by Mohammed Al-Sadawi, Muhammad Ihsan, Arismendy Nunez Garcia, Muhammad Dogar, Jessica Celenza-Salvatore and Samy I. McFarlane
Case Report
Congenital coronary artery anomalies are rare disease entities, occur only in 0.3%-5.6% of the general population. These anomalies could lead to serious complications in some cases and is associated with associated with sudden death due to lethal arrhythmias and premature coronary artery disease. Diagnosis of these anomalies is generally made during angiography. In this report, we present a rare case of absent left main coronary artery and anomalous origins of left anterior descending artery and left circumflex artery from right sinus of Valsalva in a 62 year old man presented with non-ST elevation myocardial infarction (NSTEMI).
American Journal of Medical Case Reports. 2019, 7(10), 264-266. DOI: 10.12691/ajmcr-7-10-10
Pub. Date: August 12, 2019
8304 Views1763 Downloads
by Fatai Oluyadi, Pramod Theetha Kariyanna, Apoorva Jayarangaiah, Jessica Celenza-Salvatore and Isabel M. McFarlane
Case Report
Background: The ¡®Spiked Helmet¡¯ is an electrocardiogram (EKG) finding occasionally seen in critically ill patients characterized by ST segment elevation usually represented as a ¡®spike and dome¡¯ pattern with elevation in the EKG baseline prior to the R wave and adjoining ST segment elevation resembling the German military helmet of the Prussian Empire. In the few cases reported in literature, this finding has been associated with very poor clinical outcomes, including in-hospital death. Although ST elevation is not uncommon in critically ill patients, these findings of a ¡®Spiked Helmet¡¯ sign are often transient and typically not associated with acute coronary syndrome. Case presentation: A 56-year-old male was found unresponsive by his relatives at home. It was an unknown the time that he had been unconscious. When the emergency medical services arrived, patient was found to be in pulseless electrical activity (PEA). Patient achieved return to spontaneous circulation (ROSC) 15 minutes after initiation of advanced cardiac life support protocol. An electrocardiogram done immediately post ROSC showed ST elevations in inferior and lateral leads. Patient was brought to the hospital as a ST elevated myocardial infarction (STEMI) arrest. The EKG revealed the Helmet sign in leads aVL and II, also ST segment elevation was noted in V1, V2, V3 and ST segment depression was noted in V5 and V6. Troponin was negative at the time of initial evaluation but trended up gradually during the hospitalization. A computed tomography (CT) pulmonary angiogram was negative for pulmonary embolism. A head CT showed diffuse anoxic brain injury. Patient was started on the hypothermia protocol. Upon family request patient was terminally extubated two days into hospital stay and expired shortly after. Conclusion: Although we are yet to fully understand the significance of the ¡®Spiked Helmet¡¯ Sign, this case report and literature review offers a comprehensive overview of the reported cases and draws important links and clues from them.
American Journal of Medical Case Reports. 2019, 7(10), 260-263. DOI: 10.12691/ajmcr-7-10-9
Pub. Date: August 06, 2019
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by Tariq Sharman
Case Report
Neuroleptic malignant syndrome (NMS) is a medical emergency associated with the use of neuroleptics and antiemetics. NMS is characterized by a distinctive clinical syndrome of altered mental status, rigidity, hyperthermia, and autonomic dysfunction. NMS occurs as a result of changes in presynaptic or postsynaptic dopamine signaling. Central D2 receptor blockade in the hypothalamus, nigrostriatal pathways, and spinal cord leads to increased muscular rigidity and tremor via extrapyramidal pathways. Hypothalamic D2 receptor blockade results in an elevated temperature set point and impairment of heat-dissipating mechanisms. The reported mortality rates for NMS vary between 5 to 20 percent and the occurrence of medical complications and disease severity are the strongest predictors of mortality. This is a case of a 51 year old Caucasian female who presented with altered mental status, temperature of 109¡ãF, diffuse muscular rigidity and autonomic dysfunction manifested as labile blood pressure, tachypnea, hypoxemia and tachycardia after consuming 18 tablets of Prochlorperazine over three days for gastrointestinal upset. Her clinical presentation and laboratory work up were consistent with NMS and she developed fatal complications and multi-organ dysfunction secondary to Prochlorperazine-induced neuroleptic malignant syndrome.
