Heart & Lung: The Journal of Acute and Critical Care - Articles in Press

A stepwise progression in the treatment of cardiogenic shock - Corrected Proof

2012-05-18

Abstract: Cardiogenic shock remains a deadly complication of acute myocardial infarction (MI). Early revascularization, inotropic support, and intraaortic balloon counterpulsation are the mainstays of treatment, but these are not always sufficient. New mechanical approaches, both percutaneous and surgical, are available in this high-risk population. We present a case of a young woman with a massive anterior wall MI and subsequent cardiogenic shock who was treated with advanced mechanical circulatory support. This case serves as an illustration of the stepwise escalation of mechanical support that can be applied in a patient with an acute MI complicated by refractory cardiogenic shock. We also review the literature with regard to the use of percutaneous left ventricular assist devices in the setting of cardiogenic shock.

Nurses' strategies to address self-care aspects related to medication adherence and symptom recognition in heart failure patients: An in-depth look - Corrected Proof

Tiny Jaarsma, Mariana Nikolova-Simons, Martje H.L. van der Wal — 2012-04-30

Abstract: Objective: Despite an increasing body of knowledge on self-care in heart failure patients, the need for effective interventions remains. We sought to deepen the understanding of interventions that heart failure nurses use in clinical practice to improve patient adherence to medication and symptom monitoring.Methods: A qualitative study with a directed content analysis was performed, using data from a selected sample of Dutch-speaking heart failure nurses who completed booklets with two vignettes involving medication adherence and symptom recognition.Results: Nurses regularly assess and reassess patients before they decide on an intervention. They evaluate basic/factual information and barriers in a patient's behavior, and try to find room for improvement in a patient's behavior. Interventions that heart failure nurses use to improve adherence to medication and symptom monitoring were grouped into the themes of increasing knowledge, increasing motivation, and providing patients with practical tools. Nurses also described using technology-based tools, increased social support, alternative communication, partnership approaches, and coordination of care to improve adherence to medications and symptom monitoring.Conclusion: Despite a strong focus on educational strategies, nurses also reported other strategies to increase patient adherence. Nurses use several strategies to improve patient adherence that are not incorporated into guidelines. These interventions need to be evaluated for further applications in improving heart failure management

Risk groups and predictors of short-term abstinence from smoking in patients with coronary heart disease - Corrected Proof

2012-04-25

Abstract: Objectives: We sought to identify risk groups among smoking cardiac patients from their social cognitive profiles, and to assess predictors of smoking abstinence shortly after discharge.Methods: Smoking cardiac patients (n = 133) completed questionnaires at hospital admission and 1 month after discharge. Hierarchical cluster analysis was used to detect risk groups of smokers, based on baseline scores for smoking-related social cognitions. Regression analyses were used to identify predictors of the intention to abstain from smoking and smoking abstinence 1 month after discharge.Results: Three groups of smokers were distinguished that differed significantly on the pros of nonsmoking, self-efficacy expectancies toward nonsmoking, social support, social modeling, and smoking behavior. Abstinence from smoking 1 month after discharge was predicted by group membership and a stronger intention to quit. A previous hospital admission because of a cardiac event significantly decreased the likelihood of abstinence.Conclusions: One third of cardiac patients are at high risk of continuing smoking after hospital discharge because of an unfavorable smoking and disease history and a poor social cognitive profile. Interventions for cardiac patients should address risk profiles to achieve long-term abstinence. The implications of nursing practices in smoking cessation treatments are discussed.

Treatment of severe sepsis and septic shock in critically ill patients - Corrected Proof

Silvio A. Ñamendys-Silva, Marisol Hernández-Garay — 2012-04-25

We would like to offer several comments regarding the treatment of severe sepsis and septic shock in critically ill patients. First, guidelines recommend a central venous pressure (CVP) of 8-12 mm Hg or 12-15 mm Hg as the goals of initial resuscitation in sepsis-induced hypoperfusion, if patients require mechanical ventilation or have preexisting decreased ventricular compliance. Recently, Boyd et al reported that a more positive fluid balance, both early in resuscitation and cumulatively over 4 days, is associated with an increased risk of mortality in septic shock. Of 719 patients in their study, only 28% had a CVP of 8-12 mm Hg at 12 hours, and 62% of patients had a CVP >12 mm Hg. Interestingly, at 12 hours, the patients with a CVP <8 mm Hg (9%) had the lowest mortality rate.

