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Volume 8, Issue 7

Marijuana-induced Coronary Vasospasm and Myocardial Infarction: A Case Report and Review of Literature
Original Research
The usage of marijuana and its legalization has been growing rapidly, being abused by a wide range of age groups. Its effects on the heart are well known, but coronary artery vasospasm causing ST elevation myocardial infarction (STEMI) from Marijuana alone is rather lesser known. Herein, we report a case of a middle aged African American man with a significant tobacco smoking history who presented with chest pain typical of myocardial infarction (MI) soon after smoking marijuana. ECG showed ST elevation in inferior leads with first degree AV block and a urine drug screen positive only for marijuana. Coronary angiogram showed mid right coronary artery (RCA) obstruction which was relieved upon injection of intracoronary nitroglycerine. This case report reinstates the significance of considering substance abuse as an etiology of STEMI during initial presentation, ruling out with urine drug samples. We also present a literature review of coronary vasospasm with STEMI, induced specifically by Marijuana and its pathophysiologic mechanisms.
American Journal of Medical Case Reports. 2020, 8(7), 216-220. DOI: 10.12691/ajmcr-8-7-14
Pub. Date: April 25, 2020
4663 Views911 Downloads
Extrapulmonary Involvement in Sarcoidosis: A Case Report
Case Report
Sarcoidosis is an idiopathic multisystem granulomatous disease that affects patients of all races and ethnic groups however predilection for women and African Americans is apparent. Extrapulmonary manifestations of sarcoidosis occur in up to 50% of cases. The most common sites of extrapulmonary involvement are the skin, eyes, liver, and reticuloendothelial system followed bt renal, cardiac, and neurological involvement. We present the case of a middle age man with exclusive extrapulmonary sarcoidosis affecting the renal, cardiac, hepatic, splenic and central nervous system. The patient sustained a second episode of venous thromboembolism which highlights a frequently seen complication of sarcoidosis. We discuss the proposed pathophysiology for the prothrombotic state seen in sarcoidosis and imaging modalities that can be utilized to assess extrapulmonary involvement in sarcoidosis. Lastly, sarcoidosis management is reviewed, highlighting that immunosuppressants and tumor necrosis factor inhibitors are being proposed to arrest disease progression and reduce glucocorticoid doses.
American Journal of Medical Case Reports. 2020, 8(7), 210-215. DOI: 10.12691/ajmcr-8-7-13
Pub. Date: April 25, 2020
4828 Views713 Downloads
Low-dose Methotrexate Toxicity in the Setting of Vancomycin-induced Acute Kidney Injury
Original Research
Methotrexate is a disease-modifying anti rheumatic drug (DMARD) that is often used in low dosages as the first line drug for rheumatoid arthritis patients. The chemotherapeutic agent works by inhibiting dihydrofolate reductase, and the primary route of clearance of the drug is via the kidneys. Kidney injury may delay this clearance and lead to toxic level accumulation of the drug- toxicity presenting as diarrhea, vomiting, mucositis, rash, transaminitis and myelosuppression. Antibiotics such as vancomycin may induce acute kidney injury (AKI) through various mechanisms include damage to the renal tubular epithelial cells. In this report, we describe a case in which an elderly female suffered AKI secondary to vancomycin induced nephrotoxicity. The AKI subsequently led to methotrexate accumulation and toxicity presenting as bleeding mouth ulcers, transaminitis and pancytopenia. The condition was managed with leucovorin rescue therapy and sodium bicarbonate to enhance methotrexate excretion. Renally dosing methotrexate in patients on other nephrotoxic drugs, and monitoring creatinine clearance are methods for preventing such a toxicity.
