Bilateral Leg Edema Research Articles

COVID-related constrictive pericarditis requiring pericardiectomy: a case report

BackgroundThe COVID-19 pandemic was primarily considered a respiratory malady in the early phases of the outbreak. However, as more patients suffer from this illness, a myriad of symptoms emerge in organ systems separate from the lungs. Among those patients with cardiac involvement, myocarditis, pericarditis, myocardial infarction, and arrhythmia were among the most common manifestations. Pericarditis with pericardial effusion requiring medical or interventional treatments has been previously reported in the acute setting. Notably, chronic pericarditis with pericardial thickening resulting in constriction requiring sternotomy and pericardiectomy has not been published to date.Case presentationA patient with COVID-19-associated constrictive pericarditis three years after viral infection requiring pericardiectomy was reported. The COVID-19 infection originally manifested as anosmia and ageusia. Subsequently, the patient developed dyspnea, fatigue, right-sided chest pressure, bilateral leg edema, and abdominal fullness. Following recurrent right pleural effusions and a negative autoimmune work-up, the patient was referred for cardiothoracic surgery for pericardiectomy when radiographic imaging and hemodynamic assessment were consistent with constrictive pericarditis. Upon median sternotomy, the patient’s pericardium was measured to be 8 mm thick. Descriptions of the clinical, diagnostic, and therapeutic features are provided. Within the first week after the operation, the patient’s dyspnea resolved; one month later, leg edema and abdominal bloating were relieved.ConclusionsAlthough an association between COVID-19 and cardiac complications has been established, this case adds another element of virus severity and chronic manifestations. The need for sternotomy and pericardiectomy to treat COVID-19-related constrictive pericarditis is believed to be the first reported diagnosis.

#1494 Immunotactoid glomerulopathy: a comprehensive analysis of three cases

Abstract Background Immunotactoid glomerulopathy (ITG) is an uncommon cause of glomerular disease encountered in approximately 0.06% of native kidney biopsies. This fibrillary disease is strongly associated with haematologic disorders, including lymphoma (mainly chronic lymphocytic leukaemia/small lymphocytic lymphoma), monoclonal gammopathy, and multiple myeloma. It is usually managed with oral steroids and/or treatment of an underlying lymphoproliferative disorder. Here, we report three cases of ITG, all female patients with varying severity of the disease, timing of malignancy and required treatment. Case Scenarios: Case 1: A 76-year-old lady with no significant medical background presented in May 2020 with confusion and progressive peripheral oedema. She had AKI (serum creatinine 210 µmol/L from baseline 68 µmol/L) and a sodium of 104 mmol/l. Urine PCR was 1182 mg/mmol. She was admitted to the ITU, where hyponatraemia was managed with a good clinical response. Blood screening showed negative immune, myeloma and virology screens. Complement was low. A renal biopsy showed a diagnosis of ITG. She had an extensive malignancy screen, but no malignancy was detected. She was started on prednisolone 60 mg once daily and eventually weaned off the drug by March 2021, as she maintained remission of her disease. Two years after her initial presentation, she was seen by the ophthalmologist for a right lacrimal gland mass. This was excised, and a biopsy revealed a MALT Lymphoma. Case 2: A 50-year-old lady with splenomegaly being investigated under the haematology service was referred to our renal clinic for proteinuria in June 2019. Her serum creatinine was within normal limits, and her UPCR was 302 mg/mmol. She had no paraprotein in her blood, low serum immunoglobulins, low C3 and a negative viral screen. Perindopril, initiated by her GP, was up-titrated. Renal biopsy revealed features in keeping with Immunotactoid Glomerulopathy, and completed haematological investigations revealed Chronic Lymphocytic Leukaemia. Her UPCR peaked at 842 mg/mmol before reducing to 190 mg/mmol within a year after treatment with Veneclotax and Rituximab after not tolerating FCR (Fludarabine, Cyclophosphamide, Rituximab) Chemotherapy. Case 3: A 69-year-old lady presented to the renal clinic with proteinuria in September 2018. She had a background of breast cancer diagnosed in 2007 (She had surgical resection followed by radiotherapy). Her 24-hour urine protein was 2g, and UPCR was 155 mg/mmol. Serum creatinine was 81 µmol/l and eGFR 66 ml/min. P- ANCA was positive, while PR3 and ANA were negative. She had bilateral leg oedema due to long-standing lymphedema. The biopsy report showed immunotactoid glomerulopathy. Regular surveillance of previous breast cancer with mammography and CT-CAP has shown no evidence of malignancy recurrence, hepatitis virology and paraprotein were negative, and C3/C4 were within normal limits. She had improved UPCR and maintained normal kidney function on full-dose Losartan. Conclusion Immunotactoid Glomerulopathy is a rare form of glomerular disease with a strong association with lymphoproliferative malignancies, which may precede, occur concomitantly or present years after the initial diagnosis. This common association highlights the need for diligence in screening for malignancy in each case, and it is a reason for careful follow-up of these patients. Treatment of underlying disorders is associated with positive renal outcomes, and in some cases, there is a good response to steroids.

