Publications by authors named "Mazin Khalid"

41 Publications

Recurrent Takotsubo Cardiomyopathy Presenting With Anterior Wall ST-Elevation Myocardial Infarction.

Cureus 2021 Feb 20;13(2):e13458. Epub 2021 Feb 20.

Department of Cardiology, Maimonides Medical Center, Brooklyn, USA.

Takotsubo cardiomyopathy (TC) or stress cardiomyopathy with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. The recurrence of TC is extremely rare, with an annual recurrence risk of 1.5% and approximately 5% recurrence risk after six years. We present a case of a patient with a history of TC who presented with chest pain and ST-segment elevation in her electrocardiogram and was found to have normal coronaries and diagnosed with recurrent TC.
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http://dx.doi.org/10.7759/cureus.13458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984958PMC
February 2021

Outcomes in Patients With COVID-19 Disease and High Oxygen Requirements.

J Clin Med Res 2021 Jan 12;13(1):26-37. Epub 2021 Jan 12.

Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA.

Background: Approximately 19% of people infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) progress to severe or critical stages of the coronavirus disease 2019 (COVID-19) with a mortality rate exceeding 50%. We aimed to examine the characteristics, mortality rates, intubation rate, and length of stay (LOS) of patients hospitalized with COVID-19 disease with high oxygen requirements (critically ill).

Methods: We conducted a retrospective analysis in a single center in Brooklyn, New York. Adult hospitalized patients with confirmed COVID-19 disease and high oxygen requirements were included. We performed multivariate logistic regression analyses for statistically significant variables to reduce any confounding.

Results: A total of 398 patients were identified between March 19th and April 25th, 2020 who met the inclusion criteria, of which 247 (62.1%) required intubation. The overall mortality rate in our study was 57.3% (n = 228). The mean hospital LOS was 19.1 ± 17.4 days. Patients who survived to hospital discharge had a longer mean LOS compared to those who died during hospitalization (25.4 ± 22.03 days versus10.7 ± 1.74 days). In the multivariate analysis, increased age, intubation and increased lactate dehydrogenase (LDH) were each independently associated with increased odds of mortality. Diarrhea was associated with decreased mortality (OR 0.4; CI 0.16, 0.99). Obesity and use of vasopressors were each independently associated with increased intubation.

Conclusions: In patients with COVID-19 disease and high oxygen requirements, advanced age, intubation, and higher LDH levels were associated with increased mortality, while diarrhea was associated with decreased mortality. Gender, diabetes, and hypertension did not have any association with mortality or length of hospital stay.
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http://dx.doi.org/10.14740/jocmr4405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869563PMC
January 2021

Should COVID-19 Patients > 75 Years be Ventilated? An Outcome Study.

QJM 2021 Feb 12. Epub 2021 Feb 12.

Department of Cardiology, Maimonides, Medical Center, NY, Brooklyn.

Background: Elderly patients with COVID-19 disease are at increased risk for adverse outcomes. Current data regarding disease characteristics and outcomes in this population is limited.

Aim: To delineate the adverse factors associated with outcomes of COVID- 19 patients ≥75 years of age.

Design: Retrospective cohort study.

Methods: Patients were classified into mild/moderate, severe/very severe, and critical disease (intubated) based on oxygen requirements. The primary outcome was in-hospital mortality.

Results: 355 patients aged ≥75 years hospitalized with COVID-19 between March 19th and April 25th, 2020 were included. Mean age was 84.3 years. One-third of the patients developed critical disease. Mean length of stay was 7.10 days. Vasopressors were required in 27%, with the highest frequency in the critical disease group (74.1%). Overall mortality was 57.2%, with a significant difference between severity groups (mild/moderate disease : 17.4%, severe/very severe disease : 71.3%, critical disease: 94.9%, p < 0.001). Increased age, dementia, and severe/very severe and critical disease groups were each significantly associated with increased odds for mortality while diarrhea was associated with decreased odds for mortality (OR : 0.12, 95% CI : 0.02-0.60, p < 0.05)]. None of the cardiovascular comorbidities were significantly associated with mortality.

Conclusion: Age and dementia are associated with increased odds for mortality in patients ≥75 years of age hospitalized with COVID-19. Those who require intubation have the greatest odds for mortality. Diarrhea as a presenting symptom was associated with lower odds for mortality.
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http://dx.doi.org/10.1093/qjmed/hcab029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928642PMC
February 2021

In-hospital outcomes of angiography versus intravascular ultrasound-guided percutaneous coronary intervention in ST-elevation myocardial infarction patients.

J Community Hosp Intern Med Perspect 2020 Sep 3;10(5):436-442. Epub 2020 Sep 3.

Division of Cardiology, Mount Sinai Hospital, New York, NY, USA.

Background: We compared the in-hospital complications, outcomes, cost, and length of stay (LOS) between angiography-guided percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS)-guided PCI in patients with ST-elevation myocardial infarction (STEMI) in the USA.

Methods: A nationwide inpatient database was queried to identify patients >18 years with STEMI who underwent angiography-guided and IVUS-guided PCI from January 2016 to December 2016. We compared the in-hospital mortality, complications, cost, and LOS between the two groups.

Results: We identified 100,485 patients who underwent angiography-guided PCI and 5,460 patients who underwent IVUS-guided PCI. In-hospital mortality was not statistically different (odds ratio [OR] 0.76, 95% CI 0.46 - 1.22, P = 0.24). Patients who underwent PCI with IVUS were more likely to have coronary artery dissection (OR 4.26, 95% CI 2.34 - 7.7, p = <0.01), and both groups had a similar incidence of acute kidney injury requiring hemodialysis. The mean LOS was similar, but the mean total cost was higher in the group that underwent PCI under IVUS guidance.