American Journal of Medical Case Reports. 2020, 8(7), 206-209. DOI: 10.12691/ajmcr-8-7-12
Pub. Date: April 25, 2020
3715 Views776 Downloads
Concurrent Anaplastic and Papillary Thyroid Carcinomas: A Case Report
Case Report
Anaplastic thyroid cancer (ATC) is a rare, but extremely aggressive, form of cancer with a high mortality rate. Differentiated thyroid cancer (DTC), on the other hand, including papillary and follicular subtypes, are relatively common and typically follows a more indolent course. Cases have been reported in which ATC transforms from DTC, and where DTC and ATC exist simultaneously. Given the low incidence of such cases, they have not been well studied, and the optimal treatment regimen has yet to be determined. We present a case of a 77-year-old woman who was initially presented with papillary thyroid cancer (PTC) with focal ATC. Five months after undergoing total thyroidectomy, she returned with a new right sided neck mass. Fine needle aspiration (FNA) with biopsies of the mass and lymph node at one level revealed a smear pattern consistent with ATC. However, lymph node biopsy taken from a different level revealed a smear pattern consistent with PTC. Mutation analysis was performed and results were positive for metastatic BRAF V600- mutant ATC. The patient was then started on dabrafenib/trametinib chemotherapy. Seven months later, she was tolerating treatment well. These unique clinical features including the initial presentation and the relatively favorable survival, that is more than double that of the median survival rate for ATC, suggests that those with synchronous PTC and ATC may have a more indolent course with better prognosis than those with ATC alone. It is also possible that the relatively longer survival in our patient is due to the use of the BRAF inhibitor, dabrafenib and the MEK inhibitor, trametinib in this case with concurrent ATC and PTC. While patients with both PTC and ATC have been documented to have mutations in the BRAF V600 gene, the objective of this report is to present the relatively favorable outcomes when a therapeutic regimen is guided by mutation analysis. Future research into advanced treatment options including targeted therapy and /or immunotherapy for both DTC and ATC is needed. Somatic mutation testing may also be helpful to identify oncogenic kinase abnormalities that will inform therapeutic decision making.
American Journal of Medical Case Reports. 2020, 8(7), 202-205. DOI: 10.12691/ajmcr-8-7-11
Pub. Date: April 22, 2020
3850 Views748 Downloads
Large Left Atrial Thrombus on Amplatzer Septal Occluder Secondary to Medication Nonadherence
Case Report
Patent foramen ovale (PFO) is a common clinical entity that is encountered in 20-34% of the general population. In most individuals, this anatomical variation is asymptomatic and goes undetected throughout their lives or is only incidentally discovered on cardiac investigations. In situations when the conduit is large enough and when the right atrial pressure exceeds the left atrial pressure, right to left interatrial flow may occur in these individuals. This creates a channel for translocation of air or thrombi from the venous to the arterial circulation, a phenomenon known as paradoxical embolism. Approximately 25-40% of strokes and transient ischemic attacks in patients less than 60 years of age are classified as cryptogenic and studies have identified a higher prevalence (60%) of PFO in young adults with strokes of unidentifiable etiology. Recent trials have demonstrated utility of PFO closure with mechanical devices for secondary prevention of recurrent strokes in patients aged <60 years of age. The general consensus of post-operative management of PFO closure has been largely drawn from randomized controlled trials and comprises use of aspirin and clopidogrel for 6 months followed by use of aspirin alone for at least 5 years. We present a case of an incidentally discovered left intra-atrial thrombus attached to a PFO closure device in a 36-year-old female with a history of cryptogenic stroke three months after implantation.
American Journal of Medical Case Reports. 2020, 8(7), 197-201. DOI: 10.12691/ajmcr-8-7-10
Pub. Date: April 22, 2020
1311 Views557 Downloads
Pharmaco-invasive Therapy for STEMI in a Patient with COVID-19: A Case Report
Case Report
Coronavirus disease 2019 (COVID-19) is a pandemic that started in the Wuhan province of China in December 2019. It is associated with increased morbidity and mortality mainly due to severe acute respiratory syndrome 2 (SARS-Cov-2). Cardiac manifestations related to COVID-19 include demand ischemia, fulminant myocarditis, myocardial infarction and arrhythmias. In this report, we present a case of ST-segment elevation myocardial infarction (STEMI) in a 68-year-old man with COVID-19 who initially presented with chest pain and shortness of breath. Patient's STEMI was managed with pharmaco-invasive strategy with tissue plasminogen activator (t-PA). He then developed acute hypoxic respiratory failure that was managed in the intensive care unit (ICU), together with multi-organ failure from which the patient died 2 days after presentation. Although the pathophysiologic mechanisms of STEMI in COVID-19 patients has not been clearly established, we hypothesize that interrelated pathogenetic factors, that we highlight in this report, can play a role in the development of STEMI, including plaque rupture secondary to systemic inflammation, increased pro-coagulants, endothelial dysfunction, impaired fibrinolysis and impaired oxygen utilization leading to demand/ supply mismatch and myocardial ischemia.
