Dizzy Spells Research Articles

Survey of Physicians and Healers Using Amygdalin to Treat Cancer Patients.

Amygdalin is purported to exhibit anti-cancer properties when hydrolyzed to hydrogen cyanide (HCN). However, knowledge about amygdalin efficacy is limited. A questionnaire evaluating the efficacy, treatment, and dosing protocols, reasons for use, HCN levels, and toxicity was distributed to physicians and healers in Germany, providing amygdalin as an anti-cancer drug. Physicians (20) and healers (18) provided amygdalin over 8 (average) years to nearly 80 annually treated patients/providers. Information about amygdalin was predominantly obtained from colleagues (55%). Amygdalin was administered both intravenously (100%) and orally (32%). Intravenous application was considered to maximally delay disease progression (90%) and relieve symptoms (55%). Dosing was based on recommendations from colleagues (71%) or personal experience (47%). If limited success became apparent after an initial 3g/infusion, infusions were increased to 27g/infusion. Treatment response was primarily monitored with established (26%) and non-established tumor markers (19%). 90% did not monitor HCN levels. Negative effects were restricted to a few dizzy spells and nausea. Only 58% were willing to participate in clinical trials or contribute data for analysis (34%). Amygdalin infusions are commonly administered by healers and physicians with few side effects. The absence of standardized treatment calls for guidelines. Since intravenous application bypasses metabolization, re-evaluation of its mode of action is required.

Prevalence of Hyperventilation Syndrome among Covid-19 Recovered Patients

Background: Coronavirus causes respiratory impairment in humans. In the post-acute care of COVID-19 survivors, persistent cardiorespiratory problems, such as tachycardia, dyspnea, muscle weakness, exercise intolerance, and hypocapnia due to Hyperventilation Syndrome (HVS), have been reported. Other symptoms include depression, anxiety, arthralgia, headache, and palpitations. Objective: The objective of this study was to determine the prevalence of Hyperventilation Syndrome among COVID-19 recovered patients. Methods: This cross-sectional descriptive study was conducted using a sample size of 377 participants, calculated via Raosoft. Non-probability convenience sampling was employed. Data were collected using the Nijmegen Questionnaire (NQ) and a demographic form. Participants were recruited through social media platforms and the University of South Asia (Lahore Cantt). Eligible participants were aged 17-60 years, both male and female, who had tested positive for COVID-19 and recovered. Exclusion criteria included any history of respiratory complaints such as asthma, chronic obstructive pulmonary disease, pneumonia, and chronic bronchitis. Data analysis was performed using SPSS version 25. Results: Out of 377 participants, 148 (39.26%) were male and 229 (60.74%) were female. The mean age was 29.92 years (SD = 9.734). Among the participants, 240 (63.66%) were found to have Hyperventilation Syndrome, while 137 (36.34%) did not exhibit HVS. The most frequently reported symptoms included feeling of anxiety (41.91%), palpitations (20.95%), feeling of confusion (13.26%), feeling tense (11.41%), dizzy spells (10.88%), and blurred vision (37.93%). Conclusion: Hyperventilation Syndrome is a significant post-COVID-19 complication that affects a substantial proportion of recovered patients, leading to breathing impairments and affecting their quality of life. The study highlights the need for continued monitoring and targeted interventions for managing respiratory symptoms in COVID-19 survivors.

An Unusual Cause of Increasing Excessive Daytime Sleepiness in a CPAP-treated Obstructive Sleep Apnea Patient

