by Kurnvir Singh, Mohammed Al-Sadawi, Romy Rodriguez Ortega, Khaleda Akter, Tomasz Zrodlowski, Claudia Zmijewski and Isabel M. McFarlane
Case Report
Background: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that primarily affects synovial joints. Approximately 18-41% of patients with RA develop extra-articular manifestations [1]. However, extra-articular manifestations preceding or occurring without articular symptoms in RA have rarely been reported. Such atypical presentations of RA pose a diagnostic challenge to the clinician and may delay treatment. Case presentation: A 57-year-old female with long standing diabetes, hypertension, hyperlipidemia and Raynaud’s phenomenon presented shortness of breath, cough and new subcutaneous nodules. Four years before, she had been diagnosed with non specific interstitial pneumonia but had declined treatment. The physical exam did not reveal any signs suggestive of RA however, she was seropositive for rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA). Treatment for RA-associated interstitial lung disease was discussed. Conclusion: Extra-articular involvement of RA can be observed as initial presentation of the disease in a handful of cases. However, RA diagnosis must be achieved to correctly manage these patients which can at that time receive targeted therapeutic interventions. From our literature review, pulmonary involvement was seen in over half of the cases in seropositive RA patients who lacked articular involvement at initial presentation.
American Journal of Medical Case Reports. 2019, 7(12), 342-347. DOI: 10.12691/ajmcr-7-12-10
Pub. Date: October 28, 2019
7805 Views1768 Downloads
by Pramod Theetha Kariyanna, Syed Haseeb, Yuvraj Singh Chowdhury, Apoorva Jayarangaiah, Andrii Maryniak, George Mo, Sudhanva Hegde, Jonathan D. Marmur and Isabel. M. McFarlane
Original Research
Ever since evidence about the increased risk of stent thrombosis with drug eluting stents (DES) surfaced in 2005, the Food and Drug Administration (FDA) has recommended the use of dual antiplatelet therapy (aspirin with P2Y12 inhibitor) following DES placement. The PLATO trial demonstrated lower mortality rates with the use of Ticagrelor when compared to clopidogrel (9.8% vs. 11.7%, p<0.001) when treating patients with acute coronary syndrome. Given their pleiotropic benefits, statins are today the second most prescribed drug in the United States and often co-prescribed with Ticagrelor. FDA’s post market surveillance of Ticagrelor use along with statins in post-myocardial infarction care is now revealing novel and serious adverse events. We present two cases of rhabdomyolysis and acute renal failure (ARF) which develop while the patients were on statins and Ticagrelor. Case 1: A 66-year-old female presented with bilateral thigh pain for 3 days. One month prior to presentation, she was managed for non-ST segment elevation myocardial infarction (NSTEMI) and had been started on aspirin, ticagrelor and simvastatin. Laboratory values revealed creatinine kinase (CK) level at 40,000 U/L and creatinine 3.2 mg/dL suggesting rhabdomyolysis and ARF. Case 2: A 63-year-old male presented with generalized body aches and fatigue for 4 days. He had sustained STEMI two months before and received two drug eluting stents (DES) and aspirin, ticagrelor and rosuvastatin had been initiated. CK was 380,000 U/L and creatinine 7.94 mg/dL suggesting rhabdomyolysis and ARF. Both patients presented with rhabdomyolysis and acute renal failure within weeks after ticagrelor and statin were commenced. A review of the literature indicated that 11 similar cases of ticagrelor-induced ARF and rhabdomyolysis had been reported. Ticagrelor competes with statins when metabolized by cytochrome P450 (CYP) 3A4 leading to statin retention, leading to major adverse effects like rhabdomyolysis and acute renal failure. Our review is intended to alert clinicians about this important drug interaction.
American Journal of Medical Case Reports. 2019, 7(12), 337-341. DOI: 10.12691/ajmcr-7-12-9
Pub. Date: October 18, 2019
8261 Views2052 Downloads
by Aisha Siraj and Negar Salehi
Case Report
Tuberous sclerosis complex (TSC) is a rare, autosomal dominant disease, associated with mutations in either the TSC gene. The incidence of TSC is estimated as 1 in 5,000-10,000 live births and angiomyolipomas (AML) is one of the characteristic findings of tuberous sclerosis. A 36-year-old Caucasian female admitted to the hospital after two episodes of pre-syncope in March 2016. The patient was tachycardic on examination, and laboratory studies revealed acute anemia with hemoglobin of 8.2 g/dL on admission with a decrease to a nadir of 6.2 g/dL. Imaging studies revealed bilateral fat-rich renal masses with distortion of the renal anatomy consistent with angiomyolipomas (AML). Further as a part of treatment embolization of the right renal artery was performed. However, everolimus is also approved for the treatment of AMLs not requiring surgery. Each patient should have an individualized treatment plan based on the clinical situation as determined by the physician.