American Journal of Medical Case Reports. 2019, 7(10), 253-259. DOI: 10.12691/ajmcr-7-10-8
Pub. Date: August 06, 2019
8817 Views1365 Downloads3 Likes
by Lin JM, Chen Hui, Liu QL, Huang MP, Li QQ, Huang TH and Yang XY
Original Research
Objective: To evaluate the d the safety and efficacy of 200 U vs 300 U botulinum toxin A (BTX-A) injections for patients with neurogenic detrusor overactivity (NDO) secondary to spinal cord injury (SCI). Methods: we retrieved the data for the patients who receive a single dose into the detrusor of BTX-A (300 U or 200 U). The clinical outcome included maximum detrusor pressure (Pdetmax) during cystometry, voiding volume, urinary incontinence (UI) episodes between CICs per 24 hour, and complete dryness.Related adverse events were recorded. Results: From July 2015 to June 2017, 28 cases received 300 U BTX-A injections(experiment group) while 19 cases received 200U BTX-A injections(control group). There were no significant differences in baseline evaluation items (gender, age, duration of spinal cord injury, level of neurological injury, AIS scores) between the two groups. There were significant improvement in Pdetmax, UI and I-QoL from baseline in the two groups. Patients in experiment group had statistically greater improvement than those in the control group for Pdetmax (-32.09 cmH2O vs. -28.02 cmH2O, P = 0.016), mean urinary incontinence episodes (-6.18/d vs. -5.01/d, P = 0.042), complete dryness (11 vs. 2, P = 0.031), mean voiding volume (160.52 ml vs. 133.66 ml, P <0.001), and I-QoL (28.53 vs. 20.41, P <0.001). Conclusion:Preliminary results indicate that 300 U BTX-A is more effective than 200 U BTX-A for SCI patients with NDO.
American Journal of Medical Case Reports. 2019, 7(10), 250-252. DOI: 10.12691/ajmcr-7-10-7
Pub. Date: August 02, 2019
5779 Views1237 Downloads
by Talha Mehmood, Irsa Munir, Madina Abduraimova, Miguel Antonio Ramirez, Sunny Paghdal and Isabel M. McFarlane
Case Report
Background: Lupus myelitis is a rare but disastrous complication of systemic lupus erythematosus (SLE). The transverse myelitis (TM) may involve three or more contiguous spinal cord segments and as such is designated longitudinally extensive transverse myelitis (LETM). The neurological presentation may vary based on the location of the pathology and may consist of a combination of sensory and motor deficits. TM could be the presenting feature of SLE or present after 10 years of disease, while SLE was considered to be in remission. Case presentation: 26-year-old Black man with history of biopsy proven-lupus nephritis that had progressed to ESRD, presented with sudden onset quadriplegia that resolved upon arrival to the hospital. On exam, the temperature was 101.8°F and the neurological exam was consistent with residual weakness on the left sided-upper and lower extremities. Leukopenia, lymphopenia and thrombocytopenia, along with low complements were noted. Brain MRI was normal however, the spine MRI was suspicious for an epidural process (C2-T4) and intravenous antibiotics were commenced. After five days, neurological improvement was nil and new spine MRI revealed spinal cord edema secondary to myelitis at several spinal cord levels (C2-T4). Laboratory data was consistent with a SLE flare complicated with longitudinal extensive transverse myelitis. Pulse steroids and plasma exchange were initiated. Two weeks after admission, MRI demonstrated resolution of the epidural spinal lesion and marked improvement in spinal cord edema. Conclusion: TM can be the presenting feature of SLE or appear later on during the course of their disease. LETM is the most frequently type of TM found among SLE patients. Given the grave nature of the disease, it is of paramount importance that clinical features of TM be promptly recognized among SLE patients, to prevent catastrophic or even life-threatening outcomes.
American Journal of Medical Case Reports. 2019, 7(10), 244-249. DOI: 10.12691/ajmcr-7-10-6
Pub. Date: July 31, 2019
9190 Views1659 Downloads
by Michael Haddadin, Mohammad Al-Sadawi, Sally Madanat, Eric Tam, Evelyn Taiwo, Carol Luhrs and Samy I Mcfarlane
Original Research
Multiple Myeloma (MM) is a plasma cell disorder characterized by abnormal proliferation of plasma cells resulting in overproduction of paraprotein. Proteasome inhibitors (PI) have been a corner stone for the treatment of MM. Thrombotic Microangiopathy (TMA) is a recent hematological adverse event that has newly been recognized in multiple PI. TMA leads to end-organ damage and infarction by microthromobi. TMA pathophysiology is not well understood and has multiple etiologies. We present a case of PI-induced TMA, along with literature review of cases diagnosed from 2008-2018. Unique to our case is the onset of presentation, more than 24 months after initiating carfilzomib. Our case highlights the need for vigilant monitoring and the importance of clinical suspicion in patients at risk for TMA.
