History Of Chest Pain Research Articles

Spontaneous Pneumomediastinum in a Young Gentleman

Spontaneous pneumomediastinum (SPM) is defined as presence of free air or gas in the mediastinum. It may occur in young healthy individuals without serious underlying lung disease. SPM is a rare presentation at the Emergency Department; it typically occurs among tall and thin individuals. We report a case of spontaneous pneumomediastinum in a gentleman who presented with a short history of chest and neck pain after coming back from work. Neck radiograph showed neck subcutaneous emphysema and chest radiograph showed pneumomediastinum with no evidence of pneumothorax or rib fracture.

62-Year-Old Woman With Diarrhea, Vomiting, and Chest Pain

A 62-year-old woman presented to an outside emergency department with a 24-hour history of vomiting-associated chest pain. She described a nonradiating retrosternal ache with dyspnea and diaphoresis after multiple episodes of nonbilious and severe vomiting. Recent history was notable for amoxicillin/clavulanic acid–treated colitis. After failure to improve, she was diagnosed as having Clostridium difficile and completed 10 days of treatment with vancomycin. Two weeks prior to presentation, fidaxomicin was initiated because of persistent symptoms and ongoing stool positivity.

ORAL TUBERCULOSIS: A CASE REPORT

Oral tuberculosis (TB) manifestations are uncommon and usually secondary to pulmonary changes. A 41-year-old male patient presented with the chief complaint of a painful ulcer on tip of his tongue. He reported that the ulcer developed without any remarkable event such as mechanical trauma, vesicle formation, or systemic illness. There was history of cough, fever, and chest pain. Chest x-ray and samples of acid-fast bacilli were positive. A biopsy was performed, and histological finding showed typical findings of oral TB including intense granulomatous inflammatory features with small red rods of mycobacterial organisms as well as epithelioid cells and Langerhans giant cells. After suitable antituberculosis treatments, the oral TB ulcer was almost completely healed after 1 year. We present a case of oral TB affecting the tip of the tongue in a patient with pulmonary TB and emphasize the understanding of intraoral manifestations for early diagnosis and prompt treatment of TB. Oral tuberculosis (TB) manifestations are uncommon and usually secondary to pulmonary changes. A 41-year-old male patient presented with the chief complaint of a painful ulcer on tip of his tongue. He reported that the ulcer developed without any remarkable event such as mechanical trauma, vesicle formation, or systemic illness. There was history of cough, fever, and chest pain. Chest x-ray and samples of acid-fast bacilli were positive. A biopsy was performed, and histological finding showed typical findings of oral TB including intense granulomatous inflammatory features with small red rods of mycobacterial organisms as well as epithelioid cells and Langerhans giant cells. After suitable antituberculosis treatments, the oral TB ulcer was almost completely healed after 1 year. We present a case of oral TB affecting the tip of the tongue in a patient with pulmonary TB and emphasize the understanding of intraoral manifestations for early diagnosis and prompt treatment of TB.

Post-mortem CT: A Useful Tool to Confirm a Case of Suspected Sudden Cardiac Death

Sudden cardiac death (SCD) is defined as the unexpected death of an individual, not due to any extracardiac cause, occurring within one hour of symptom onset or within 24 hours of last being seen in good health if the death is unwitnessed. Forensic pathologists routinely encounter several SCD cases in their practice. The presentation of such cases can be of two types; firstly, with typical signs and symptoms suggestive of cardiac pathology, and secondly, devoid of any presentation history. This history helps forensic pathologists look for relevant findings during the autopsy examination. The authors intend to explore the feasibility of using advanced radiological techniques like post-mortem CT (PMCT) in determining the cause of death through a minimally invasive approach. In the present case, a 65-year-old male was found unresponsive at his residence on the morning of his death. He had a history of dull chest pain for the past two days, which had resolved after he self-prescribed a few medications. The presenting complaint of chest pain had started the intervening night prior to his death. The deceased was a known case of hypertension and was not compliant with treatment, as stated by the relatives. He was declared as brought dead by the treating emergency medicine physician at the Fortis Flt. Lt. Rajan Dhall Hospital and the body was sent by the authorities to the mortuary of the Department of Forensic Medicine, AIIMS, New Delhi for autopsy examination since an autopsy should be conducted by a government hospital or institute by law. PMCT depicted an alternate hyperdense and hypodense region circumferentially surrounding the heart, indicating hemopericardium. It was followed by a traditional autopsy and histopathology examination, which confirmed the presence of hemopericardium and left ventricular rupture associated with acute coronary insufficiency. Such cases with an indicative history, circumstantial evidence, and PMCT findings can be considered for minimal invasive autopsy. If the external findings indicate the application of physical force, then an explorative dissection could be done. Therefore, we conclude that PMCT can be used as a reliable tool for determining the cause of death in SCDs on a case-to-case basis.