Conclusions: The in-hospital mortality, hemodialysis, and the use of support devices did not reach a statistical difference between the two groups. However, we observed higher rates of coronary dissection with the use of IVUS in STEMI management.
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http://dx.doi.org/10.1080/20009666.2020.1800970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671732PMC
September 2020

Acute Pulmonary Embolism Presenting With Angina and a Positive Cardiac Stress Test.

Cureus 2020 Oct 17;12(10):e11006. Epub 2020 Oct 17.

Cardiology, Maimonides Medical Center, Brooklyn, USA.

Acute pulmonary embolism (PE) is a commonly missed clinical entity. Prompt diagnosis of PE and the initiation of anticoagulation therapy is vital for the reduction of patient mortality. Recognizing initial electrocardiogram manifestations can aid rapid diagnosis and prompt management. The most common EKG findings associated with PE are sinus tachycardia, S1Q3T3 pattern, presence of T wave inversions in V1-V3 associated with the presence of right ventricular (RV) dysfunction, and right bundle branch block. These findings, while specific, are modestly sensitive and not always present. The gold standard of diagnosis is computerized tomographic angiography and ventilation and perfusion (V/Q). Here we present a patient who presented with symptoms mimicking angina with EKG changes in his stress test, prompting coronary angiography, which showed obstructive coronary artery disease requiring revascularization. Subsequently, further evaluation revealed a saddle pulmonary embolism that necessitated pulmonary thrombectomy.
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http://dx.doi.org/10.7759/cureus.11006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671078PMC
October 2020

Venous Stent Migrating to the Right Heart Causing Severe Regurgitation.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620974220

Maimonides Medical Center, Brooklyn, NY, USA.

Venous stent migration to the cardiopulmonary system is a rare but serious complication. Cardiopulmonary involvement has various presentations such as valvulopathy, acute heart failure, arrhythmias, endocarditis, and tamponade. The presenting symptoms depend on the eventual location of the stent in the heart or lungs, size of the stent, and valve involvement. Extracardiac dislodgement can be managed by catheter-directed extraction or proper deployment within the containing vessel or surgical extraction. Intracardiac stents may require open surgery to prevent life-threatening complications. We present an asymptomatic patient with stent migration that lead to severe tricuspid regurgitation and required tricuspid valve replacement.
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http://dx.doi.org/10.1177/2324709620974220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672755PMC
November 2020

A Rare Case of Partial Aortic Mechanical Valve Thrombosis With Intact Mitral Mechanical Valve Presenting With ST-Elevation Myocardial Infarction Patients.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620963567

Maimonides Medical Center, Brooklyn, NY, USA.

The incidence of mechanical valve thrombosis (MVT) is around 0.4 per 100 patient-years. Mitral valve thrombosis has a higher incidence than aortic valve thrombosis with a nearly 5-fold increase. Various factors contribute to MVT. The most common cause of valve thrombosis is poor adherence/disruption of anticoagulation therapy. Low cardiac output is known to increase the risk of prosthetic valve thrombosis. Other factors such as diabetes, hypertension, and other patient comorbidities might also play a role. Decreased flow promotes hypercoagulability. Lower pressure in the left atrium (and higher velocities in the left ventricle) can partially contribute to the higher incidence of mitral MVT versus aortic MVT. The presenting symptoms usually depend on the severity of the valve thrombosis; nonobstructive valve thrombosis patients have progressive dyspnea, signs of heart failure, and systemic embolization with strokes being the most common complication. In this article, we present a case of a middle-aged woman with a history of mitral and aortic mechanical prosthesis who presented with an ST-segment elevation myocardial infarction and pulmonary edema due to mechanical aortic valve prosthesis thrombosis. She had an isolated mechanical aortic valve prosthesis thrombosis with intact mitral valve, which, to the best of our knowledge, has not yet been described. We performed a literature review by searching PubMed and Embase using the keywords "mechanical valve," "thrombosis," "aortic," and "mitral," our search did not show similar cases.
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http://dx.doi.org/10.1177/2324709620963567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543143PMC
October 2020

Pneumococcal Meningitis Complicated by Spinal Cord Dysfunction and Acute Polyradiculopathy.

Ochsner J 2020 ;20(2):219-221

Department of Medicine, Interfaith Medical Center, Brooklyn, NY.

Meningitis caused by is associated with devastating clinical outcomes. A considerable number of patients will develop long-term neurologic complications. Hearing loss, diffuse brain edema, and hydrocephalus are frequently encountered. Acute spinal cord dysfunction and polyradiculopathy can develop in some patients. A 63-year-old female was admitted to our hospital with sudden-onset bilateral lower extremity weakness. On admission, the patient had evidence of spinal cord dysfunction given the abnormal motor and sensory physical examination findings and the absent sensation with a sensory level at dermatome T4 on neurologic examination. Computed tomography myelography did not show evidence of spinal cord compression or transverse myelitis. Cerebrospinal fluid examination was positive for pneumococcal meningitis. The patient was treated with antibiotics and steroids. Nerve conduction studies demonstrated the absence of response, suggesting damage to the peripheral nerves and polyradiculopathy. The patient was treated with plasmapheresis for possible Guillain-Barré syndrome; however, she did not improve despite appropriate antibiotics, steroids, and plasmapheresis. She developed persistent quadriparesis, sensory impairments in upper and lower extremities, and bowel and bladder sphincter dysfunction. Our case demonstrates the development of spinal cord dysfunction (supported by the sudden onset of paraplegia and the presence of a sensory level) and polyradiculopathy (flaccid paralysis, ascending weakness, and absence of response in neurophysiologic studies suggesting severe damage to the peripheral nerves). The appearance of either complication is unusual, and the simultaneous occurrence of both complications is even more uncommon.
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http://dx.doi.org/10.31486/toj.18.0153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310179PMC
January 2020

Narrow Escape: A Novel Approach to the Endovascular Treatment of Superior Vena Cava Syndrome Secondary to Pacemaker Leads with Excellent Long-term Outcomes.

