Publications by authors named "Hafez Mohammad Ammar Abdullah"

31 Publications

Republished: Amiodarone-induced diffuse alveolar haemorrhage: a rare but potentially life-threatening complication of a commonly prescribed medication.

Drug Ther Bull 2020 07 30;58(7):107-111. Epub 2020 Apr 30.

Internal Medicine, University of South Dakota Sanford, School of Medicine, Sioux Falls, South Dakota, USA

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http://dx.doi.org/10.1136/dtb.2019.232149repDOI Listing
July 2020

High output heart failure in a young woman secondary to massive arteriovenous malformations from a uterine tumor.

BMJ Case Rep 2020 Feb 10;13(2). Epub 2020 Feb 10.

Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA

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http://dx.doi.org/10.1136/bcr-2019-233887DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035803PMC
February 2020

Great saphenous vein stump: a risk factor for superficial/deep venous thrombosis and an indication for prophylactic anticoagulation? - a retrospective analysis.

J Community Hosp Intern Med Perspect 2019 14;9(6):473-476. Epub 2019 Dec 14.

Department of Internal Medicine, Abington - Jefferson Health, Abington, USA.

: Great saphenous vein (GSV) grafts are used for coronary artery bypass surgeries, but the remaining stump of the GSV may be the nidus for superficial and deep vein thrombosis. This study aims to determine the risk of thrombosis in the GSV stump in patients who developed lower extremity swelling following coronary artery bypass graft (CABG). : We conducted a single-center retrospective analysis at Abington Jefferson Hospital of 100 patients who underwent CABG with GSV. Patients were monitored via follow-up for seven days for the development of saphenous vein thrombosis without any prophylactic anticoagulation for venous thrombosis. Risk factors including age, diabetes, hypertension, smoking, familial thrombophilia's, family history of thrombosis, malignancy, and confounding factor-like early mobilization that may potentially alter the results were recorded. : The mean age of included patients was 70 years, and 65% of participants were men, 35% were women. Fourteen percent of the patients developed pain, swelling and edema in a leg where the graft was taken. We included patients aged >50 years with coronary artery disease who underwent CABG with SVG and developed lower extremity symptoms concerning for thrombosis. These patients underwent duplex ultrasound for possible GSV stump thrombosis. Any patients with coronary artery disease but no CABG or no lower extremity edema were excluded from the study. We found no saphenous vein thrombosis in the stump of the GSV in patients with clinical symptoms of thrombosis in their lower extremities based on duplex imaging. : Based on our findings, the postoperative risk of developing thrombosis at the GSV stump and its extension to the deep veins is low and does not warrant prophylactic anticoagulation for venous thromboembolism. However, we recommend that further prospective studies with larger samples for an extended duration are warranted for better assessment of the risk of venous thrombosis in the GSV stump with minimal confounding factors.
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http://dx.doi.org/10.1080/20009666.2019.1655626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6968707PMC
December 2019

Role of echocardiography in diagnostic evaluation of patients admitted to observation unit.

Am J Cardiovasc Dis 2019 15;9(6):127-133. Epub 2019 Dec 15.

Cardiology, Abington-Jefferson Health 1200 Old York Road, Abington, PA 19001, USA.

Background: Syncope is a transient loss of consciousness due to transient decrease in cerebral perfusion. Syncope accounts for a 3-6% of all emergency department visits. Etiology of syncope can be neural, cardiogenic, or vascular. Previous studies have evaluated the types and management of syncope. Echocardiography is a commonly used test in the evaluation of causes of syncope. Whether the benefit compared to financial burden of this diagnostic study is in all subsets of syncope cases remains unclear.

Aim: To evaluate the impact of echocardiography in the diagnostic evaluation of syncope and to evaluate the subset of patients that would benefit more from this diagnostic imaging.

Methods: We performed a retrospective chart review of patients > 18 years of age with a primary diagnosis of syncope in a period of January 1 2015-January 31 2017. Our inclusion criteria included patients > 18 years of age who were admitted to the observation floor with the primary complaint as syncope, had a normal or abnormal physical examination for syncope, had a normal or abnormal electrocardiogram during admission, had an echocardiography performed at admission. Our exclusion criteria included patients with seizures, hypoglycemia, myocardial infarction, patients who didn't get echocardiography, and patients who had a positive marker of cardiac injury.