Neurological comorbidity affects prognosis in left ventricular hypertrabeculation/noncompaction - Corrected Proof

Claudia Stöllberger, Gerhard Blazek, Christian Wegner, Josef Finsterer — 2012-04-19

Abstract: Objective: Left ventricular hypertrabeculation/noncompaction (LVHT) is a cardiac abnormality frequently associated with neuromuscular disorders (NMDs). Whether differences exist between LVHT patients with and without NMDs remains unknown. This study compared the baseline characteristics and prognoses of LVHT patients with and without NMDs.Methods: This prospective, observational study included patients in whom LVHT was diagnosed at one echocardiographic laboratory between June 1995 and June 2011. Patients underwent a baseline cardiologic examination, and were invited to participate in a neurological investigation. In June 2011, patients were contacted by telephone.Results: One hundred and seventy-two patients received a diagnosis of LVHT (53 female; mean age, 53 standard deviation [SD] ± 16 years). One hundred and twenty-three patients (72%) were investigated neurologically. A specific NMD was diagnosed in 25, including metabolic myopathy (n = 16), Leber's hereditary optic neuropathy (n = 3), myotonic dystrophy (n = 3), Becker muscular dystrophy (n = 1), postpoliomyelitis syndrome (n = 1), and Duchenne muscular dystrophy (n = 1). An NMD of unknown etiology was diagnosed in 79 patients, and the neurological investigation produced normal results in 19 patients. During a follow-up of 64 months, the mortality amounted to 4.84%/year. Baseline data did not differ between patients with and without NMDs. No deaths occurred among patients without NMDs, even though their observation periods were much longer (8 vs. 4 years, P = .01) than those of patients who were not investigated neurologically.Conclusions: The presence or absence of NMDs influences the prognosis of patients with LVHT. Patients should be investigated by a neurologist when LVHT is diagnosed. Patients with LVHT and an NMD should be educated about the symptoms of arrhythmias and heart failure. They should be closely followed, and the implantation of cardiac electronic devices should be considered.

A rare combination of left ventricular noncompaction, patent ductus arteriosus, and persistent left superior vena cava demonstrated by multidetector computed tomography and echocardiography - Corrected Proof

2012-04-13

Abstract: Noncompaction of the ventricular myocardium (NCM) is a disorder characterized by numerous prominent ventricular trabeculations and deep intertrabecular recesses. It may present in an isolated form or in association with other cyanotic heart diseases, obstructions of the ventricular outflow tract, and anomalies of coronary arteries. We report on a rare combination of NCM, patent ductus arteriosus, and persistent left superior vena cava in a 27-year-old man examined via echocardiography and multidetector computed tomography.

An unusual presentation of lymphoma: Chylotamponade - Corrected Proof

2012-04-01

Abstract: Chylopericardium is an uncommon but potentially life-threatening clinic entity. Here we reported a case with chylopericardium causing tamponade and shock as an unusual presentation of lymphoma. The patient was managed by immediate pericardiocentesis. Further analysis of the pericardial fluid revealed immature T-cells compatible with precursor T-lymphoblastic lymphoma.

Mycoplasma pneumoniae preceding Lemierre’s syndrome due to Fusobacterium nucleatum complicated by acute Epstein–Barr virus (EBV) infectious mononucleosis in an immunocompetent host - Corrected Proof

Natalie C. Klein, Andrew Petelin, Burke A. Cunha — 2012-03-30

Abstract: We report an unusual case of Lemierre’s syndrome due to a rare species of Fusobacterium, that is, Fusobacterium nucleatum preceded by Mycoplasma pneumoniae pharyngitis and followed later by Epstein–Barr virus infectious mononucleosis.

Feasibility and compliance with daily home electrocardiogram monitoring of the QT interval in heart transplant recipients - Corrected Proof

2012-03-29

Abstract: Background: Recent evidence suggests that acute allograft rejection after heart transplantation causes an increased QT interval on electrocardiogram (ECG). The aims of this pilot study were to (1) determine whether heart transplant recipients could achieve compliance in transmitting a 30-second ECG every day for 1 month using a simple ECG device and their home telephone, (2) evaluate the ease of device use and acceptability by transplant recipients, and (3) evaluate the quality of transmitted ECG tracings for QT-interval measurement.Methods: A convenience sample of adult heart transplant recipients were recruited and trained to use the device (HeartOne, Aerotel Medical Systems, Holon, Israel). Lead II was used with electrodes that were easy to slip on and off (expandable metal wrist watch-type electrode for right wrist and C-shaped band electrode for left ankle). Patients used a toll-free number with automated voice prompts to guide their ECG transmission to the core laboratory for analysis.Results: Thirty-one subjects (72% were male; mean age of 52 ± 17 years; 37% were nonwhite) achieved an ECG transmission compliance of 73.4% (daily) and 100% (weekly). When asked, how difficult do you think it was to record and transmit your ECG by phone, 90% of subjects replied “somewhat easy” or “extremely easy.” Of the total 644 ECGs that were transmitted by subjects, 569 (89%) were acceptable quality for QT-interval measurement. The mean QTc was 448 ± 44 ms (440 ± 41 ms for male subjects and 471 ± 45 ms for female subjects). Eleven subjects (35%) had an extremity tremor, and 19 subjects (55%) had ≥ 1+ left leg edema. Neither of these conditions interfered with ECG measurements.Conclusion: Transplant recipients are compliant with recording and transmitting daily and weekly ECGs.

