An Atypical Presentation of Cystic Echinococcosis

Cystic echinococcosis (CE) is an infection caused by the Echinococcus granulosus tapeworm. CE generally manifests in the liver, but it may present in any organ. These patients often first present to the emergency department. Mortality over 10 years is significant for those who go undiagnosed. We report the case of a 34-year-old patient who immigrated from Yemen six years earlier. She presented with acute onset dysuria, suprapubic pain, and fever. Imaging revealed a primary multicystic mass on the right renal pole with a secondary lesion in the right hepatic lobe. On further investigation, the patient’s serum was positive for echinococcus antibodies

Renal Cysts in an Immigrant Patient: An Atypical Presentation of Echinococcosis

Introduction: Cystic echinococcosis (CE) is an infection caused by the Echinococcus tapeworm that results in the creation of cysts within a range of visceral organs. Ninety percent of these cysts are in the liver or lungs. In the United States, cases are quite rare and most are found in immigrants from endemic countries. Patients with CE may remain asymptomatic for years. If left undiagnosed and untreated, mortality from CE is estimated to be 90% by ten years. In this case, we discuss a patient who presented to the emergency department with genitourinary complaints and was diagnosed with CE of primary renal involvement, a rare anatomic location. Case Description: A previously healthy 34-year-old female presented to the emergency department with dysuria, suprapubic pain, myalgias and fever of one day duration. The patient had immigrated from Yemen 6 years prior. On presentation, she was febrile to 38.8C and tachycardic to 133. Complete blood count and lactic acid were within normal limits and urinalysis was not consistent with a urinary tract infection. Ultrasound revealed a mass on the right kidney and computerized tomography (CT) showed a subcapsular right renal cystic mass with septations as well as a secondary liver lesion. Further imaging by magnetic resonance confirmed the subscapular multi-cystic mass along the right kidney measuring 7 x 5.2 x 6.1 cm consistent with CE stage III and a 1.7 cm cystic lesion in the right hepatic lobe also consistent with CE. Serum IgG for echinococcus was positive. The patient was diagnosed with echinococcal disease and was initiated on albendazole 200mg BID for 3-4 months with future plans for surgical intervention. Discussion: Echinococcal disease is a parasitic infection with the majority of cases originating in the Middle East, South and Central America and sub-Saharan Africa. The clinical presentation of Echinococcus infection is largely dependent on the location and size of the cysts. Small cysts may be asymptomatic whereas larger cysts may cause mass effect or may present with toxic appearance with rupture. Some cysts present with symptoms up to several decades after initial infection or remain asymptomatic indefinitely. The most common sites of involvement are the liver (approximately 66%) followed by the lungs (25%). Less commonly reported sites include the brain, kidneys, muscle, bone and heart. Our patient’s primary renal cyst was large enough to cause mass effect, leading to dysuria and suprapubic pain. Generally, diagnosis of echinococcal disease is made with both imaging and serology. With regards to imaging, ultrasonography is 90-95% sensitive for CE and CT is only moderately better with 95-100% sensitivity; however, CT is superior to ultrasonography for evaluation of extrahepatic cysts. MRI offers no major advantage over CT. When considering serology, antibody detection has greater sensitivity than antigen detection. Our patient tested positive for echinococcal IgG. IgE and IgM were not pursued as IgG has better sensitivity. Management of these cysts are based on the WHO classification criteria and typically use a combination of observation, albendazole, PAIR (percutaneous puncture, aspiration, injection, re-aspiration) and surgery. Our patient’s renal cyst was classified as WHO stage III, for which the recommended treatment is albendazole followed by either PAIR or surgery. Conclusion: Although CE is uncommon in the United States, careful attention should be paid in individuals who have immigrated from endemic countries. While the liver and lungs are most commonly involved, cysts can be found in any organ and symptoms are often specific to the affected system. The best imaging modality for extrahepatic cysts in particular is by CT. The majority of these patients should be started on albendazole initially with definitive treatment often requiring evaluation by several subspecialists including Infectious Disease, Interventional Radiology and Surgery.https://scholarlycommons.henryford.com/merf2020caserpt/1123/thumbnail.jp

Diltiazem Induced Bullous Leukocytoclastic Vasculitis

Diltiazem is a calcium ion cellular influx inhibitor approved by the U.S. Food and Drug Administration for the management of hypertension and chronic stable angina. Diltiazem is commonly used off label for chronic ventricular rate control in atrial fibrillation. Very few cases of widespread cutaneous vasculitis have been described in association with diltiazem since 1988. We report on a patient developing diffuse petechiae with overlying palpable purpura and tense bullae in both lower extremities, which progressed to the thighs, buttocks, abdomen, and upper extremities 6 days after starting diltiazem for management of atrial fibrillation. Skin biopsy revealed leukocytoclastic vasculitis.https://scholarlycommons.henryford.com/merf2020caserpt/1009/thumbnail.jp

Oliguria on the Day of Intubation Is Associated With Mortality in Patients With Acute Respiratory Distress Syndrome