Cureus 2020 Mar 12;12(3):e7249. Epub 2020 Mar 12.

Cardiology, Maimonides Medical Center, Brooklyn, USA.

Pacemaker or defibrillator placement is a common procedure done in more and more patients due to increased longevity and the prominence of cardiac disease. With more indications for cardiac implantable electrode devices, the devices themselves have evolved into more complex structures with more leads. The mechanical stress, risk of infection, and decreased blood flow through the superior vena cava (SVC) put patients at risk for SVC obstruction. Herein, we present a rare case of complete SVC obstruction secondary to fibrosis due to pacemaker leads which was treated with venoplasty and showed excellent long-term results. We also review the current literature on different approaches to treating SVC obstruction in this group of patients.
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http://dx.doi.org/10.7759/cureus.7249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152578PMC
March 2020

The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study.

Gastroenterology Res 2020 Feb 1;13(1):19-24. Epub 2020 Feb 1.

Department of Gastroenterology, Wayne State University/John D. Dingell VA Medical Center, Detroit, Michigan, USA.

Background: Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce.

Methods: The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module.

Results: Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk.

Conclusion: Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.
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http://dx.doi.org/10.14740/gr1234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011915PMC
February 2020

Endobronchial valves for persistent air leak all-cause mortality and financial impact: US trend from 2012-2016.

J Community Hosp Intern Med Perspect 2019 1;9(5):397-402. Epub 2019 Nov 1.

Pulmonary Division, Interfaith Medical Center, Brooklyn, NY, USA.

: Endobronchial valves (EBV) are considered an innovation in the management of the persistent air leak (PAL). They offer a minimally invasive alternative to the traditional approach of pleurodesis and surgical intervention. We examined trends in mortality, length of stay (LOS), and resources utilization in patients who underwent EBV placement for PAL in the US. : We utilized discharge data from the Nationwide Inpatient Sample (NIS) for five years (2012-2016). We included adults diagnosed with a pneumothorax who underwent EBV insertion at ≥ 3 days from the day of chest tube placement; or following invasive thoracic procedure. We analyzed all-cause mortality, LOS, and resources utilization in the study population. : A total of 1,885 cases met our inclusion criteria. Patients were mostly middle-aged, males, whites, and had significant comorbidities. The average LOS was 21.8 ± 20.5 days, the mean time for chest tube placement was 3.8 ± 5.9 days, and the mean time for EBV insertion was 10.5 ± 10.3 days. Pleurodesis was performed before and after EBV placement and in 9% and 6%, respectively. : Our study showed that the all-cause mortality rate fluctuated throughout the years at around 10%. Despite EBV being a minimally invasive alternative, its use has not trended up significantly during the study period. EBVs are also being used off-label in the US for spontaneous pneumothorax. This study shall provide more data to the scarce literature about EBV for PAL.
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http://dx.doi.org/10.1080/20009666.2019.1675229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830260PMC
November 2019

Ecstasy induced acute systolic heart failure and Non-Ischemic Cardiomyopathy in a young female: a rare case report and literature review.

J Community Hosp Intern Med Perspect 2019 5;9(4):336-339. Epub 2019 Sep 5.

Department of Cardiology, Interfaith Medical Center, Brooklyn, NY, USA.

Ecstasy or 3,4-methylenedioxymethamphetamine (MDMA) is an illicit recreational drug. Effects include euphoria, increased sensory awareness, and central stimulation. Although various arrhythmias, as well as dilated cardiomyopathy, have been previously noted to occur with chronic use, cardiac toxicities are seldom reported in an acute setting. Herein, we present a 28-year-old female patient with no prior medical condition that presented to the Emergency Department with chest pain following intake of MDMA. Electrocardiographic findings, as well as laboratories, were suggestive of possible Acute Non-ST elevation myocardial infarction. Upon admission, cardiac catheterization revealed patent coronary arteries. Stark regional wall motion abnormalities were observed along with reduced ejection fraction. Acute systolic heart failure was treated with standard medical management. Subsequent reassessment of ventricular function with Echocardiography revealed marked improvement. This article describes a case of MDMA induced heart failure, including details of evaluation, management, and monitoring of patient progress. It brings further attention to potential acute harmful effects of MDMA on cardiac function and viability.
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http://dx.doi.org/10.1080/20009666.2019.1650593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6735291PMC
September 2019

Characteristics of 30-day readmission in spontaneous pneumothorax in the United States: a nationwide retrospective study.

J Community Hosp Intern Med Perspect 2019 19;9(3):215-220. Epub 2019 Jun 19.

Pulmonary Division, Interfaith Medical Center, Brooklyn, NY, USA.

