Faculty Bibliography

Portal vein thrombosis (PVT) is the blockage or narrowing of the portal vein by a thrombus. It is relatively rare and has been linked with the presence of an underlying liver disease or prothrombotic disorders. We present a case of a young male who presented with vague abdominal symptoms for approximately one week. Imaging revealed the presence of multiple nonocclusive thrombi involving the right portal vein, the splenic vein, and the left renal vein, as well as complete occlusion of the left portal vein and the superior mesenteric vein. We discuss pathogenesis, clinical presentation, and management of both acute and chronic thrombosis. The presence of PVT should be considered as a clue for prothrombotic disorders, liver disease, and other local and general factors that must be carefully investigated. It is hoped that this case report will help increase awareness of the complexity associated with portal vein thrombosis among the medical community.

Background. Takotsubo cardiomyopathy is defined as a transient left ventricular dysfunction, usually accompanied by electrocardiographic changes. The literature documents only two other cases of Takotsubo cardiomyopathy in the latter setting. Methods. A 78-year-old female presented to the ED with severe shortness of breath, hypertension, and tachycardia. On physical exam, heart sounds (S1 and S2) were regular and wheezing was noticed bilaterally. We found laboratory results with a WBC of 20.0 (103/muL), troponin of 16.52 ng/mL, CK-mb of 70.6%, and BNP of 177 pg/mL. The patient was intubated for acute hypoxemic respiratory failure. A chest X-ray revealed a large left-sided tension pneumothorax. Initial echocardiogram showed apical ballooning with a LVEF of 10-15%. A cardiac angiography revealed normal coronary arteries with no coronary disease. After supportive treatment, the patient's condition improved with a subsequent echocardiogram showing a LVEF of 60%. Conclusion. The patient was found to have Takotsubo cardiomyopathy in the setting of a tension pneumothorax. The exact mechanisms of ventricular dysfunction have not been clarified. However, multivessel coronary spasm or catecholamine cardiotoxicity has been suggested to have a causative role. We suggest that, in our patient, left ventricular dysfunction was induced by the latter mechanism related to the stress associated with acute pneumothorax.

We present a case of drug-induced myocarditis manifesting as acute heart failure in a young patient with bipolar disorder being treated for depression. The case describes a 20-year-old man being treated in the psychiatry ward for worsening depression when he started complaining of chest pain and shortness of breath. His list of medications included clozapine, lithium, lorazepam, and haloperidol. The main findings on physical examination were tachycardia, low-grade fever, crackles in both lung bases on auscultation, and the absence of any notable edema. Abnormal labs included a troponin of 0.9, with a CK of 245 and CK-MB of 3.1. An ECG revealed sinus tachycardia and left anterior fascicular block (LAFB). An echocardiogram revealed global hypokinesis, severe left ventricular dysfunction with an ejection fraction estimated at 20%. The patient had an admitting diagnosis of acute left ventricular systolic dysfunction likely secondary to drug-induced myocarditis (suspect clozapine) versus acute coronary syndrome. He was managed conservatively and transferred to another facility for endomyocardial biopsy confirming myocarditis. This case is an example of one of the most typical presentations of suspected drug-induced acute myocarditis and will hopefully prompt the reader to think of this underdiagnosed entity in the right clinical setting.

Walking impairment is a clinical hallmark of multiple sclerosis (MS). Dalfampridine-ER, an extended-release formulation of dalfampridine (also known by its chemical name, 4-aminopyridine, and its international nonproprietary name, fampridine), was developed to maintain drug plasma levels within a narrow therapeutic window, and assessed for its ability to improve walking in MS. The putative mechanism of action of dalfampridine-ER is restoration of axonal conduction via blockade of the potassium channels that become exposed during axonal demyelination. Two pivotal phase III clinical trials demonstrated that dalfampridine-ER 10-mg tablets administered twice daily improved walking speed and patient-reported perceptions of walking in some patients. Dalfampridine-ER was generally well tolerated, and, at the approved dose, risk of seizure was neither elevated relative to placebo nor higher than the rate in the MS population. Dalfampridine-ER (AMPYRA(R)) was approved in the United States for the treatment of walking in patients with MS as demonstrated by an increase in walking speed. The use of the dalfampridine-ER is contraindicated in patients with a history of seizure. It is the first pharmacologic therapy for this indication and has been incorporated into clinical management of MS.

Peripartum cardiomyopathy is a life-threatening cardiac condition affecting pregnant women either late in pregnancy or early in the post-partum period. The latest studies show a dramatic improvement in the mortality rates of women affected with this disorder, which has been correlated with advances in medical therapy for heart failure. However, patients continue to die of this condition. The following case report describes a typical patient with peripartum cardiomyopathy diagnosed on clinical grounds, along with echocardiogram findings of severe systolic dysfunction and global hypokinesis consistent with dilated cardiomyopathy. Emergency cesarean delivery had to be performed for fetal distress. There was significant improvement of the patient's condition with standard pharmacological management for heart failure at the time of discharge. However, five weeks after discharge, fatal cardiac arrest occurred. It is hoped that this article will raise awareness about this rare but potentially fatal condition and promote understanding of its main clinical features, diagnostic criteria, and conventional pharmacological management.