American Journal of Medical Case Reports. 2019, 7(10), 240-243. DOI: 10.12691/ajmcr-7-10-5
Pub. Date: July 31, 2019
6621 Views1362 Downloads
by Pramod Theetha Kariyanna, Alix Charles, Muhammad Faizan Ahmed, Apoorva Jayarangaiah, Sushruth Das, Mohammed Al-Sadawi, Madina Abduraimova and Samy I. McFarlane
Case Report
The sport of boxing carries with it the risk of brain injury with acute and chronic neurological injuries such has contusion, concussion and intracranial bleeding has been reported. The force sustained from a boxing blow can be as powerful as being hit with a 6-kg wooden mallet striking at 20 mph. Bilateral cerebellar hemorrhage secondary to trauma is a rare entity that has not been reported in the literature previously. One can only speculate as to how a boxer could potentially develop a cerebellar bleed. Regardless of whether a very powerful punch or the act of falling back and hitting the occipital region directly on the floor, it is very likely that a predisposing factor exist. We present you a rare case of a 26 year-old male boxer who was knocked out in a boxing match and was noted to have acute parenchymal and subarachnoid hemorrhage bilaterally in the cerebellar hemispheres. Our report highlights the need to consider cerebellar bleed in boxers who present after ataxia after boxing/knocked out.
American Journal of Medical Case Reports. 2019, 7(10), 236-239. DOI: 10.12691/ajmcr-7-10-4
Pub. Date: July 31, 2019
7797 Views1650 Downloads
by Irsa Munir MD, Talha Mehmood MD and Isabel M. McFarlane
Case Report
Amyotrophic lateral sclerosis is a fatal neurodegenerative disorder with progressive deterioration of both upper and lower motor neuron functions. It is a rare disease with one study demonstrating a prevalence of 3.9 cases per 100,000 in the USA in the year 2010-2011. It is a fatal disease with most of the deaths resulting from respiratory failure. There is no cure of this illness with some evidence supporting an improved median survival by two to three months with Riluzole (one of the agents used for treatment). Not much is known about the possible etiologies of ALS, a few studies have shown a possible likely association of ALS with various malignancies. Here we present an interesting case of a 35-year-old female with a diagnosis of chronic myeloid leukemia for seven years presented with a sub-acute decline in her motor function.
American Journal of Medical Case Reports. 2019, 7(10), 230-235. DOI: 10.12691/ajmcr-7-10-3
Pub. Date: July 31, 2019
11048 Views1481 Downloads
by David Bassilly, Michael Figart, Krithika Suresh, Mohamed Saad Eldin and Samuel Massoud
Case Report
The most recognizable features of hyperthyroidism are those that result from the effects of triiodothyronine (T3) on the heart and cardiovascular system: decreased systemic vascular resistance and increased resting heart rate, left ventricular contractility, blood volume, and cardiac output. Although these measures of cardiac performance are enhanced in hyperthyroidism, the finding of clinical cardiac failure can be somewhat paradoxical. About 6% of thyrotoxic individuals develop symptoms of heart failure, but less than 1% develop dilated -cardiomyopathy with impaired left ventricular systolic function. Heart failure resulting from thyrotoxicosis is due to a tachycardia-mediated mechanism leading to an increased level of cytosolic calcium during diastole with reduced ventricular contractility and diastolic dysfunction, often with tricuspid regurgitation. Pulmonary artery hypertension in thyrotoxicosis is gaining awareness as a cause of isolated right-sided heart failure. In both cases, older individuals are more likely to be affected. Treatment needs to be directed at management of the acute cardiovascular complications, control of the heart rate, and thyroid-specific therapy to restore a euthyroid state that will lead to resolution of the signs and symptoms of heart failure.
American Journal of Medical Case Reports. 2019, 7(10), 228-229. DOI: 10.12691/ajmcr-7-10-2
Pub. Date: July 26, 2019
7565 Views1384 Downloads
by Tariq Sharman and Jeffrey Song
Case Report
Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals. Chylothorax refers to the presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct or one of its main tributaries. Chylothorax is classified as non-traumatic or traumatic. Non-traumatic chylothorax is mainly caused by malignant etiologies accounting for more than 50% of chylothorax diagnoses. Lymphoma is the most common etiology. Chyloperitoneum is the extravasation of milky chyle rich in triglycerides into the peritoneal cavity, which can occur as a result of trauma or obstruction of the lymphatic system. Chylous ascites is an uncommon finding that can be caused by malignancy, cirrhosis and lymphatic disruption after abdominal surgery. The combination of chyloperitoneum and chylothorax is rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. The Patient is an 82 year old Caucasian male who presented with worsening shortness of breath and abdominal distension. Chest X-ray showed moderate left sided pleural effusion. Bedside ultrasound-guided paracentesis and thoracentesis revealed milky ascetic and pleural fluid respectively. Triglyceride level was 271 mg/dl in the ascetic fluid, and 221 mg/dl in the pleural fluid. Pleural fluid was exudative with lymphocytic predominant cell count and negative cytology. Lymph node biopsy confirmed Non-Hodgkin’s Lymphoma causing the concurrent chylothorax and chyloperitoneum.
American Journal of Medical Case Reports. 2019, 7(10), 223-227. DOI: 10.12691/ajmcr-7-10-1
Pub. Date: July 24, 2019
7931 Views1552 Downloads2 Likes