: Our study aimed to determine the national estimates of the 30-day all-cause readmission rate among patients with spontaneous pneumothorax and to investigate the burden of these readmissions in terms of mortality, length of stay and hospitalization costs in the USA. : We utilized the Nationwide Readmission Database for 2013-2014 and identified adults with a primary diagnosis of spontaneous pneumothorax. We analyzed and reported patient- and hospital-level variables of the study cohort. Our primary outcome was 30-day readmission rate, including the reasons for readmission. Our secondary outcomes included all-cause mortality, resources utilization and predictors of readmissions. : We identified 47,108 index admissions with spontaneous pneumothorax. The 30-day readmission rate was 13.6%. The most common reason for admission was recurrent pneumothorax. In index admissions, the in-hospital mortality rate was 3.1%; whereas, in readmissions, the mortality was higher (4.6%, < 0.001). Both age group 45-64 (: 1.31, 95% : [1.15-1.49], < 0.001) and history of cancer (: 1.34, 95% : [1.17-1.53], < 0.001) were found to predict the risk of 30-day readmission. : The 30-day readmission rate in patients with spontaneous pneumothorax was 13.6%, and a recurrent event was the most likely cause. The 30-day readmissions were associated with higher mortality and hospitalization charges. Middle age and history of cancer increase likelihood of 30-day readmission.
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http://dx.doi.org/10.1080/20009666.2019.1618135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586084PMC
June 2019

Prediction of Aspartate Aminotransferase to Platelet Ratio Index with Size of Esophageal Varices in Liver Cirrhosis.

J Nepal Health Res Counc 2019 Apr 28;17(1):38-41. Epub 2019 Apr 28.

KIST Medical College, Lalitpur, Nepal.

Background: Liver cirrhosis is one of the major causes of morbidity and mortality. The threatening complication of Liver cirrhosis is variceal bleeding. Early diagnosis and initiation of therapy can reduce mortality associated with variceal bleeding. This study is designed to predict the esophageal varices by non-invasive method using aspartate aminotransferase to platelet count ratio index (APRI).

Methods: A total of 100 patients were studied between March 2016 and February 2017 with the diagnosis of Liver cirrhosis admitted at Bir Hospital fulfilling the inclusion and exclusion criteria. Ethical approval was obtained from Institutional review board of National Academy of Medical Sciences.

Results: Out of one hundred patients, 80 were males and 20 females. On endoscopy, small varices were present in 28 (28%) patients and large varices in 51(51%) patients. APRI with a cutoff value of 0.908 has sensitivity of 87.3% and specificity of 71.4%, positive predictive value of 92% and negative predictive value of 60% (p=0.001) for the detection of varices.

Conclusions: Aspartate aminotransferase to platelet count ratio index can be a useful tool to indirectly predict esophageal varices in a patient with Liver Cirrhosis.
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http://dx.doi.org/10.33314/jnhrc.1392DOI Listing
April 2019

Clozapine-Induced Cardiotoxicity Presenting as Sepsis: A Case Report and Literature Review.

Case Rep Med 2019 31;2019:3435108. Epub 2019 Mar 31.

Department of Cardiology, Interfaith Medical Centre, Brooklyn, NY, USA.

Clozapine is an atypical antipsychotic agent indicated in the treatment of medication-resistant schizophrenia. It is often reserved as a last line of treatment owing to the potential for serious and potentially life-threatening side effects, the most serious being agranulocytosis requiring close hematological monitoring and possible discontinuation of the medication from further use in the patient even when the agranulocytosis resolves. Other complications of clozapine include sedation, weight gain, elevated triglyceride levels, postural hypotension, and tachycardia. However, the potentially serious complication of myocarditis, though rare (with an incidence of 3%), may lead to cardiomyopathy as described in our present case. We present a 21-year-old patient who was started on clozapine for management of schizophrenia. He developed fever and tachycardia and was admitted to the medical unit on intravenous antibiotics for management of sepsis as he met the criteria for systemic inflammatory response syndrome. His labs revealed an elevated troponin and trending eosinophilia, which, in the context of clozapine use, raises the suspicion of clozapine cardiotoxicity. Echocardiogram showed reduced systolic function (45%). Clozapine was immediately discontinued, and his repeat echocardiogram showed normalization of his systolic function. In view of the increased prevalence of psychiatric illnesses, internists should be aware of rare but potentially life-threatening side effects.
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http://dx.doi.org/10.1155/2019/3435108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462315PMC
March 2019

Polysomnographic variables in Alternate overlap syndrome: data from sleep heart health study.

J Community Hosp Intern Med Perspect 2019 Apr 12;9(2):108-112. Epub 2019 Apr 12.

Department of Pulmonary Medicine, Interfaith Medical Centre, Brooklyn, NY, USA.

: To evaluate influence of asthma on polysomnographic variables of patients with obstructive sleep apnea (OSA).: A longitudinal retrospective study using data collected from the Sleep Heart Health Study (SHHS).: All 2822 patients included had OSA, 2599 were non-asthmatic whereas 223 were asthmatics. Average BMI for non-asthmatics was 28.8 kg/m whereas asthmatics had 29.5 kg/m. Median pack-years of smoking was 1.42 vs. 1.98 in non-asthmatic and asthmatic groups, respectively. Sex distribution, age (in years), BMI, FEV, FVC, AHI ≥ 4% (all apneas, hypopneas with ≥4% oxygen desaturation or arousal per hour of sleep), RDI ≥ 3% (overall respiratory distribution index at ≥3% oxygen desaturation or arousal), sleep latency, percentage of sleep time in apnea/hypopnea and Epworth sleep scale score were all statistically significant. Non-asthmatics had greater AHI (12.63/hr) compared to asthmatics (11.34/hour), = 0.0015. RDI in non-asthmatics and asthmatics was (23.07 vs 20.53; = 0.009). Sleep latency was found to be longer in asthmatics 19.8 minutes vs. 16 minutes ( = 0.008). Epworth sleepiness scale score was high in asthmatics (9 vs. 8, = 0.002).: OSA was found more severe in non-asthmatic subgroup, but asthmatics had statistically significant higher Epworth sleepiness scale score and sleep latency. Clinicians should be vigilant and keep low threshold to rule out OSA particularly on patients with difficult to control asthma, smoker, GERD, obese and nasal disease.
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http://dx.doi.org/10.1080/20009666.2019.1595951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6484460PMC
April 2019

Elevated Liver Enzymes in Patients with Type 2 Diabetes Mellitus and Non-alcoholic Fatty Liver Disease.