AbstractThe onset of narcolepsy type 1 (NT1) occurs after 50 years of age in less than 2% of the cases. In older adults, the diagnosis is often delayed due to the presence of neurological degenerative and inflammatory comorbidities and overlapping sleep disorders.We report the case of a 63-year-old man with a 5-year history of excessive daytime sleepiness (EDS) and a 2-year diagnosis of obstructive sleep apnea syndrome (OSAS), which. OSAS was confirmed by respiratory polygraphy that showed an apnea-hypopnea index (AHI) of 71 events/hour of sleep associated with significant nocturnal hypoxemia (lowest oxygen saturation: 53%), which lead to the initiation of continuous positive airway pressure (CPAP) treatment. Cognitive complaints, unexplained spells of dizziness, and lack of improvement in EDS with CPAP led to further diagnostic investigation of infectious, inflammatory, and neurodegenerative disorders. Low hypocretin levels in the cerebrospinal fluid (CSF) confirmed the diagnosis of NT1, and the patient's symptoms improved with the treatment with pitolisant.Though exceptional in older adults, NT1 should be suspected in the presence of atypical EDS with neurological complaints, unexplained dizzy spells, or OSAS that resists the CPAP treatment. Low levels of hypocretin in the CSF are highly specific and rule out other neurological and sleep disorders.

What's in a Name? Chronic Vestibular Migraine or Persistent Postural Perceptual Dizziness?

Current consensus diagnostic criteria for vestibular migraine (VM) describes this as an episodic disorder. However, a minority of patients report prolonged (>72 h duration) or even persistent VM symptoms, prompting whether a chronic variant of vestibular migraine (CVM) should be introduced to the current classification and how best to define it. Here we summarize current evidence of such a potential chronic variant of VM and critically review proposed definitions for CVM. Potential approaches to establish a diagnostic framework for CVM include (a) following the distinction between episodic and chronic migraine headaches, namely, frequent and/or prolonged episodes of VM (but not persistent vertigo or dizziness) in the context of chronic migraine headaches or (b) daily dizzy spells over more than 6 months that responded well to prophylactic anti-migraine therapy. A key challenge when defining diagnostic criteria for CVM is how to distinguish it from other chronic vestibular syndromes such as motion sickness, persistent postural-perceptual dizziness (PPPD), and mal de débarquement syndrome. Indeed, more than 50% of patients with PPPD and up to 46% with mal de débarquement syndrome fulfil diagnostic criteria for episodic migraine headaches, suggesting these disorders may all lie along a spectrum. We propose that when VM becomes persistent, it is best classified as PPPD but that VM and PPPD are not mutually exclusive, such that patients with PPPD need not have features of VM, and the triggering event for persistent dizziness may be independent of migraine. However, further research is needed to better characterize the spectrum of clinical phenotypes in patients with chronic dizziness, migraine headaches and anxiety, to define whether a chronic variant of VM sufficiently differs from current persistent dizziness definitions.

New Insights on DR and DQ Human Leukocyte Antigens in Anti-LGI1 Encephalitis.

To explore the clinical characteristics and HLA associations of patients with anti-leucine-rich glioma-inactivated 1 encephalitis (LGI1E) from a large single center in Israel. Anti-LGI1E is the most commonly diagnosed antibody-associated encephalitic syndrome in adults. Recent studies of various populations reveal significant associations with specific HLA genes. We examined the clinical characteristics and HLA associations of a cohort of Israeli patients. Seventeen consecutive patients with anti-LGI1E diagnosed at Tel Aviv Medical Center between the years 2011 and 2018 were included. HLA typing was performed using next-generation sequencing at the tissue typing laboratory of Sheba Medical Center and compared with data from the Ezer Mizion Bone Marrow Donor Registry, containing over 1,000,000 samples. Our cohort displayed a male predominance and median age at onset in the 7th decade, as previously reported. The most common presenting symptom was seizures. Notably, paroxysmal dizziness spells were significantly more common than previously reported (35%), whereas faciobrachial dystonic seizures were found only in 23%. HLA analysis revealed overrepresentation of DRB1*07:01 (OR: 3.18, CI: 20.9 p < 1.e-5) and DRB1*04:02 (OR: 3.8, CI: 20.1 p < 1.e-5), as well as of the DQ allele DQB1*02:02 (OR: 2.8, CI: 14.2 p < 0.0001) as previously reported. A novel overrepresentation observed among our patients was of the DQB1*03:02 allele (OR: 2.3, CI: 6.9 p < 0.008). In addition, we found DR-DQ associations, among patients with anti-LGI1E, that showed complete or near-complete linkage disequilibrium (LD). By applying LD analysis to an unprecedentedly large control cohort, we were able to show that although in the general population, DQB*03:02 is not fully associated with DRB1*04:02, in the patient population, both alleles are always coupled, suggesting the DRB1*04:02 association to be primary to disease predisposition. In silico predictions performed for the overrepresented DQ alleles reveal them to be strong binders of LGI1-derived peptides, similarly to overrepresented DR alleles. These predictions suggest a possible correlation between peptide binding sites of paired DR-DQ alleles. Our cohort presents distinct immune characteristics with substantially higher overrepresentation of DRB1*04:02 and slightly lower overrepresentation of DQB1*07:01 compared with previous reports implying differences between different populations. DQ-DR interactions found in our cohort may shed additional light on the complex role of immunogenetics in the pathogenesis of anti-LGI1E, implying a possible relevance of certain DQ alleles and DR-DQ interactions.

