Diffuse Spasm Research Articles

A Case of Churg-Strauss Syndrome With Necrotizing Crescentic Glomerulonephritis Accompanied by Acute Coronary Syndrome Due to Vasospasm

We report a case of Churg-Strauss syndrome coexistent with coronary vasospasm and pauci-immune necrotizing crescentic glomerulonephritis. A 54-year-old man with bronchial asthma and allergic rhinitis was admitted to our hospital because of acute coronary syndrome. Angiography showed diffuse coronary artery spasm without anatomic stenosis. Acute coronary syndrome due to vasospasm was diagnosed. However, subsequent administration of vasodilators did not suppress angina symptoms. In addition, marked eosinophilia, eosinophilic pneumonitis, chronic sinusitis, pericardial effusion, and slight hematuria with red blood cell casts were detected. Although kidney function was normal, a kidney biopsy showed necrotizing crescentic glomerulonephritis with eosinophilic infiltration in both glomeruli and interstitium. With the diagnosis of Churg-Strauss syndrome, oral prednisolone at a dose of 60 mg/d was administered. Cardiac symptoms, pulmonary and sinonasal lesions, pericardial effusion, and urine sediment resolved rapidly. Six months later, a repeated kidney biopsy showed remarkable improvement and no eosinophilic infiltration. Coronary vasospasm with eosinophilia might be refractory to vasodilators and sensitive to corticosteroid therapy and often has been related to Churg-Strauss syndrome. Slight abnormalities in urine sediment can be the clue to the diagnosis of severe kidney involvement of Churg-Strauss syndrome.

Coronary Artery Dissection After Surgical Cryoablation Procedure

Cryoablation can be used to treat atrial fibrillation (AF) surgically. We describe a 71-year-old woman who underwent cryoablation after 6 months of AF. Four hours post-surgery, electrocardiographic changes were observed in the circumflex artery territory associated with hemodynamic instability, which responded to inotropic agents. Angiography revealed a diffuse circumflex artery spasm with a heterogeneous aspect of the posterior branch evoking a dissection. Platelet anti-aggregant and trinitrine therapy were started. Recovery was uneventful and the patient was discharged on day 13. Cryoablation-associated circumflex artery dissection is rare. Caution is required when locating the ablation lines to avoid coronary artery injury.

Diffuse coronary artery spasm treated by extracorporeal membrane oxygenation

Diffuse coronary vasospasm is an unpredictable and serious complication following coronary artery bypass surgery. The treatment of this emergency is dependent on patient suitability for angiography and direct injection of vasodilators into the affected vessels. In patients unable to proceed to angiography the diagnosis can only be suspected but treatment is nevertheless still towards reinstitution of coronary blood flow. We present one such case in which re-grafting and extracorporeal membranous oxygenation proved successful in restoring cardiac function in a patient with diffuse coronary artery spasm.

Transient Lower Esophageal Sphincter Relaxation in Morbid Obesity

There is strong evidence that morbid obesity is often accompanied by gastroesophageal reflux. Gastroesophageal reflux is caused predominantly by transient lower esophageal sphincter relaxations (TLESRs). Only few data are available about TLESRs in patients with stage III obesity (body mass index > 35). The aim of this study was to analyze the frequency and types of TLESRs in patients with morbid obesity in different physiological stages (postprandial: upright and recumband) compared to patients with normal weight gastroesophageal reflux disease (GERD) and diffuse esophagus spasm (DES). In order to measure TLESRs in obese patients with and without GERD, three subgroups were prospectively performed: group I consisted of seven healthy controls, group II consisted of seven obese patients, group III consisted of seven non-obese patients with GERD, and in group IV, five patients were recruited with diffuse esophageal spasm. All participants underwent both conventional water-perfused stationary esophagus manometry and a 24-h ambulatory esophagus manometry, 24-h ambulatory pH monitoring, and esophago-gastroscopy. In order to measure the lower esophageal sphincter pressure (LESP) over a prolonged time under physiological conditions, a special solid-state sleeve catheter was used. Additionally, all patients were interviewed using a standardized questionnaire. Compared to normal subjects, patients with morbid obesity and patients with gastroesophageal reflux show a substantial increase of TLESRs in the postprandial phase. There was a tendency towards more TLESRs per hour in patients with DES than in healthy subjects, but the difference was not statistically significant. The types of TLESRs differed with the LESP. The majority of isolated TLESRs were complete and incomplete. Some of the isolated TLESRs were accompanied by contractions of the tubular esophagus. Morbid obesity is associated with gastroesophageal reflux. The frequency of TLESRs has significantly increased compared to healthy subjects and does not differ statistically from patients with GERD. Isolated TLESRs are mostly incomplete in patients with a hypotonic LES.

