of death was seen in the age groups of 55 to 64 years in men (23.11%) and women (21.81%), respectively. In terms of US census regions, the South region has the highest AAMR from cardiovascular deaths with comorbid sarcoidosis compared with other regions (0.78 [95% CI, 0.74-0.82]). CONCLUSIONS: The increase of AAMR from cardiovascular deaths with comorbid sarcoidosis and higher cardiovascular mortality rates among adults aged 55 to 64 years highlight the importance of early screening for cardiovascular diseases among patients with sarcoidosis.

Apical Hypertrophic Cardiomyopathy Presenting With Syncope in a Hispanic Woman: A Report of a Rare Case.

Yamaguchi syndrome or apical hypertrophic cardiomyopathy is a rare subtype of non-obstructive hypertrophic cardiomyopathy that is defined as the focused hypertrophy of the left ventricular apex. It is typically seen in Asian populations. Herein, we present a rare case of Yamaguchi syndrome seen in a Hispanic female.

A Rare Case of Fulminant Myocarditis Caused by COVID-19 and Influenza B Co-infection.

Coronavirus disease 2019 and influenza B can have similar presentations and are self-limited in most cases. They are rarely associated with fatal cardiovascular complications. Coronavirus and influenza B-induced myocarditis is a rare but reversible cause of cardiogenic shock. Early detection plus administration of antiviral agents and supportive care with mechanical circulatory support in the form of an intra-aortic balloon pump can be a lifesaving measure in myocarditis.

McKittrick-Wheelock Syndrome: A Rare Case of Secretory Diarrhea.

McKittrick-Wheelock syndrome commonly presents with a triad of chronic secretory diarrhea, electrolyte disturbances, and renal failure. Secretory diarrhea is due to active ion secretion secondary to secretagogue secretion (cyclic adenosine monophosphate and prostaglandin E2). The mainstay of treatment for these lesions is surgical since it will arrest the loss of electrolytes that may lead to serious clinical consequences. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin may be used to decrease electrolyte secretion in patients that desire a nonsurgical approach. Our patient is unique in that this is the first case of a tubular adenoma with high-grade dysplasia leading to MWS and progressing to circulatory collapse with severe electrolyte disturbances. Aggressive replacement of fluids and electrolytes is essential to the survival of these patients.

Diabetic Ketoacidosis-Induced Cardiomyopathy and Reversible Dialysis-Dependent Renal Failure With Successful Outcome: A Report of a Rare Case.

Stress-induced or Takotsubo cardiomyopathy (TCM) is a phenomenon that typically occurs in postmenopausal women in the setting of acute emotional or medical stressors. It typically causes reversible akinesis of the heart apex with opposite hyperdynamic basal segments. An electrocardiogram (ECG) would show ischemic ST elevation in anterior leads in >90% of cases with elevated troponin, yet coronary angiography rules out occlusive disease. Takotsubo cardiomyopathy in the setting of diabetic ketoacidosis (DKA) is a rare phenomenon that has been attributed to severe acidosis. Here, we report the case of a 37-year-old male with severe DKA that was complicated by stress cardiomyopathy and progressed to cardiogenic shock.

Takotsubo Cardiomyopathy After Cocaine Intoxication.

Introduction: Cocaine is a highly addictive substance that stimulates the sympathetic nervous system and cardiovascular system. A multitude of adverse cardiovascular events are associated with cocaine use including arrhythmia, congestive heart failure, coronary artery spasm and myocarditis. Case Report: We present a rare case of Takotsubo cardiomyopathy after recent use of cocaine in a female without any other identifiable risk factor. Discussion: Takotsubo cardiomyopathy (TCM) is a reversible cause of cardiomyopathy characterized by transient decrease in ejection fraction. Cocaine is a sympathomimetic that causes catecholamine surge and a variety of cardiovascular abnormalities. The association of cocaine use with Takotsubo cardiomyopathy is a rare occurrence, however the prognosis is generally good if diagnosis is made promptly. Conclusion: Physician vigilance is required to diagnose this rare cause of cardiomyopathy and reduce morbidity and mortality. LEARNING POINTS: This case highlights the need to investigate the use of cocaine in patients with cardiovascular disease because it may influence the disease diagnosis and management strategies.Left heart catheterization is imperative for diagnosis, and cessation of cocaine is the primary goal of post discharge therapy.This case shows that TCM should be suspected in a patient with a history of cocaine use.

Splenic Marginal Zone Lymphoma With Histological Transformation to Hodgkin's Lymphoma.