Results: A total of 369 patients were initially identified with a primary diagnosis of syncope, however only 120 of these patients fulfilled our inclusion and exclusion criteria. A total of n=25 of included patients had either an abnormal physical exam or abnormal echocardiography. Among this "high risk" group, 24% (n=6) of the patients had an abnormal finding on their transthoracic echocardiography. On the other hand, in the "low risk" group with a normal physical examination and electrocardiogram (EKG), 14 had a trans-thoracic echocardiography (TTE) positive for cause of syncope, that led to a change in medication, workup, or intervention in 6.7% (n=8) of the patients.

Conclusion: The analysis of our study suggested that the diagnostic yield of transthoracic echocardiography in syncope is very limited in the absence of an abnormal physical exam or electrocardiogram, and it increase the health care cost burden with no additional benefits.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971420PMC
December 2019

Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis.

BMJ Case Rep 2019 Dec 9;12(12). Epub 2019 Dec 9.

Rheumatology, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.
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http://dx.doi.org/10.1136/bcr-2019-231474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904172PMC
December 2019

Anastrozole-induced liver injury after a prolonged latency: a very rare complication of a commonly prescribed medication.

BMJ Case Rep 2019 Nov 27;12(11). Epub 2019 Nov 27.

Division of Gastroenterology, Rutgers New Jersey Medical School, Newark, New Jersey, USA.

Anastrozole is an aromatase inhibitor that has been used more frequently over the last decade especially for oestrogen receptor-positive breast cancer. It has a relatively safe side effect profile. However, occasionally it has been associated with serious adverse events. Here, we present the case of a 58-year-old woman who presented with significantly elevated liver enzymes 4 years after starting anastrozole. She was not taking any other medications and an extensive workup did not reveal any other cause for her liver injury. The patient's liver enzymes normalised after discounting the anastrozole. She scored 4 on the updated Roussel Uclaf Causality Assessment Method grading system which was possible for drug-induced liver injury. A review of the literature revealed six prior cases of anastrozole-related liver injury. Anastrozole should be considered as a possible culprit in patients who develop an unexplained acute liver injury.
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http://dx.doi.org/10.1136/bcr-2019-231741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887447PMC
November 2019

Duration of in-hospital cardiopulmonary resuscitation and its effect on survival.

Indian Heart J 2019 Jul - Aug;71(4):314-319. Epub 2019 Sep 19.

Cardiology, Abington - Jefferson Health, 1200 Old York Road, Abington, PA, 19001, USA.

Objective: This study aims to determine the correlation between the duration of cardiopulmonary resuscitation (CPR) and the return of spontaneous circulation (ROSC) in an in-hospital cardiac arrest cohort.

Methods: All patients (age ≥ 17 years) who underwent CPR at our institution from 2015 to 2017 were included. The primary endpoint was ROSC or death. A total of 88 patients were included in the study. The Pearson correlation of CPR duration with the establishment of ROSC was calculated using the IBM SPSS, version 25.

Results: In all, 88 patients who received CPR, 55% (n = 48) experienced ROSC and survived. The remaining 45% (n = 40) of the total and 56% (n = 27) of those with ROSC died during the same hospitalization (Fig. 1). Among the 48 patients with ROSC, the documented duration of their CPR was about 10 min on average in comparison with 27.5 min CPR for patients who did not achieve ROSC (Fig. 2). Among all the patients, there was a negative correlation between the duration of the CPR and the establishment of ROSC. This is shown in Fig. 3.

Conclusion: Our study shows that CPR duration is inversely associated with the establishment rates of ROSC. Most of the benefits of CPR can be achieved in the first 15 min, and a further increase in the duration of CPR provides a minimal gain. Still, survival was achievable till 38 min in some cases, and the ideal duration of resuscitation should remain a bedside decision taking into consideration the whole clinical picture.
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http://dx.doi.org/10.1016/j.ihj.2019.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890953PMC
May 2020

The role of echocardiography in diagnostic evaluation of patients with syncope-a retrospective analysis.

Am J Cardiovasc Dis 2019 15;9(5):78-83. Epub 2019 Oct 15.

Thomas Jefferson University Hospital Philadelphia, USA.

