United States

Rare vallecular cysts can have severe consequences in an anesthetized patient. The presence of a vallecular cyst makes obtaining and maintaining an airway difficult. We report a case of an unexpected difficult airway of a 9-year-old boy who presents for an MRI of the brain with and without contrast, to rule out a structural cause for his nocturnal headaches. After sedation, the patient’s airway completely obstructed and was later found to be due to the presence of a vallecular cyst. This case report will detail the management of an unexpected difficult airway in a remote location. 


AMA Research Challenge 2022

Unexpected Difficult Airway in a Remote Location: Vallecular Cyst

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poster

Background: Myocarditis has been a rare, but well-documented side effect of the mRNA-based vaccines against SARS-CoV-2 as well as a complication of viral infections including SARS-CoV-2. However, myopericarditis as a complication of monoclonal antibody infusion or as complication of allergic reaction to antibody infusions might be and underreported.

Case presentation: In this case, we report a 30-year-old man with a previous diagnosis of COVID infection 1 week prior to presentation, unvaccinated for SARS-CoV-2 who was referred from a monoclonal infusion center where he received casirivimab and imdevimab and 15 minutes after infusion began to complain of chills, chest pain, shortness of breath and was hypotensive. While in the infusion center he received epinephrine, Benadryl and was directed to the emergency room. While in the ER, patient was febrile, tachycardic, and hypotensive. Initial troponin was 1.91 which peaked at 11.73 with the CK-MB that peaked at 21.2. EKG had no ischemic changes. First two-dimensional echocardiogram showed an ejection fraction of about 45%, with a left ventricular dysfunction and trivial posterior pericardial effusion. Diagnosed as myopericarditis. On admission he was started on full dose lovenox, aspirin, fluid resuscitation, steroids, remdesevir and bipap due to his respiratory compromise. 3 Days later with clinical improvement, repeat 2-d echocardiogram with EF of 65%, with normal ventricular contractility and no pericardial effusion. Patient was discharged home with close cardiology follow up.

Conclusions: Though this could be simple case of viral myopericarditis with troponinemia secondary to demand-ischemia, the differential should be broadened to complication of monoclonal antibody, given the sudden symptom onset after infusion completion and/or a possible Kounis syndrome. Though there have not been any reported cases of casirivimab and imdevimab causing myopericarditis, adverse cardiac events after monoclonal therapy have been reported mainly in cancer patients receiving monoclonal infusions.


A Case of Possible Casirivimab/Imdevimab Induced Myopericarditis in a COVID Positive Young Male

A Case of Romano-Ward Congenital Long QT Syndrome in Mother and Daughter

Cardiac malignancies are exceedingly rare, with metastatic disease more common than primary tumors. Regardless of origin, cardiac tumors have insidious clinical presentations, from mild chest pain to florid heart failure depending on the size and location of the tumor. We present an unusual case of cardiac disease. 
A 56-year-old woman with a history of stage I uterine leiomyosarcoma status post chemotherapy and hysterectomy presented with epigastric discomfort eight years after cancer remission. CT chest demonstrated a heterogeneously enhancing mass in the right atrium accompanied by a large pericardial effusion and regional lymphadenopathy. She underwent pericardiocentesis due to tamponade physiology, but no malignant cells were seen on cytologic analysis. Subsequent CTA of the heart and cardiac MRI confirmed an 8.2 cm x 6.3 cm hypervascular tumor in the anterior pericardial space that straddled the right heart, compressing the atrium and ventricle, and encasing the right coronary artery. Pericardial mass core biopsy was consistent with leiomyosarcoma. One month after diagnosis, she was admitted to the hospital to start the first cycle of neoadjuvant chemotherapy with mesna, adriamycin, ifosfamide, and dacarbazine. During the first cycle, she developed episodes of non-sustained ventricular tachycardia concerning for an arrhythmogenic effect of the mass versus the cardiotoxic effects of chemotherapy. She was started on a low dose beta-blocker. Following completion of three cycles of chemotherapy, she is planned for tumor restaging and potential surgery. 
Although rare, cardiac tumors should be considered in patients with a history of malignancy, and given the anatomic location of the heart, cardiac pathology should remain on the differential for epigastric pain. Having a high index of clinical suspicion can lead to more rapid identification, especially with advancements in imaging techniques such as cardiac MRI and CTA. Leiomyosarcomas are aggressive tumors, and symptoms may only arise once the tumor is at an advanced stage, as in this patient. Prompt initiation of chemotherapy and surgical resection can improve overall prognosis. Ultimately, this patient requires close coordination between the cardiology, oncology, and cardiothoracic teams to provide the most optimal care.