Vertigo/dizziness following COVID-19 vaccination

PurposeThis study assessed the vertigo/dizziness in patients following COVID-19 vaccination. Patients and methodsFrom July 2021 to June 2022, totaling 50 patients with dizzy spells following COVID-19 vaccination by AZ (AstraZeneca-Oxford University, AZD1222), BNT (Pfizer-BioNTech, BNT162b2) or Moderna (Moderna, mRNA-1273) vaccine were enrolled in this study. The interval from vaccination to the onset of vertigo/dizziness was compared with inter-episodic interval of vertigo/dizziness in the same patients, but without vaccination, during past one year (2020). ResultsThe incidences of severe systemic complication per 106 shots were 0.86 for Moderna vaccine, 1.22 for AZ vaccine, and 1.23 for BNT vaccine. Conversely, rate of post-vaccination vertigo/dizziness was noted in the Moderna group (66 %), followed by the AZ group (20 %) and the BNT (14 %) group, meaning that type of COVID-19 vaccine may affect various organ systems. The median time to the onset of vertigo/dizziness following vaccination is 10d, which is consistent with the onset of IgG production, and significantly less than inter-episodic interval (84d) in the same patients without vaccination. ConclusionPost-vaccination vertigo/dizziness can manifest as exacerbation of previous neurotological disorder. The median time to the onset of vertigo/dizziness following COVID-19 vaccination is 10d. Since the outcome is fair after supportive treatment, the immunomodulatory effect of the vaccines does not undermine the necessity of the COVID-19 vaccination.

Giant Cell Arteritis of the Superior Mesenteric Artery Presenting With Wernicke Encephalopathy From Thiamine Deficiency

Objective N/A. Background Giant cell arteritis (GCA) is one of the most common systemic vasculitides in adults over the age of 50 with incidence ranging from 15 to 35 per 100,000 individuals. The disorder is often included in the differential diagnosis of maladies producing atypical facial pain, headache, visual loss, amaurosis fugax, jaw pain, elevated inflammatory markers, and anemia. GCA is typically known to affect cranial arteries with physical exam findings of tenderness to palpation of the temporal arteries and cranial neuropathies. Clinical diagnosis is further supported by new headache, temporal artery abnormality, elevated ESR (= 50 mm/h), and abnormal artery biopsy. Design/Methods N/A. Results A 68-year-old female with history of primary generalized seizures presented to clinic with a 6-week history of paroxysms of acute confusional episodes, the inability to arise from a seated position due to lower extremity weakness bilaterally, alterations of consciousness without loss of consciousness, severe anorexia, and weight loss. MRI with contrast including Axial FLAIR/T2/Diffusion revealed bilateral pan-lobar cortical and subcortical atrophy with ex-vacuo ventriculomegaly and mild leukoaraiosis in the subcortical white matter tracts. PET-CT body revealed linear uptake involving the aortic root, extending into subclavian arteries bilaterally with segmental involvement of proximal common carotids, and extending inferiorly to the level of the common iliac arteries and the mesenteric arteries. Temporal artery biopsy revealed presence of granulomas with multinucleated giant cells. Serology panel revealed pan hypovitaminoses in Vitamins A, B1, B6, B12, and D. Conclusions Traditional GCA workup initially resulted inconclusive for the patient, whose condition deteriorated as the patient's altered mental status and dizziness spells continued unremittingly. This case highlights the link between large vessel vasculitis and malabsorption syndromes, with the involvement of the superior mesenteric artery, a medium sized vessel, in GCA previously unrecognized. Furthermore, this case is a superb example of multiple etiologies of treatable causes of reversible dementia.