Coping strategies and adaptation to coronary artery bypass surgery as experienced by three couples - Corrected Proof

David R. Whitsitt — 2012-03-29

Abstract: Objective: Coping strategies affect the psychosocial adaptation of couples in which one of the partners has undergone coronary artery bypass grafting. Research has focused on coping strategies of patients and spouses as individuals, but little is known about how couples cope with this procedure. The purpose of this study was to understand couples’ coping strategies and their influence on adaptation to bypass surgery.Methods: Three couples were recruited from the Cardiac Wellness Institute of Calgary, Alberta, Canada. The descriptive phenomenological psychological method was used to analyze data from 2 interviews with each couple.Results: The analysis revealed a single structure that described the couples’ lived experiences. The structure and interview data revealed coping strategies and key factors influencing adaptation postsurgery.Conclusion: Coping strategies, such as redefining the illness, seeking spiritual support, and partnering, enhanced psychosocial adaptation for couples. In addition, marital quality, coping congruence, and shared meaning contributed to effective coping and better adaptation.

Cardiovascular implantable electronic device endocarditis treated with daptomycin with or without transvenous removal - Corrected Proof

2012-03-22

Abstract: Background and Methods: Nine patients with cardiovascular implantable electronic device (CIED) endocarditis were treated with daptomycin after the failure of previous treatment. The blood and CIED lead cultures of 1 patient were negative. In the other 8 patients, we observed 6 monomicrobic infections and 2 polymicrobic infections. Overall, 10 strains were isolated in these patients: 4 methicillin-sensitive Staphylococcus aureus, 2 methicillin-sensitive Staphylococcus epidermidis, 1 methicillin-resistant Staphylococcus aureus, 1 methicillin-resistant Staphylococcus epidermidis, 1 methicillin-sensitive Staphylococcus hominis, and 1 Propionibacterium acnes. The CIED was removed transvenously in 7 patients. Two patients were too sick for the removal of their CIED, and were cured with 6 mg/kg of daptomycin for 60 and 110 days, respectively, without adverse events.Results: One patient died 4 days after the removal of his CIED because of a complicated abdominal aortic aneurysm. The other 8 patients were cured, with a mean follow-up of 17 ± 8 months. The removed leads were negative, after daptomycin therapy, in 4 cases out of 7. The mean ratio between peak daptomycin concentration and minimal inhibitory concentration (MIC) of the causative strains was 38.3 ± 18.5. For patients whose data were available, the ratio between peak daptomycin concentration and minimal bactericidal concentration (MBC) was 13.2 ± 3.2.Conclusion: Daptomycin monotherapy may be a useful therapeutic tool in difficult-to-treat CIED endocarditis, resulting in a high rate of cures and sterilized leads removed. The ratio between peak daptomycin concentration and MIC or MBC may be useful as predictive tool for treatment success.

Community trends in the use and characteristics of persons with acute myocardial infarction who are transported by emergency medical services - Corrected Proof

2012-03-22

Abstract: Objective: Limited data exist on recent trends in ambulance use and factors associated with ambulance use in patients hospitalized with acute myocardial infarction (AMI), particularly from the more generalizable perspective of a community-wide investigation. This population-based prospective epidemiologic study describes the decade-long trends (1997-2007) in the use of emergency medical services (EMS) by residents of the Worcester, Massachusetts, metropolitan area who are hospitalized for AMI and the characteristics of patients with AMI who are transported to the hospital by EMS (n = 3789) compared with those transported by other means (n = 1505).Methods: The study population consisted of 5294 patients hospitalized for AMI at 11 greater Worcester medical centers in 5 annual periods between 1997 and 2007. Information on the use of EMS and the factors associated with EMS use was obtained through the review of hospital medical records.Results: There was a progressive increase in the proportion of greater Worcester residents with AMI who were transported to central Massachusetts hospitals by ambulance over time (66.9% transported in 1997; 74.9% transported in 2007). Patients transported by EMS were older, more likely to be women, and more likely to have a greater prevalence of previously diagnosed comorbidities.Conclusion: Our findings provide encouragement for the use of EMS in residents of a large central New England community hospitalized with AMI. Despite increasing trends in ambulance use, more research is needed to explore the reasons why patients with AMI do not use EMS in the setting of an acute cardiac emergency.