Background: Syncope is a symptom complex comprising of a brief loss of consciousness leading to a transient decrease in cerebral blood flow that resolves completely. 2D-transthoracic echocardiography (TTE) is a useful tool to detect underlying structural heart disease, which can lead to syncope, e.g., aortic stenosis, atrial masses. This study aimed to find the subgroups of patients with syncope who would benefit the most from a TEE.

Methods: We did a retrospective chart review of all patients aged 18 years or older, admitted to our hospital with a primary diagnosis of syncope between January 2015 and January 2017 to determine the frequency and findings of echo in all these patients. The baseline characteristics, demographics were taken into account for the inclusion of these patients into the study.

Results: A total of 369 patients were initially studied, but only 139 patients were included in the final analysis based on inclusion criteria. Among the high-risk patients (i.e., abnormal Physical exam and/or abnormal EKG, population), 43.75% had significant echocardiographic finding. While among low-risk patients (i.e., normal EKG and exam), 10% (9/91) had a significant finding. Patients with abnormal EKG or examination findings were 7.08 times (95% CI = 2.89-17.3) more likely to have an abnormal echocardiogram (P < 0.001).

Conclusion: Our study suggests that the diagnostic yield of 2D-TTE in the absence of abnormal physical exam and/or abnormal EKG is very limited and may add an extra burden on the finances and resources of both the patient and the hospital.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6872465PMC
October 2019

Amiodarone-induced diffuse alveolar haemorrhage: a rare but potentially life-threatening complication of a commonly prescribed medication.

BMJ Case Rep 2019 Oct 25;12(10). Epub 2019 Oct 25.

Internal Medicine, University of South Dakota Sanford, School of Medicine, Sioux Falls, South Dakota, USA

Amiodarone is an antiarrhythmic agent that is used commonly in clinical practice. It is associated with many side effects, the most common being pulmonary manifestations. Interstitial pneumonitis is one of the most common complications, however rarely amiodarone can cause diffuse alveolar haemorrhage (DAH) too. We describe the case of a 73-year-old woman who presented with shortness of breath and haemoptysis 4 days after starting amiodarone. She was diagnosed with amiodarone-induced DAH based on imaging and bronchoalveolar lavage. She was treated with intravenous and then oral steroids, and amiodarone was discontinued. The patient made a significant clinical and radiological recovery. She was discharged 10 days after her presentation. This case highlights a rare but potentially life-threatening complication of a commonly used medication.
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http://dx.doi.org/10.1136/bcr-2019-232149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827782PMC
October 2019

Herpes Simplex Esophagitis in Immunocompetent Patients: A Rare But Easily Managed Condition.

S D Med 2019 Aug;72(8):344-347

Florida Hospital Orlando, Florida.

Herpes simplex (HS) is an opportunistic infection, primarily in immunocompromised patients, caused by herpes simplex virus. Oral and genital mucosa are the most commonly involved sites; it is rare for HSV to invade the esophagus and cause esophagitis, especially in immunocompetent patients. Here, we present a case where an immunocompetent patient presented with HS esophagitis, which had evolved into esophageal ulcers. He was successfully treated with acyclovir. Subsequently, we did a comprehensive literature search and tabulated all the possible complications and management plans of previously reported cases of HS in immunocompetent patients.
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August 2019

Human cytomegalovirus pneumonia in an immunocompetent patient: a very uncommon but treatable condition.

BMJ Case Rep 2019 Aug 26;12(8). Epub 2019 Aug 26.

Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA.

Human cytomegalovirus (CMV) is a double-stranded DNA virus that can cause widespread severe infection in immunocompromised individuals but is more typically a subclinical infection in immunocompetent individuals. Rarely, it can cause a serious infection in immunocompetent individuals. Here, we describe a 36-year-old otherwise healthy male who presented with fever, cough and malaise who was diagnosed with CMV pneumonia. He made a rapid recovery after initiation of ganciclovir and has been doing well on follow-up visits. We performed a comprehensive review of CMV pneumonia in immunocompetent individuals and have summarised the prior 16 reported cases of CMV pneumonia in immunocompetent patients. This article highlights the importance of considering CMV as a cause of pneumonia even in immunocompetent individuals, especially when the more common causes have been excluded. Early diagnosis allows prompt treatment and potentially complete recovery.
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http://dx.doi.org/10.1136/bcr-2019-230229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6721223PMC
August 2019

Rapid onset type-1 diabetes and diabetic ketoacidosis secondary to nivolumab immunotherapy: a review of existing literature.

