Aortic Dissection: The Insidious Menace

Introduction: Aortic dissection represents a critical emergency characterized by the cleavage of aortic wall layers, creating a deceptive false lumen. Associated with high mortality rates, prompt diagnosis and intervention are needed to ensure survival. Case: A 63-year-old male with no significant medical history presented to the emergency with two days of worsening mid-sternal chest pain. Upon presentation, he was hemodynamically stable. Blood pressure was 130/85 mm Hg (similar in both arms), heart rate 90 bpm, and saturating 98 % on room air. Physical examination did not reveal any new murmurs. EKG showed normal sinus rhythm, no ischemic changes, and a negative troponin50), but given low clinical suspicion for a pulmonary embolism, a CT angiography (CTA) was not pursued, especially since Wells Score was 3. The patient did meet one criterion (chest pain) for The Aortic Dissection Detection Risk Score, but unfortunately, neither a D-Dimer nor CTA was performed due to low clinical suspicion. Chest pain improved after Aspirin, sublingual Nitroglycerin, and Morphine. Troponin was negative x 2. A transthoracic echocardiogram, conducted after a delay of ten hours, disclosed a dilated aortic root measuring 4.7 cm and a 5 cm dilated ascending aorta. Additionally, a linear echo-density exhibiting flow, corroborated by color Doppler, raised suspicion of aortic dissection originating close to the right coronary cusp. Cardiothoracic surgery was immediately consulted, and a CTA was ordered. Regrettably, twenty minutes later, the patient became unresponsive with PEA cardiac arrest, and CPR was initiated. After 18 minutes of CPR, there was no return of spontaneous circulation, and the patient was pronounced deceased. Discussion: Our case underscores the deceptive nature of aortic dissection, which can present with benign physical examination, labs, and radiographic findings. In cases of uncertainty, prompt imaging with transthoracic/ transesophageal echocardiography or CTA should be performed as early detection and treatment can significantly improve prognosis

Cardiotoxicity induced by capecitabine and oxaliplatin in gastric cancer treatment: a rare case of cardiac arrest and cardiogenic shock

Introduction: Combination-based adjuvant chemotherapy utilising capecitabine and oxaliplatin is widely used in gastric cancer treatment. Rare but severe cardiac events such as prolonged QT, cardiac arrest and cardiogenic shock can result from their use. Case description: A 45-year-old female with gastric adenocarcinoma was started on capecitabine-oxaliplatin chemotherapy one week before presenting to the emergency department with weakness. Blood pressure was 78/56 mmHg, heart rate 140 bpm and oxygen saturation 85%. She became unresponsive with pulseless ventricular fibrillation; CPR was initiated with immediate intubation. She received two shocks with a return of spontaneous circulation. Laboratory tests revealed serum potassium (3.1 mmol/l), magnesium (1.1 mg/dl) and troponin (0.46 ng/ml). An EKG revealed sinus tachycardia with a prolonged QT interval (556 ms). The combined effects of capecitabine, oxaliplatin and electrolyte abnormalities likely contributed to the QT prolongation. An echocardiogram demonstrated an ejection fraction of 10%–15%. An emergent right-heart catheterisation showed right atrial pressure of 10 mmHg and pulmonary artery pressure of 30/18 mmHg; cardiac output and index were not recorded. An intra-aortic balloon pump was placed, and she was admitted to the ICU for cardiogenic shock requiring norepinephrine, vasopressin and dobutamine. A repeat echocardiogram showed a significantly improved ejection fraction of 65%, and she was discharged. Discussion: Capecitabine and oxaliplatin cardiotoxicity is an exceedingly rare occurrence, with both drugs reported to cause QT prolongation. Conclusion: Healthcare providers must recognise the QT prolongation effects of capecitabine and oxaliplatin, leading to life-threatening cardiac arrhythmias

A Rare Case of Cardiac Angiosarcoma Presenting as Recurrent Atrial Flutter/Fibrillation