Cement pulmonary embolism after percutaneous vertebroplasty and kyphoplasty: An overview - Corrected Proof

2012-03-19

Abstract: Background: Because of the aging of the American population, osteoporotic vertebral fractures are becoming a common problem in the elderly. Minimally invasive percutaneous vertebral augmentation techniques have gained a great deal of importance in relieving the pain associated with these fractures, and are becoming the standard of care.Methods: These procedures involve the injection of polymethylmethacrylate (PMMA) into the vertebral body. However, these techniques have their complications, and among these, pulmonary embolism is one of the most feared. It is attributable to the passage of cement into the pulmonary vasculature. After encountering a case of PMMA embolism in our practice, we decided to highlight this topic and discuss the incidence, clinical presentation, diagnosis, and treatment of cement pulmonary embolisms.

Correlation of noninvasive markers of cardiac allograft rejection with endomyocardial biopsy: A case report - Corrected Proof

Marian Manankil, Ashim Aggarwal, Sunil Pauwaa, Geetha Bhat — 2012-03-15

Abstract: Although endomyocardial biopsy remains the gold standard to diagnose cardiac allograft rejection, the search continues for clinical parameters that may aid in the early diagnosis of rejection. We report the case of a 29-year-old man who underwent orthotopic heart transplantation and subsequently had multifocal moderate allograft rejection. During the patient’s hospital course, he exhibited a number of clinical parameters that served as important clues for the worsening rejection. After aggressive immunosuppression, the improvement of these markers hinted toward his eventual recovery.

Complete heart block in takotsubo cardiomyopathy - Corrected Proof

2012-03-15

Abstract: Tako-tsubo cardiomyopathy is a relatively recently recognized clinical entity, which presents similar to an acute myocardial infarction but there is no evidence of obstructive coronary artery disease on cardiac catheterization. It mostly affects postmenopausal women and an episode of acute illness or stress can often be identified preceding the presentation. Tako-tsubo cardiomyopathy (TCM) usually has a favorable outcome and an excellent prognosis but, in rare instances, it can be associated with life threatening complications. We report a unique case of TCM where the patient presented with a transient complete heart block.

Association of body mass index with exercise cardiopulmonary responses in lung function-matched patients with chronic obstructive pulmonary disease - Corrected Proof

2012-03-15

Abstract: Background and Objectives: Lung function is traditionally used to define the severity of chronic obstructive pulmonary disease (COPD). However, this does not exclude other factors. This study investigated the influence of body mass index (BMI) on exercise responses and quality of life in patients with COPD matched for values of forced expiratory volume in 1 second (FEV1).Methods: Underweight, normal-weight, and overweight patients with COPD, matched for FEV1, were studied. All patients were evaluated by spirometry, a cardiopulmonary exercise test, respiratory muscle strength, and, St. George's Respiratory Questionnaire (SGRQ).Results: The baseline characteristics and mean FEV1 of the 3 groups were similar (P > .05). Respiratory muscle strengths and SGRQ scores were lowest in underweight patients (P < .05). In terms of exercise response, the lowest oxygen uptake at anaerobic threshold and peak exercise, the highest ventilatory equivalent, and the lowest oxygen pulse were evident in underweight patients (P < .05).Conclusions: Underweight patients with COPD had lower respiratory muscle strength, impaired exercise capacity, earlier anaerobic metabolism, ineffective ventilation, and poorer quality of life.

Rare case of left-dominant arrhythmogenic right ventricular cardiomyopathy with dramatic reverse remodeling after cardiac resynchronization as an adjunct to pharmacological therapy - Corrected Proof

2012-03-14

Abstract: A 57-year-old man presented with near syncope and hemodynamic compromise after exercise. A sustained ventricular tachycardia (VT) of right bundle-branch block morphology was evident upon examination at our emergency department. Baseline 12-lead electrocardiography revealed a sinus rhythm with a complete left bundle-branch block after successful cardioversion of the VT. Coronary angiography revealed patent coronary arteries, whereas left ventriculography demonstrated impaired systolic function, accompanied by a peculiar basal lateral aneurysm. Both echocardiography and magnetic resonance imaging were consistent with a diagnosis of left-dominant arrhythmogenic right ventricular cardiomyopathy. Four months later, substantial ventricular reverse remodeling and clinical improvements were observed after cardiac resynchronization therapy with a defibrillator, as an adjunct to conventional pharmacological therapy.