Pericardial effusion and impaired diastolic cardiac function as a result of a giant colonic diverticulum

This case report describes a Giant Colonic Diverticulum (GCD) found in association with a significant pericardial effusion and impaired cardiac function. A 63-year-old man presented to the Emergency Department with bilateral leg edema, mild dyspnea, and diarrhea. An echocardiogram demonstrated a large pericardial effusion and abnormal diastolic cardiac function. Abdominal imaging studies identified a 29 cm x 18 cm x 13 cm gas filled structure in the left upper quadrant concerning for GCD causing significant compression of the left lung and heart. Following surgical resection, the pericardial effusion resolved, cardiac function normalized, and the patient’s leg swelling improved. This is the first case report to record an association between GCD and pericardial effusion with impaired diastolic cardiac function.

Abstract 12234: Concurrent Amyloid Light-Chain Cardiac Amyloidosis and Abdominal Leiomyosarcoma - Diagnostic and Therapeutic Challenges

Background: AL amyloidosis is a rare disorder characterized by organ infiltration of unstable misfolded light chain proteins. Diagnosis requires a high degree of suspicion, and cardiac involvement has poor outcomes. Anthracycline-based regimens are preferred for treating abdominal leiomyosarcoma (LMS) but pose a challenge in the presence of cardiac AL amyloidosis. Case: A 66-year-old male presented with bilateral leg edema and underwent evaluation for new heart failure. Echocardiography revealed preserved left ventricle ejection fraction (LVEF) with mild hypertrophy, increased interventricular septum thickness, and diastolic dysfunction. Due to concern for cardiac amyloidosis, the patient underwent nuclear scintigraphy scan, which was negative. Ongoing clinical suspicion prompted endomyocardial biopsy, which was positive for Congo Red staining, and serum studies revealed monoclonal lambda spike with increased free light chains. PET-CT was done to assess the lung nodule, revealing abdominal LMS. While Anthracycline is the drug of choice for LMS, its potential cardio-toxic effect in the presence of heart failure need be addressed. Treatment decisions involved a multidisciplinary team, resulting in bortezomib for AL amyloidosis, gemcitabine/paclitaxel for LMS, and symptomatic heart failure management. Decision-making: Anthracycline therapy was avoided due to potential cardiotoxicity. Daratumumab was added to expedite light chain reduction and minimize cardiotoxic effects. Individualized treatment considered the patient's clinical presentation and comorbidities. Conclusion: Diagnosing cardiac amyloidosis requires a high index of suspicion. Concurrent AL amyloidosis and LMS is extremely rare and presents a therapeutic dilemma, necessitating personalized management. Further research is needed to assess the potential cardio-toxic effect of anthracycline in the presence of cardiac AL amyloidosis.