Myocardial Infarction Due to Nonvalvular Papillary Fibroelastoma of the Left Coronary Sinus: The Importance of Multimodal Imaging

A 44-year-old woman with a history of type II diabetes and obesity presents, with a two- month history of syncope. In the week prior to presentation, she reported exertional angina. She presented to the emergency department with a 2-hour history of chest pain at rest (intensity 8/10 on the visual analog scale), that radiated to her left arm. Her blood pressure on presentation was 95/60 mmHg and heart rate was 88 bpm. The initial electrocardiogram demonstrated diffuse ST-segment depression and ST elevation in aVR (Figure 1).

Atypical Pulmonary Tuberculosis as the First Manifestation of Advanced HIV Disease-Diagnostic Difficulties.

Tuberculosis (TB) is the leading cause of morbidity, hospitalisations, and mortality in people living with HIV (PLWH). The lower CD4+ T-lymphocyte count in the course of HIV infection, the higher risk of active TB, and the higher odds for atypical clinical and radiologic TB presentation. These HIV-related alterations in TB presentation may cause diagnostic problems in patients not knowing they are infected with HIV. We report on a patient without any background medical conditions, who was referred to a hospital with a 4-month history of chest and feet pains, mild dry cough, fatigue, reduced appetite, and decreasing body weight. Chest X-ray revealed mediastinal lymphadenopathy, bilateral reticulonodular parenchymal opacities, and pleural effusion. A preliminary diagnosis of lymphoma, possibly with a superimposed infection was established. Further differential diagnostic process revealed pulmonary TB in the course of advanced HIV-1 disease, with a CD4+ T-lymphocyte count of 107 cells/mm3. The patient completed anti-tuberculous therapy and successfully continues on antiretroviral treatment. This case underlines the importance of screening for HIV in patients with newly diagnosed TB.

Identification of a novel FGFR2-KIAA1217 fusion in esophageal gastrointestinal stromal tumours: A case report

BackgroundGastrointestinal stromal tumours (GISTs) rarely arise in the esophagus. The clinical course and treatment options for esophageal GISTs are poorly understood because of their rarity. In general, the mutation spectrum of esophageal GISTs resembles that of gastric GISTs. Wild-type (WT) GISTs lacking KIT and PDGFRA gene mutations occasionally occur in adults; primary esophageal GISTs are commonly WT.Case presentationHerein, we report the case of a 41-year-old female patient who presented with a 1-week history of anterior upper chest pain. Chest computed tomography revealed a 3.7 cm × 2.8 cm × 6.7 cm soft tissue mass in the right posterior mediastinum adjacent to the esophagus. The patient underwent thoracoscopic mediastinal tumor resection and was subsequently diagnosed with an esophageal GIST. Neither KIT nor PDGFRA mutations were detected by Sanger sequencing; however, next-generation sequencing (NGS) identified an FGFR2-KIAA1217 gene fusion in the tumor tissue. No relapse was observed in this patient during the 8-month treatment-free follow-up period.ConclusionTo the best of our knowledge, this report is the first to describe an FGFR2-KIAA1217 fusion in a patient with a quadruple WT esophageal GIST. When WT KIT/PDGFRA GISTS are suspected, intensive genetic analysis is recommended, and obtaining a better molecular characterization of these tumours might reveal novel therapeutic avenues.

Factors Determining Primary Coronary Slow Flow Phenomenon among Opium Users and Non-users: A Case Control Study in Northern Iran.