Pulmonary hemorrhage after the use of sildenafil - Corrected Proof

Jorge Luiz Pereira e Silva, Cesar Augusto Araujo Neto, Edson Marchiori — 2012-03-09

We read with great interest the well-written case report by Azuma et al regarding a patient with pulmonary hemorrhage induced by an epileptic seizure. Computed tomography (CT) of the chest revealed diffuse ground-glass opacities in both lungs. The authors suggested that epileptic seizures may have induced increased pulmonary vascular permeability and structural damage to the blood-gas barrier, which may have caused the pulmonary hemorrhage, and they concluded that this condition could be included in the list of differential diagnoses of hemoptysis in patients with epilepsy.

Human leukocyte antigen-DQ beta 1 chain (DQB1) gene polymorphisms are associated with dilated cardiomyopathy: A systematic review and meta-analysis - Corrected Proof

Xiaoping Li, Rong Luo, Rongjian Jiang, Ruizhen Chen, Wei Hua — 2012-03-05

Abstract: Background: Previous studies reported an association between the human leukocyte antigen (HLA)-DQ antigen beta 1 chain (DQB1) alleles and dilated cardiomyopathy (DCM). However, the results of those studies have been inconsistent. To clarify the association between HLA-DQB1 and DCM, we performed a systematic review and meta-analysis of case-control studies.Methods: Searches were performed using the PubMed database, the Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials database, the Science Citation Index database, the China Biology Medicine disc, the China National Knowledge Information database, the Wanfang database, and the Chinese Scientific and Technological Journal Database (VIP database). The search terms included “dilated cardiomyopathy” and “DQB1.” Ten case-controlled studies were included in the systematic review to assess the association between DCM and the HLA-DQB1∗0201, ∗0302, ∗0504, ∗0301, and ∗0602 alleles.Results: In total, 8 studies were included in the meta-analysis of the HLA-DQB1 ∗0201 allele. The pooled odds risk (OR) for this allele was .47, with a 95% confidence interval (CI) of .28 to .77 (P < .01). With respect to the HLA-DQB1 ∗0504 allele, only 3 studies were included in our meta-analysis. The pooled OR was .36 (95% CI, .15 to .84; P < .05). Nine, 8, and 7 studies of the HLA-DQB1 ∗0301, ∗0302, and ∗0602 alleles, respectively, were included in our meta-analysis. No statistically significant difference was evident in the frequency of these 3 alleles between the DCM and normal control groups.Conclusion: The HLA-DQB1 ∗0201 and ∗0504 alleles may be protective against DCM.

Infectious mononucleosis-like syndrome probably attributable to Coxsackie A virus infection - Corrected Proof

Burke A. Cunha, Nardeen Mickail, Andrew P. Petelin — 2012-02-10

Abstract: Infectious mononucleosis (IM) is a clinical syndrome most often attributable to Epstein-Barr virus (EBV). Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly ± maculopapular rash. Laboratory features of EBV IM include atypical lymphocytes and elevated levels of serum transaminases. Leukopenia and thrombocytopenia are not uncommon. The syndrome of IM may also be attributable to other infectious diseases, eg, cytomegalovirus (CMV), human herpes virus-6 (HHV-6), or Toxoplasma gondii. Less commonly, viral hepatitis, leptospirosis, brucellosis, or parvovirus B19 may present as an IM-like infection. To the best of our knowledge, only 2 cases of IM-like infections attributable to Coxsackie B viruses (B3 and B4) have been reported. We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult.

Legionella pneumophila community-acquired pneumonia (CAP) in a post-splenectomy patient with myelodysplastic syndrome (MDS) - Corrected Proof

Burke A. Cunha, Jean E. Hage — 2011-12-26

Abstract: Legionnaire’s disease is a cause of community-acquired pneumonia (CAP) in normal hosts, but those with impaired cell-mediated immunity (CMI) and T-lymphocyte function are particularly predisposed to Legionella species CAP. Myelodysplastic syndrome (MDS) is a disorder of the elderly that is associated with impaired CMI. Cases of MDS or Legionella species CAP are rare. Splenectomized patients primarily have impaired humoral immunity and B-lymphocyte function, and, to a lesser extent, some decrease in CMI. For this reason, Legionnaire’s disease has rarely been reported in splenectomized patients. We believe this to be the first reported case of Legionella pneumophila CAP in an asplenic patient with MDS.

