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

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

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

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

Assessment of functional ability by anthropometric and physiological parameters during six-minute walk test in healthy children

Objective: To assess the functional ability and vitals of young children using six-minute walk test. Method: The analytical cross-sectional study was conducted from October 2019 to January 2020 at public and private schools of Rawalpindi and Islamabad after approval from the ethics review committee of Riphah College of Rehabilitation Sciences, Westridge Campus Rawalpindi, Pakistan, and comprised healthy children aged 7-12 years who were subjected to the six-minute walk test according to standardised guidelines. Data was collected using a semi-structured questionnaire. Anthropometric measurements, distance walked in six minutes, heart rate, respiratory rate, oxygen saturation, and rate of perceived exertion were the outcome variables. Data was analysed using SPSS 26. Results: Of the 376 subjects, 225(59.8%) were boys and 151(40.2%) were girls. The mean age of the sample was 9.25±1.64 years. Mean distance covered by the children was 482.63±119.76 metres. Public school students performed better than those studying in private schools (p=0.001). The difference in gender terms was non-significant (p=0.926). Significant difference was observed in mean heart rate and respiratory rate post-walk (p0.05). Conclusion: The level of functional ability of the young students improved with age and was better among those studying at public schools. Besides, anthropometric and physiological parameters influenced the text performance. Key Words: Children, Six-minute walk test, Heart rate, Perceived exertion

Navigating a Complex Case of

INTRODUCTION: Blue rubber bleb nevus syndrome is a rare disorder of venous malformations, with around 200 cases reported. We present a case of CASE DESCRIPTION: A 40-year-old female with blue rubber bleb nevus syndrome, asthma, and bronchiectasis came to the pulmonology clinic with shortness of breath and a cough. She was recently admitted for a bronchiectasis exacerbation but continued to have a worsening productive cough and fevers. The most recent CT scan of the chest showed interval stable right upper lobe fibrocavitary disease, demonstrating gradual progression over two years. She had occasional positive cultures for CONCLUSION: Due to the high mortality of LEARNING POINTS: The decision to initiate treatment for non-tuberculous mycobacterium infections is often challenging with prolonged treatment.Lifetime monitoring is required in patients with blue rubber bleb nevus syndrome, which can have pulmonary complications

Asplenia-Associated Babesiosis: A Quagmire Traversed by Exchange Transfusion.

Babesiosis is a potentially life-threatening tick-borne parasitic infection. Severe disease in splenectomized individuals may require exchange transfusion. A 58-year-old male with a history of splenectomy presented with 2 weeks of subjective fever, weakness, and abdominal pain. He denied any rashes, tick bites, or recent travel. He had a motor vehicle accident a few years ago and had undergone an emergency splenectomy. On examination, the patient was febrile (39.3 °C), tachycardic (106/min), and jaundiced. Labs revealed anemia and thrombocytopenia. Computed tomography (CT) abdomen revealed asplenia. As it was summer, there was concern for a tick-borne illness. A peripheral smear showed schistocytes, and labs revealed hyperbilirubinemia, high lactate dehydrogenase (LDH), low haptoglobin, and reticulocytosis (13%), consistent with hemolysis. Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)