Abstract 17455: Heart in Crisis: Graves’ Thyrotoxicosis-Induced Cardiomyopathy

Background: We present a case of a young healthy male who presented with signs and symptoms of congestive heart failure and was subsequently diagnosed with dilated cardiomyopathy secondary to an unknown history of Graves’ disease. Case Presentation: A 40-year-old male with no medical history presented to the hospital with scrotal and bilateral lower leg edema for 4 days with associated shortness of breath. Physical examination was significant for an irregularly irregular heart rhythm. Electrocardiogram showed atrial fibrillation with a rapid ventricular response (Image B). Initial laboratory findings were elevated NT-proBNP of 1,240 pg/mL (<125 pg/mL). Chest x-ray revealed significant cardiomegaly (Image A). Echocardiogram demonstrated an ejection fraction of 20% with a severely dilated bilateral atrium, left ventricle with severe diffuse hypokinesis of the left ventricle, and severe mitral regurgitation (Images C and D). Endocrine was consulted for abnormal thyroid function tests with TSH of <0.010 mU/L (0.27-4.2 mU/L), free T4 of 6.06 ng/dL (.93-1.70 ng/dL), T3 of 258 ng/dL (80-200 ng/dL), thyroid-stimulating immunoglobulin of 9.51 IU/L (0.00-.55 IU/L) and TSH receptor antibody 14.00 IU/L (0.00-1.75 IU/L). The patient was started on methimazole and metoprolol with close follow-up with cardiology and endocrinology. Discussion: Severe Cardiomyopathy in adult patients with hyperthyroidism is rare occurring in approximately 6% of patients with less than 1% developing dilated cardiomyopathy with impaired left ventricular systolic function. Although the mechanism of dilated cardiomyopathy is still being researched it has been suggested that prolonged uncontrolled hyperthyroidism and autoimmunity as the potential causes. Further studies are needed to develop optimal management studies as it has been shown that the management of thyrotoxicosis can reverse cardiovascular manifestations and prevent irreversible cardiomyopathy.

Using Compression Therapy to Treat Bilateral Lower Limb Edema in Patients with Lung Cancer: A Case Series.

Although rare, marked bilateral leg edema (BLE) can occur in patients with lung cancer. Systemic therapy for the underlying disease is important, but adjunct therapy might also be helpful. In this case series, the authors report on treating BLE in patients with lung cancer with compression therapy using elastic stockings and bandages. From April 2013 to March 2022, the authors conducted a retrospective survey of seven patients who developed marked BLE and received compression therapy. They evaluated effects based on improvements in subjective symptoms as well as objective findings 2 months after the start of the therapy. The bandage therapy was useful in patients who were driver-gene negative, but it was not effective in those who already had "progressive disease" with specific agents for their driver genes. No adverse events were observed. Compression therapy, even when attached or detached by nonmedical personnel, may provide favorable effects and should be considered as an adjunct treatment option in this population, in addition to effective systemic cancer therapy. These results indicate that a prospective clinical trial would be worthwhile.

SAT484 High Degree AV Block And Sinus Arrest: Cardiovascular Manifestations Of Myxedema Coma