To investigate the relationship between oliguric acute kidney injury (AKI) and mortality in patients with acute respiratory distress syndrome (ARDS). DESIGN: Retrospective cohort study. SETTING: This investigation took place at a single-center, tertiary referral multidisciplinary comprehensive healthcare hospital in metropolitan Detroit, Michigan. PATIENTS: Adult patients 18 years old or older hospitalized in the ICU and diagnosed with ARDS on mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three hundred eight patients were included in the final analysis. Risk factors associated with mortality included advanced age (p \u3c 0.001), increased body mass index (p = 0.008), and a history of chronic kidney disease (p = 0.023). Presence of AKI by day 1 of intubation, with elevated creatinine (p = 0.003) and oliguria (p \u3c 0.001), was significantly associated with mortality. On multivariate analysis, advanced age (relative risk [RR], 1.02), urine output on the day of intubation (RR, 0.388), bicarbonate level (RR, 0.948), and Sequential Organ Failure Assessment severity score (RR, 1.09) were independently associated with mortality. A receiver operating characteristic curve identified a threshold urine output on the day of intubation of 0.7 mL/kg/hr (area under the curve, 0.75; p \u3c 0.001) as most closely associated with inpatient mortality (i.e., urine output \u3c 0.7 mL/kg/hr is associated with mortality). CONCLUSIONS: For patients with ARDS, oliguria on the day of intubation was independently associated with increased mortality. Urine output of less than 0.7 mL/kg/hr predicted 80% of inpatient deaths. These findings herald an augmented understanding of the role of urine output in medical decision-making and prognostication

Utility of cerebral embolic protection in non-TAVR transcatheter procedures

BACKGROUND: Cerebrovascular events that occur during structural and interventional procedures are a well known risk which is associated with increased mortality. The FDA has approved the use of the Sentinel device in TAVR. Hereby we report on our experience on the safety and efficacy of using Sentinel in a patient population undergoing non-TAVR transcatheter procedures. METHODS: Retrospective analysis of a single center experience with using the Sentinel device for non-TAVR transcatheter procedures. RESULTS: We identified 33 patients (average age was 73.8 years, 36.7% females, and 30% with history of a prior stroke) felt to be at high risk for cerebroembolic events that underwent Sentinel device placement. Sentinel placement was successful in all patients. Examples of high risk features included high atheroma burden in the aortic arch, left sided valve vegetations, intra-cardiac thrombi and severe left sided valve calcifications/thrombi. No patients developed periprocedural stroke or vascular complications. CONCLUSION: Overall, the use of Sentinel for non-TAVR indications appears feasible and safe. The use of cerebral protection devices should be studied further in non-TAVR patients to establish its role and its benefits, especially with expanding the number of non-TAVR transcatheter interventions

An Atypical Presentation of Cystic Echinococcosis

Cystic echinococcosis (CE) is an infection caused by the Echinococcus granulosus tapeworm. CE generally manifests in the liver, but it may present in any organ. These patients often first present to the emergency department. Mortality over 10 years is significant for those who go undiagnosed. We report the case of a 34-year-old patient who immigrated from Yemen six years earlier. She presented with acute onset dysuria, suprapubic pain, and fever. Imaging revealed a primary multicystic mass on the right renal pole with a secondary lesion in the right hepatic lobe. On further investigation, the patient’s serum was positive for echinococcus antibodies

Preclosure of large bore venous access sites in patients undergoing transcatheter mitral replacement and repair

OBJECTIVE: We aim to report on the efficacy and safety of large bore venous access (LBVA) preclosure with Perclose™ (Abbott Vascular Devices) suture-mediated device use following transcatheter edge-to-edge (TEER) and replacement (TMVR). BACKGROUND: Patients requiring TEER and TMVR require LBVA. Clinical outcome data on the use of suture-mediated devices for LBVA site closure are limited. METHODS: Between 2012 and 2019, 354 consecutive high-risk patients with mitral valvular heart disease underwent TEER (n = 287) with MitraClip and TMVR (n = 67) with Edwards Sapien Valves. Patients had LBVA with 24 or 16 French sheaths. All patients underwent preclosure of LBVA except for one that underwent manual hemostasis. RESULTS: There were no closure device failures. None of the cases required surgical repair of the access site following venous preclosure. Two cases had large hematomas (\u3e6 cm) following Perclose in each group. Six cases had small hematomas (2 cm) with three in each group. There was one major bleeding using Mitral Valve Academic Research Consortium 2 definition (retroperitoneal bleed from arterial puncture) unrelated to the venous closure. Transfusion related to vascular access complication was required in five cases. There were two immediate acute deep venous thromboses postprocedure; one of which occurred after preclosure. There were no arteriovenous malformations, pseudoaneurysms, or access site infections reported following Perclose. CONCLUSION: In this large sample size analysis, Proglide preclosure technique is a feasible and safe alternative approach to achieving hemostasis after removal of LBVA sheaths in patients undergoing TEER and TMVR. Randomized trials are needed to compare the different modalities of hemostasis