by Philip Tulio, Randol Kennedy, Ryan Choudhury and Jehad Azar
Case Report
May-Thurner syndrome (MTS) remains an underdiagnosed cause of venous thromboembolism (VTE) because most individuals with MTS anatomy are asymptomatic. The most common variant of MTS is due to compression of the left iliac vein between the overlying right common iliac artery and the fifth lumbar vertebrae. Clinical features include chronic venous hypertension that usually presents as lower extremity pain and swelling. Acute VTE almost exclusively affects the left lower extremity. In cases of acute VTE of an unknown etiology, MTS should be considered when other more common pathologies have been ruled out. A 65-year-old African American gentleman with past medical history of hypertension and coronary artery disease presented with left lower extremity pain and swelling of the leg for five days. He had no history of leg trauma, recent surgery, bed rest, travel, malignancy, previous clotting episodes or family history of hypercoagulable disorders. Patient regularly ambulates. He is a lifetime non-smoker and does not take any medication. His left lower extremity was swollen from the calf down to the ankle and foot, tense, erythematous and tender to palpation. Dorsalis pedis and posterior tibial pulses were weakly palpable. Homan’s sign was appreciated while the rest of the physical exam was unremarkable. Duplex ultrasound of the left lower extremity showed thrombi in the left popliteal, posterior tibial and peroneal veins. CT abdomen and pelvis with IV contrast demonstrated significant compression of the left common iliac vein as it crosses posterior to the left internal iliac artery, consistent with MTS. Spiral chest CT was significant for subsegmental emboli in the bilateral lobe pulmonary arteries. Patient was started on anticoagulation, then he was referred to an advanced vascular center to consider the need for angioplasty and stenting and for possible thrombolysis. MTS was first described in 1908 by Virchow, who observed that iliofemoral vein thrombosis was five times more likely to occur in the left leg than in the right leg. May and Thurner discovered an anatomical variant where the right iliac artery compressed the left iliac vein against the fifth lumbar vertebra. Clinicians should have a high index of suspicion for MTS in the presence of unprovoked DVT in the left lower extremity, and/or signs of chronic venous hypertension. Angioplasty and stenting of the affected lesion is the definitive treatment for MTS, while anticoagulation management is similar to patients with provoked VTE. Therefore, it can be argued that in patients with an unexplained cause of VTE, investigation for MTS if clinically suspected can impact management decisions.
American Journal of Medical Case Reports. 2020, 8(1), 26-30. DOI: 10.12691/ajmcr-8-1-7
Pub. Date: December 02, 2019
9446 Views1078 Downloads1 Likes
by Bader Madoukh, Ayman Battisha, Henry Ukwu, Mohammed Al-Sadawi and Shakil Shaikh
Review Article
The association between atrial fibrillation and stroke is well-known by use of the CHA2DS2VASc risk assessment. However, little is known about the thromboembolic risk in patients who have isolated systolic heart failure (HF) with sinus rhythm. Despite growing literature which shows how HF in the setting of normal sinus rhythm is a risk factor for thromboembolic disease, the recommendation for use of anticoagulation, whether warfarin or direct oral anticoagulation (DOAC) in this setting, is not yet reflected in cardiology guidelines. To reduce the risk of thromboembolism, anticoagulation trials have been done but have not conclusively shown benefit over risk. We present a case of left middle cerebral artery (MCA) stroke after de novo HF in a patient with sinus rhythm, who was previously not on anticoagulation. Case: A 57-year-old male presented to our hospital with worsening shortness of breath for 3 days. He had signs of hypervolemia consistent with an acute heart failure exacerbation. Pertinent physical exam findings included lower extremity edema, rales, and jugular venous distension. He also had fatigue and exertional dyspnea. During his hospital course, he underwent imaging studies that revealed cardiomegaly, absence of pulmonary embolism, and a severely reduced ejection fraction. During his acute heart failure admission, he developed a left MCA stroke suspected to be of cardioembolic etiology and was successfully treated with tissue plasminogen activator (tPA). Conclusion: According to the most recent AHA/ACC cardiovascular disease guidelines, anticoagulation is not indicated in systolic heart failure patients with sinus rhythm. However, our case is rare because the patient had no underlying risk factors for thromboembolism and significant past medical history. He developed new-onset nonischemic cardiomyopathy complicated by a stroke. Therefore, we suggest the need for prophylactic anticoagulation should be assessed on an individual basis, with the assistance of shared decision making, especially when the ejection fraction is acutely and severely reduced.