Abstract Disclosure: J. Bosques-Lorenzo: None. P. Rivera: None. J. Colon-Castellano: None. Y. Otero-Dominguez: None. Bosques-Lorenzo Jaymilitte, Rivera-Cariño Patricia, Colon-Castellano Janet, Otero-Dominguez Yomaira. Background: Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. The most common presenting symptoms are altered mentation, hypothermia, edema, and respiratory depression. The cardiovascular system is often involved, in the form of sick sinus syndrome, bradycardia, low voltage QRS complex, QT prolongation, and rarely cardiac arrest. Here we present a case of myxedema coma complicated with high degree AV block and sinus arrest. Clinical Case: A 84 year-old man with history of hypothyroidism on levothyroxine 125 mcg, presented to the ER due to disorientation, bilateral leg edema, and abdominal discomfort for 3 days. Vital signs revealed a temperature of 97.5 F, HR of 60bpm, BP 174/88 mmHg, and oxygen saturation of 100% at room air. Physical exam was pertinent for bilateral lower extremity edema, facial puffiness, macroglossia, slow mentation, and scattered rales on lung auscultation. Laboratories showed an elevated TSH (296.8 uIU/mL), with low total T3 and free T4 (45.03 ng/dL and 0.228 ng/dL respectively) with a myxedema score of 45. Altered renal parameters as per BUN and creatinine levels (83.4 mg/dL and 5.75 mg/dL) without electrolytes disturbances and elevated CPK (1250 U/L). Infectious process was ruled out. Chest X-ray showed vascular congestion. Echocardiogram showed a small pericardial effusion. Patient was admitted to ICU and started on IV Levothyroxine, along with hydrocortisone. Liothyronine was initially not available. On second admission day, the patient developed hypothermia (94.3 F) which was managed with passive warming. Telemetry monitoring recorded multiple episodes of bradycardia raging from 30 to 50 bpm, high-degree AV block, and one episode of sinus arrest of 15 seconds with self-resolution. Altered mentation persisted for which endotracheal intubation was performed to secure airway. A temporary transvenous pacing was placed emergently. Levothyroxine dose was further adjusted and liothyronine was initiated. After a few days of treatment, patient demonstrated clinical improvement that was supported with follow up thyroid function test. Patient was extubated and transitioned to oral levothyroxine. Nevertheless, he remained dependent of transvenous pacing for which permanent pacemaker placement was coordinated. Conclusion: Cardiovascular complications in myxedema coma are associated with poor prognosis with a mortality approaching 80%. Few cases of sinus or cardiac arrest associated to Myxedema coma have been reported in the literature. In this case, the patient developed high-degree AV block with concomitant sinus arrest despite prompt initiation of intravenous thyroid hormone. Prompt identification of cardiovascular involvement can prevent cardiovascular morbidity and mortality in myxedema coma. Presentation Date: Saturday, June 17, 2023

Dependent Leg Edema in Older Patients with or without Skin Lesion.

Objective: This study aimed to clarify the features and causes of dependent edema (DE) in the legs of patients in geriatrics. Patients and Methods: We retrospectively reviewed 224 patients with DE, aged ≥65 years, who visited our clinic from April 2009-March 2022. DE was defined as bilateral leg edema in patients without known systemic edemagenic conditions, venous insufficiency confirmed by duplex venous scanning, or a cancer treatment history in the pelvic/inguinal lesions. Results: The median patient age was 77 years (range: 65-94 years), where 74% were female. Overall, 198 patients (88%) had gait disturbances caused mainly by musculoskeletal disorders, but 58 (26%) walked without aid. Compared with patients with DE only (N=129), patients with DE and venous stasis-related skin lesions (N=95) included a larger number of those with obesity than did those with DE only (26% vs. 14%, p=0.02). Conclusion: The primary cause of DE in older patients was the sedentary lifestyle secondary to aging and gait disturbance, not solely because of reduced leg function. The complications of obesity are associated with increased venous stasis-related skin lesions.

Right ventricular failure due to acute pulmonary embolism associated with Graves’ disease: A case report

Background Graves' disease is a prevalent endocrine disorder characterized by diverse clinical manifestations affecting multiple organs, exhibiting varying degrees of severity. Cardiovascular system involvement is one of the most common manifestations, which include palpitation, tachycardia, cardiomyopathy, atrial fibrillation, pulmonary hypertension, or heart failure. Additionally, excessive thyroid hormone can lead to a hypercoagulable state, increasing the risk of venous thrombosis. However, thrombotic events, particularly deep vein thrombosis, cerebral venous thrombosis, or pulmonary embolism, are rare complications of Graves’ disease. Case presentation In this report, we present the case of a 53 years old woman who presented with progressively worsening dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral leg edema, and jaundice for 2 weeks. She had also reported a weight loss of 4 kilograms within 3 months. Upon admission to our hospital, she initially received a diagnosis of congestive heart failure with atrial fibrillation and thyrotoxicosis. Following diuretic therapy, the patient developed hypotension and severe hypoxemia. Subsequent investigation revealed acute right ventricular failure due to an acute sub-segmental pulmonary embolism, which was confirmed by computed tomography of the pulmonary artery. The patient's condition improved after resuscitation involving intravenous fluid administration to increase right ventricular preload, intravenous vasopressor infusion to elevate systemic blood pressure, management of severe thyrotoxicosis, and intravenous administration of heparin. Conclusion Graves’ disease, accompanied by hemodynamic disturbances due to acute right ventricular failure, necessitates admission to the intensive care unit for resuscitation and close monitoring. Although acute pulmonary embolism is an uncommon condition associated with Graves’ disease, it should be considered, particularly in patients who develop acute right ventricular failure.