Cardiac implantable electronic devices: an overview for primary care.

Cardiac rhythm management (CRM) is the treatment of arrhythmias. Arrhythmias can cause a range of symptoms including palpitations, dizzy spells, blackouts, and sudden cardiac arrest. Contemporary management of arrhythmia may involve cardiac implantable electronic devices (CIEDs) and catheter ablation.1 CIEDs are used to manage slow and fast heart rates, and in the treatment of selected patients with heart failure. Types of CIED include permanent pacemakers (PPMs), implantable cardioverter defibrillators (ICDs), and cardiac resynchronisation therapy (CRT) devices. CIEDs are usually implanted under the skin, with one to three leads threaded down a vein to connect to the heart.1 ### PPMs: types and what they do

Brainstem Infarction and Vertebral Artery Vasculopathy After Ramsay Hunt Syndrome.

A 45-year-old man presented with right auricle rash, facial weakness, otalgia, deafness, and transient dizzy spells. He had leftward spontaneous, bidirectional gaze-evoked and unsuppressed leftward head-shaking nystagmus in head-shaking tilt suppression test (Figure 1). MRI results showed a subacute infarct on the right dorsolateral pons and medulla oblongata and incomplete flow void in the right vertebral artery. After acyclovir and dexamethasone therapy, the ischemic lesion and vascular narrowing on MRI vanished and the patient's symptoms disappeared (Figure 2). Concomitant intracranial vasculopathy and brainstem stroke may occur in Ramsay Hunt syndrome,1,2 which could be easily missed but possibly detected by careful eye movement assessments.

Ventricular Tachycardia Unveiling an Obstructive Cardiomyopathy Complicated with an Apical Aneurysm

Background: We report the case of a 58-year-old hypertensive patient under treatment who presented with a ventricular tachycardia unveiling an obstructive cardiomyopathy complicated with an apical aneurysm. Aim: Highlight the rarity of the case and the difficulty of management. Case Presentation: This patient was transferred from Regional Hospital of Ziguinchor in southern Senegal for a brutal dizzy spell without loss of consciousness. The electrocardiogram showed a wide monomorphic QRS complex regular tachycardia with a rate of 215 beats/min. An external electrical cardio version at 300 joules was applied which led to the recovery of a sinus rhythm on the electrocardiogram. The Doppler echocardiography showed an asymetricalmedio-ventricular hypertrophy with a maximum left intraventricular gradient at 10 mm Hg at rest. The coronarography via the radial artery was normal. The evolution was labeled with a recurrence of the ventricular tachycardia. The patient was then put on amiodarone 200 mg, beta-blocker (bisoprolol 10 mg) and anti-vitamin K (acenocoumarol 4 mg). Facing rhythmic instability, an implantable automatic defibrillator was fitted. No complication has been reported after one year of evolution. Conclusion: HCM with medio ventricular obstruction and apical aneurysm complicated with ventricular arrhythmias is a rare entity. Its management is difficult and controversial.