American Journal of Medical Case Reports. 2020, 8(1), 22-25. DOI: 10.12691/ajmcr-8-1-6
Pub. Date: November 24, 2019
8516 Views1274 Downloads3 Likes
by Peter Rafferty
Case Report
Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare and fatal spongiform encephalopathy characterized by rapidly progressive dementia and myoclonus. The rarity of this disease and its variable initial presentation make early diagnosis fairly challenging, especially considering it is a diagnosis of exclusion. We present a case of a patient initially admitted for sudden onset of confusion, memory loss, dysmetria, and ataxia after a recent diagnosis of Waldenstrom’s Macroglobulinemia. Within four weeks, after work-up for suspected Bing-Neel syndrome and failure to respond to appropriate symptomatic treatment, acute deterioration of mental status, akinetic mutism, and myoclonus were evident & Cerebrospinal fluid (CSF) analysis was positive for protein 14-3-3. Brain magnetic resonance imaging (MRI) showed hyperintensities in the cortex and basal ganglia in diffusion-weighted imaging (DWI). The probable diagnosis of sCJD was reached based on the patient’s unresponsiveness to treatment, clinical features, characteristic findings on MRI, as well as positive 14-3-3 CSF assay.
American Journal of Medical Case Reports. 2020, 8(1), 18-21. DOI: 10.12691/ajmcr-8-1-5
Pub. Date: November 29, 2019
5038 Views625 Downloads
by Shahed- Morshed, Hasanat MA, Fariduddin Md, Nusrat- Sultana, Mahmood T, Ghani MH, Faisal I and Sharmin- Jahan
Case Report
We describe a 65-year-old male of Graves¡¯ disease with thyroid-associated orbitopathy who developed thrombocytopenia during the course of illness. Clinical features, temporal relationship with drugs and investigations supported the diagnosis of immune thrombocytoenic purpura. Several immunosuppressive drugs failed to improve thrombocytopenia. At last platelet count returned back to normal and remained stable with addition of dapsone and restoration of euthyroidism.
American Journal of Medical Case Reports. 2020, 8(1), 14-17. DOI: 10.12691/ajmcr-8-1-4
Pub. Date: November 18, 2019
7378 Views1122 Downloads
by Derek J. Estes, Winnie Szeto, Michael Kingsley, Julio Cesar Poveda, Thiago Beduschi and Amar R. Deshpande
Case Report
Drug-induced autoimmune hepatitis (DI-AIH) is a poorly defined, underreported liver disorder. This report describes a rare case of anti-TNF DI-AIH in a patient with Crohn’s disease resulting in acute liver failure requiring orthotopic liver transplantation in which a novel technique of leveraging a delayed abdominal fascial closure to perform ileocolonic anastomotic revision was used.
American Journal of Medical Case Reports. 2020, 8(1), 11-13. DOI: 10.12691/ajmcr-8-1-3
Pub. Date: November 14, 2019
6070 Views1091 Downloads
by Tariq Sharman, Jeffrey Song, Misam Zawit and Una Ijeoma-Nchinda
Case Report
Angiotensin-converting enzyme (ACE) inhibitors are amongst the commonest prescribed medications in the United States and considered to be the leading causes of drug induced angioedema. High bradykinin levels stimulate vasodilation and increased vascular permeability of the post-capillary venules and allow for plasma extravasation into the submucosal tissue, leading to angioedema. Usually, the angioedema occurs within the first week of exposure to therapy, but cases occurring after years of stable ACE inhibitor usage are not uncommon. Here, we present a 43-year-old Caucasian female who developed acute respiratory failure requiring mechanical ventilation secondary to ACEi–induced angioedema after five years of Lisinopril usage. This case will help to increase physicians’ awareness that this potentially fatal complication can still occur after years of ACE inhibitor usage.
American Journal of Medical Case Reports. 2020, 8(1), 8-10. DOI: 10.12691/ajmcr-8-1-2
Pub. Date: November 12, 2019
2014 Views701 Downloads1 Likes
by Abhimanyu Amarnani, Perry Wengrofsky, Cindy L. Tsui, Pramod Theetha Kariyanna, Naureen Kabani, Louis Salciccioli and Isabel M. McFarlane
American Journal of Medical Case Reports. 2020, 8(1), 1-7. DOI: 10.12691/ajmcr-8-1-1
Pub. Date: November 05, 2019
6392 Views1204 Downloads