BMJ Case Rep 2019 Aug 26;12(8). Epub 2019 Aug 26.

Endocrinology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Nivolumab is a programmed cell death receptor (PD-1) inhibitor that is increasingly used for various malignancies, both as a first line agent and as salvage therapy. Being a PD-1/PD-1 ligand checkpoint inhibitor, it is known to cause autoimmune inflammation of various organs and has been associated with thyroiditis, insulitis, colitis, hepatitis and encephalitis to name a few. There are increasing reports of nivolumab leading to acute onset fulminant type 1 diabetes and diabetic ketoacidosis (DKA). We present a case of a 68-year-old man who developed DKA after 2 doses of nivolumab for metastatic melanoma. He was found to have type 1 diabetes, but no diabetes related antibodies were positive. He recovered from diabetes and continues to use insulin 1 year after his diagnosis. This case and associated review illustrates the importance of educating and monitoring patients who start nivolumab therapy regarding this potentially life threatening complication.
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http://dx.doi.org/10.1136/bcr-2019-229568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6721076PMC
August 2019

Importance of Basal Metabolic Index in the Diagnosis of Heart Failure With B-Type Natriuretic Peptide.

Cardiol Res 2019 Aug 31;10(4):211-215. Epub 2019 Jul 31.

St. Mary Medical Center, Langhorne, PA, USA.

Background: Increased basal metabolic index (BMI) is associated with decreased levels of B-type natriuretic peptide (BNP). This makes the diagnosis of the congestive heart failure challenging in the obese population. We sought to determine the association and strength of the relationship between the two variables.

Methods: The association between BMI and BNP was examined in 405 patients utilizing a retrospective chart review in a single center study. Pearson correlation and regression analyses were performed to identify trends. BNP trends were also correlated with age.

Results: The mean age of patients was 77 years with 45% men and 55% women. Mean BNP level was 1,158 standard deviation (SD) ± 1,537. Mean BMI was 33 SD ± 28. BNP levels were found to be inversely related to increasing BMI (P value < 0.001). Using a cut-off of 3,500 pg/mL, there was a linear negative correlation on the dotted graph. In regression analysis the measure of effect of BMI on BNP levels was -0.90 pg/mL. There was no significant association between age and BNP levels (P = 0.90).

Conclusions: Irrespective of age, obese patients have lower BNP levels, complicating the diagnosis of heart failure exacerbation in such patients. Our results suggest that BNP levels in patients with BMI greater than 33 should be adjusted 9 pg/mL per unit increase in BMI.
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http://dx.doi.org/10.14740/cr898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681847PMC
August 2019

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) do not always represent multiple myeloma: diffuse large B cell lymphoma presenting with CRAB symptoms in a 69-year-old man.

BMJ Case Rep 2019 Aug 4;12(8). Epub 2019 Aug 4.

Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) are a constellation of signs and symptoms that are collectively referred to as the CRAB features. When present together, multiple myeloma (MM) should be at the top of the differential diagnosis. We present a 69-year-old man who presented with severe body aches and bone pain in his ribs and pelvis, associated with fatigue and constipation. He was found to have hypercalcaemia, acute kidney injury, anaemia and numerous lytic lesion on chest imaging. Physical examination and imaging were unremarkable for any enlarged lymph nodes. The patient was initially suspected to have multiple myeloma, however, serum and urine protein electrophoresis, and serum free light chain assays were negative. The patient was ultimately diagnosed with diffuse large B cell lymphoma based on a bone marrow biopsy. This case highlights the fact that presence of hypercalcaemia, renal dysfunction, anaemia and bone lesions are not usually specific for MM.
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http://dx.doi.org/10.1136/bcr-2018-229070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6685385PMC
August 2019

Cardiac arrest in a young healthy male patient secondary to kratom ingestion: is this 'legal high' substance more dangerous than initially thought ?

BMJ Case Rep 2019 Jul 19;12(7). Epub 2019 Jul 19.

Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Kratom is a psychoactive herb that has stimulant properties at low doses and has opioid-like properties at higher doses. It has been used for centuries in southeast Asia as a stimulant but has gained increasing popularity as a substitute for opioids in western countries as it is easily available. As most cases of kratom use involve other drugs too, the Food and Drug Administration (FDA) has stopped short of restricting kratom due to difficulty in assessing the adverse effects of kratom alone. We present the case of a young healthy 35-year-old man who suffered a cardiac arrest due to kratom use with no other coingestants. He was subsequently intubated and found to have systolic dysfunction and small brain infarcts. Fortunately, he made a successful recovery and was discharged after a stay at thebehavioural health centre. Our case highlights the potential adverse effects of kratom and the need to regulate its use.
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http://dx.doi.org/10.1136/bcr-2019-229778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6663180PMC
July 2019

Percutaneous removal of a retained appendicolith causing recurrent perihepatic abscesses between the liver and diaphragm.

BMJ Case Rep 2019 Jul 18;12(7). Epub 2019 Jul 18.

Department of Interventional Radiology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Many cases of appendicitis can be associated with appendicoliths. These may sometimes be lost during appendectomies and may be lodged in the body. Most of these cases lead to recurrent abscess formation, and these appendicoliths invariably need removal. Typically, this used to be done as an open surgery or laparoscopically. Here we describe the case of a transcutaneous removal of an appendicolith that was lodged between the liver and diaphragm that led to recurrent perihepatic abscess formation in a 24-year-old otherwise healthy man. The patient made a successful recovery without any recurrence. A transcutaneous approach to remove a retained appendicolith may be a feasible, a safe and an easy method to extract appendicoliths that are accessible for transcutaneous removal.
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http://dx.doi.org/10.1136/bcr-2019-230176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6663240PMC
July 2019

Cardiac tamponade and purulent pericarditis secondary to an oesophageal pericardial fistula as an initial presentation of squamous cell carcinoma of the oesophagus.

BMJ Case Rep 2019 Jul 17;12(7). Epub 2019 Jul 17.

Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Pericardial effusions resulting in a cardiac tamponade have previously been reported with oesophageal cancers. However, most of these cases have been reported in association with radiation and chemotherapy. Rarely as oesophageal pericardial fistuls (OPF) have been reported as the culprits in causing pericardial effusions in patients with oesophageal cancers. Here we present the case of a 61-year-old woman who presented clinically with cardiac tamponade. She was found to have an OPF due to oesophageal squamous cell cancer that resulted in a purulent pericardial effusion. She underwent a median sternotomy, pericardial decompression, and mediastinal debridement. An oesophageal stent was attempted unsuccessfully. The patient refused any more aggressive treatments and was discharged to a hospice where she passed away 13 days after presentation. This case and the associated literature review highlights an unusual presentation of oesophageal cancer and an uncommon cause of cardiac tamponade.
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http://dx.doi.org/10.1136/bcr-2019-229634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6663317PMC
July 2019

ST-Segment Elevation Myocardial Infaction Alert During the Night Shift, A Misfortune for the Patient or an Overstatement?

Cardiol Res 2019 Jun 7;10(3):150-156. Epub 2019 Jun 7.

Abington - Jefferson Health, Abington, PA, USA.

Background: Conflicting data exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on intervention timings. It is believed that short staffing at night hours may lead to a lapse in the delivery of effective, efficient and timely medical intervention.

Methods: A retrospective single-center study was performed, and a total of 436 patients were randomized into two groups. Group A had 279 patients who had the heart catheterization done during the daytime (between 6 am and 6 pm), while group B had 157 patients who had the same intervention performed at night (between 6 pm and 6 am).

Results: Door to balloon (DTB) time during the day was about 16 min shorter than the DTB time at night (81.29 ± 3.26 vs. 97.30 ± 8.54) with no statistical difference (P = 0.051). The mean troponin rise during the day was 1.94 ± 10.60 SEM (95% confidence interval (CI): -22.70 to 18.90) higher than night troponin levels (71.75 ± 7.18 vs. 69.80 ± 7.18), but P value was 0.85. The left ventricular ejection fraction (LVEF) fall for daytime was 0.93% vs. 0.90% for night time patients (P = 0.94).