Diagnosis of chest pain with foregut symptoms in Chinese patients

To evaluate the diagnosis of chest pain with foregut symptoms in Chinese patients. Esophageal manometric studies, 24-h introesophageal pH monitoring and 24-h electrocardiograms (Holter electrocardiography) were performed in 61 patients with chest pain. Thirty-nine patients were diagnosed with non-specific esophageal motility disorders (29 patients with abnormal gastroesophageal reflux and eight patients with myocardial ischemia). Five patients had diffuse spasm of the esophagus plus abnormal gastroesophageal reflux (two patients had concomitant myocardial ischemia), and one patient was diagnosed with nutcracker esophagus. The esophageal manometric studies, 24-h intra-esophageal pH monitoring and Holter electrocardiography are significant for the differential diagnosis of chest pain, particularly in patients with foregut symptoms. In cases of esophageal motility disorders, pathological gastroesophageal reflux may be a major cause of chest pain with non-specific esophageal motility disorders. Spasm of the esophageal smooth muscle might affect the heart-coronary smooth muscle, leading to myocardial ischemia.

Postpartum Cerebral Angiopathy Mimicking Hypertensive Putaminal Hematoma: A Case Report

Objective: To present an emerging clinical entity which may mimick another common entity. Methods: A 31 year-old woman complained of sudden severe headache and collapsed. She had delivered by Cesarean section one week previously. She had a normal antenatal history and did not have any evidence of hypertension. Results: Clinical examination revealed her to be in altered sensorium, GCS E2V2M5 with reduced movements on the left side. CT scan showed a large right putaminal hematoma with mass effect and midline shift. MRI also showed the hematoma but the MRV was normal. Despite antiedema measures and hyperventilation, the patient continued to deteriorate and so underwent right hemicraniectomy. MRA was done postoperatively and showed diffuse spasm of both middle cerebral arteries. A diagnosis of postpartum cerebral angiopathy was made and she was put on methylprednisolone and other antiedema measures were continued. With this she improved significantly. At one year she had residual hemiparesis but had returned to work. Four-vessel angiogram repeated 1 year later showed no arterial spasm. She later had cranioplasty to cover the defect. Conclusions: This case is presented to show that in a postpartum patient, if she presents with putaminal hematoma, postpartum angiopathy needs to be suspected and appropriate investigations and treatment, including steroids, should be given as the overall prognosis is good.

Severe diffuse coronary artery spasm in the early phase of cardiogenic shock

Coronary artery vasospasm rarely appears as a diffuse phenomenon that involves all the coronary tree. We present a clinical case of acute myocardial infarction complicated by ventricular fibrillation and cardiogenic shock. Urgent coronary angiography showed occlusion of proximal Circumflex coronary artery and a TIMI I flow in the left anterior descending artery due to severe, diffuse coronary vasospasm. Patient was successfully treated with intra-aortic balloon pump and intracoronary bolus of nitroglycerin with restoration of flow in left coronary branches and complete resolution of shock.

Variant(Prinzmetal)-Angina mit diffusem Koronarspasmus ohne Koronarsklerose

A 49-year-old man developed, over a period of three years, progressively more frequent nocturnal attacks of angina and palpitations. Exercise electrocardiogram was negative. 24-hour Holter monitoring revealed ventricular extrasystoles and tachycardia with ST segment elevations. The dominant left coronary artery, which was free of atherotic changes, went into diffuse spasm after ergonovine administration, accompanied by angina and ventricular extrasystoles. Registration of spontaneous ischaemia confirmed the diagnosis of variant (Prinzmetal) angina. Administration of twice daily 90 mg diltiazem retard and once daily 120 mg isosorbide dinitrate retard at night ended the spasms and with it the attacks of angina and the arrhythmias. This case illustrates that typical angina and ventricular tachyarrhythmias can be caused by spontaneous coronary spasms, even in the presence of normal exercise ECGs and coronary angiograms. If coronary artery spasms are not detectable by ECG, the ergonovine test may further the diagnosis.