A Rare Cardiac Tumor Presenting as Epigastric Pain

Background: Takotsubo cardiomyopathy (TCM), also known as an apical ballooning syndrome or stress cardiomyopathy, is a rare clinical syndrome defined as a profound but reversible left ventricular dysfunction in the absence of coronary artery disease. TCM is commonly associated with physical and emotional stress, but the pathophysiology is unknown. Here we present a 42-year-old female who develops TCM due to prolonged emotional stress causing the progression of motor neuron dysfunction. 
Case Presentation: A 42-year-old female presented to the ER with loss of consciousness after developing several bouts of cough followed by acute onset of breathlessness triggered by a prolonged stressful event for several months. She developed cardiac arrest, for which CPR was successfully performed. The family denied that she had chest pain, palpitations, and lower extremity edema. Echocardiography showed apical ballooning of the left ventricle (LV), distal
septum, and apex appeared hypokinetic, with a reduced EF of 40%. Repeated screening echo showed improvement in EF alone. Prior to this event, the patient had a history of severe muscle weakness, fatigue, and bulbar symptoms for 8 months, breathing difficulty with weakness in both upper and lower limbs, loss of appetite, and weight loss of about 9 kgs in 3 months. She noticed progressive thinning of leg and arm muscles. There were no visual symptoms, sensory symptoms of bowel and bladder, or systematic symptoms. Her nerve conduction velocity was normal. Antibody testing for AchR, as well as MUSK antibodies, was negative. The patient died approximately 3 months after the first cardiac arrest.
Discussion: 
Prolonged stress, myasthenic crisis, and hyperthyroidism can lead to TCM. Here
we report a patient with clinical signs and symptoms of bulbar onset ALS who had prolonged emotional and physical stress that led to TCM, thereby progressing neuromuscular weakness. We advocate screening, careful cardiac monitoring, and management of Motor neuron disease (MND) patients, especially ALS, regularly and, more importantly, during acute emotional or physical stress, as there is a potential risk of developing TCM and rapid progression of MND/ALS symptoms leading to fatal respiratory failure.

A rare case of Takotsubo cardiomyopathy associated with amyotrophic lateral sclerosis

Abstract Title:
A Triple Threat: Triple-Valve Endocarditis Case Report and Literature Review
Background
Triple Valve Endocarditis (TVE) is uncommon and infrequently described in the current medical literature. Large-scale studies studying its incidence, characteristics, and management are difficult to conduct. Here we describe a case of TVE in an intravenous (IV) drug user and review the literature of TVE identification, treatment, and prognosis. 

Case Presentation
A 37-year-old man was brought to our hospital due to behavior changes since being tossed from an unknown person’s car onto a driveway four days earlier. He had completed treatment for methicillin-resistant Staphylococcus aureus infective endocarditis (IE) two months earlier but continued to use IV heroin. He was intubated for airway protection and started on broad-spectrum antibiotics. A transthoracic echocardiogram identified vegetations on the aortic, mitral, and tricuspid valves. Magnetic resonance imaging (MRI) of the lumbar spine revealed evidence of osteomyelitis and paraspinal abscesses at the L5 - S1 levels. MRI brain showed multiple areas of acute infarction. Blood cultures obtained on arrival were positive for methicillin-sensitive Staphylococcus aureus and the patient was changed to IV Nafcillin. His hospital course was complicated by the development of acute renal failure. Cardiac surgery deemed the patient a poor surgical candidate. Due to the extensive metastatic disease and his lack of response off sedation, his family had the patient terminally extubated on day three of hospitalization. 

Discussion

Streptococcus and Staphylococcus species are the most frequent causes of TVE. Case series of patients with TVE are lacking due to its uncommon nature. Multi-valve endocarditis (two and three valve involvement) represented 18% of cases in one study of 14 patients, 31% in a series with 383 patients, and 12% in a study of 48 patients. The mitral, tricuspid, and aortic valves were most commonly involved in TVE. A transesophageal echocardiogram is the imaging modality of choice as it increases the sensitivity of identifying vegetations to about 90%. Antibiotic treatment is similar to single-valve IE but surgical intervention remains challenging due to a high incidence of postoperative complications. However, a multidisciplinary team-based approach can decrease the expected one-year mortality rate by nearly fifty percent. Because TVE is associated with higher risks of complications and poorer outcomes, prompt identification and treatment are especially important.


