Wellens Syndrome Electrocardiogram Pattern in a Patient With Multi-Vessel Coronary Artery Disease.

Wellens syndrome is an electrocardiogram (ECG) pattern associated with critical stenosis of the proximal left anterior descending (LAD) artery. In patients with Wellens syndrome, characteristic biphasic or inverted T waves are seen on ECG. This case report presents a 48-year-old male admitted for chest pain and shortness of breath who was found to have a Wellens syndrome ECG pattern. Oddly, cardiac catheterization revealed multi-vessel coronary artery disease, and critical proximal LAD artery stenosis was not appreciated. Ultimately, the patient was treated with coronary artery bypass graft (CABG) surgery and later discharged in stable condition.

Acute Pericarditis Post mRNA-1273 COVID Vaccine Booster.

Cardiovascular complications such as arrhythmias, hypoxemic cardiomyopathy, pericarditis, myocardial infarction, heart failure, and myocarditis are rare but seen in COVID-19 patients. These cardiac injuries could be the result of direct SARS-CoV-2 effects. The most prominent mediator of this hypothesis is angiotensin-converting enzyme-2 (ACE2) receptors, which are highly expressed in heart and lung tissues. These ACE2 receptors are found to be the functional receptors for the Coronavirus. Another hypothesis for cardiac complications in COVID-19 patients is macrophage-induced inflammation. The SARS-CoV-2 infection leads to invasion of epithelial cells by binding with ACE-2 receptors, localized inflammation, endothelial and macrophage activation, tissue damage, and dysregulated cytokine release. Current data have shown that mRNA COVID-19 vaccines are efficacious and safe for indicated patients. However, these vaccines can cause mild adverse reactions similar to those of traditional vaccines, and more severe side effects can also be seen infrequently. The exact pathogenesis of COVID-19 vaccine-induced pericarditis remains unknown, but there are several hypotheses regarding the pathophysiology of pericarditis after COVID-19 vaccine administrations. There has been speculation that mRNA vaccines can produce a large number of antibodies in a small subgroup of people, especially young individuals, and this elicits an inflammatory response similar to the multisystem inflammatory syndrome associated with SARS-CoV-2 infection. Another proposed mechanism is the cross-reaction between produced antibodies and the pericardium, leading to myocardial and pericardial inflammation induction. This report describes a 69-year-old female who presented with three days of chest pain that started one day after a booster shot of the Moderna COVID-19 vaccine. The patient was diagnosed with pericarditis, and she was effectively treated with colchicine and later steroids.

Coronary Vasospasm Presenting as ST-Elevation Myocardial Infarction.

Vasospastic angina (VSA), also known as Prinzmetal angina, is caused by reversible diffuse or focal vasoconstriction of coronary arteries. It is the most common diagnosis among patients presenting with signs of ischemia but no obstructive coronary artery disease. Patients with VSA can present with typical acute coronary syndrome (ACS) symptoms of chest pain or pressure, dyspnea, diaphoresis, fatigue, and syncope. VSA is a challenging diagnosis for physicians due to its nearly identical clinical presentation to active acute coronary syndrome patients. This report describes a similar diagnosis dilemma when a 69-year-old female presented with ST-elevation myocardial infarction (STEMI), who was eventually diagnosed with and treated for vasospastic angina.

Stress-Induced Cardiomyopathy Raising Concern for Myocardial Ischemia.

Stress-induced cardiomyopathy (SIC), or Takotsubo syndrome, is considered a reversible dysfunction of the left ventricle that may mimic an acute coronary syndrome (ACS). Patients may present with chest pain, dyspnea, syncope, or other serious complications including cardiogenic shock, ventricular arrhythmias, and thrombus formation. Diagnostic criteria for SIC include several factors, including electrocardiogram changes, cardiac biomarker elevations, ventricular regional wall abnormalities on echocardiogram, and absence of occlusive coronary disease on coronary angiography. There is no standardized protocol for the treatment of SIC, although the current consensus is that patients should be risk-stratified, managed for complications, and treated with supportive therapy accordingly. In this case study, we present an 85-year-old female who presented with one month of fatigue, lower extremity weakness, and exertional dyspnea with chest pressure. She received a cardiac workup which revealed lab and imaging findings consistent with SIC. She received treatment for SIC, pericarditis, and Clostridium difficile colitis.

Mycotic Pseudoaneurysm Formation at the Cannulation Site in the Ascending Aorta.

The formation of mycotic pseudoaneurysms in the ascending aorta is a rare but sometimes fatal complication after open-heart surgery, requiring cardiopulmonary bypass (CPB). There has been little cited about this rare complication. We present a case of a 51-year-old man who developed a mycotic pseudoaneurysm in the ascending aorta at a previous aortic cannulation site nine years after coronary artery bypass surgery. The patient presented to the emergency department with two weeks of worsening substernal chest pain and was found to have pseudoaneurysm in the anterior wall of the ascending aorta on chest computed tomography angiography (CTA) during his chest pain workup. The patient's blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA). During the hospital course, the patient's respiratory status worsened, and repeat CTA revealed enlargement of the pseudoaneurysm arising from the anterior proximal arch of the aorta. Chest X-ray obtained because of hypoxia demonstrated widening of the upper mediastinum, which appeared increased compared with the previous exam. Because of concern for rupture of an aneurysm, the patient was taken to the operating room for redo sternotomy and repair of the pseudoaneurysm with femoral artery cannulation for cardiopulmonary bypass. The patient completed eight weeks of IV nafcillin, and rifampin was added to decrease biofilm formation.