Rare case of an unroofed coronary sinus - Corrected Proof

2011-12-26

Abstract: Unroofed coronary sinus (CS) is a rare congenital cardiac anomaly described by a communication between the CS and the left atrium due to the partial or complete absence of the CS roof. Echocardiography is the most widely used imaging modality for suspected unroofed CS, but it is limited in its ability to visualize the posterior cardiac structures. Multidetector computed tomography has allowed the visualization and accurate anatomic and morphologic evaluation of these structures. We report a rare case of unroofed CS found incidentally in a 41-year-old man who was studied by echocardiography and multidetector computed tomography.

Systemic lupus erythematosus (SLE) cerebritis versus Listeria monocytogenes meningoencephalitis in a patient with systemic lupus erythematosus on chronic corticosteroid therapy: The diagnostic importance of cerebrospinal fluid (CSF) of lactic acid levels - Corrected Proof

Lucas M. McCaffrey, Andrew Petelin, Burke A. Cunha — 2011-12-19

Abstract: Background: Listeria monocytogenes is a motile, aerobic, Gram-positive intracellular bacillus that causes enteritis, meningitis, meningoencephalitis, or subacute bacterial endocarditis. Patients with impaired T-lymphocyte function/cell-mediated immunity are predisposed to intracellular pathogens, e.g., L. monocytogenes. In adults, infection by L. monocytogenes of the central nervous system (CNS) clinically manifests as either acute bacterial meningitis or meningoencephalitis. In patients with systemic lupus erythematosus (SLE) presenting with headache and fever, SLE cerebritis must be differentiated from acute bacterial meningitis by lumbar puncture and cerebrospinal fluid (CSF) analysis. Neuropathogenic viruses are the most common causes of meningoencephalitis. The most rapid and accurate way to differentiate bacterial meningoencephalitis from nonbacterial meningoencephalitis is CSF lactic acid levels.Methods: We present a patient receiving chronic corticosteroid therapy and manifesting SLE and severe L. monocytogenes meningoencephalitis. An early diagnosis of L. meningoencephalitis was achieved by demonstrating a very highly elevated level of lactic acid in his CSF, days before CSF and blood cultures tested positive for L. monocytogenes.Results and Conclusion: In this patient, the highly elevated levels of lactic acid in his CSF ruled out both viral meningoencephalitis and SLE cerebritis. The case was complicated by communicating hydrocephalus, and the patient later underwent placement of a shunt. He completed 6 weeks of meningeal dosed ampicillin.

Fever of unknown origin (FUO) attributable to indolent lymphoproliferative disorder due to a plasmacytoma expressing immunoglobulin A - Corrected Proof

Burke A. Cunha, Andrew P. Petelin, George K. Turi, Attilio Oraji — 2011-12-16

Abstract: Background: The most common categories causing fevers of unknown origin (FUOs) include infective rheumatic/inflammatory disorders and malignancies. Among neoplastic causes of FUOs, lymphomas, hepatomas, renal hypo-nephromas, and hepatomas are the most common. Other malignancies rarely present with FUOs (eg, multiple myeloma).Case Report: We describe a 58-year-old man who presented with an FUO accompanied by night sweats, weight loss, and a groin mass. A biopsy of the groin mass (ie, his lymph node) was negative for infectious diseases, rheumatic or inflammatory diseases, and malignancies. Histochemical and immunological studies of the lymph node showed it to contain a plasmacytoma expressing immunoglobulin A (IgA). An immunohistochemical study of the plasma-cell infiltrate demonstrated strong CD138 staining. A bone marrow biopsy was negative for multiple myeloma.Conclusion: We believe this is the first reported rare case of an indolent, lymphoproliferative disorder attributable to an IgA-secreting plasmacytoma presenting as an FUO.

Cryptococcal pneumonia in a patient with presumptive sarcoidosis and selective immunoglobulin A deficiency - Corrected Proof

Jean E. Hage, Jason Wu, Burke A. Cunha — 2011-12-15

Abstract: Sarcoidosis is a multisystem granulomatous disease of unknown cause associated with impaired T-lymphocyte function and impaired cell-mediated immunity. Decreased cell-mediated immunity predisposes one to intracellular pathogens (eg, cryptococci).