Palliative interatrial septum stenting with a vascular stent in a chronic thromboembolic pulmonary hypertension patient: Is it beneficial?

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is a serious disease that can progress and lead to a deadly outcome. Despite optimal drug therapy, pulmonary hypertension (PH) remains fatal. Untreatable right heart failure (RHF) from CTEPH is eventually a significant cause of death. However, unloading the right heart and increasing systemic output are the treatment goals in these patients.Case presentationA 42-year-old female presented to the emergency department with worsening dyspnea experienced for three days before admission. There were also complaints of leg edema, ascites, orthopnea, and palpitation. Physical examination revealed an attenuated second heart sound, abdominal ascites, and bilateral leg edema. She had a history of frequent readmissions due to RHF despite optimal medical therapy and was diagnosed with CTEPH 5 months ago. It was decided that the patient would undergo interatrial septal (IAS) stenting with a vascular stent of 8 mm × 39 mm × 135 cm. The results were good; her symptoms and signs of RHF improved, and she was eventually discharged from the hospital. Four months after the procedure, the patient was able to engage in physical activities without any limitations.ConclusionsA palliative IAS stent is one of the choices for intractable RHF management in patients with CTEPH. The vascular stent can be used as an alternative in order to make the interatrial connection more stable and last longer.

Autoimmune hepatitis overlapping with subacute cutaneous lupus erythematosus: A case report

Autoimmune hepatitis (AIH) is an autoimmune liver disorder which rarely coexists with systemic lupus erythematosus (SLE) and presents as an overlap syndrome affecting multiple organs. Herein, we report a case of a 35-year-old healthy male who was evaluated for bilateral leg oedema and was diagnosed with AIH 5 years back. Four years later he developed fever and multiple photosensitive skin rashes, worsening leg oedema and proteinuria to which a diagnosis of coexisting SLE was made. He was diagnosed with the rare entity of AIH subacute cutaneous lupus erythematosus overlap syndrome. He was medically managed with immunosuppressive medication to which he responded.

A simple pleural effusion or not?

A 60-year-old man presented with a 2-week history of progressive dyspnea and bilateral leg edema. He had undergone a prosthetic mitral valve replacement 9 years earlier. The patient was in respiratory distress (respiratory rate 32/min, oxygen saturation 86% on air, heart rate 124/min, blood pressure 109/56 mmHg). Examination revealed bilateral lung crackles and reduced air entry with dullness to percussion and elevated jugular venous pressure. The electrocardiogram showed sinus tachycardia. A chest X-ray (CXR) (Figure 1) and bedside lung ultrasonography were performed (Figure 2A). A diagnosis of a large pleural effusion was made and urgent thoracocentesis was considered in view of the patient’s respiratory distress. A repeat ultrasonographic scan with adjusted angulation to identify the most suitable entry point for the chest drain (Figure 2B) yielded new results that led to the cancellation of the thoracocentesis.