American Journal of Medical Case Reports. 2019, 7(12), 334-336. DOI: 10.12691/ajmcr-7-12-8
Pub. Date: October 08, 2019
6631 Views847 Downloads1 Likes
by Philip Lee, Filip Oleszak, Aditya Nihalani, Vinodkumar Velayudhan and Isabel M. McFarlane
Original Research
Background: Urinary tract infections (UTI) have been found to be associated with a variety of neuropsychiatric disorders, and could play a role in the pathophysiology of relapse of affective and nonaffective psychosis. In addition, prior history of infarction in areas of the brain such as the cerebellum, basal ganglia, and mid-brain have been reported in patients with new onset psychotic symptoms. Case presentation: A 29-year-old woman was brought to the hospital with acute mental status changes and signs of sepsis. Infectious work-up was initiated including blood cultures, brain imaging, lumbar tap and urinalysis. Brain MRI revealed abnormalities in the basal ganglia and the urinalysis revealed signs of a urinary tract infection (UTI). Further history revealed episodes of mania and depression compatible with bipolar disorder with psychotic features that had acutely worsened. The patient’s condition improved with intravenous antibiotics and the introduction of anti-psychotics. She was discharged in stable condition with outpatient psychiatric follow-up. Conclusion: Infectious diseases (UTIs in particular) are not only more prevalent among patients with acute relapse of psychiatric disorders, but have also been found to have triggered acute psychosis among stable psychiatric patients. Organic brain lesions must be thoroughly investigated among patients presenting with new psychiatric disorders in order to initiate appropriate therapy to control the symptoms.
American Journal of Medical Case Reports. 2019, 7(12), 329-333. DOI: 10.12691/ajmcr-7-12-7
Pub. Date: October 08, 2019
9782 Views1353 Downloads
by Dennis Miraglia, Lourdes A. Miguel and Wilfredo Alonso
Original Research
The incidence of out-of-hospital cardiac arrest (OHCA) reported from the Resuscitation Outcomes Consortium (ROC) and the CARES registry in 2016 suggests that 110.8 individuals per 100,000 population or 347,000 adults annually suffer from OHCA in the United States (US); likewise, the incidence of in-hospital cardiac arrest (IHCA) reported by Get With The Guidelines-Resuscitation (GWTG-R) suggests that each year, 209,000 people are treated for IHCA. Double sequential defibrillation (DSD) has been proposed as an alternative treatment for refractory ventricular fibrillation (VF) as there appears to be a trend of promising outcomes, including termination of refractory VF, sustained ROSC, increased short term survival and favorable outcomes to hospital discharge. We report a case of prolonged resuscitation of an 72-year-old man who developed pulseless ventricular tachycardia (pVT) that progressed to refractory VF terminated by DSD. In addition, we provide a quick reference that summarizes the characteristics and resuscitative parameters of the reported case.
American Journal of Medical Case Reports. 2019, 7(12), 325-328. DOI: 10.12691/ajmcr-7-12-6
Pub. Date: September 23, 2019
6306 Views2486 Downloads
by Mohammed Al-Sadawi, Bader Madoukh, Ayman Battisha, Shakil Shaikh, Jonathan Marmur, Fadi Yacoub and Samy I. McFarlane
Case Report
Atrial septal defect (ASD) is a risk factor for multiple vascular thrombotic events, which can occur either sequentially or simultaneously. In this report we present a case of ST-elevation myocardial infarction (STEMI) and cerebrovascular accident (CVA). The severity of adverse cardiovascular or cerebrovascular events can be increased by the presence of specific type of ASD, such as a patent foramen ovale (PFO) or osteum secundum defect. This case report discusses a unique presentation of a 48-year old male on warfarin therapy for a history of cerebral venous thrombosis (CVT) who subsequently presented with simultaneous STEMI with CVA, and who was incidentally found to have an ostium secundum defect on echocardiography. He was emergently taken for cardiac catheterization, which revealed significant proximal LAD occlusion. There has been a long standing debate within the international scientific communities regarding the therapeutic benefit of PFO closure for long-term secondary prevention of recurrence CVA. We discuss the different points of view regarding PFO closure for secondary prevention of CVA with a review of the literature on this rather controversial topic.
American Journal of Medical Case Reports. 2019, 7(12), 320-324. DOI: 10.12691/ajmcr-7-12-5
Pub. Date: September 22, 2019
8566 Views1604 Downloads
by Alaa El-Kheir, Charif Khaled, Raia Doumit, Chawki Nohra and Antoine Khoneisser
Case Report
Currarino syndrome is a rare congenital disease and its appearance in adulthood is exceptional. It is neglected in the typical differential diagnosis of a presacral mass. This results in severe complications following simple mass resection.