Clinical presentation and electrocardiographic features of Brugada syndrome in Iraq

Background: Brugada syndrome is a clinical entity composed of twelve leads electrocardiographic changes of coved or saddle shaped ST-segment elevation in V1 and V2 with serious ventricular arrhythmias which may cause sudden cardiac death. Objectives: The objectives of this study is to highlight the clinical presentation and the types of ECG changes of Brugada syndrome cases seen in Iraq and to orient physicians about this fatal condition. Patients and Methods: Patients presented with symptoms of palpitation, dizzy attacks or syncope and diagnosed as Brugada syndrome were included in this case series study. The diagnosis of Brugada syndrome based mainly on the typical coved or saddle shaped or variant ST-Segment elevation in electrocardiographic leads V1, V2. Results: Eighteen patients were included in this case series study. All are males. Age ranged from 15-45 Y. The presenting symptoms were palpitation in 12 patients, syncope in 8, dizzy spells and pre syncope in 14 and chest pain seen in 2. The arrhythmic events were clinically documented in 10. Monomorphic VT seen in 4, VF in 2, atrial fibrillation in 2 and atrial flutter in 2. Induced VF by EP study seen in 2. Type I Brugada ECG pattern was seen in 6 patients, type II in 4 and three of type III. Five showed a variant type of the syndrome. Family history of sudden cardiac death was seen in 8 patients while in 10 it was negative. ICD was implanted in 6 patients. In 12 patients (67%) the diagnosis of Brugada syndrome was missed during the provisional medical contacts. Conclusion: Brugada syndrome is not uncommon in Iraq but needs a high diagnostic suspicion through appreciating the symptomologies and electrocardiographic features of this fatal syndrome to plan management to prevent sudden cardiac death. Key words: Brugada syndrome, Iraq

Misdiagnosis of bradyarrhythmias in clinical practice in Iraq

Background and objective: Bradyarrhythmias are one of the many causes of syncope, pre-syncope, and dizzy spells. Missing the diagnosis of bradyarrhythmias, an underlying etiology of those symptoms, may lead to serious complications and even mortality. This study aimed to set a standard case definition of bradyarrhythmias, which will improve patient survival. Methods: Patients presented with partial or total loss of consciousness, who were misdiagnosed as other non-arrhythmic etiologies and later diagnosed as bradyarrhythmia, were included in this study. Diagnosis of bradyarrhythmias was reached by either 12 leads electrocardiography, Holter monitor, or electrophysiological study. Results: A total of 150 patients who fulfilled the definition of missed diagnosis of bradyarrhythmias were included. A total of 100 males and 50 females were collected over 10 years. The pre arrhythmic over-diagnosis included transient ischemic attacks in 35 patients, vertebrobasilar insufficiency in 40 patients, vertigo in 30 patients, and other nonspecific diagnoses in 45 patients. The final diagnosis of bradyarrhythmias was reached by electrocardiogram only in 45, Holter recording in 75, and electrophysiological study in 30. All the diagnosed cases of bradyarrhythmias received permanent pacemaker therapy. Conclusion: Misdiagnosis of bradyarrhythmias in patients presenting with syncope is not uncommon in clinical practice in Iraq, which may have a bad impact on patients' morbidity and mortality. Understanding the causative factors for the missed diagnosis can help set up an educational program to minimize this problem. Keywords: Misdiagnosis; Bradyarrhythmia; Syncope; Dizzy spells.

Effect of Video Games on the Otolithic Reflex System

Background: Video gaming (VG) has since the 1980s become increasingly ubiquitous entertainment among the adolescents and young adults. Many young people expe­rienced dizzy spells, but not vertiginous episodes, after playing VG. Objectives: This study performed ocular vestibular-evoked myogenic potential (oVEMP) and cervical VEMP (cVEMP) tests in subjects before and after engaging on VG to investigate the effect of VG on the otolithic reflex system. Methods: Twenty subjects who frequently played VG (>3 days per week) for more than 10 years were assigned to the long-term group. Another 20 subjects with engaging on VG <3 days per week or <10 years were assigned to the short-term group. Each subject underwent baseline oVEMP and cVEMP tests first, followed by playing VG for 1 h. Then, all subjects underwent the same paradigm. The “VG-year” is defined as frequency of VG playing within 1 week (day/week) multiplied by total length of VG engagement (year). Results: Engagement on VG rarely affected the oVEMP responses for either short- or long-term players. In contrast, the response rates of cVEMP significantly declined from pre-VG period (80%) to post-VG period (58%) in the short-term group, but not in the long-term group. The cutoff value for predicting absent cVEMP in VG engagement is 21 VG-year. Conclusion: Short-term engagement on VG may result in temporary cVEMP loss, while permanent cVEMP loss could be identified in long-term VG players. The cutoff value for predicting absent cVEMP in VG engagement is 21 VG-year, indicating that damage to the sacculo-collic reflex system could be anticipated in a subject who has played VG at least 1 h per session, 7 days weekly for 3 years.