A Triple Threat: Triple-Valve Endocarditis Case Report and Literature Review

Amiodarone Induced Bone Marrow Granulomas: A literature Review of Case reports

Background
Amiodarone is classified as a class III antiarrhythmic drug primarily indicated in the treatment of ventricular arrhythmias. The agent has a wide array of adverse effects that may affect multiple organ systems, including the pulmonary, central nervous system, cardiovascular, thyroid, liver, eyes, and skin. A rare and uncommon occurrence from amiodarone use is the development of bone marrow granulomas. This review article summarizes the mechanism of action, clinical uses of amiodarone therapy and reviews the unique presentation of amiodarone-associated bone marrow granulomas using ten case reports. It also includes a discussion section summarizing literature that can further aid healthcare professionals and patients in the diagnosis, management, and education of this adverse effect.

Methods
An electronic database search of scientific platforms such as PubMed, Pubmed Central (PMC), and Google Scholar was conducted. Respective data was collected and reviewed to conduct this
manuscript. 10 previously published case reports regarding amiodarone induced bone marrow granulomas were analyzed and reported. Articles were selected based on the keywords mentioned above.

Results
As per the reported cases of amiodarone- associated granulomas, subjects taking a dosage of 100 mg – 200 mg for a duration of 6 to 18 months was enough to ensure bone marrow granulomas. Repeated bone marrow biopsy 3 to 6 months after discontinuation of the offending agent demonstrated an improvement. All ten case reports revealed noncaseating granulomas confirmed by bone marrow biopsy. Subjects that did develop cases of anemia, EPO showed great improvements to raise Hb levels. 4 of the 10 cases continued treatment despite the confirmed bone marrow granulomas due to the intractable nature of their cardiac condition. In such cases, routine monitoring is recommended, and repeated bone marrow biopsies may be required.

Conclusion
Bone marrow granulomas are seen commonly in infectious and malignant etiologies. A thorough
history and workup can reveal uncommon causes such as medication-induced and prevent misdiagnosis. Bone marrow granulomas in subjects previously receiving treatment with amiodarone should arouse clinical suspicion for possible drug-induced etiology.


Amiodarone Induced Bone Marrow Granulomas: A Literature Review of Case Reports

Background: 
Catheter ablation-induced visual symptoms are reported to be rare. Catheters can cause an iatrogenic atrial septal defect (IASD) that can remain open for up to nine months.  A similar dynamic  change in the patent foramen ovale (PFO) has also been hypothesized to be caused by IASD. This can result in paradoxical emboli containing particulate material from the equipment and/or microemboli, both of which result in cortical spreading without infarction in the brain, resulting in visual complications. 

Case Presentation :
A 72-year-old Caucasian woman with paroxysmal atrial fibrillation (AF) but no migraines presented to our hospital with acute visual changes.  She had an uneventful AF catheter ablation four days prior to her presentation.  
Her medications were flecainide 50 mg twice/day and apixaban 5 mg twice/day.  
She experienced nausea, constipation, and headaches after catheter ablation, which subsided after three days. On the fourth day after the procedure, she noticed blurriness, a right visual field defect, and blind spots in both eyes. These visual changes were episodic and lasted for 15-20 minutes without any known precipitating or relieving factors. She denied fever, chest pain, palpitations, confusion, dizziness, loss of consciousness, and motor or sensory deficits. Her general physical exam, including a thorough neurological examination, was normal. Vitals were stable. The patient's initial 12-lead ECG and telemetry strips showed normal sinus rhythm. Normal blood and metabolic lab results. MRI and CT brain angiography showed no abnormalities. Her symptoms resolved after 24 hours while she remained under observation.  
She was discharged home and has reported no recurrence of symptoms to her cardiologist. 

Discussion:
With the increased use of catheter ablation procedures for symptomatic arrhythmias, rare but significant post-procedural symptoms such as visual disturbances have been reported. Monitoring for IASD, which can potentially cause complications after catheter ablation, with transthoracic echo (TTE) or transesophageal echo (TEE), can be helpful in determining the etiology; more research is needed in this area to avoid unnecessary, lengthy, and costly investigations that burden patients and institutions. We hypothesize that this patient's visual symptoms resulted from IASD-related complications as a result of her catheter ablation.