Cureus 2018 Nov 23;10(11):e3626. Epub 2018 Nov 23.

Internal Medicine, Interfaith Medical Center, Brooklyn, USA.

Background Non-alcoholic fatty liver disease (NAFLD) is emerging as the most common chronic liver condition. Approximately 70% of type 2 diabetes mellitus (T2DM) patients have a fatty liver; the progression to non-alcoholic steatohepatitis (NASH) dramatically increases the risks of cirrhosis and hepatocellular carcinoma. The aim of our study was to assess the profile of liver enzymes in subjects with T2DM and NAFLD. Method This was a cross-sectional clinic-based study in patients with T2DM. An ultrasonography of the abdomen was done in all patients in order to examine the presence of a fatty liver. Body mass index (BMI), lipid profile, and liver enzymes were also analyzed in all patients. Institutional Review Board (IRB) approval was provided by the National Academy of Medical Sciences, Bir Hospital, Nepal. Unpaired -test, Chi-square/Fisher's exact test (for categorical variables), and the Pearson/Spearman correlation test were used to find a significant difference, association, and correlation between two or more groups, respectively. The Statistical Package for Social Sciences (SPSS)® Statistics, version 16 (IBM SPSS Statistics, Armonk, NY) was used to analyse the data. Results The study was carried out in 210 patients, and out of the 210 patients, 119 (56.6%) were male and 91 (43.3%) were female. The patients were divided into two groups, i.e., the normal alanine aminotransferase (ALT) group and the elevated ALT group. The mean age of the patients was 56.28 ± 12.3 years in the normal alanine aminotransferase (ALT) group and 58.6 ± 24.7 in the elevated ALT group. The number of T2DM patients with a fatty liver was 117 (55.7%) and those with a non-fatty liver was 93 (44.2%) based on an ultrasonography scan. Subjects with NAFLD had a significantly higher ALT (p < 0.001) but no significant rise in serum aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), and alkaline phosphatase (ALP) levels. The area under the receiver operating characteristic (AUROC) curve for the prediction of fatty liver based solely on the ALT was 0.84 with the confidence interval (CI) between 0.76 and 0.92 (p < 0.05). Conclusions Non-alcoholic fatty liver disease is highly prevalent in patients with T2DM. Timely diagnosis and management of the abnormal liver parameters may help to minimize liver-related morbidity and mortality in the diabetic population.
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http://dx.doi.org/10.7759/cureus.3626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347442PMC
November 2018

Rectourethral Fistula Secondary to Transurethral Resection of the Prostate.

Cureus 2018 Oct 22;10(10):e3476. Epub 2018 Oct 22.

Internal Medicine, Interfaith Medical Center, Brooklyn, USA.

An 82-year-old male with benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP) presented to the hospital with suprapubic pain, abdominal distension, and diarrhea. The physical examination was remarkable for an indwelling Foley's catheter. Diagnostic imaging confirmed the diagnosis of a rectourethral fistula (RUF). The most common presenting symptoms of RUF are pneumaturia, fecaluria, and urine leakage from the rectum, which may present similarly to diarrhea. He lacked the common features of RUF such as pneumaturia and fecaluria, which may be explained by a blockage of the catheter with fecal material. This case represents a rare outcome following a TURP, and it is significant due to the high morbidity associated with RUF. As such, clinicians must suspect a RUF in a post-TURP patient with diarrhea and no other obvious etiology due to the morbidity associated with RUF.
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http://dx.doi.org/10.7759/cureus.3476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318087PMC
October 2018

Contrast-induced Nephropathy Following Percutaneous Coronary Intervention at a Tertiary Cardiac Center in Nepal.

Cureus 2018 Sep 18;10(9):e3331. Epub 2018 Sep 18.

Internal Medicine, Interfaith Medical Center, Brooklyn, USA.

Background Contrast-induced nephropathy (CIN) is one of the leading causes of morbidity and mortality including increased financial burden in high risk patients undergoing percutaneous coronary intervention (PCI). Methods This is an observational prospective study. We aimed to study the incidence of CIN in Nepalese populations and compare the outcome to international reprinted values with coronary artery disease (CAD) undergoing PCI. All consecutive patients with CAD undergoing PCI between February 2010 and July 2010 were enrolled in the study. Results One hundred fifty-two patients were enrolled in the study during six months period. Twenty (13.20%) patients developed CIN following PCI. Out of them 70% were diabetics and 30% were non-diabetics. Mean age of patients was 58.5 ± 23 years; male:female ratio was 2.7:1. Mean contrast volume injected was 160.3  ±  78.3  mL. Diabetic patients 21.8% (14/64) had significant CIN compared to non-diabetic patients 6.8% (6/88) following PCI (<0.01). Conclusions CIN is a common complication following PCI especially in diabetics. Despite the use of iodinated material we had similar incidence of CIN comparing the incidence of CIN among various radiocontrast compounds used to visualize vessels. None of the patients received hemodialysis as compared to available studies and there was no observed mortality.
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http://dx.doi.org/10.7759/cureus.3331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248688PMC
September 2018

Case Report: Diffuse T wave inversions as initial electrocardiographic evidence in acute pulmonary embolism.