"Antibody of Unknown Significance" (AUS): The Issue of Interpreting Antibody Test Results.

"Antibody of Unknown Significance" (AUS): The Issue of Interpreting Antibody Test Results.

Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient.

Introduction: This prospective cohort study determined which questions in patient history are most likely to identify symptoms that are independently associated with a diagnosis of benign paroxysmal positional dizziness (BPPV) in patients presenting with dizziness, and to evaluate whether the patient's age and type of BPPV are of influence.Methods: We included adult patients with dizziness referred to our dizziness center, Apeldoorn, the Netherlands, from December 2018 to November 2019. All patients completed a questionnaire, underwent vestibular testing and received a diagnosis. Symptoms strongly suggesting BPPV were tested with multivariable analysis to determine their independent associations with BPPV. Subgroup analysis was performed for patient age, and the type of BPPV.Results: We included a total of 885 patients, 113 of whom (13%) were diagnosed with BPPV. The duration of dizziness spells <1 min (Q2) and dizziness provoked by rolling over in bed (Q4) were independently associated with the diagnosis BPPV. Q2 showed a sensitivity of 43%, and a specificity of 75%; Q4 scored 81% and 68%, respectively. Overall, the way patients perceived their dizziness (vertigo, light-headedness or instability) was not independently associated with the diagnosis BPPV. In younger patients, light-headedness and instability decreased the likelihood of BPPV compared to vertigo.Conclusion: The most reliable predictors for BPPV in patient history are a short duration of the dizziness spell and provocation of dizziness by rolling over in bed. Unlike younger patients, elderly patients with BPPV do not only perceive the dizziness as vertigo, but also as a feeling of instability.

Cerebral vasospasm, intracardiac clot, wellens syndrome, and popliteal vein aneurysm in a hypercoagulable state in lassa fever

Background: Lassa fever could precipitate a condition of hypercoagulable state with multiple organ involvement. We report an unusual presentation of cerebral vasospasm, intracardiac clot, Wellens syndrome, and popliteal vein aneurysm in a case of Lassa fever. We demonstrate the use of noninvasive imaging in the diagnosis and management of hypercoagulable state in a first case presentation in Lassa fever. Methods: We present a 53-year-old Nigerian woman, with a high-grade fever (39°C) that was associated with chills, headaches, insomnia, anxiety, chest pain, diaphoresis, palpitation, general weakness, muscle aches in all extremities, muscle cramps, dizziness spells, hyperacusis, nausea, vomiting, diarrhea, hematochezia, and abdominal pain. She admitted that her home is infested with rodents. Physical examination revealed severe anemia. Laboratory tests including blood sample analysis and biochemistry were conducted. Lassa fever was confirmed using Lassa virus-reverse transcription-polymerase chain reaction tests. Electrocardiography (ECG), two-dimensional echocardiography, venous duplex ultrasound of the leg veins, and transcranial Doppler ultrasound were performed. Results: Blood tests showed electrolyte imbalance and hypertriglyceridemia. Ultrasound tests revealed intracardiac clots with dyskinetic apical septal wall motion abnormality, saccular aneurysm with popliteal venous thrombosis of the right leg popliteal vein, and cerebral vasospasm of the right internal carotid artery due to cardiogenic microemboli. ECG demonstrated Wellens syndrome. The patient was successfully treated with intravenous ribavirin, whole blood transfusion, broad-spectrum antibiotics, isosorbide dinitrate, pentoxifylline, metronidazole, antimalarial, dexamethasone, erythropoietin, anticoagulants (low-molecular-weight heparin and warfarin), and supportive care. Conclusion: Noninvasive ultrasound modalities were useful for early detection and treatment of hypercoagulable state in Lassa fever.

