Faculty Bibliography

Coronavirus Disease 19 (COVID-19) has led to a global pandemic and has been the center of attention across the entire medical community. This novel virus was initially thought to affect primarily the respiratory system, but now it is evident that it has a multitude of effects on the human body. Our point of interest is to establish the effect of COVID-19 infection on the conducting system of the heart. We present a case series of four patients who developed complete heart block (CHB) shortly after being infected with COVID-19 without any previous known risk factors of complete heart block. There have only been a few previous case reports on the occurrence of CHB in COVID-19 patients highlighting the importance and the need of our case series to the literature of cardiovascular outcomes in COVID-19 patients. Our case series highlight that COVID-19 can indeed affect the conduction system of the heart and cause CHB in patients who then recovered spontaneously further elucidating the transient nature of cardiovascular effects caused by the novel virus.

The practice of heating heroin and inhaling its vapors, commonly referred to as "chasing the dragon" has been around for decades, but only gained popularity in the United States in the 1990s. Since then, there have been many documented cases of heroin-induced leukoencephalopathy (HIL) and takotsubo cardiomyopathy (TTC). This case highlights a patient with a history of heroin inhalation who presented with multiple neurological features, including bilateral upper and lower extremity weakness, blurry vision and slurred speech. Symptoms progressively worsened over the course of multiple weeks and brain imaging was consistent with toxic leukoencephalopathy secondary to heroin inhalation. Medical course was complicated by a rare associated feature of HIL: reverse Takotsubo cardiomyopathy (rTTC). Transesophageal echocardiogram demonstrated a classic basal hypokinesis and ballooning characteristic of rTTC. The patient's symptoms were treated as currently there is no guideline directed therapy for HIL or rTTC. This case demonstrated a rare and significant complication of heroin inhalation: HIL and rTTC and described potential therapies currently being studied.

Pediculosis is a common condition caused by an infestation of head and body louse (ectoparasites) and remains a public health concern. Generally, infestation presents as pruritus in children and has a benign course, but there have been a handful of cases reported in the literature describing severe iron deficiency anemia (IDA) in high-risk groups such as children, history of psychiatric disorder including depression, and low socioeconomic status. Though an uncommonly encountered etiology of anemia, the aim of this case is to increase awareness of a rare cause of severe anemia from an ectoparasites affecting a high risk population, even in developed countries.

The incidence of pericardial effusion in the U.S. is roughly 3.4% [1]. While most causes of pericardial effusions are indolent and transient, malignancy is a much more insidious cause that cannot be overlooked. Most cases of documented pericardial effusion secondary to malignancy have been due to mass effect from benign thymic tumors, such as thymomas. Our case highlights a 41-year-old male who presented with a dry cough and epigastric pain, found to have a large pericardial effusion and incidental thymic mass. The mass was biopsied and found to be keratinizing squamous cell carcinoma. This case expands our knowledge base as clinicians that pericardial effusions can be caused by malignant extension of tumors, rather than simply by mass effect of benign tumors.

The global pandemic of Coronavirus 2019 (COVID-19) or SARS-CoV-2 has numerous manifestations in different organ systems. It is known that SARS-CoV-2 infects the hepatobiliary system leading to presentations such as acute cholecystitis, choledocholithiasis and hepatitis. Although the exact mechanism of the underlying pathology is unknown, it is likely attributed by the tropism of the virus to the ACE2 receptors in the hepatocytes and bile duct cells resulting in a cytokine storm that precipitates as systemic symptoms from acute COVID-19 infection. In this case report we present a case of a 47-year-old male who presented with signs consistent with acute cholecystitis. It was confirmed on ultrasound and he was incidentally found to be positive for COVID-19 on routine surveillance testing. He was asymptomatic and was being prepped for cholecystectomy, but developed an acute elevation of liver enzymes suggesting choledocholithiasis. After endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy the patient experienced a rapid normalization of liver enzymes and improvement of his abdominal symptoms.

Vasospastic angina (VSA) is the spasm of coronary arteries causing transient myocardial ischemia. VSA is commonly managed with antispasmodic medications including calcium-channel blockers (CCB) and nitrates. When vasospasm is refractory to conventional medications, unconventional treatment modalities may be used for symptomatic relief (Tandon et al., 2019 Feb) [1]. There are several mediators of vasospasm, with serotonin playing a major role. Serotonin is a product of platelet aggregation and has multiple effects on the endothelium, which forms the basis of an unconventional treatment modality that may be used for symptomatic relief of VSA. In this case, a 44 year old female with a history of coronary artery disease (CAD) status post coronary artery bypass graft (CABG) with recent drug-eluting stent (DES) placement was admitted for shortness of breath and chest pain, found to have a positive stress echocardiogram (Echo), and had unremarkable coronary angiography. Given persistent symptoms while on optimal medical therapy and with negative coronary angiography, the diagnosis of refractory VSA was made. Patient was started on a serotonin receptor blocker with improvement of her symptoms.