ADENOSQUAMOUS LUNG CARCINOMA COMPLICATED WITH MARANTIC ENDOCARDITIS AND CHRONIC DISSEMINATED INTRAVASCULAR COAGULATION

Background: Adenosquamous lung carcinoma is a relatively rare subtype of non-small-cell lung cancer that contains both adenocarcinoma (ADC) and squamous cell carcinoma (SCC) components. It is difficult to reach a proper diagnosis before surgery, with the histopathological examination of the resected specimen being the method of choice. A supplementary immunohistochemistry examination of the sample is needed. In order to initiate targeted treatment, molecular testing is mandatory. Case presentation: A 47-year-old female, smoker (15 packs-year), without pathological personal history, presented for fatigue and moderate bilateral leg edema for about 3 months. The blood tests showed severe microcytic, hypochromic anemia and chronic disseminated intravascular coagulation. Computed tomography (CT) scan revealed a tumor in the right basal pleura with secondary pleural effusion, multiple lymphadenopathies, disseminated in the mediastinum, abdominal and pelvic cavity. Two other tumors were noticed, one in the right breast (7 mm) and the other in the vesicouterine pouch (7/10 mm). Prior to lung biopsy, a transthoracic and then transesophageal echocardiography were performed, highlighting the presence of a band on the aortic valve, suggesting marantic endocarditis. Tumor markers were also elevated. In evolution, the patient became bradypsychic, with head CT showing a brain metastasis in the left high-parietal region. Immunohistochemistry examination of the biopsy sample suggested a adenosquamous lung carcinoma. Conclusion: We reported the diagnostic path of a rare subtype of lung cancer in a young female without known comorbidities, with an atypical presentation - multiple extrapulmonary non-metastatic manifestations: metabolic etiology - weight loss, fatigue; vascular and hematological etiology – marantic endocarditis (a very rare complication), severe microcytic, hypochromic anemia and chronic disseminated intravascular coagulation; neurological etiology – peripheral sensorimotor neuropathy of the right arm. A tissue biopsy was performed from the most accessible region – 1/3 inferior right thorax, posterior axillary line. The particularity of the adenosquamous lung carcinoma in this case lies in multiple metastases in less common sites (breast, vesicouterine pouch and probably kidney).

Abstract 14421: Avoid Pericardiectomy in Transient Constrictive Pericarditis

Case Presentation: A male in his 40s presented for chest pain, dyspnea and bilateral leg edema. He has a history of hypertrophic cardiomyopathy treated with septal myectomy complicated by constrictive pericarditis (CP) that was treated with right-sided pericardiectomy, NSAIDs, colchicine, and steroids. Echo showed LVEF of 55% with thickening of the pericardium, abnormal septal bounce, tethering of the right atrium, respiratory variation in flow across the mitral and tricuspid valves and IVC plethora. Cardiac MRI showed diffuse mild thickening of residual left-sided pericardium, mild diffuse circumferential pericardial enhancement, mild diastolic septal bounce, diastolic restraint, exaggerated inspiratory flattening and conical deformity of the ventricles without evidence of myocardial inflammation or scarring. Right heart catheterization showed near equalization of RV and LV pressures, RV and LV respiratory concordance, aortic pulsus paradoxus with an inspiratory decrease of 15 mmHg, and Kussmaul’s sign with an inspiratory increase in RA pressure of 68 mmHg. Left heart catheterization showed normal coronaries. The patient was diagnosed with CP and underwent repeat pericardiectomy and was treated with NSAIDs and diuretics. On follow-up, patient had symptomatic improvement but still had evidence of residual constriction on echocardiogram. Discussion: Pericardiectomy is the definitive treatment for CP, however it carries high morbidity and mortality rates. Recurrence of constrictive pericarditis requiring repeat pericardiectomy is very rare and risk factors for recurrence are not well-defined. His initial pericardiectomy was complicated with evidence of active visceral epicarditis with epicardial constriction. This case suggests that active inflammation at the time of pericardiectomy is a potential risk factor for recurrent CP requiring repeat pericardiectomy, and surgery should be deferred until the active inflammation has subsided.

Abstract 11155: Recovery of Tricuspid Valve Function After Resection of a Primary Ovarian Carcinoid Tumor