F1000Res 2018 13;7:738. Epub 2018 Jun 13.

Internal Medicine Residency Program, Interfaith Medical Center, Brooklyn, NY, 11213, USA.

Acute pulmonary embolism (PE) is a life-threatening condition and is typically diagnosed by a combination of symptoms, clinical signs and imaging. Electrocardiogram may be helpful in diagnosis, and the most widely described pattern of occurrence is the so-called S Q T pattern. Here, we describe the case of an African-American male who presented with typical chest pain, diffuse T wave inversions with serial troponin elevation. There was initial concern for Wellen's syndrome but was finally diagnosed as acute PE. This case underscores the necessity of vigilance and a lower threshold for PE work up even in patients presenting as acute coronary syndrome.
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http://dx.doi.org/10.12688/f1000research.14927.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178910PMC
September 2019

Valproic acid induced acute liver injury resulting in hepatic encephalopathy- a case report and literature review.

J Community Hosp Intern Med Perspect 2018 15;8(5):311-314. Epub 2018 Oct 15.

Department of Medicine, Wayne State University/Detroit Medical center, Detroit, MI, USA.

Valproic acid (VPA) is a commonly used agent in the management of seizures and psychiatric disorders. Hyperammonemia is a common complication of VPA with 27.8% of patients having elevated levels - that is unrelated to hepatotoxicity and normal transaminases. Common side effects include obesity, insulin resistance, metabolic disorder and severe forms of hepatotoxicity. Other rare and idiosyncratic reactions have been reported, one of which is presented in our case. A 27-year old patient presented with hyperammonemia and encephalopathy as a consequence of idiosyncratic VPA reaction causing drug-induced liver injury (DILI) with severely elevated transaminases. DILI is commonly overlooked when investigating encephalopathy in the setting of VPA. Physicians should consider DILI in the context of hyperammonemia and transaminitis.
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http://dx.doi.org/10.1080/20009666.2018.1514933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197012PMC
October 2018

Moderate Hypertriglyceridemia Causing Recurrent Pancreatitis: A Case Report and the Literature Review.

Case Rep Gastrointest Med 2018 24;2018:8714390. Epub 2018 Sep 24.

Department of Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA.

Recurrent acute pancreatitis secondary to hypertriglyceridemia (HTG) with levels below 1000 mg/dL has been rarely reported in the literature. HTG is the third most common cause of acute pancreatitis and has been established in the literature as a risk factor when levels are greater than 1000 mg/dL. A 43-year-old patient presented to the hospital with severe epigastric abdominal pain. Initial laboratory investigations were significant for a lipase level of 4143 U/L and a triglyceride level of 600 mg/dL. Computed tomography (CT) of the abdomen showed diffuse enlargement of the pancreas consistent with pancreatitis. A diagnosis of severe acute pancreatitis secondary to high triglycerides was made based on the revised Atlanta classification 2012. The patient was initially managed with intravenous boluses of normal saline followed by continuous insulin infusion. Diabetic Ketoacidosis (DKA) was ruled out due to a past medical history of diabetes. Her clinical course was complicated by acute respiratory distress syndrome requiring intubation and mechanical ventilation. During the course, she improved symptomatically and was extubated. She was started on nasogastric feeding initially and subsequently switched to oral diet as tolerated. After initial management of HTG with insulin infusion, oral gemfibrozil was started for long-term treatment of HTG. Emerging literature implicates HTG as an independent indicator of poor prognosis in acute pancreatitis (AP). Despite the paucity of data, the risk of developing AP must be considered even at triglyceride levels lower than 1000 mg/dL.
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http://dx.doi.org/10.1155/2018/8714390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174808PMC
September 2018

A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia (>10 000 mg/dL) Successfully Resolved With Insulin Therapy Alone: A Case Report and Literature Review.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618798399. Epub 2018 Sep 1.

Interfaith Medical Center, New York, NY, USA.

A 48-year-old male presented to the psychiatric emergency room for dysmorphic mood. He was admitted to medical service for the management of hyponatremia, which was discovered in his initial laboratory workup. After the first day of admission, he developed abdominal pain and fever, and subsequent laboratory work revealed a triglyceride level of 10 612 mg/dL (reference range = 0-194 mg/dL). Computed tomography scan of the abdomen and pelvis revealed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid suggestive of hemorrhagic pancreatitis. Based on the laboratory findings and imaging, we diagnosed acute pancreatitis (AP) secondary to hypertriglyceridemia. The patient was initiated on intravenous fluids and insulin to help decrease the triglyceride level with the plan to initiate apheresis. However, the patient improved on insulin therapy alone, which negated the need for apheresis, and the patient was discharged with fenofibrate with no further complications. While elevated triglycerides are a well-known cause of AP, we sought to assess various treatment options in management, especially considering a severely elevated triglyceride level of >10 000 mg/dL. Along with supportive care in AP, there are additional options in hypertriglyceridemia AP, including heparin, insulin, apheresis, antioxidants, and fibrates. Currently, there are no clear guidelines favoring one therapeutic option over the other.
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http://dx.doi.org/10.1177/2324709618798399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6120174PMC
September 2018

Sofosbuvir Based Regimens in the Treatment of Chronic Hepatitis C with Compensated Liver Cirrhosis in Community Care Setting.