Post-Menopausal Symptoms

Menopause is a universal occurrence. Menopause refers to that time when woman's periods stop and her ovaries lose their reproductive function. Usually, this occurs between the age group of 45 and 55 years. A descriptive study was undertaken on post-menopausal symptoms among women in the selected urban community, Amritsar. This study included 100 post-menopausal women who were recruited by the convenient sampling technique. Tools for the data collection consisted of socio-demographic profile and the Standardised Women Health Questionnaire related to post-menopausal symptoms. The findings revealed that the mean age of post-menopausal women in the study was 64.13 ± 8.92 years, whereas the mean age at menopause was 47.11 ± 3.66 years. Majority (80%) of post-menopausal women had backache, followed by 76% had loss of appetite, 71% reported restlessness, 68% had difficulty in getting to sleep, and 64% felt miserable and sad. The findings of the study reveal that more than half (52%) of post-menopausal women were not able to cope up with symptoms and 43% agreed to have overall good quality of life. A large proportion of post-menopausal women also reported loss of appetite, loss of interest in things, dizzy spells, headache and poor memory. A larger study is required to generalise the findings.

Extremely rapid growth of a left atrial myxoma

A 56-year-old lady presented to the Accident and Emergency department with worsening shortness of breath, decreased exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, and recurrent dizzy spells. Symptoms had been persistent in the last one month but worsened over the last two weeks prior to presentation. She is a professional horse rider/trainer and has had multiple trauma to her hip following falls over the past 17 years. Her medical history includes previous small left cerebellar infarct 10 years ago, asthma, previous multiple trauma to the hip with open reduction and internal fixation (ORIF) to the pelvis and right hip replacement, awaiting left total hip replacement, spondylolisthesis L5/S1, previous pulmonary embolism two years prior, previous fall from a horse resulting in fractured clavicle (ORIF right clavicle) and ribs two years prior, lifetime non-smoker. She has had multiple computed tomography (CT) scans for these reasons which were available for comparison (Video1). At presentation, she was dyspneic at rest (NYHA IV) and tachycardic, bilateral crepitations with a soft mid diastolic murmur at the cardiac apex. D-dimer was 1407 ng/mL, with a mild Troponin T rise of 17 ng/L. Emergency department suspected pulmonary embolism and an urgent computed tomography pulmonary angiogram (CTPA) revealed a large filling defect in the left atrium (LA) measuring 6.2 cm by 4.2 cm (Figure 1). She was reviewed by the cardiologist and trans-thoracic echocardiogram confirmed a large mobile mass in the LA measuring 7.67 cm by 3.46 cm. The mass was attached to the left superior pulmonary vein area, plunged into the left ventricle obstructing the mitral orifice in diastole. Right ventricle was dilated with preserved function (Figure 2) (Video2). Her brain natriuretic peptide (BNP) was 4269 pg/mL. She was managed for decompensated heart failure due to obstructive atrial myxoma, commenced on diuretics, anticoagulation, and urgent referral made to the on-call cardiac surgeon. Based on the acute clinical condition and symptoms (frequent dizzy episodes) she was prioritized for out of hours emergency surgery. On induction, she became bradycardic and hypotensive (peri-arrest) but recovered after placing in a Trendelenburg position with right lateral rotation. The rest of the surgery was uneventful. Median sternotomy, bi-caval cannulation, and cardioplegic arrest was performed. Trans-septal approach was used; a large mass was noted, attached by a 2 cm wide base to the back of the LA between the left pulmonary veins; the mass was excised (Figure 3). No patch was required. The mitral valve was normal. The procedure was completed as per routine. Her post-operative course was uneventful. Histology confirmed a left atrial myxoma. At eight weeks follow-up her breathing had improved and she was back to her normal baseline with excellent exercise tolerance.