Case Presentation: A 51-year-old woman presented with a >1-year history of bilateral leg edema, diarrhea, and facial flushing. Examination revealed a large abdominal mass, which CT scan confirmed to be a 15x11x13 cm ovarian mass with solid and cystic components. She underwent hysterectomy and bilateral salpingo-oophorectomy. Histopathology revealed a 17 cm ovarian dermoid cyst containing an insular carcinoid tumor. Her post-operative urinary 5-hydroxyindoleacetate (HIAA) level was 23 umol/d (normal 10-40 umol/d) and chromogranin-A level was 95 ug/L (normal <94 ug/L), but positron emission tomography (PET) scan showed lymph node metastasis, prompting initiation of lanreotide, a somatostatin analogue. A perioperative echocardiogram revealed thickened, fixed, and retracted tricuspid and pulmonic valves with severe tricuspid and pulmonary regurgitation consistent with carcinoid heart disease. The right ventricle was dilated but showed preserved systolic function. Valve intervention was considered but deferred as right heart catheterization 15 weeks after surgery showed normal right-sided pressures. A follow-up echo 8 months post resection showed unchanged pulmonary regurgitation but significant improvement in tricuspid valve mobility with a corresponding reduction in tricuspid regurgitation to a mild-to-moderate level. Discussion: Thickened and fixed tricuspid valve leaflets with significant regurgitation represents a hallmark of carcinoid heart disease that can lead to progressive right heart failure, often necessitating surgical intervention. This is a rare case of carcinoid heart disease where there was marked improvement in tricuspid valve function after surgical resection of a primary carcinoid tumor and initiation of somatostatin analog therapy. It highlights the potential for timely treatment to reverse the deleterious effects of carcinoid tumors on cardiac valves, which may ultimately spare the need for cardiac surgery.

Acute heart failure associated with toxic shock syndrome due to methicillin-susceptible Staphylococcus aureus during the postpartum period: case report and systematic literature review

BackgroundToxic shock syndrome (TSS) caused by Staphylococcus aureus in the postpartum period is a rare but life-threatening disease. We present a case of acute heart failure as the initial presentation of TSS due to methicillin-susceptible Staphylococcus aureus (MSSA) and describe its clinical characteristics with a systematic literature review.Case presentationA 34-year-old woman, 8 days after a normal vaginal delivery presented to our hospital with dyspnea and fever. She had jugular venous distension, bilateral leg edema, and erythema. Laboratory examinations revealed elevated NT-pro-BNP level of 3,233 pg/mL. Transthoracic echocardiography showed elevated tricuspid regurgitation peak gradient, with decreased respiratory variability of the inferior vena cava diameter and bilateral pleural effusions. The patient was hospitalized with suspicion of congestive heart failure. MSSA positive for toxic shock syndrome exotoxin-1 was detected in the culture of the perineal incision wound, and we diagnosed TSS caused by MSSA. Intravenous diuretics were administered, along with eventual cefazolin plus clindamycin. After 2 weeks of antimicrobial therapy, the patient showed improvement and was discharged. No recurrence was observed at the 24-month follow-up.ConclusionThis is a rare case report of acute heart failure being the initial manifestation of TSS due to MSSA in the postpartum period. Clinicians should consider TSS as a possibility in postpartum patients with acute heart failure. This systematic review provides insights into its clinical features, treatment regimens, and prognosis of TSS by S. aureus in the postpartum period. TSS requires an appropriate, prompt diagnosis, because delayed treatment can be fatal.

S3138 Primary Hepatic Angiosarcoma: A Rare Cause of Decompensated Pseudo-Cirrhosis and Acute Liver Failure

Introduction: Primary hepatic angiosarcoma (PHA) is a rare aggressive endothelial cell tumor which is seen in patients in their 60s and 70s with 3:1 male predominance. Industrial exposure to vinyl chloride, radium, chronic arsenic ingestion, anabolic steroid use, and iatrogenic exposure to thorotrast radiocontrast are some of the known etiologies for the development of PHA. Whereas, in most cases, attributable risk factors are rarely identified. Case Description/Methods: A 68-year-old male patient with NIDDM presented with chest pain and abdominal distension. Examination revealed marked ascites, abdominal tenderness, and bilateral leg edema. Labs were significant for thrombocytopenia and cholestatic pattern of liver enzymes with AST 94, ALT 47, ALP 413, T bilirubin 5.7. Paracentesis was negative for SBP or malignant cytology and was indicative of portal hypertensive ascites. Tumor marker workup was positive for CA 19-9 106.1, whereas negative for CEA 1.82, and AFP 2.7. CT A/P showed multifocal large heterogeneous enhancing lesions in the liver which were biopsied showing diffuse proliferation of abnormal vascular endothelial cells staining positive for CD34 and a diagnosis of PHA was made. With multifocal lesions, the patient was started on paclitaxel chemotherapy, which was eventually stopped with worsening liver function. The hospital course was complicated by hepatic encephalopathy and coagulopathy. The patient and the family later chose to transition to palliative therapy for comfort (Figure 1). Discussion: PHA is a rare and aggressive tumor with poor outcomes and an average survival rate of less than a year. Early diagnosis is challenging as it presents with nonspecific abdominal symptoms. With progression, PHA can present as decompensated pseudocirrhosis due to compression of liver parenchyma leading to portal hypertension. Contrast-enhanced US and CT can help in diagnosis by showing lesions characteristic of central non-enhancement and peripheral irregular enhancement in the arterial and portal phase, and complete wash-out in the late phase. A definitive diagnosis of PHA is established via histopathological analysis with immunohistochemistry staining but can make diagnosis more challenging due to the potential of associated bleeding. Surgical excision with negative surgical margins is the standard treatment for PHA which is localized and resectable. Multifocal and metastatic PHA is a radio-resistant tumor with a paucity of treatment options, however, TACE and/or salvage chemotherapy can be potentially attempted.Figure 1.: CT Abdomen pelvis showing multiple mass lesions occupying most of liver parenchyma.