Coronary slow flow phenomenon (CSFP) represents a clinical entity with recurrent chest pain leading to living impairment. The present study aimed to investigate whether opium use correlates with primary CSFP. This study included Iranian patients with suspected coronary artery disease who underwent myocardial perfusion imaging. Coronary blood flow was measured quantitatively using the thrombolysis in myocardial infarction (TIMI) frame count and slow flow was defined as TIMI grade 2 standard deviations. Age and clinical conditions including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), history of chest pain, and opium use were recorded. First, the characteristics of the two groups were compared and then the main analyses were conducted to examine the relationship between CSFP and opium use. Data were analyzed using t test and chi-square test via SPSS 25.0. The significance level was set at P<0.05. This study was conducted on 44 male patients with documented CSFP who had no stenotic lesions and 134 control group male patients who had normal coronary arteries with normal flow. The mean age was similar in the two groups (54.25 vs.52.69, P=0.474). Two groups were significantly different in terms of history of chest pain (P=0.003), but there was no significant difference in HTN (P=0.084), DM (P=0.284), HLP (P=0.183), smoking (P=0.696), and opium use (P=0.107). This study indicated that opium use is not associated with primary CSFP.

Coronary artery to pulmonary artery fistula: Catheter or scalpel? A case report.

IntroductionCoronary artery fistula (CAF) is an abnormal connection between coronary artery and a major vessel or cardiac chamber with left to right shunt having an incidence of 0.002 % in recent literature. Fistulous communication of coronary artery with pulmonary artery (PA) is a rare subtype and comprises of about 17 % of all the CAF cases.Case presentationWe report a case of a middle-aged gentleman, known case of asymptomatic CAF for the last 20 years. He presented to us with 6 months history of chest pain on exertion. On coronory angiogram he was diagnosed to have a preexisting CAF of proximal LAD to main PA and severe coronary artery disease in left anterior descending coronary artery (LAD). He was managed surgically and underwent ligation of the fistula along with coronary artery bypass grafting (CABG).Clinical discussionManagement of CAF is medical, percutaneous or open-heart surgery. Due to rarity of the disease no international guidelines exists and treatment is controversial. Complications of CAF include endocarditis, early atherosclerosis, rupture, hemopericardium, pulmonary hypertension and myocardial ischemia, hence early correction is warranted. Our case emphasizes on the natural course of this rare disease and how to change management plan accordingly in the better interest of patient.ConclusionOur case presents the natural course and management of a rare congenital cardiac disease. Surgery was chosen as an appropriate option due to CAD involving proximal LAD and concomitant coronary artery to PA fistula.

A Rare Cause of Chronic Chest Pain Syndromes; Scimitar Syndrome Apropos of a CAS

This is Mr. M, 38 years old History of intermittent chest pain with a type of contraction evolvings in childhood and increased by food.

Association of plasma visfatin with epicardial fat thickness and severity of coronary artery diseases in patients with acute myocardial infarction and stable angina pectoris.

Elevated serum visfatin levels have been reported in some chronic inflammatory diseases such as cardiovascular diseases (CVDs) and rheumatoid arthritis. The purpose of the present study was to investigate the correlation between visfatin and interleukin-6 (IL-6) and anthropometric, angiographic, echocardiographic, and biochemical parameters in patients with acute myocardial infarction (AMI). In this case-control study, 90 patients who were candidates for angiography were divided into the following 3 groups: non-coronary artery disease group (non-CAD; n = 30) with a history of chest pain without angiographic changes, stable angina pectoris group (SAP; n = 30), and AMI group (n = 30). Anthropometric, angiographic, echocardiographic, and biochemical parameters were measured in all subjects. The mean age of patients in the non-CAD, SAP, and AMI groups was 62.26 ± 13.24, 62.93 ± 8.35, and 52.83 ± 10.26 years (P < 0.001) respectively. The results showed that the median [interquartile range] of visfatin level was higher in the AMI group [7 (6.30-9.30), pg/ml] compared with the SAP [5.85 (5.20-6.60); P < 0.001] and non-CAD [5.20 (3.30-5.70); P < 0.001] groups. In addition, median [interquartile range] IL-6 levels were higher in the AMI group [17.5 (16-21), pg/ml] compared with the SAP [15.50 (14-18); P < 0.01] and non-CAD [14 (11-17); P < 0.001] groups. Furthermore, there was a positive association between plasma level of visfatin, and epicardial fat thickness (EFT) and the Gensini score in the SAP and AMI patients. The results of multivariate linear regression analysis revealed that white blood cell ý(WBC) count and IL-6 were independently associated with plasma visfatin level. The current study showed an association between visfatin and EFT in AMI patients. Increased visfatin levels in patients with AMI may contribute to atherosclerosis; however, further studies should be conducted to confirm this finding.