Introduction Cardiac angiosarcomas are extremely rare, with an incidence of only 0.056%. They can have various presentations, including arrhythmias. Case A 65-year-old male presented to an outside hospital one year ago with palpitations. Heart rates were 130 bpm, and EKG revealed new-onset atrial flutter with 2-1 block. Apixaban and metoprolol tartrate were started, with plans for a TEE and cardioversion in 4 weeks. He went to the emergency department twice the following month with rapid atrial fibrillation and had TEE and cardioversion twice one week apart. A 2.5 cm mass in the right atrium was noted on the TEE. The atrial mass was concerning for a myxoma. A cardiac MRI was done as an outpatient, showing a large mass (31 x 22 x 35 mm) at the roof of the right atrium consistent with myxoma. A right atrial biopsy was performed, with pathology showing malignant vascular neoplasm favoring angiosarcoma. Primary cardiac angiosarcoma was diagnosed, and chemotherapy was initiated. He was referred to a cardiothoracic surgeon and underwent a right atrial sarcoma resection, left atrial appendage clip, and MAZE procedure. A few weeks later, the patient presented to our hospital with atrial flutter/fibrillation and rapid heart rates. Given multiple recurrences of symptomatic atrial fibrillation and intolerance of rate control medications, it was decided to proceed with an AV nodal ablation, which was successful. Conclusions Cardiac angiosarcoma is a rare malignant tumor. Diagnosis is challenging due to nonspecific presentations based on its location in the heart and can be the etiology for recurrent atrial fibrillation/flutter

Rheumatoid arthritis: a rare cause of pachymeningitis and optic neuritis

Introduction: Rheumatoid pachymeningitis and optic neuritis are rare complications of rheumatoid arthritis (RA) and are a diagnosis of exclusion. Case description: A 75-year-old male with a history of seronegative RA presented to the emergency department with left eye pain and blurry vision lasting two days. He had been diagnosed with seronegative RA around nine months previously. His blood pressure was elevated at 204/75 mmHg upon arrival. Physical examination revealed left conjunctival injection, mild ptosis, painful extraocular movements and tenderness over the orbit and sinuses. Initial treatments included painkillers and intravenous labetalol, which alleviated his symptoms and decreased his blood pressure. Laboratory tests showed a C-reactive protein of 2.5 mg/dl and an erythrocyte sedimentation rate of 32 mm/h, with other blood work unremarkable. A computed tomography (CT) angiogram of the head and neck showed no high-grade stenosis. Given his RA history, initial concerns included scleritis. A magnetic resonance imaging (MRI) of the brain and orbit revealed inflammation around the left optic nerve, and pachymeningitis at the left cerebral convexity and interhemispheric fissure, suggesting hypertrophic pachymeningitis. An ophthalmologic examination was unremarkable. Treatment was adjusted to include pulse doses of intravenous methylprednisolone for optic neuritis, resulting in significant pain relief. Though inadequate for complete testing, a lumbar puncture indicated an inflammatory disorder with elevated glucose (199 mg/dl), protein (109 mg/dl), and unremarkable WBC/RBC and Gram staining. Cytology and culture were unremarkable. The most likely diagnosis at this point was rheumatological meningitis and rheumatological optic neuritis. The patient improved markedly with high-dose steroids over four days and was discharged on prednisone. Conclusion: In cases of optic neuritis and pachymeningitis, RA should remain on the differential in patients with or without a prior diagnosis

Look past the bleed! A case of non-traumatic thoracic aortic pseudoaneurysm presenting as haemoptysis

Introduction: Aortic pseudoaneurysms are a type of contained rupture where most of the aortic wall is breached, leaving only a thin rim of the remaining wall or adventitia to hold the blood. This condition carries a high risk of rupture and potentially fatal complications. Typically, patients present with chest pain; haemoptysis can also occur, though rarely. Case description: A 64-year-old male who presented with two episodes of haemoptysis, with no history of cardiovascular surgery or trauma. A chest computerized tomography (CT) followed by an aortogram revealed a thoracic aortic pseudoaneurysm and the patient underwent surgical aortic repair without any complications. This case underscores the rare presentation of thoracic aortic pseudoaneurysm. Discussion: Haemoptysis is a rare manifestation of thoracic aorta pseudoaneurysm and can be a warning sign of impending rupture. Haemoptysis may occur due to formation of aortopulmonary fistula or direct erosion of pseudoaneurysm into lung parenchyma. Conclusion: It is imperative for clinicians to recognise such manifestations early for prompt diagnosis and prevention of complications