The importance of early thrombolysis in acute myocardial infarction has been highlighted in several large trials. The clinical decision is often taken by physicians who need to take a rapid action with the risk of misdiagnosing non-coronary events that mimic myocardial infarction. Here we describe a case of acute pericarditis in a 37-year-old man whom received thrombolysis and developed a sudden hemorrhagic pericardial effusion that evolved rapidly into a cardiac tamponade. These errors leading to lethal thrombolysis complications have been surprisingly rare; but a correct diagnosis of aortic dissection or hemorrhagic pericarditis needs to be stressed because even after obtaining the correct diagnosis, the prolonged disturbance of hemostasis prevents a rapid therapy being instigated.

BACKGROUND: Two phase 3 clinical trials demonstrated that dalfampridine extended-release 10-mg tablets (D-ER), twice daily, significantly improved walking relative to placebo in patients with multiple sclerosis (MS). The objective of this study was to evaluate the efficacy and safety of D-ER in patients with MS using pooled data from the two phase 3 trials. METHODS: Data were pooled from the two trials, and D-ER was compared with placebo for timed-walk responder rate, changes in walking speed, and the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Response rates were evaluated with respect to demographic and clinical characteristics. RESULTS: D-ER had a significantly higher proportion of timed-walk responders relative to placebo (37.6% vs. 8.9%; P < .0001). The responder rate was independent of age, gender, race, body-mass index, type of MS, duration of MS, baseline Expanded Disability Status Scale score, baseline walking speed, and concomitant use of immunomodulatory therapies. Significant improvements were observed in walking speed and in MSWS-12 score for the pooled D-ER group compared with placebo. The safety profile was consistent with the individual studies; no new safety or tolerability concerns were identified. CONCLUSIONS: D-ER demonstrated efficacy for the improvement of walking in patients with MS; response was independent of demographic and clinical characteristics.

Objectives: Sudden cardiac death in the dialysis population comprises 25% of all-cause of mortality. The epicardial approach for cardiac rhythm device leads may be preferred over transvenous leads. Background: The transvenous route has been the most frequently used method for insertion of Cardiac Rhythm Device (CRD) leads. However, this route can cause major problems including central venous stenosis and cardiac device infection during episodes of dialysis access-related bacteremia. Methods: This is a case report where a 56 year-old man on chronic hemodialysis presented with episodes of cardiac arrest due to ventricular fibrillation. He had had an amputation due to osteomyelitis and an arteriovenous-graft (AVG) infection of the right upper extremity in the past. At present evaluation he had a left upper extremity AVG. Results: Vascular evaluation revealed right subclavian vein and superior vena cava stenoses. Along with the presence of a left upper extremity AVG, this posed a dilemma regarding safety and usefulness of a transvenous rhythm device. An ERD-AICD was placed and one year later there were no cardiac or infectious events reported. Conclusions: Epicardial leads should be considered in hemodialysis patients who require a new CRD or replacement of existing transvenous CRD leads. Transvenous CRD leads can cause central venous stenosis and are vulnerable to contamination during AVG or tunneled hemodialysis catheter-related bacteremia. Because these complications are not infrequent in hemodialysis patients an alternative pathway is warranted. Epicardial leads do not traverse through the central veins and are not directly exposed to blood flow and do not cause central venous stenosis

Background: Hemodialysis (HD) is capable of inducing Left ventricular dysfunction, which may persist even after hemodynamic or clinical status has returned to normal. Repeated episodes of myocardial depression result in myocardial hibernation, remodeling, and some degree of irreversible loss of contractile function. Objectives: Our goal is to highlight the impact of this phenomenon, sometimes not considered an important risk factor for cardiovascular morbidity. Methods: Review of literature, identifying predisposing factors, diagnostic approaches and therapeutic options. Discussion: Predisposing factors include dialysis-related, cardiac and medical. The most important are: * Large volume of fluid removal. * Hemodialysis-related hypotension. * Small cardiac chamber size or chamber hyperthrophy. * Microvascular endothelial dysfunction. * Overmedication with antihypertensive agents * Reduced fluid intake or volume loss. Symptoms occur during HD and include chest discomfort, palpitations, and general fatigue as well as ECG changes. Echocardiography is ideally suited to diagnose transient reversible regional wall motion abnormalities (RWMA) that are hallmark to this condition. Increase in troponin T levels is also related with presence and severity of myocardial dysfunction. The therapeutic approach is aimed to reduce the episodes of intradialytic hypotension and avoid large UF volumes. Biofeedback dialysis, reduced dialysate temperatures, frequent dialysis sessions, switch peritoneal dialysis and use of beta-blockers are some options. Conclusions: Cardiac dysfunction occurs in two-thirds of HD patients and predicts a substantial increase in mortality. As shown, HD-related myocardial ischemia with recurrent ischemic insults leads to structural and functional changes resulting in systolic dysfunction. Preliminary evidence has shown that modifications of dialysis technique may reduce the myocardial perturbation