Congenitally Corrected Transposition of Great arteries with AV block -cohabitation of structural and electrical cardiac abnormality: a case report

Congenitally Corrected Transposition of Great Arteries (c-TGA) is an anomaly with atrioventricular and ventriculoarterial discordance where left atrium connects to right ventricle and right atrium to left ventricle. However in this case of double inversion, aorta carries saturated blood and pulmonary artery carries venous blood. So, normal physiological circulation is maintained. Our patient, a 38-years-old Bangladeshi male presented with palpitation, dizziness and effort intolerance (NYHAII) during exertion since childhood, which has recently become much worse. However, he had no history of central cyanosis, chest pain or syncope. We diagnosed him as a case of Corrected TGA and second-degree AV block with intermittent complete heart block. A Dual chamber permanent Pacemaker was inserted without any complications. No invasive treatment including corrective surgery was performed because patient’s cardiac function was almost normal. Patient became totally asymptomatic after pacemaker implantation Bangladesh Heart Journal 2022; 37(1): 77-80

C44 VENTRICULAR TACHYCARDIA IN PATIENT WITH PSEUDOISCHEMIC VENTRICULAR SCAR

Abstract We describe a case of 76 years old men. He was referred to emergency room for chest pain and short of breath. The medical history escluded pre–existent miocardial infarction, no history of fever and chest pain has been declared,.The electrocardiogram (ECG) showed a 200 pbm tachycardia with right bundle branch and right axial deviation. The transition was in V4 (Fig. 1). The tachycardia was not tolerated and after ineffective administration of amiodarone, the tachycardia was terminated by DC shock (200 J synchronized). We performed an echocardiogram with evidence of minimal ventricular dilatation, the inferior–posterior–lateral akinesia, inferior–posterior scar and severe reduction of ejection fraction (about 30%). For better characterization of the scar, we performed cardio magnetic resonanc imaging with evidence of significative thinning of the left ventricle free wall and trasmural LGE of the of left ventricle free wall suggest ischemic myocardial injury (Fig. 2 a,b,c,d,e). The coronary arteriography was performed without evidence of critical coronary stenosis.We decide to implant a single lead ICD. After one month, because of recurrence of tachycardia, we performed the electrophysiological study. We induced clinical ventricular tachycardia and the electroanatomical mapping highlighted an area of anomalous potentials extended in the infero–posterior and lower–basal region more at the epicardial level. In these areas, at the epicardial level, late potentials were highlighted and the ablation performed making the tachycardia no longer inducible. Despite of evidence of pseudo–ischemic scar localized at the basal portion of ventricle at the cardiac MRI, no critical coronary stenosis has been demonstrated and the arrhythmogenic substrate was exclusively epicardic. The preliminary hypothesis was a MINOCA, not of recent onset considering the negativity of myocardial enzymes at the admission and the absence of acute ischemic changes on post cardioversion ECG.We have therefore also considered forms of previous extensive myocarditis however with the limited longitudinal extension. From what has been described in the literature, the MRI images could also be attributable to a form of left ventricle arrhythmogenic dysplasia even in the absence of involvement of the apical portions. Forms of infiltrative cardiomyopathies such as sarcoidosis should be excluded due to the lack of involvement of the interventricular septum.

Abnormal Electrocardiogram in a Man Presenting With Dyspnea and Chest Pain.