Botulinum Toxin Use as an Adjunctive Modality in a Patient with Multiple Flexor Tendon Ruptures

Botulinum toxin A has been described in treatment protocols for several disease processes, from primary axillary hyperhydorosis to esophageal dysfunction. It is best known for its use in plastic and dermatological practices. Botulinum toxin has a straightforward mechanism of action. The toxin inhibits acetylcholine release at the neuromuscular junction causing a chemical denervation, which ceases contractions of the muscle. With its minimal side effect profile, botulinum toxin should be considered when muscle spasm is a detriment. This case involves an injury to the hand of a patient with a history of intermittent diffuse muscle spasms. Subsequently, due to the patient's previous upper extremity muscle spasms, repeated flexor tendon repair ruptures of the index finger occurred until botulinum toxin was administered to the offending muscle. The patient has not required any additional surgical interventions for the repaired tendon and is now actively flexing all digits. This case report demonstrates how botulinum toxin can be used in a clinical scenario when decreased muscle activity is desired to promote tendon healing.

Ergotamine-induced lower extremity arterial vasospasm presenting as acute limb ischemia

Ergotamine-induced limb ischemia is rare and usually results from an accidental overdose. Several agents, including erythromycin and tetracycline, raise serum ergotamine levels and augment its effect. We present a case of acute lower limb ischemia with characteristic angiography findings of diffuse arterial spasm resulting from use of ergotamine and an erythromycin derivative, clarithromycin. The history of the patient and classic features seen on angiography helped us establish the diagnosis. The patient was successfully treated with low molecular heparin and epidural infusion of bupivacain. Since ergot vasospasm is a self limited and medically treatable condition, interventional radiologists must be aware of ergotamine-induced acute limb ischemia to avoid any unnecessary interventional procedures, unless necrosis and gangrene are imminent.

Sildenafil relieves symptoms and normalizes motility in patients with oesophageal spasm: a report of two cases

Oesophageal spasm presents with dysphagia and chest pain. Current treatments are limited by poor efficacy and side effects. Studies in health and oesophageal dysmotility show that sildenafil reduces peristaltic pressure and velocity; however the clinical efficacy and tolerability in symptomatic oesophageal spasm remains uncertain. We provided open-label sildenafil treatment to two patients with severe, treatment resistant symptoms associated with oesophageal spasm. The effects of sildenafil on oesophageal function and symptoms were documented by high resolution manometry (HRM). Patients were followed up to assess the efficacy of maintenance treatment with sildenafil b.i.d. HRM revealed focal and diffuse spasm in the smooth muscle oesophagus that were associated with symptoms in both cases, especially on swallowing solids. Lower oesophageal sphincter function was normal. A therapeutic trial of 25-50 mg sildenafil suppressed oesophageal contraction almost completely for water swallows; however effective, coordinated peristalsis returned with reduced frequency of spasm for solid swallows. Dysphagia and chest pain resolved during the therapeutic trial and efficacy was maintained on maintenance treatment with 25-50 mg sildenafil b.i.d. without troublesome side effects. This report shows that sildenafil can improve oesophageal function and relieve dysphagia and chest pain in patients with oesophageal spasm in whom other treatments have failed.

Clinical and Angiographic Characteristics of Acute Myocardial Infarction Caused by Vasospastic Angina Without Organic Coronary Heart Disease

Vasospastic angina (VA) can occasionally cause acute myocardial infarction (AMI). From January 2003 to June 2005, coronary spastic angina was diagnosed in 292 patients by performing spasm provocation tests. Among the 292 patients, 21 (7.2% of all the VA patients) had an AMI. There were 20 patients who initially visited the emergency room for AMI without suffering prior VA. One patient with a history of VA had an AMI when he discontinued his medication. Among the 21 VA patients with AMI, 14 had experienced severe emotional stress before they visited the emergency room. The spasm provocation test showed that the VA patients with AMI had more multivessel and diffuse spasm than the VA patients without AMI (p<0.001). Clinically, the VA patients with AMI usually had their first symptom of VA as the severe chest pain of AMI. Two-thirds of the VA patients with AMI had experienced emotional stress before their AMI. Angiographically, the spasm provocation test for VA patients with AMI showed more multivessel and diffuse spasm than in VA patients without AMI.