Conclusion: There is no significant difference in the mean DTB time, the rise in troponin, fall in LVEF, readmission rates, or mortality, and hence no negative effects on patient outcomes based on the patient's time of presentation between the two groups.
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http://dx.doi.org/10.14740/cr862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6575109PMC
June 2019

A not so happy ending: coital cephalgia resulting from an acute non-traumatic intraparenchymal haemorrhage in a female with no comorbidities.

BMJ Case Rep 2019 May 27;12(5). Epub 2019 May 27.

Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA.

A sexual headache or coital cephalgia is a headache associated with sexual activity and is a well-recognised condition. It is usually benign, primary and self-limiting. However, occasionally sexual headaches can result from more sinister causes. Intraparenchymal and subdural haemorrhages have been reported as secondary causes of sexual headaches. We present the case of a 61-year-old woman with no comorbidities who presented acutely with a sexual headache and vision loss, and was found to have an occipital and parietal intraparenchymal haemorrhage. She was normotensive and after extensive workup was found to have no predisposing condition for her haemorrhage. The patient had an uneventful recovery with physical rehabilitation and had regular follow-ups, with no residual weakness. She was in a completely normal state of health 1 year after her event, and continued to be off any medications.
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http://dx.doi.org/10.1136/bcr-2018-228872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536206PMC
May 2019

Wolf in the sheep's clothing: intestinal angioedema mimicking infectious colitis.

BMJ Case Rep 2018 Dec 13;11(1). Epub 2018 Dec 13.

Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA.

Hereditary angioedema (HAE) is a relatively rare clinical entity that can potentially cause life-threatening airway or intestinal oedema, patients with the latter usually presents with symptoms of gastroenteritis like vomiting, diarrhoea and abdominal pain. Here, we present a unique case of a less recognised type of HAE that is type III in a patient who presented with signs and symptoms consistent with infectious colitis. She previously had similar episodes and was managed multiple times with antibiotics, with no satisfactory response. There, she underwent extensive diagnostic evaluation. On the basis of findings of further investigations on the current visit, she was eventually diagnosed with intestinal angioedema. To the best of our knowledge, the present paper represents the third reported case of type III HAE-induced intestinal angioedema. Additionally, we undertake a literature review of HAE.
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http://dx.doi.org/10.1136/bcr-2018-226682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301529PMC
December 2018

Another "D" in MUDPILES? A Review of Diet-Associated Nondiabetic Ketoacidosis.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618796261. Epub 2018 Aug 23.

Jinnah Hospital, Allama Iqbal Medical College, Lahore, Pakistan.

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of "dietary ketosis" in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless "dietary ketosis" can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling the safety of ketogenic diet into question. In this article, we chronicle a unique case of ketogenic (Atkins) diet-associated ketoacidosis, and we present a comprehensive literature review on the etiology of ketoacidosis.
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http://dx.doi.org/10.1177/2324709618796261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6108016PMC
August 2018

Acute oesophageal necrosis: a rare but potentially fatal association of cocaine use.

BMJ Case Rep 2018 Jul 19;2018. Epub 2018 Jul 19.

Department of Internal Medicine, Griffin Hospital, Derby, Connecticut, USA.

Acute oesophageal necrosis (AON), also known as 'black oesophagus', is a rare condition characterised by the necrosis of the oesophagus usually involving the distal part. It has been associated with various conditions, and the pathogenesis is thought to involve hypovolaemia combined with decreased function of oesophageal protective mucosal barriers and may be compounded by the effect of gastric secretions on oesophageal mucosa. The hallmark of this condition is characteristic circumferential black discolouration of the distal oesophagus that may extend proximally. We present a case of a man who presented with haematemesis associated with cocaine abuse. Oesophagogastroduodenoscopy confirmed black oesophagus. The patient was managed with intravenous fluids, packed red blood cell transfusions, proton pump inhibitors and sucralfate suspension; however, he failed to recover. We have also reviewed the previous reported cases of AON in association with cocaine use.
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http://dx.doi.org/10.1136/bcr-2018-225197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6058151PMC
July 2018

Terminal deoxynucleotidyl transferase (TdT)-negative T-cell lymphoblastic lymphoma with loss of the T-cell lineage-specific marker CD3 at relapse: a rare entity with an aggressive outcome.