A 70-year-old man with a history of smoking presented at the emergency department with dyspnea and a 24-hour history of intermittent chest pain that had acutely worsened. His heart rate was 128 beats/min; blood pressure, 114/81 mmHg; respiratory rate, 24 breaths/min; and oxygen saturation, 85% on 4 L of oxygen. He had bibasilar crackles and a grade 3/6 holosystolic murmur over the left sternal border. A basic metabolic panel showed nothing unusual. A coronavirus nasopharyngeal swab test was negative. The patient's N-terminal pro-brain-type natriuretic peptide level was 1,583 pg/mL (normal, &lt;100 pg/mL), and his cardiac troponin I level was 39 ng/mL (normal, ≤0.04 ng/mL). He became hypoxic and needed intubation. He was started on intravenous vasopressors and was taken to the cardiac catheterization laboratory, where an intra-aortic balloon pump was placed. His presenting electrocardiogram (ECG) is shown below (Fig. 1).In addition to ST-segment-elevation myocardial infarction (STEMI), what diagnosis should be suspected from this ECG?B) Ventricular septal ruptureIn cases of delayed STEMI, mechanical complications can occur. The differential diagnosis in acute myocardial infarction (AMI) complicated by a holosystolic murmur includes papillary muscle rupture (PMR) and ventricular septal rupture (VSR). Free wall rupture would not present with a holosystolic murmur, and aortic dissection resulting in aortic regurgitation would cause a diastolic murmur. Patients with acute PMR typically present with shock and acute pulmonary edema. In acute PMR, the systolic murmur may be soft or absent, given pressure equalization between the left ventricle and left atrium; conversely, in VSR, there is hemodynamic compromise and a harsh systolic precordial murmur.Inferior and anterior STE with inferior Q waves, such as in our patient's ECG, should raise suspicion for VSR.1 Hayashi and colleagues2 observed STE in the inferior and anterior leads in 42.9% of patients who had VSR, but in only 3.6% of patients without VSR. Moreover, abnormal Q waves appeared in all inferior leads (II, III, and aVF) in 44.4% of patients with VSR but in only 4% of those without.2 Whereas the ventricular septum receives a dual blood supply from the left anterior descending coronary artery (LAD) and right coronary artery, in a dominant “wrap-around” LAD, the ventricular apex is supplied only by the LAD. Occlusion of the LAD (Fig. 2, arrow) results in necrosis of the anterior and inferior walls, leading to STE in the anterior and inferior leads, and a risk of VSR (Fig. 3, arrow) if reperfusion is delayed.3 This case highlights that, in AMI, an ECG showing STE in the anterior and inferior leads with inferior Q waves should raise suspicion for VSR.Conflicts of interest: NoneFunding: None

Thymoma, surgical resolution by video-assisted thoracoscopy of a rare malignant tumor. Case report

BACKGROUND: Thymomas are rare epithelial tumors which originate from the thymic gland, with an incidence of 0.13 cases per 100 000 inhabitants in one year, more commonly seen between 40 and 60 years of age. These tumors do not present specific clinical signs and 30% to 60% of the patientsare asymptomatic; in most cases, the tumors are found incidentally by CT-scans. The primary treatment involves surgery. There are few reports in Ecuador, thus it is important to publish this clinical case for the knowledge of the medical community. CASE REPORT: 62-year-old male patient, with a history of osteoarthritis and smoking. He came with a four-month history of chest pain, productive cough that progressed later to haemoptysis and significant unquantified weight loss. The chest CT scan reported a mass located in the right anterior and middle mediastinum, causing mass effect on the heart and great vessels; also, there were small pretracheal mediastinal adenopathies. EVOLUTION: After the diagnosis of a mediastinal mass, highly suggestive of a tumor dependent on the thymus, we decided surgical approach by video-assisted thoracoscopy. Incomplete R1 resection (focally in contact with the resection limit) was achieved, with a positive biopsy for thymoma, type AB (WHO classification), stage IIB (modified Masaoka classification). Adjuvant radiotherapy was administered, presenting complete remission of the disease, with no recurrence during 2-year follow up. CONCLUSION:Thymomas are rare malignant tumors; its first-line treatment involves radical surgery in Masaoka stages I, II and III. Video-assisted thoracoscopy thymectomy is a less invasive procedure and reduces complications, improving postoperative life quality; however, the possible need to add adjuvant radiotherapy in cases of incomplete resection with this technique should be taken into consideration.

An Unusual Case of Ruptured Sinus of Valsalva Misdiagnosed as Acute Coronary Syndrome

Background: Ruptured sinus of Valsalva aneurysm (RSOVA) is rare and can mimic many other diseases. It may be misdiagnosed on initial evaluation. Uncorrected almost invariably, it has a rapid downhill course. We present a case which was initially misdiagnosed as acute coronary syndrome (ACS). Case Summary: A 49-year-old lady presented to a local hospital with history of chest pain. She was diagnosed with ACS based on history and electrocardiogram findings and treated conservatively. She deteriorated and developed multiorgan failure. She was transferred to our center for further management. On re-evaluation, transthoracic echocardiography showed RSOVA. She was treated with transcatheter device closure. She recovered well and was discharged in stable condition. Discussion: This case highlights the diagnostic difficulty when patients present with features of other common diseases. Right heart failure evaluation in the setting of appropriate clinical features should prompt consideration of RSOVA as a differential diagnosis. RSOVA if managed appropriately can lead to complete recovery.