Esophageal Ultrasonography: A New View on Esophageal Motility

Esophageal manometry has long been the gold standard for assessment of esophageal motility. Recently, high-frequency intraluminal ultrasonography (HFIUS) has been introduced to measure esophageal contractility and the thickness of esophageal muscle. Greater esophageal muscle thickness has been reported in patients with achalasia, diffuse spasm, and hypertensive peristalsis. In this issue of the Journal, Mittal and colleagues report additional observations in patients with esophageal symptoms referred for esophageal manometry. Their findings confirm earlier observations in patients with spastic motor disorders and report new findings of greater muscle thickness in patients with nonspecific motor disorders as well as normal manometry. Greater muscle thickness was associated with a greater prevalence of dysphagia suggesting the possibility that symptoms may be related, at least in part, to alterations in the biomechanics of the esophagus. The place of HFIUS in the assessment of esophageal function remains to be determined, but it offers the possibility of greater insights into esophageal physiology as well as clinical esophageal motor disorders.

Coronary Artery Multistenting in the Treatment of Life-Threatening Refractory Coronary Spasm After Coronary Artery Bypass Grafting

A 74-year-old man had undergone on-pump coronary artery bypass grafting (CABG) for effort-induced angina pectoris. Soon after CABG using the left internal thoracic artery for the left anterior descending artery and saphenous vein for the left circumflex artery, ST elevation was found in the inferior leads and complete atrioventricular block, ventricular tachycardia, and circulatory collapse occurred. Emergent coronary angiography revealed diffuse severe spasm of the right coronary artery (RCA). Despite the intravenous and intracoronary administration of massive doses of vasodilators and intra-aortic balloon pumping, the coronary spasm did not resolve. Five stents were deployed from the distal to the proximal portion of the RCA. After multistenting, coronary flow was dramatically improved and the ST elevations in the inferior leads were also improved. Coronary artery spasm after CABG is relatively rare, but when it occurs, it can be fatal. Multistenting is a useful treatment for life-threatening refractory coronary spasm after CABG.

Motor disturbances participate in the pathogenesis of eosinophilic oesophagitis, beyond the fibrous remodelling of the oesophagus

Motor disturbances participate in the pathogenesis of eosinophilic oesophagitis, beyond the fibrous remodelling of the oesophagus

Patients with low-amplitude simultaneous oesophageal contractions are notably similar to diffuse spasm patients in age, gender and symptom profile

Gastrointestinal Investigation Unit, University of Sydney, Royal North Shore Hospital, Sydney, Australia Special Issue of the 8th World Congress of OESO Avignon, September 3–6, 2006 Oral, Video and Poster Sessions

Severe Hepatic Artery Spasm and Nonocclusive Mesenteric Ischemia After Cardiac Surgery

Non-occlusive mesenteric ischemia (NOMI) is a life-threatening condition, and renal failure is one of its underlying factors [1]. A 64-year-old woman with a 26-year history of hemodialysis underwent aortic and mitral valve replacement for calcific valvular stenoses. Her early postoperative course was good, but she suddenly fell into a state of shock 6 days after surgery. Severe metabolic acidosis and abdominal pain suggested intestinal necrosis. An emergency angiography revealed a typical finding of NOMI [1], namely, severe diffuse spasm of the superior mesenteric artery (Fig 1).

Heart Failure Resulting from Chemotherapy for Testicular Neoplasm: A Follow-Up on a Patient Reported 20 Years Earlier

Heart Failure Resulting from Chemotherapy for Testicular Neoplasm: A Follow-Up on a Patient Reported 20 Years Earlier

Intracoronary Adenosine Triphosphate for Refractory Coronary Artery Spasm

A 62-year-old woman underwent aortic valve replacement for aortic stenosis. Her hemodynamics deteriorated with ST-T depression 6 hours postoperatively. Emergency coronary catheterization showed diffuse right coronary artery spasm. The spasm persisted despite intracoronary infusion of nitrates and calcium antagonists. Intracoronary adenosine triphosphate infusion finally resolved the spasm and stabilized the cardiac function.

Primary disorders of oesophageal motility.

Primary motor disorders of the oesophagus have distinct manometric patterns but require full oesophageal investigation to exclude a secondary cause. Myotomy and forceful dilatation give good results in achalasia, though myotomy is superior in the long term. Indications for surgery are rare in diffuse spasm and nutcracker oesophagus. Non-cardiac chest pain may be related to reflux, diffuse spasm or nutcracker oesophagus, but correlation between motor abnormalities and symptoms is poor and psychological disturbances are frequent.