American Journal of Medical Case Reports. 2020, 8(7), 192-196. DOI: 10.12691/ajmcr-8-7-9
Pub. Date: April 22, 2020
4186 Views638 Downloads
Dyshidrotic Eczema Associated with Contraceptive Tubal Occlusion Device
Case Report
Nickel-related hypersensitivity reactions associated with the Essure micro-insert (Contraceptive Tubal Occlusion Device and Delivery System) are extremely rare, with only four reports in the current literature. We present a case of a 37-year-old woman who presented to our clinic for initial dermatologic evaluation of dermatitis localized to both hands three years after device placement. A diagnosis of dyshidrotic eczema, classically associated with systemic nickel exposure, was made after careful clinical and histopathologic evaluation. The micro-insert contraceptive device was suspected as the cause given our patient’s self-reported history of nickel allergy, which was further supported by positive patch test results. Currently, our patient has seen significant improvement in her condition with topical steroids and occasional intralesional steroid injections. This case represents a diagnostic challenge given the presentation of a seemingly localized dermatitis secondary to systemic nickel exposure from a distant source. In addition, the delayed development of our patient’s rash posed a clinical challenge in drawing a causal relationship between device placement and her allergic reaction. Practitioners should be cognizant of eliciting a history of implanted devices (plates, screws, implants, endovascular prostheses etc.) for all patients, even if the allergic reaction is seemingly localized such as dyshidrotic eczema.
American Journal of Medical Case Reports. 2020, 8(7), 189-191. DOI: 10.12691/ajmcr-8-7-8
Pub. Date: April 19, 2020
1041 Views421 Downloads
A Case of Invasive Mucinous Adenocarcinoma of the Appendix
Case Report
Background: Although mucinous neoplasms are primarily found within the colon, there are rare instances in which these tumors arise from within the appendix. The appendix is a small blind pouch located at the beginning of the large colon. The incidence of primary appendicular mucoceles found in appendectomies is a rare occurrence, common in those over 50. These tumors often present with the symptoms of appendicitis. Of the appendiceal tumors, invasive mucinous appendicular carcinoma is rare subtype. If improperly managed, this malignancy may present with adverse tumor burden outcomes upon local invasion. Case Presentation: An 83-year-old male with a past medical history of GERD and hyperlipidemia presented with clinical symptoms of appendicitis. CT imaging of the abdomen was consistent with a distended appendix, also consistent with appendicitis. However, upon excision of the appendix, pathology revealed a rare occurrence of primary mucinous adenocarcinoma of the appendix. Conclusion: We present a case of primary mucinous adenocarcinoma of the appendix successfully managed with urgent surgical removal. Given the vague presentation of mucinous adenocarcinoma of the appendix prior to appendiceal rupture and local metastasis, this case demonstrates the importance of a surgical approach regarding appendicitis in the elderly population, rather than medical treatment.
American Journal of Medical Case Reports. 2020, 8(7), 187-188. DOI: 10.12691/ajmcr-8-7-7
Pub. Date: April 17, 2020
3729 Views509 Downloads1 Likes
Unusual Case of Acute Pulmonary Edema as a Manifestation of Postpartum Preeclampsia: A Case Report
Case Report
Background: Hypertensive disease of pregnancy remains a leading cause of maternal morbidity and mortality. Four subcategories of hypertensive disorders of pregnancy are recognized by the international society for the study of hypertension in pregnancy: chronic hypertension; gestational hypertension, pre-eclampsia, & white coat hypertension. Pre-eclampsia is defined as systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 on two occasions at least 4 hours apart after 20 weeks of gestation with accompanying signs of end organ damage in a woman with previously normal blood pressure. The majority of cases present ante-partum or immediately post-partum. I review the case of a woman diagnosed with pre-eclampsia at 2 weeks post-partum. Case presentation: A 38-year-old woman presented with increasing dyspnea, orthopnea, intermittent palpitations, and central chest pain 2 weeks after an uncomplicated vaginal delivery. On arrival, she was hypertensive at 168/117, spO2 of 100% on BiPAP. Exam was notable for diffuse rales, a regular rhythm, no JVD, and 1+ peripheral edema. Urine was positive for hemoglobin and protein and the liver panel revealed transaminitis (AST=50 ALT=53), Chest X-ray demonstrated increased pulmonary vasculature congestion, confirmed on CT angiography which was negative for venous thromboembolism. Echocardiography found a preserved ejection fraction without diastolic dysfunction or valvular abnormalities. She was managed with a nitroglycerin infusion and parenteral diuresis with resolution of her pulmonary edema. Conclusion: Pre-eclampsia affects 4-9% of all pregnancies and confers a high risk for both fetal and maternal morbidity and mortality. The definitive treatment for preeclampsia is delivery of fetus and placenta but there is limited information to guide the management of post-partum pre-eclampsia. It has been hypothesized that activation of maternal platelets in the placental bed play a role in preeclampsia through activation of inflammasomes such as sFlt-1. Yes, further research is needed to explore the benefit of suppressing these inflammasomes. Although peri-partum cardiomyopathy and venous thromboembolism usually come to mind in women with cardio-pulmonary complaints post-partum. In the appropriate setting, post-partum pre-eclampsia should also be entertained in the differential.