Anomalous right coronary artery from distal left circumflex coronary artery: a rare case report

Coronary artery anomalies (CAAs) being a group of congenital disorders, present with highly variable manifestations and have diverse pathophysiological manifestations. In middle aged to elderly patients, a coronary anomaly is often an incidental finding. We presented a case of 65-year-old female with history of diabetes for past 9 years who presented to our emergency department with history of exertional chest pain for past 4 weeks. Anomalous origin of right coronary artery (RCA) from distal left circumflex artery (LCX) was observed on coronary angiography. Patient was managed with optimised medical therapy (OMT).

Pericardial and pulmonary actinomycosis, simulating inflammatory myofibroblastic tumor: the role of surgery

Background: Pericardial and pulmonary actinomycosis is a rare disease that remains undiagnosed during life due to a lack of clinical manifestations and a low positive culture rate. Actinomycosis can involve any part of the body. Thoracic actinomycosis is the second most common site after the cervicofacial. Patients with pulmonary actinomycosis usually present with a history of chest pain, cough, fever, shortness of breath on exertion, and sometimes massive hemoptysis. Pericardial involvement has been reported in the medical literature. It is written in line with process case series criteria. Method: From 2008 to 2021, 8 patients, 6 men, and 2 women (mean age 59 y) underwent surgical resection for thoracic lesion initially diagnosed as myofibroblastic tumor on true cut biopsy, but the final histopathologic report revealed actinomycosis. We reviewed preoperative clinical manifestations. Computed tomographic (CT) findings, preoperative true-cut biopsy report, surgical indications, and outcomes. Results: Five patients (62.5%) had poor oral hygiene; 2 patients (25%) had sinusitis, and 1 patient had bronchiectasis (12.5%). Seven patients were symptomatic (87.5%), with hemoptysis, shortness of breath, and weakness. One patient, 12.5%, presented with chest wall mass, chest pain, and fever. The basis of the imaging study (CT thorax). Six patients (87.5%) had CT guided biopsy that revealed a myofibroblastic tumor. In 2 patients (25%), CT scans showed the mass was close to the heart, so a biopsy was not done. We panned a surgical procedure based on the history of hemoptysis and a true cut-biopsy report. Four patients (50%) had a lobectomy, 2 patients (25%) had pericardial resection with a wedge of lung tissues, and 1 patient had chest wall resection enblock with right upper lobectomy. Conclusion: In patients with radiographic findings of pulmonary neoplasm and initial true cut biopsy report showing myofibroblastic tumor, surgery is mandatory. The final histopathology report showed actinomycoses. If the preoperative histopathologic diagnosis is available, then surgery has no role. The ideal treatment is the administration of systemic penicillin therapy. All our patients postoperatively received systemic antimicrobial therapy; they fully recovered and resumed back to everyday life.

Role Of Immunomodulators And Early Mechanical Circulation Support In A Life Threatening Presentation Of Fulminant Lymphocytic Myocarditis