BMJ Case Rep 2018 Jun 8;2018. Epub 2018 Jun 8.

Department of Pathology, Rehman Medical Institute, Peshawar, Pakistan.

Terminal deoxynucleotidyl transferase (TdT)-negative T-cell lymphoblastic lymphoma is a variant of T-cell lymphoblastic lymphoma/T-cell lymphoblastic leukaemia. TdT is a marker of immaturity expressed in 90%-95% cases of lymphoblastic lymphoma and useful in differentiating it from other mature lymphomas/leukaemias. It has been associated with poorer response to chemotherapy and a more aggressive outcome. Here we present a case of TdT-negative T-cell lymphoblastic lymphoma in a 28-year-old man who presented with superior vena cava syndrome. The patient was treated with hyper-cyclophosphamide,vincristine, Adriamycin, dexamethasone (CVAD), however unfortunately suffered a relapse 1 year later. A unique feature of our case was that on relapse, the patient lost expression of the T-cell lineage-specific marker CD3, which has previously not been reported in association with TdT-negative T-cell lymphoblastic lymphoma. The patient failed to respond to chemotherapy on his relapse and died.
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http://dx.doi.org/10.1136/bcr-2018-224570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6011547PMC
June 2018

Pathological fracture of femoral neck in a middle-aged woman: a rare presentation of primary hydatid cyst disease in humans.

BMJ Case Rep 2018 Feb 8;2018. Epub 2018 Feb 8.

Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Hydatid disease in humans is caused by It most commonly involves the liver and, to a lesser extent, the lungs and spleen; however, it is known to involve other areas, too. Involvement of bone by hydatid cyst is rare. Here, we describe the case of a 37-year-old woman who presented with pain in the left groin and swelling in the left thigh. The radiological imaging showed a fracture of the femoral neck and cysts in the shaft of the femur. Diagnosis of hydatid cyst was confirmed on the basis of histopathology of biopsy specimens. The patient recovered after surgical excision of the cyst. This case illustrates the various sites and presentations of hydatid cyst disease, and the need to investigate for it if cystic bony lesions are encountered especially in endemic regions, as a delay in diagnosis can lead to long-term morbidity and even death.
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http://dx.doi.org/10.1136/bcr-2017-222980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836630PMC
February 2018

Dieulafoy's lesion of the colon and rectum: a case series and literature review.

BMJ Case Rep 2017 Oct 25;2017. Epub 2017 Oct 25.

Sanford USD Medical Center, Sioux Falls, SD, USA.

Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without obvious ulceration. It is most commonly located in the lesser curvature of the stomach but rare occurrences in extragastric sites have also been reported. Herein, we describe a case series of three patients who presented with lower gastrointestinal bleeding. Colonoscopy revealed a caliber-persistent tortuous submucosal artery protruding into the lumen of the colon or rectum. The patients were diagnosed with Dieulafoy's lesion and primary haemostasis was achieved with the endoscopic haemoclip application. The purpose of this review is to summarise the available data on the pathophysiology, epidemiology, clinical presentation, diagnosis and management of patients with Dieulafoy's lesion of the colon and rectum.
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http://dx.doi.org/10.1136/bcr-2017-220431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5665348PMC
October 2017

Primary cardiac leiomyosarcoma presenting as haemoptysis in a 22-year-old patient: an unusual presentation of a rare condition.

BMJ Case Rep 2017 Jul 13;2017. Epub 2017 Jul 13.

Department of Histo-Pathology, Rehman Medical Institute, Peshawar, Pakistan.

Primary cardiac sarcomas are rare malignant tumours and among them, leiomyosarcoma is extremely rare. They are especially rare in a young age group. We present a case of a 22-year-old male patient with primary leiomyosarcoma of the left atrium involving the pulmonary veins who presented with haemoptysis and shortness of breath. He underwent surgical excision of the tumour along with mitral valve replacement followed by adjuvant chemotherapy. No recurrence was reported on his second 6 monthly follow-ups.
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http://dx.doi.org/10.1136/bcr-2017-219416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534805PMC
July 2017

Invasive Mucormycosis Induced Pneumopericardium: A Rare Cause of Pneumopericardium in an Immunocompromised Patient.

Case Rep Infect Dis 2017 17;2017:1424618. Epub 2017 May 17.