American Journal of Medical Case Reports. 2019, 7(12), 317-319. DOI: 10.12691/ajmcr-7-12-4
Pub. Date: September 20, 2019
6097 Views948 Downloads
by Mohammed Al-Sadawi, Bader Madoukh, Ayman Battisha, Shakil Shaikh, Pramod Theetha Kariyanna, Jonathan Marmur, Tarek S. Abdellateef, Gil Hevroni and Samy I. McFarlane
Case Report
Introduction: Congenital coronary artery anomalies are quite uncommon with estimates ranging from 0.2% to 1.3% on coronary angiography. The rarity of these anomalies makes their diagnosis a formidable challenge. Variable arterial courses have been described. In this report, we present a case with unique arterial course, which starts as a hyperacute take-off of the right coronary artery (RCA) from the left main coronary artery (LMCA), with subsequent coursing, without external compression, between the right ventricular outflow tract and aorta. Our case is relevant to the concept of whether we should keep a reasonable index of suspicion for coronary artery anomalies during cardiac evaluations of patients undergoing non-cardiac surgeries. Clinical case: This is an asymptomatic 47-year-old African American female who presented for cardiac clearance for renal transplantation. She had a past medical history of hypertension, bronchial asthma, and former smoking of 10 years (quitting 15 years prior to presentation). She also has end-stage renal disease on hemodialysis. Cardiac workup revealed left ventricular hypertrophy on EKG, multi-chamber dilation seen on echo, and anomalous RCA course seen on CT coronary angiography. Cardiac catheterization revealed non-obstructive coronary artery disease of the LCX and RCA. After consulting with cardiothoracic surgery, conservative medical management was decided based on the patient’s risk stratification. She was advised to have close monitoring of her condition. Discussion: Coronary artery anomalies represent the second most common cause of sudden cardiac death in young athletes. At this time, the prevalence of right coronary artery (RCA) take off from the left coronary sinus occurs at a percentage of 0.019% to 0.49%. The RCA origination from the left main coronary artery (LMCA) accounts for only 0.65% of these anomalies. Our patient had high-risk anatomy consisting of a hyper-angulated take-off of the RCA from the LMCA as well as course between the pulmonary artery and right ventricular outflow tract (RVOT). CT coronary angiography is the most useful imaging modality that characterizes coronary artery anomalies. Although this patient exhibited no signs or symptoms of cardiorespiratory compromise, she warranted a full cardiac workup preoperatively that incidentally revealed a coronary anomaly. Recognition of this disease is critical for timely prevention of potential complications as well as discussion of goals of care. Guidelines for medical versus surgical management are available, but the management strategy should be individualized, with the highest consideration given to risk-benefit analysis.
American Journal of Medical Case Reports. 2019, 7(12), 311-316. DOI: 10.12691/ajmcr-7-12-3
Pub. Date: September 19, 2019
10745 Views1897 Downloads1 Likes
by Fatma Mnif, Asma Zargni, Dhoha Ben Salah, Mouna Mnif Feki, Nabila Rekik and Mohamed Abid
Case Report
Composite pheochromocytomas are considered rare neoplasms of the adrenal gland. We report a case of composite pheochromocytoma in a 53-year-old woman, with a 4-year medical history of uncontrolled hypertension without hypokalemia and treated with three antihypertensive. A computed tomographic scan was performed, showing the presence of a spontaneously hypodense adrenal mass of 6 x 6 x 3 cm at the expense of the outer arm of the right adrenal gland, and with microcalcifications and a double component. Laboratory studies showed elevated urinary metanephrines. Diagnosis of pheochromocytoma was retained. The patient underwent surgery and pathologic examination concluded the presence of a composite pheochromocytoma.
American Journal of Medical Case Reports. 2019, 7(12), 308-310. DOI: 10.12691/ajmcr-7-12-2
Pub. Date: September 16, 2019
5500 Views988 Downloads
by Mehlika İşcan, İsmail Sarbay, Şebnem Batur and Akif Turna
Case Report
The mediastinum is a rare localization, as it has been reported in a few cases in the literature for hamartoma, which is a benign tumor. The treatment is surgical resection when an image consistent with anterior mediastinum is observed. In addition, thymoma resection may provide remission in Myasthenia Gravis as it is frequently seen with Myasthenia Gravis and Thymoma. In this case, we submitted our case in which we have resected the anterior mediastinal lesion by applying biportal extended VATS thymectomy in the patient of Myasthenia Gravis with pre-diagnosis of thymoma. Remarkably, the pathology of our case was reported as Hamartoma, and the postoperative six-month follow-up has also indicated regression of Myasthenia Gravis disease.
American Journal of Medical Case Reports. 2019, 7(12), 305-307. DOI: 10.12691/ajmcr-7-12-1
Pub. Date: September 15, 2019
6222 Views1094 Downloads