Arteriovenous fistula of the wrist after transradial coronary intervention - Corrected Proof

Francesco Summaria, Enrico Romagnoli, Marina Mustilli — 2011-12-15

Yang et al recently reported on an interesting case of iatrogenic arteriovenous fistula (AVF) after a transradial coronary intervention. The authors described a radial AVF submitted to surgical revision after the discontinuation of short-term dual antiplatelet treatment in a patient with a previously implanted drug-eluting stent. Radial AVFs are a very rare complication of transradial percutaneous interventions. The more likely physiopathologic explanation for the formation of AVFs after a transradial percutaneous coronary intervention involves the superficial course of large veins near the radial artery (RA). The risk of this complication may be increased in cases of deeper artery course despite a lack of data to confirm this hypothesis. About one third of iatrogenic AVFs will close spontaneously within 1 year. Therefore, conservative management is often attempted first. In other patients, specific treatment is required to prevent serious local disability and circulatory complications. Previous studies reported on the successful management of symptomatic radial AVFs via surgical or percutaneous approaches. We recently reported on a 66-year-old man referred to our hospital because of right forearm swelling, edema, and pain related to an AVF of the wrist. One year earlier, the patient had undergone a primary transradial angioplasty for an segment elevation myocardial infarction. Considering the persistence of his symptoms and the disability in his forearm, we proceeded with a percutaneous closure of the fistula. Under ultrasound guidance, a 5-cm 5 French Introducer (Ultimum, St. Jude Medical, St. Paul, MN) was positioned in the proximal segment of the right RA (antegrade approach). A monorail 3.5 × 18 mm pericardium-covered stent (Aneugraft, ITGI Medical, Or Akiva, Israel) was then successfully implanted into the RA at the site of the fistula. The clinical and echo color Doppler findings during 6-month follow-up confirmed the patency of the RA and the closure of the fistula. Our experience confirms that in selected cases, eg, in the presence of an effective collateral flow from the homolateral ulnar artery as assessed by ultrasound, an iatrogenic radial AVF can be treated via a percutaneous antegrade approach with the use of a short introducer and a biocompatible coronary covered stent. This approach represents a safe alternative to surgical revision, when the discontinuation of dual antiplatelet treatment can lead to an increased risk of stent thrombosis, eg, among patients in whom a drug-eluting stent was previously implanted.

Spontaneous healing of posttraumatic focal coronary aneurysm: A case report - Corrected Proof

2011-11-04

Abstract: We report on the spontaneous healing of a posttraumatic focal coronary aneurysm in a previously healthy 61-year-old man after his involvement in a motor vehicle accident, resulting in blunt chest trauma that injured the anterior wall of his left ventricle.Left-sided cardiac catheterization and selective coronary angiography 1 month after the accident showed an aneurysm in the proximal part of the left anterior descending artery, and normal coronary arteries otherwise. Intravascular ultrasound revealed that the lesion was a pseudoaneurysm protruding toward the myocardium.Surgical removal of the aneurysm was not considered, and the patient was discharged after 2 months of uneventful hospitalization. Follow-up coronary angiography and intravascular ultrasound at 3 months and 1 year after the accident showed a total regression of the aneurysm. The patient has remained asymptomatic, with no residual ischemia 3 years after the accident.This case indicates that careful conservative treatment is a therapeutic option for posttraumatic coronary pseudoaneurysms.

Response to pulmonary vasodilator treatment in a former smoker with combined interstitial lung disease complicated by pulmonary hypertension: Case report and review of the literature - Corrected Proof

Valentina Mercurio, Guido Carlomagno, Serafino Fazio — 2011-11-04

Abstract: We describe a 76-year-old former smoker with a diagnosis of combined pulmonary fibrosis and emphysema associated with pulmonary hypertension and rapidly progressive right heart failure, in whom combined treatment with sitaxsentan and sildenafil resulted in sustained improvement of his clinical condition and exercise performance, without any relevant adverse events. Combined pulmonary fibrosis and emphysema comprises a recently identified syndrome, probably related to tobacco use, and characterized by the coexistence of upper-lobe emphysema and fibrotic changes of the lower lobes, preserved lung volumes, significant hypoxemia, and a high prevalence of pulmonary hypertension, resulting in severe dyspnea. To date, no prospective series, to the best of our knowledge, has reported on the effects of pulmonary vasodilator therapy in such patients.

Lethal hemorrhagic alveolitis after adenovirus pneumonia in a lung transplant recipient - Corrected Proof

2011-11-04

Abstract: Viral infections are frequent and severe in lung transplant recipients. They frequently occur during the first year after transplantation. We report on a rare case of bilateral adenovirus necrotizing pneumonia with a diffuse alveolar hemorrhage, 4 years after bilateral lung transplantation. The medical evolution was lethal in 72 hours because of respiratory, renal, and cardiac failure. Considering this case and the growing evidence on the severity of adenoviral infections, we call for controlled studies and therapeutic recommendations.