Clinical presentation of Long QT Syndrome in a case series study in Iraq

Background: Long QT syndrome is an important cause of arrhythmic death, and it is characterized by electrocardiographic changes and a prolonged QT interval. Patients may present with sudden cardiac death, recurrent syncope, and palpitation.Objective: Clinical orientation for the Long QT syndrome and minimizing its misdiagnosis to achieve high diagnostic index.Patients and Methods: Patients presenting with ventricular arrhythmias, syncope, dizzy spells, and prolonged, non-drug-induced QT interval from 2004 uptil 2019 at Al Nasirya Heart Center , Al Sulaimanya Heart Hospital, and Al Nahrain Teaching Hospital were enrolled in this study. All aptients studied clinically and followed up. Management included beta blocker drug therapy and ICD implantation.Results: Forty-two patients were included within 15 years, comprising 22 pediatric and 20 adult patients (26 males, 16 females). Ventricular fibrillation reported in 18 patients and ventricular tachycardia in five patients. Thirty-eight patients received beta blockers, and 85% showed marked reduction in ventricular arrhythmia events. Implantable cardioverter-defibrillator (ICD) was implanted in 34 patients.The diagnosis of Long QT syndrome was missed in 85% of cases during the provisional medical contacts .Conclusion: In this case series study patients with LQTS presented with syncope, recurrent dizzy spells or palpitation. The diagnosis requires high index of diagnostic suspicion.This case study is intended to orient physicians to diagnosis this fatal problem.

SUN-929 An Unusual Presentation of Insulinomas-Profound Hypophosphatemia

BACKGROUND: Insulin induces intracellular shift of phosphorus, causing hypophosphatemia. This is mild, transient and quiescent in normal persons. Persistent hyperinsulinemia in patients with depleted phosphorus stores can cause profound symptomatic hypophosphatemia. Clinical Case: A 36yr old man with MEN 1 presented in follow-up. His original manifestation of MEN 1 was familial primary hyperparathyroidism (pHPT) for which he had parathyroidectomy in 2009. At one of his endocrine clinic visits, he was noted to have asymptomatic hypophosphatemia with serum phosphorus of 2.4 (2.7–4.5 mg/dL) and mildly elevated PTH of 89 (9–77 pg/mL). This was presumed to be due to mild persistent/recurrent pHPT, and he was advised to increase dietary phosphorus intake. About a year later, he presented to the emergency room (ER) with palpitations and marked asthenia. Serum phosphorus was 1.0. He was treated with intravenous phosphorus and discharged on oral phosphorus replacement with advice to increase his dietary phosphate intake. Despite this, he continued to have recurrent spells of dizziness, weakness, palpitations, and marked hypophosphatemia several requiring repeat ER visits. His degree of mild pHPT remained stable and imaging studies to identify a possible cause for tumor induced osteomalacia with phosphate wasting was unrevealing. He volunteered at a follow up visit that he had a long history of low blood sugar spells (confirmed by fingerstick) that he had learnt to manage with frequent carbohydrate rich snacks. This prompted the consideration of a possible insulinoma as the cause for his persistent hypophosphatemia. Despite significant hypoglycemia on an abbreviated supervised fast, an OGTT and mixed meal test showed profound severe insulin mediated hypoglycemia. CGMS also showed multiple extended early morning severe hypoglycemic spells <50mg/dl over a 2 wk period. Multiple imaging tests were negative but a Gallium Dotatate scan revealed multiple areas of uptake in his pancreas. Endoscopic ultrasound of the pancreas demonstrated multiple masses in the pancreas: one 7 x 5 cm mass in the body and one 4 x 4 cm mass near the neck of the pancreas. Fine needle aspiration biopsy revealed well-differentiated neuroendocrine tumors. He had distal pancreatectomy and tumor enucleation of 5 tumors identified on intraoperative sonography. Histopathology confirmed multiple neuroendocrine tumors, with immunostaining for insulin. He has had no further episodes of hypophosphatemia since despite being off oral phosphate supplements. Conclusion: Profound hypophosphatemia can be the dominant presentation of persistent hyperinsulinemia seen in patients with insulinoma. Insulinomas and other causes of persistent hyperinsulinemia need to be considered in the differential diagnosis of persistent/recurrent hypophosphatemia.