American Journal of Medical Case Reports. 2020, 8(7), 185-186. DOI: 10.12691/ajmcr-8-7-6
Pub. Date: April 17, 2020
4389 Views714 Downloads
Isolated Bone Lytic Lesions as a Form of Presentation of Gastric Cancer with Signet Ring Cells
Case Report
Gastric cancer (GC) is still the second most common cause of cancer-related death worldwide. In addition, gastric cancer is the most commonly diagnosed malignancy in Korea, Japan, China, South America and Eastern European nations, with the lowest frequency observed in the United States and Canada. Metastatic gastric cancer is a therapeutic challenge for medical oncologists, especially those with bone marrow metastases. Bone marrow metastases occur in many solid tumors such as breast, lung, prostate and gastric cancer [1]. Our case is about a woman diagnosed of gastric adenocarcinoma with signet ring cells presenting with bone marrow infiltration.
American Journal of Medical Case Reports. 2020, 8(7), 182-184. DOI: 10.12691/ajmcr-8-7-5
Pub. Date: April 16, 2020
1332 Views540 Downloads
Shift From Left to a Right Bundle Block on ECG Leading to the Diagnosis of a Malpositioned Lead in the Coronary Sinus: A Case Report
Case Report
On electrocardiography (ECG), ventricular pacing appears as a spikes that precede induced QRS complexes. The induced complexes with a right ventricular lead have the morphology of a left bundle branch block (LBBB). We describe a case of malposition right ventricular (RV) lead in the coronary sinus diagnosed based on the changes noted in the ECG tracing. An 80-year-old man with a pacemaker implanted for high-grade AV block was found unresponsive. Six minutes of cardiopulmonary resuscitation resulted in return of spontaneous circulation. The ECG demonstrated a new paced right bundle branch block (RBBB) pattern. Chest radiography revealed a misplaced right ventricular (RV) lead in the coronary sinus which was confirmed by 2D-echocardiography. The patient’s healthcare proxy (HCP) declined invasive interventions. The patient expired due multiorgan failure secondary to ventilator associated pneumonia. When an RBBB pattern is seen with RV pacing, patients must be evaluated for mispositioning of the RV lead navigation through an atrial septal defect (ASD) or perforation of the ventricular septum, aberrant retrograde conduction, pre-existing right bundle disease and the “pseudo-RBBB” pattern (seen with the ventricular lead placed in the RV apex/distal septum). A frontal axis of 0˚ to 90˚ and precordial transition by lead V3 differentiates RV septal pacing from all forms of LV pacing, including lead placement in the coronary sinus. Our patient had precordial transition at V3.