Effect of coronary revascularization on serum collagen biomarkers and left ventricular remodeling in patients with acute myocardial infarction - Corrected Proof

Hai-Zhou Ren, Xue-Song Zhang, Le-Xin Wang — 2011-11-04

Abstract: Objective: After an acute myocardial infarction (AMI), early coronary revascularization alleviates the synthesis of cardiac collagen and ventricular remodeling. However, the impact of late coronary revascularization on the synthesis of myocardial collagen or on serum collagen biomarkers is unknown. This study aimed to investigate the effects of late coronary revascularization on serum collagen biomarkers after AMI.Methods: Forty-five patients were divided into early (n = 20) and late (n = 25) coronary revascularization groups. The early coronary revascularization group received either successful percutaneous coronary intervention (PCI) or thrombolytic therapy within 6 hours of their myocardial infarction (MI), whereas the late PCI group received PCI between 12 and 14 days after their MI. Serum type I procollagen (PICP) and type III procollagen (PIIINP) were measured by radioimmunoassay.Results: In the early coronary revascularization group, the amount of serum PICP on days 60 and 180 was similar to that of week 1 (P > .05). The PICP on days 90 and 180 in the late coronary revascularization group was higher than in the early coronary revascularization group at the same time point (P < .05). No significant difference was evident in mean serum PIIINP between the two groups on day 60 or 180 after the MI (P < .05).Conclusion: Late coronary revascularization in patients with acute ST-elevation MI was associated with an elevation in serum PICP. Early coronary revascularization should be performed in patients with ST-elevation, to alleviate myocardial remodeling.

Novel c.367_369del LMNA mutation manifesting as severe arrhythmias, dilated cardiomyopathy, and myopathy - Corrected Proof

2011-10-24

Abstract: Objective: The 3-bp deletion in exon 2 of the Lamin A/C (LMNA) gene has not been described in association with dilated cardiomyopathy, which is characterized by progressive heart failure, atrioventricular (AV) block, tachyarrhythmias, and variable skeletal muscle involvement.Case Report: In a 43-year-old woman with a long-term history of palpitations and newly diagnosed AV blocks I and II, ventricular ectopic beats, inducible nonsustained ventricular tachycardias (VTs), cardiac arrest, and successful resuscitation, an implantable cardioverter defibrillator was successfully implanted. Her family history was positive for sudden cardiac death (her father and sister), dyspnea and heart failure (her grandmother and sister), palpitations (her brother), and elevated levels of creatine-kinase (CK) (her sister). Two cousins had died of nonspecific muscular dystrophy at ages 10 years and 11 years. Upon neurological investigations revealing sore neck muscles, reduced tendon reflexes, and detached, spot-like white matter lesions bilaterally, a neuromuscular disorder was suspected. The direct sequencing of all exons and flanking intronic regions of the LMNA gene detected the heterozygote 3-bp deletion (AAG) c.367_369del in exon 2 of the gene. This mutation resulted in the deletion of a lysine at position 123 (p.lys123del) in the lamin A/C protein.Conclusions: The novel 3-bp deletion in exon 2 of the LMNA gene may phenotypically manifest as dilated cardiomyopathy, heart failure, severe tachyarrhythmias, and muscular dystrophy. Sudden cardiac death from ventricular fibrillation may be prevented in LMNA mutation carriers if the diagnosis is established early enough to implant a cardioverter defibrillator.

Recurrence of sarcoidosis: The follow-up of splenic involvement - Corrected Proof

Ying-Ting Wang, Yi-Ping Han, Qiang Li, He-Zhong Chen — 2011-10-24

Abstract: We report the case of a 53-year-old woman who initially presented with an intermittent dry cough that had lasted for 6 months. An investigation into these symptoms with thoracic computed tomography demonstrated hyperdense shadows in her lungs, and ultrasonography showed the presence of multiple hypoechoic nodules on her spleen. A lung biopsy was then performed, which revealed noncaseating epithelioid cell granulomas. Magnetic resonance imagining of her spleen was performed, which showed low signal intensity. The patient was treated with glucocorticoids, and 3 months later the lesions in her lungs had disappeared completely. Five months later, the lesions in her spleen had disappeared also. However, after 13 months of low-dose prednisone, a miliary pattern was observed on the patient's chest x-ray, although no lesions were observed in her spleen. Laboratory tests demonstrated that her blood level of angiotensin-converting enzyme had increased to 96 IU/L. The dose of prednisone was then increased, and the lung images returned to normal after 2 months of therapy.

Widespread systemic embolization with isolated tricuspid valve endocarditis - Corrected Proof

Smita I. Negi, Aashish Anand — 2011-10-10

Abstract: Concurrent systemic and pulmonary septic emboli from isolated right-sided infective endocarditis are rare. One mechanism described is that of intrapulmonary shunting. We describe a case of widespread pulmonary and systemic septic embolization with sequelae in an intravenous drug user with concomitant chronic hepatitis C infection and discuss possible mechanisms involved in the pathogenesis.