Intractable Cough Associated With Renal Cell Carcinoma.

Renal cell carcinoma (RCC) is known to cause abdominal pain, hematuria, flank pain, fevers, night sweats, and weight loss, but its association with paraneoplastic syndromes such as intractable cough is rare. Here, we present the case of an 86-year-old female who presented with a persistent dry cough for two months. Computed tomography (CT) of the abdomen and pelvis with contrast revealed large left renal mass consistent with renal cell carcinoma spreading through Gerota's fascia and metastatic to regional lymph nodes. Biopsy of the mass tested positive for renal cell carcinoma markers. Ultimately, the patient was deemed a nonsurgical candidate and treated with immunotherapy. In this case study, we discuss the rare but important clinical findings leading to the possible diagnosis of paraneoplastic cough secondary to RCC.

Formation of a Rectus Sheath Hematoma Secondary to COPD Exacerbation While Taking Dual Antiplatelet Therapy.

Rectus sheath hematomas can occur due to nontraumatic increases in abdominal pressure from respiratory disease such as chronic obstructive pulmonary disease (COPD). This case study describes a 59-year-old male who was on dual antiplatelet therapy after a right coronary percutaneous intervention for acute coronary syndrome. He developed abdominal pain and ecchymosis on dual antiplatelets and was found to have a rectus sheath hematoma. The hematoma resolved with conservative care and did not require surgical intervention. The etiology of rectus sheath hematoma is thought to be due to coughing spells from chronic obstructive pulmonary disease exacerbation while taking dual antiplatelet therapy. Cases of rectus sheath hematomas continue to emerge in the literature with similar patient histories, and we should be cognizant of this possible complication in patients with chronic coughing.

ANCA-Associated Vasculitis in a Patient Presenting With Rapid Progressive Glomerulonephritis.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare disease distinguished by the presence of circulating ANCA along with inflammation and destruction of primarily small blood vessels. AAV includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Overall, AAV occurs more frequently in Caucasian populations with an approximate incidence of 20 per million per year in Europe and North America. This report presents a case of a 70-year-old female with a history of interstitial lung disease who was hospitalized due to markedly reduced renal function and eGFR within the range of end-stage renal disease on admission. The patient tested positive for perinuclear (p)-ANCA, also known as myeloperoxidase (MPO)-ANCA. The patient was subsequently started on hemodialysis and induction therapy of cyclophosphamide and methylprednisolone for glomerulonephritis secondary to p-ANCA vasculitis. The patient was discharged with improved renal function, and she was expected to follow up with nephrology for maintenance therapy to prevent future relapse. This report demonstrates a case of p-ANCA-positive glomerulonephritis treated with cyclophosphamide and methylprednisolone and discusses the current treatment guidelines for glomerulonephritis secondary to p-ANCA vasculitis.

Metastatic Porocarcinoma Effectively Managed by Pembrolizumab.

Eccrine porocarcinoma (EPC) is a rare malignancy of the sweat glands. Currently, there is no standard algorithm for its presentations, diagnosis, and management. However, immunotherapy is an emerging option that may be crucial to the treatment of EPC. This report presents a case of a 79-year-old male who had a skin biopsy of an anterior scalp lesion, which revealed EPC. The patient underwent Mohs micrographic surgery to excise the tumor followed by two additional Mohs surgeries for recurrence and adjuvant radiotherapy. A follow-up positron emission tomography (PET) scan revealed yet another recurrence at the scalp as well as metastases to the left parotid gland and left submandibular lymph node. The patient was started on immunotherapy with pembrolizumab, a programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor, and later achieved remission. This report demonstrates the effective management of EPC using immunotherapy with pembrolizumab.

Acute Pericarditis Secondary to COVID-19 Infection.

The Coronavirus disease 2019 (COVID-19) pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cardiac injuries are among the complications caused by COVID-19. This report presents the case of a 25-year-old patient hospitalized due to Coronavirus infection with the complication of recurrent acute pericarditis. The patient was treated with colchicine and high-dose ibuprofen, and the patient was then discharged in stable condition. This report demonstrates an effective treatment plan for acute pericarditis secondary to COVID-19 infection.

Suprasellar Ganglioglioma: Expanding the Differential Diagnosis.

This case study describes a young man with symptoms suggestive of the presence of a space-occupying lesion within the cranial cavity. Imaging studies confirmed a lesion in the suprasellar region and surgical intervention to remove the tumor yielded an unexpected diagnosis. Neuroimaging characteristics and histopathology including immunohistochemistry are described. Gangliogliomas are uncommon CNS neoplasms and are most commonly found in the temporal and frontal lobes of young, male adults. They are rarely seen in the suprasellar region and only a handful of cases have been reported to date. The differential diagnoses associated with these suprasellar region lesions can be dependent on the age of the patient and neuroimaging characteristics. The present report highlights the importance of histopathological examination and the need to consider a wide range of diagnostic entities in the differential diagnosis of lesions in this topographic distribution, including rarely encountered tumors such as gangliogliomas.