University of Arizona, Tucson, AZ 85701, USA.

and cause life-threatening infections primarily involving the lungs and sinuses, which disseminate very rapidly by necrosis and infarction of the contiguous tissues. We present a case of a 64-year-old African American posttransplant patient who presented with a productive cough and weight loss. He had a past surgical history of renal transplant for renal cell carcinoma and was on dual immunosuppressive therapy, that is, mycophenolate and tacrolimus. During his hospital stay, he developed a pneumopericardium due to the direct extension of a lung lesion. The diagnosis was made by radiological imaging and PCR result which was consistent with species. He was treated with antifungal therapy. The purpose of this report is to highlight the unusual association of mucormycosis with pneumopericardium.
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http://dx.doi.org/10.1155/2017/1424618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5449744PMC
May 2017

First reported case of disseminated Nocardia kroppenstedtii sp nov. infection presenting with brain abscess and endocarditis in an immunocompromised patient with mantle cell lymphoma: challenges in diagnosis and treatment.

BMJ Case Rep 2017 Jan 6;2017. Epub 2017 Jan 6.

Department of Internal Medicine, University of Arizona, Tucson, Arizona, USA.

A 72-year-old man with a history of blastoid variant stage IV relapsed refractory mantle cell lymphoma presented with new central nervous system (CNS) symptoms. Brain imaging was positive for rim-enhancing lesions along with a mitral valve mass on the echocardiogram. It was a challenge to establish the exact aetiology of these lesions in this patient. He was empirically treated with chemotherapy on the presumption that the brain lesions were secondary to progressive malignancy. However, brain biopsy was negative for malignancy and blood cultures were found positive for Nocardia kroppenstedtii sp nov. He subsequently improved with antibiotic therapy. Disseminated Nocardia can present with multiorgan involvement. Clinical and microbiological diagnosis can be challenging. Antimicrobial treatment-related side effects require close monitoring, and dosage changes or therapy adjustments may be necessary.
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http://dx.doi.org/10.1136/bcr-2016-217337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256573PMC
January 2017

Posterior reversible encephalopathy syndrome in malignant hypertension secondary to focal segmental glomerulosclerosis.

BMJ Case Rep 2016 Aug 17;2016. Epub 2016 Aug 17.

Department of Internal Medicine, University of Arizona Medical Center, Tucson, Arizona, USA.

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition that occurs secondary to a variety of causes like autoimmune diseases, uncontrolled hypertension and immunosuppressive agents. We report an unusual association of PRES and malignant hypertension secondary to focal segmental glomerulosclerosis in a young woman, presenting with sudden loss of vision and seizures. She had uncontrolled hypertension and a Glasgow Coma Scale of 6/15. Brain MRI revealed high signals in cortical and subcortical white matter and some involvement of the periventricular areas. She improved dramatically with antihypertensive and antiepileptic medications and was discharged home in a stable condition. It is important to have a high clinical suspicion for this uncommon condition in an appropriate clinical setting, because a timely intervention can prevent long-term complications.
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http://dx.doi.org/10.1136/bcr-2016-216512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015126PMC
August 2016

Haemophagocytic lymphohistiocytosis (HLH): a rare but potentially fatal association with Plasmodium vivax malaria.

BMJ Case Rep 2016 Jun 13;2016. Epub 2016 Jun 13.

Department of Internal Medicine, Hayatabad Medical Complex, Peshawar, Khyber Pakhtunkhwa, Pakistan.

Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal syndrome that is caused by an abnormal activation of the immune system. It can present as the primary syndrome or occur secondary to a variety of conditions such as malignancy, autoimmune diseases and infections. We present a case of a man who developed HLH secondary to Plasmodium vivax infection. He presented with symptoms of fever, chills and myalgias. Physical examination revealed significant hepatosplenomegaly. The presence of pancytopaenia, elevated ferritin levels and haemophagocytosis on bone marrow biopsy confirmed the diagnosis of HLH (based on HLH-2004 criteria). There was a significant improvement after the initiation of intravenous antimalarials. No relapses were documented on follow-up. It is imperative that physicians should promptly recognise and treat this rare condition, as a timely intervention can be lifesaving.
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http://dx.doi.org/10.1136/bcr-2016-215366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932401PMC
June 2016