Introduction Lymphocytic Myocarditis is a rare cause of myocarditis with an incidence of 22 cases per 100,000. There is limited data in terms of role of immunomodulators and protocolized initiation of mechanical circulation support (MCS). We present a case to emphasize early recognition and prompt initiation of MCS to manage the hemodynamic derangements caused by fulminant myocarditis. Case Description A 19-year-old female with no significant past medical history presented to the ED due to a four-day history of chest pain, dyspnea, fatigue, and palpitations associated with leukocytosis, elevated lactate, and troponins. Initial EKG and telemetry showed SVT with heart rate in the 140s. Treatment with diltiazem led to hypotension, syncope, and clinical deterioration necessitating a transfer to the CVICU. Initial echocardiogram showed mild left ventricular thickness due to edema, minimal LV enlargement, and estimated ejection fraction at 25%. Patient's right heart catheterization showed a CI of 1.09 with a SVR of 2275 dynes on ionotropic support. Due to third degree heart block and junctional escape rhythm, a transvenous pacemaker was placed. Intra-aortic balloon pump (IABP) was placed to unload the left ventricle and endomyocardial biopsy (EMB) was performed. Patient further deteriorated due to development of refractory sustained ventricular tachycardia (VT) unresponsive to defibrillation. A decision was made to escalate to peripheral veno-arterial extracorporeal membrane oxygenation (ECMO). In addition, patient also developed multiorgan failure; AKI, altered mental status and shock liver which were monitored closely. EMB showed extensive lymphocytic infiltration, myocardial edema associated with myocardial cell necrosis and patient was diagnosed with lymphocytic myocarditis. Patient was initiated on 0.5 mg per kg of IVIG for two days and scheduled steroids followed by a taper. Her lactate cleared after 48 hours of ECMO, BNP and ALT down-trended significantly and creatinine improved subsequently. She was weaned off ECMO, and eventually IABP and inotropes. She was downgraded and eventually discharged after a total stay of 12 days. Conclusion Though there is scarce data regarding management of myocarditis, our case illustrates improvement in hemodynamics with prompt initiation of IVIG and steroids combined with ECMO support. We advocate quick escalation to MCS before the electrical storm sets in place from cardioversion of ventricular arrythmias. Additionally, it emphasizes the role of bedside echocardiogram, troponins, BNP, and EKG in an ED setting for early recognition and timely initiation of hemodynamic support can be lifesaving. The role of EMB is paramount. Lymphocytic Myocarditis is a rare cause of myocarditis with an incidence of 22 cases per 100,000. There is limited data in terms of role of immunomodulators and protocolized initiation of mechanical circulation support (MCS). We present a case to emphasize early recognition and prompt initiation of MCS to manage the hemodynamic derangements caused by fulminant myocarditis. A 19-year-old female with no significant past medical history presented to the ED due to a four-day history of chest pain, dyspnea, fatigue, and palpitations associated with leukocytosis, elevated lactate, and troponins. Initial EKG and telemetry showed SVT with heart rate in the 140s. Treatment with diltiazem led to hypotension, syncope, and clinical deterioration necessitating a transfer to the CVICU. Initial echocardiogram showed mild left ventricular thickness due to edema, minimal LV enlargement, and estimated ejection fraction at 25%. Patient's right heart catheterization showed a CI of 1.09 with a SVR of 2275 dynes on ionotropic support. Due to third degree heart block and junctional escape rhythm, a transvenous pacemaker was placed. Intra-aortic balloon pump (IABP) was placed to unload the left ventricle and endomyocardial biopsy (EMB) was performed. Patient further deteriorated due to development of refractory sustained ventricular tachycardia (VT) unresponsive to defibrillation. A decision was made to escalate to peripheral veno-arterial extracorporeal membrane oxygenation (ECMO). In addition, patient also developed multiorgan failure; AKI, altered mental status and shock liver which were monitored closely. EMB showed extensive lymphocytic infiltration, myocardial edema associated with myocardial cell necrosis and patient was diagnosed with lymphocytic myocarditis. Patient was initiated on 0.5 mg per kg of IVIG for two days and scheduled steroids followed by a taper. Her lactate cleared after 48 hours of ECMO, BNP and ALT down-trended significantly and creatinine improved subsequently. She was weaned off ECMO, and eventually IABP and inotropes. She was downgraded and eventually discharged after a total stay of 12 days. Though there is scarce data regarding management of myocarditis, our case illustrates improvement in hemodynamics with prompt initiation of IVIG and steroids combined with ECMO support. We advocate quick escalation to MCS before the electrical storm sets in place from cardioversion of ventricular arrythmias. Additionally, it emphasizes the role of bedside echocardiogram, troponins, BNP, and EKG in an ED setting for early recognition and timely initiation of hemodynamic support can be lifesaving. The role of EMB is paramount.

A Catamenial Pneumothorax: Role Of Serial Chest Radiographs In The Diagnosis Of ARare Entity .

Catamenial Pneumothorax is generally considered to be a rare entity. The lack of a clear cause means that diagnosis and treatment is challenging. The objective of this case report is to increase awareness and highlight the role of serial chest radiographs in improving the diagnosis of the pathology. A 33-year-old mother of two presented at the radiology department with a history of recurrent right-sided chest pain that corresponded with her menstrual period. Previous chest radiographs performed in the preceding six months all showed the presence of a right-sided pneumothorax, with associated pleural effusion. In considering the patient’s age, spontaneous pneumothorax occurring in conjunction with the menstrual cycle, and in the absence of other respiratory diseases, a diagnosis of catamenial pneumothorax was made. The patient was commenced on oral contraceptive pills (oestrogen-progestogen) and she recovered.