American Journal of Medical Case Reports. 2020, 8(7), 178-181. DOI: 10.12691/ajmcr-8-7-4
Pub. Date: April 14, 2020
4484 Views688 Downloads
Snorkeling Induced Pulmonary Edema: A Case Report and Review of the Literature
Case Report
Swimming-induced pulmonary edema (SIPE), also called immersion pulmonary edema (IPE), is a medical condition seen in various water-based activities such as scuba diving, swimming, aqua jogging, triathlete competition and snorkeling. It occurs when transcapillary filtration of low protein fluid collects in the lungs, in the absence of water aspiration during an aquatic activity, causing acute dyspnea, cough and/or hemoptysis. The hallmark of this entity is the complete resolution of symptoms within 48 hours. SIPE in snorkeling is an under-reported and understudied subject. The true prevalence of SIPE is unknown with an estimated range from 1.8-60% among combat swimmers trainee and 1.4% in triathletes. Recent developments have been done in elucidating the pathophysiology of SIPE with regards to pulmonary capillary pressure so that the predisposing factors and potential causes can be targeted. SIPE can be a potentially life-threatening condition, which needs to be recognized by the swimmers, divers, supervising physicians in order to diagnose and manage it promptly. We report a rare case of SIPE in snorkeling which presented with acute respiratory symptoms and managed with supportive measures in the hospital.
American Journal of Medical Case Reports. 2020, 8(7), 173-177. DOI: 10.12691/ajmcr-8-7-3
Pub. Date: April 14, 2020
4904 Views714 Downloads
Myocardial Infarction as the Initial Presentation for Fibromuscular Dysplasia
Case Report
Background: Fibromuscular dysplasia (FMD) is a non-atherosclerotic disease that affects medium-sized arteries and results in stenosis, dissection, aneurysm or occlusion. It is most commonly reported in the renal and carotid arteries. Involvement of coronary arteries is quite rare and and leads to serious consequences. Case: A 62-year-old African American woman with a history of mitral valve prolapse presented with chest discomfort associated with diaphoresis. Her EKG initially showed ST segment changes in leads II, III, and V2-V5 which resolved in approximately 30 minutes. Her troponin peaked to 20 ng/L during her hospital course. A bedside echocardiogram revealed an EF of 45% with mid, distal septal and apical hypokinesis. Decision-making: The patient was admitted to the Cardiac Care Unit for treatment of an NSTEMI. She underwent cardiac catheterization, which revealed single-vessel coronary disease with diffuse narrowing of the distal LAD, beyond the first diagonal branch down to the apex. CT angiography of her abdomen and pelvis showed mild narrowing of the mid-right renal artery with a small fusiform aneurysm measuring approximately 5 mm. Her carotid duplex showed tortuosity in the right internal carotid artery. Given the multiple vascular anomalies, a diagnosis of fibromuscular dysplasia was considered. Conclusion: Acute coronary syndrome in fibromuscular dysplasia requires an integrated approach to management, especially if there is associated malignant hypertension and/or dissection.
American Journal of Medical Case Reports. 2020, 8(7), 166-172. DOI: 10.12691/ajmcr-8-7-2
Pub. Date: April 12, 2020
4962 Views716 Downloads
Pulmonary Sarcomatoid Giant Cell Carcinoma with Paraneoplastic Hypertrophic Osteoarthropathy: A Case Report
Case Report
Giant-cell carcinoma of the lung (GCCL) is a rare histological form of poorly differentiated non-small-cell lung cancer, which is classified as a subtype of pulmonary sarcomatoid carcinomas. In this case report, we describe the case of a 57 year old female with a past medical history of HIV on HAART (CD4 count at the time was 621 cell/µl) .She presented to the hospital with a two months history of productive cough with yellowish sputum containing streaks of blood, twelve pound weight loss, bilateral hand swelling, and knee pain with noticeable finger clubbing on physical examination. Chest computed tomography scan and subsequent bronchoscopy was performed and revealed a protruding endobronchial lesion in the right upper lobe (RUL) bronchus. Definitive diagnosis established by way of pathologic analysis of the resected specimen obtained from RUL lobectomy revealed sarcomatoid giant cell carcinoma, with tumor size 9.5 cm and invasion of the visceral pleura and 1/13 hilar lymph node involvement. The pathological stage was determined as pT3N1Mx based on the tumor node metastasis (TNM) staging system. The patient was started on adjuvant combination cisplatin and docetaxel therapy with supplemental G-CSF four months after surgery and followed as an outpatient. The significance of this case is that it highlights a very rare lung cancer, unveiling a possible paraneoplastic syndrome associated with this malignancy and the impact of HIV HAART therapy in carcinogenesis.
American Journal of Medical Case Reports. 2020, 8(7), 162-165. DOI: 10.12691/ajmcr-8-7-1
Pub. Date: April 12, 2020
4206 Views693 Downloads