Sprue-like disease possibly related to a single dose of methotrexate

Sir, Methotrexate is an antimetabolite commonly used in dermatology for inflammatory and autoimmune diseases, including psoriasis. Malabsorption secondary to treatment with methotrexate after its use in high doses and/or long-term has been described in the literature. However, only several cases of a sprue-like disease secondary to a low dose of methotrexate have been described. Herein, we report an exceptional case of a sprue-like disease after a single dose of methotrexate. A 43-year-old female was admitted to our department with psoriatic erythroderma (Figs. 1a and 1b). Treatment with MTX was administered at a dose of 12.5 mg/week as well as folic acid supplements. Three days later, the patient developed bilateral leg edema, associated with biological malabsorption syndrome (hypoalbuminemia at 19 g/L, hypocholesterolemia at 0.98 g/L, prothrombin time at 45%, blood glucose at the lower limit of 0.7 g/L, and normocytic normochromic anemia at 9.4 g/dL). A duodenal biopsy performed three weeks later revealed no villous atrophy (Fig. 2). The discontinuation of methotrexate led to the disappearance of the leg edema and the progressive correction of biological parameters.

Raw oyster consumption causing vibrio vulnificus bacteremia in ESRD patient

Vibrio is gram negative bacteria found in warm salty water [1]. Vibrio vulnificus is one of the most common species causing vibriosis in the United States [2]. It is associated with primary sepsis, skin infections as well as gastrointestinal tract infection. Here we present a case of Vibrio vulnificus bacteremia in a hemodialysis dependent ESRD patient [3], with h/o treated colon carcinoma, and liver cirrhosis presenting as bilateral leg edema rapidly escalating to septic shock.

Mechanical thromboprophylaxis is effective in reducing postoperative venous thromboembolism.

Venous thromboembolism (VTE) is a result of factors described by Virchow’s triad: venous stasis, hypercoagulability, and endothelial injury. Clinically manifested as pulmonary embolism (PE), deep vein thrombosis (DVT) or both, VTE is a major cause of postoperative morbidity and mortality, frequently occurring early after discharge from hospital. Venous stasis in surgical patients is multifactorial. Leg immobility during surgery under general or regional anaesthesia is usually followed by reduced mobility of variable magnitude and duration during the postoperative phase. Specific types of surgery such as bariatric surgery, or operations requiring high-pressure pneumoperitoneum, reverse Trendelenburg or lithotomy positions are likely to exaggerate venous stasis. During operative recovery, reduction in leg mobility may be the result of the waning effects of regional anaesthesia, pain (particularly when the procedure was performed on a leg), sedation for intubated patients or cognitive impairment, unilateral or bilateral leg oedema, or physician orders. Development of complications may also adversely affect patient mobility. Under-recognized causes of venous stasis include vein compression or infiltration by a pelvic tumour, and venous ligation because of injury during procedures such as excision of a pelvic tumour. Furthermore, operative venodilatation may cause endothelial injury to the leg veins.