Int J Hepatol 2018 1;2018:4136253. Epub 2018 Aug 1.

Department of Medicine and Gastroenterology, Interfaith Medical Center, 1545 Atlantic Avenue, Brooklyn, NY 11213, USA.

Background: Direct-acting antiviral (DAA) drugs have been highly effective in the treatment of chronic hepatitis C (CHC) infection. We aim to evaluate the treatment response of Sofosbuvir based DAA in CHC patients with compensated liver cirrhosis as limited data exists in the real-world community setting.

Methods: All the CHC patients with compensated liver cirrhosis treated with Sofosbuvir based DAAs between January 2014 and December 2017 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with the sustained virologic response at 12 weeks posttreatment (SVR12), and adverse reactions were assessed.

Results: One hundred and twelve patients with CHC infection and concurrent compensated cirrhosis were included in the study. Black patients represented the majority of the study population (64%). Eighty-seven patients were treated with Ledipasvir/Sofosbuvir (LDV/SOF) ±Ribavirin and 25 patients were treated with Sofosbuvir/Velpatasvir (SOF/VEL). Overall, SVR 12 after treatment was achieved in 90% in patients who received one of the two DAA regimens (89.7% in LDV/SOF group and 92% in SOF/VEL group). SVR 12 did not vary based on age, sex, body mass index, baseline HCV viral load, HCV/HIV coinfection, type of genotype, and prior treatment status. Apart from a low platelet count, there were no other factors associated with a statistical difference in SVR 12(0.002) between the two regimens. Fatigue (35%) was the most common adverse effect and no patients discontinued treatment due to adverse effects.

Conclusion: In the community care setting, Sofosbuvir based DAAs are safe, effective with high overall SVR, and well tolerated in patients with CHC patients with compensated liver cirrhosis.
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http://dx.doi.org/10.1155/2018/4136253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6093047PMC
August 2018

A Rare Case of Systemic Lupus Erythematosus with Gastric Ulcer and Acute Pancreatitis: A Case Report and Literature Review.

Gastroenterology Res 2018 Aug 8;11(4):321-325. Epub 2018 Feb 8.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease which can manifest in many different organ systems. Gastrointestinal (GI) involvement is common in SLE, but the symptoms are usually mild. More severe GI complications including acute pancreatitis and peptic ulcer bleeding are rare but represent a significant risk of morbidity and mortality. We present a case of a 25-year-old Hispanic female with a severe SLE flare. The initial presentation included symptoms of hematemesis and epigastric abdominal pain secondary to both gastric ulceration and acute pancreatitis, an atypical presentation of an SLE flare. The non-specific symptom of abdominal pain makes both acute pancreatitis and gastric ulcer disease a clinical challenge; however, clinicians need to have a high suspicion for these conditions co-existing at the same time due to higher mortality rates.
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http://dx.doi.org/10.14740/gr1048wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089583PMC
August 2018

Metachronous Granular Cell Tumor of the Descending Colon.

Gastroenterology Res 2018 Aug 8;11(4):317-320. Epub 2018 Feb 8.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Granular cell tumors (GCTs) are uncommon tumors. They are believed to be neuronal in origin and are usually found in the head and/or neck area of the body. They have also been reported in various locations of the gastrointestinal (GI) system, usually discovered during routine screening colonoscopy. We report a case of GCT in a 58-year-old asymptomatic African American female as a metachronous tumor of a well-differentiated adenocarcinoma of the sigmoid colon, which was an incidental finding in screening colonoscopy. To our knowledge, this is the first case with GCT identified as a metachronous tumor following an adenocarcinoma of the colon.
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http://dx.doi.org/10.14740/gr1045wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089591PMC
August 2018

Association Between Vitamin D Levels and Treatment Response to Direct-Acting Antivirals in Chronic Hepatitis C: A Real-World Study.

Gastroenterology Res 2018 Aug 8;11(4):309-316. Epub 2018 Feb 8.

Department of Medicine and Division of Gastroenterology and Hepatology, New York-Presbyterian Brooklyn Methodist Hospital, 506, 6th St, Brooklyn, NY 11215, USA.

Background: Low serum vitamin D levels in chronic hepatitis C (CHC) is associated with advanced liver fibrosis; and there remains an imprecise relationship with the treatment response based on the vitamin D levels. Previous studies have shown conflicting results on the vitamin D levels, and association with treatment response in CHC treated with interferon-based regimens.

Methods: Patients with CHC treated with direct-acting antivirals (DAAs) between January 2016 and December 2017 in the community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with the sustained virologic response at 12 weeks post-treatment (SVR 12) were assessed in CHC patients with deficient, insufficient, and normal levels of vitamin D measured before the initiation of DAA therapy.

Results: Two hundred and ninety-one patients were included in the study. Direct-acting antivirals included in the study were ledipasvir/sofosbuvir ± ribavirin, ombitasvir + paritaprevir + ritonavir + dasabuvir ± ribavirin, and sofosbuvir/velpatasvir. An overall sustained virologic response was achieved in 95% (n = 276) of patients. SVR 12 rates among patients with vitamin D deficiency, vitamin D insufficiency and normal vitamin D levels were 92%, 96.2%, and 97.2% respectively and was not statically significant (P = 0.214). A total of 71 patients were cirrhotic. The prevalence of vitamin D insufficiency (20 - 29.9 ng/mL) and deficiency (< 20 ng/mL) was significantly higher in cirrhotic patients (P = 0.01). Despite this, pretreatment vitamin D levels did not show any impact on the virologic response. The most common adverse effect observed was fatigue. None of the patients had to discontinue the treatment due to adverse events.