Marginal zone lymphoma (MZL) is a rare, slow-growing/indolent B cell lymphoid neoplasm accounting for 10.5% to 11.8% of all B cell lymphomas. MZL originates from the mature B lymphocytes, which are usually present in the marginal zone of the lymphoid follicle. Histological transformation (HT) is defined as sheets of large cells arising in an indolent lymphoma with morphological and immunophenotypic changes suggestive of a high-grade lymphoma such as Hodgkin's lymphoma, diffuse large B cell lymphoma (DLBCL), or Burkitt lymphoma. The median time of transformation ranges from one year to 15 years following the initial diagnosis of MZL. Studies reported that the deletion of TP53 and 7q and mutations in NOTCH2 are commonly associated with HT in MZL. This case report outlines the rare happening of an MZL transformation into a nodular subtype of Hodgkin's lymphoma in a 56-year-old female, which prompted further investigations and a different therapeutic approach. By reporting this case, we emphasize that HT changes the natural history and significantly affects the overall survival of patients with MZL. Hence, it is necessary to get a core needle or excisional biopsy whenever there is a clinical suspicion of HT in MZL for early diagnosis and a better therapeutic approach.

A Rare Case of Aggressive Metastatic Laryngeal Chondrosarcoma Presenting as Bilateral Necrotizing Pneumonia.

Laryngeal chondrosarcomas are rare tumors that account for only 0.2% of malignant tumors of the larynx. Approximately 80% of these tumors are low grade and well differentiated and are associated with a good long-term prognosis. Herein, we report a case of a 77-year-old male presenting with acute hypoxic respiratory failure that required intubation and mechanical ventilation. Chest CT showed multiple pulmonary nodules and cavities. He then required a tracheostomy, and a soft tissue mass in the subglottic mass was discovered. A laryngoscopy-guided excisional biopsy of the mass was performed. Histopathological examination confirmed the diagnosis of laryngeal chondrosarcoma. Clinicians should consider metastatic laryngeal chondrosarcoma as a differential diagnosis for lung cavities. Overall, we believe this to be the first case of aggressive laryngeal chondrosarcoma with mediastinal and pulmonary metastasis mimicking necrotizing pneumonia.

Developing, conducting and evaluating the internship preparatory program (Ipp).

BACKGROUND: Medical schools worldwide have employed different practices to facilitate a smooth transition from medical school into the internship phase to promote success in graduates' future professional life. The College of Medicine at Princess Nourah University (PNU) has developed a unique internship preparatory program focusing on soft and clinical skills. OBJECTIVE: The aim of this study was to describe the internship preparatory program (IPP) and evaluate its effectiveness in improving medical students' transition to internship. MATERIALS AND METHODS: The IPP for fifth-year medical students at PNU was planned and designed based on students' needs, the Saudi-Med framework, and similar national/international programs. The one-year longitudinal IPP in 2016-2017 covered four modules conducted as ten workshops focusing on soft skills, clinical skills, and professional development for the future. All data were analyzed by using SPSS version 20. RESULTS: The IPP was attended and evaluated by 48 participants; 70% of them attended 80% of the IPP workshops. The satisfaction rate for workshop participants was 6.8-8.8 out of 10. Most participants were either satisfied or strongly satisfied with respect to each item on the IPP satisfaction scale; the median satisfaction score was 4 out of 5. A positive significant correlation between the satisfaction score and the number of workshops attended was detected. CONCLUSION: The IPP was a satisfying initiative for most participants. It refines their clinical and soft skills, facilitates future planning, and provides a smooth transition from medical school to internship.

Loculated Empyema and SARS-CoV-2 Infection: A Report of Two Cases and Review of the Literature.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clinical manifestations are diverse and can vary from mild respiratory symptoms to severe hypoxic respiratory failure. In severe cases, infection can cause gastrointestinal, renal, cardiac, neurological and haematological complications and result in multi-organ failure. There are very few reports of parapneumonic effusion in patients with COVID-19. We describe two patients with COVID-19 who had loculated empyema and discuss the clinical course and therapeutic options. LEARNING POINTS: The clinical manifestations of COVID-19 vary from mild to severe disease and can result in multi-organ failure.Pleural empyema is usually treated with a combination of antibiotics and surgical drainage of the pleural cavity.

Graves' Disease in a Patient With Human Immunodeficiency Virus Infection as an Immune Reconstitution Inflammatory Syndrome.

The use of highly active antiretroviral therapy (HAART) in the management and treatment of human immunodeficiency virus type 1 (HIV-1) has dramatically changed the course of the disease and improved overall survival. HAART results in significant decrease in viral load and enhancement of CD4 cells and gradual restoration of the immune system. However, a subset of patients may experience a paradoxical worsening after the initiation of HAART due to a heightened and dysregulated immune response. This phenomenon is termed immune reconstitution inflammatory syndrome (IRIS). The manifestation of Graves' disease (GD) after the introduction of HAART has been identified as IRIS manifestation in some patients. Thus, this occurrence should be suspected and further investigated in patients with HIV on antiretroviral therapy (ART) who present with symptoms consistent of hyperthyroidism to avoid overt hyperthyroidism. We report a case of IRIS associated Graves' disease. Our case adds to the very limited literature about this phenomenon.