Approach to Visual Manifestations Following Catheter Ablation

Introduction:

Epsilon waves on electrocardiogram (ECG) are low voltage potentials following the QRS complex representing delayed right ventricular conduction. These are characteristic of arrhythmogenic right ventricular cardiomyopathy (ARVC). This condition has been associated with sudden cardiac death.

Case Presentation:

We present a 59-year-old female with a family history of sudden cardiac death who was admitted to the hospital for syncope and found to have a subdural hematoma managed with Burr hole drainage. On day 2, the patient had a sudden episode of sustained monomorphic ventricular tachycardia and loss of consciousness requiring cardioversion to sinus rhythm and initiated on amiodarone. Subsequent ECG showed sinus rhythm with incomplete right bundle branch block, T wave inversions and epsilon waves in precordial leads. Transthoracic echocardiogram showed severely dilated right ventricle and reduced ejection right ventricular ejection fraction (RVEF) of 45%. Cardiac MRI showed worsening RVEF of 27% and regional right-ventricular hypokinesia. Additional genetic testing for ARVC was negative. As per Task Force 2010 criteria the patient met at least two major and two minor criteria which confirmed a “definite” diagnosis of ARVC. The patient was continued on mexiletine and metoprolol and advised to avoid endurance exercise. She received a secondary prevention cardioverter-defibrillator and was referred to advanced heart failure specialist for cardiac transplant evaluation.

Discussion

ARVC involves mutations in the genes coding desmosomes thus causing replacement of the myocardium with fibrofatty tissue. This results in delayed intraventricular conduction allowing for fatal reentrant ventricular arrhythmias. We emphasize the importance of recognizing epsilon waves on ECG which are highly specific to this disease process. The incidence of epsilon waves in ARVC accounts for 30%. Moreover, recognition of LV involvement in patients with ARVC can help identify patients at higher risk of mortality that may go on to benefit with heart transplant evaluation.

Epsilon Waves and Preventing Sudden Cardiac Death

Background:
Sarcoidosis is a multisystem granulomatous inflammation disorder of unknown etiology which can involve a variety of organs. The incidence usually varies according to ethnicity, gender and region. It usually affects the lymph nodes and lungs; however, the skin, the central nervous system, the eyes, the muscles and the heart can also be affected. The heart is not a commonly affected organ in sarcoidosis
Cardiac signs and symptoms can include complete heart block, bundle branch block, ventricular tachycardia, congestive heart failure, and sudden death are not usually the first presentation of the disease.
Case Presentation:
This case illustrates the challenge of diagnosing isolated cardiac sarcoidosis in a 56 year old gentleman who presented with symptoms of acute heart failure.
Echocardiography showed EF of 40% and elevated filling pressure, grade 3 central mitral regurgitation and grade 2 aortic insufficiency. Coronary angiogram was negative, CT angiogram was negative for pulmonary embolism. EP studies showed ventricular premature beats bigeminal and trigeminal sequence.
MIBG scan showed diffuse fixation of MIBG in both ventricles but more markedly in the lateral wall of the left ventricle. Cardiac biopsy showed noncaseating granulomas. Steroids resulted in marked improvement of his cardiac function with an  EF 52%, grade 1 central mitral regurgitation and aortic insufficiency grade 1-2, while tapering of steroids resulted in deterioration of EF to 35 %. 
After this deterioration, Methotrexate was added and after few months the patient was able to be tapered off the steroids and achieve stability of symptoms.
Discussion:
Cardiac involvement in sarcoidosis is common. However, heart failure and isolated cardiac sarcoidosis are not commonly seen as the first presentation. High clinical suspicion is always the key to identifying those cases and recognizing the presenting signs and symptoms such as ventricular arrhythmias, conduction abnormalities and heart failure coupled with the use of the right imaging techniques including MIBG scan, FDG PET and cardiac MRI. Early initiation of the management is the most important step to prevent sudden cardiac death. Immunosuppressants, mostly corticosteroids, are the main stay of management and implantable cardioverter-defibrillator device might be needed to prevent sudden cardiac death.

Isolated Cardiac Sarcoidosis Presenting As Heart Failure

Fungal infective endocarditis (FIE) is a rare condition with poor prognosis commonly associated with immunosuppression. Aspergillus fumigatus, which can resemble Neosartorya pseudofischeri, is the most common pathogen associated with invasive fungal infections in immunocompromised hosts. Echocardiographic evaluation of invasive disease is a useful tool for prognostication and clinical decision-making.

Next from AMA Research Challenge 2022

A Case of Possible Casirivimab/Imdevimab Induced Myopericarditis in a COVID Positive Young Male

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