Conclusions: DAAs are safe and effective with a high overall SVR 12 in CHC and treatment response does not depend on the pretreatment vitamin D levels. The prevalence of both vitamin D insufficiency and deficiency was observed to be higher in cirrhotic cohorts compared to non-cirrhotic counterparts.
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http://dx.doi.org/10.14740/gr1072wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089592PMC
August 2018

Sofosbuvir based regimens in the treatment of chronic hepatitis C genotype 1 infection in African-American patients: a community-based retrospective cohort study.

Eur J Gastroenterol Hepatol 2018 10;30(10):1200-1207

Department of Medicine and Division of Gastroenterology and Hepatology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York.

Background: Direct-acting antiviral (DAA) drugs have been highly effective in the treatment of chronic hepatitis C (HCV) infection. Limited data exist comparing the safety, tolerability, and efficacy of DAAs in African-American (AA) patients with chronic hepatitis C genotype 1 (HCV GT-1) in the community practice setting. We aim to evaluate treatment response of DAAs in these patients.

Patients And Methods: All the HCV GT-1 patients treated with DAAs between January 2014 and January 2018 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with a sustained virologic response at 12 weeks post-treatment (SVR12), and adverse reactions were assessed.

Results: Two-hundred seventy-eight patients of AA descent were included in the study. One-hundred sixty-two patients were treated with ledipasvir/sofosbuvir (SOF)±ribavirin, 38 were treated with simeprevir/SOF±ribavirin, and 38 patients were treated with SOF/velpatasvir. Overall, SVR at 12 weeks was achieved in 94.6% in patients who received one of the three DAA regimens (93.8% in ledipasvir/SOF group, 92.1% in simeprevir/SOF group, and 97.4% in SOF/velpatasvir group). Previous treatment experience, HCV RNA levels and HIV status had no statistical significance on overall SVR achievement (P=0.905, 0.680, and 0.425, respectively). Compensated cirrhosis in each of the treatment groups did not influence overall SVR of 12. The most common adverse effect was fatigue (27%). None of the patients discontinued the treatment because of adverse events.

Conclusion: In the real-world setting, DAAs are safe, effective, and well tolerated in African-American patients with chronic HCV GT-1 infection with a high overall SVR rate of 94.6%. Treatment rates did not differ on the basis of previous treatment and compensated cirrhosis status.
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http://dx.doi.org/10.1097/MEG.0000000000001233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133221PMC
October 2018

Hyperacute liver injury following intravenous fluconazole: A rare case of dose-independent hepatotoxicity.

J Family Med Prim Care 2018 Mar-Apr;7(2):451-454

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Fluconazole is a triazole antifungal medication used in the treatment of various fungal infections. It is available in both oral and parenteral formulations. Liver damage has been reported with fluconazole use, but most commonly it is benign elevated liver transaminases. Acute liver failure (ALF) in fluconazole use is rare, with cases being reported sporadically in literature and large cohorts describing incidence rates of acute liver injury ranging from 0.0 to 31.6/10,000 patients. We present a case of a 45-year-old African-American male with no history of liver disease who presented with superficial candidiasis and superimposed bacterial cellulitis. He was subsequently started on intravenous fluconazole and clindamycin. Shortly after he developed ALF and a drug-induced liver injury (DILI) was suspected. Fluconazole was stopped, and the clinical picture improved shortly afterward, leading to a diagnosis of fluconazole-induced ALF. Patient underwent laboratory and clinical evaluation to exclude competing etiologies of liver injury as well as a standardized assessment for causality and disease severity such as Roussel Uclaf Causality Assessment Method/Council for International Organizations of Medical Sciences score, which concluded a "Highly Probable" DILI, and a Naranjo score identifying adverse drug reaction (ADR) which concluded a "Definite ADR." Due to the severity of ALF and the routine use of fluconazole in clinical practice, clinicians should be aware that fluconazole can be a causative agent of ALF, even in low-risk populations.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_330_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6060922PMC
August 2018

Rhabdomyolysis: An Unusual Presentation of Infection in an Adult-A Case Report and Literature Review.

Case Rep Med 2018 21;2018:6897975. Epub 2018 Jun 21.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

is a common cause of community-acquired pneumonia, and many extrapulmonary manifestations have been described, but rhabdomyolysis is infrequently reported in adults. Of the few cases that have been reported in adults, it was almost exclusively seen when pneumonia was present. We report a case of a 30-year-old male who came in with complaints of fever and myalgia for three days. Immunoglobulin M antibodies for were positive and trending up, despite having no radiographic evidence of pneumonia on chest X-ray or CT scan. He was treated successfully with levofloxacin and intravenous hydration. Later, his condition was clinically and biochemically improved, and he was discharged. Our patient did not present with typical respiratory tract symptoms of a mycoplasma infection. In addition, there was an absence of pneumonia on imaging, suggesting that rhabdomyolysis secondary to mycoplasma might be underdiagnosed and go untreated in the setting of low clinical suspicion. Upon review of the literature, there is only one other case of mycoplasma infection where rhabdomyolysis occurred in the absence of pneumonia. However, the degree of rhabdomyolysis in our case was much more severe. Although rare, when faced with rhabdomyolysis, should be kept as a differential diagnosis even in the absence of pneumonia on radiological imaging.
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http://dx.doi.org/10.1155/2018/6897975DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033244PMC
June 2018