659 Myocardial infarcion and ischaemic stroke in a COVID-19 patient: nothing happens by chance

A 68-years-old man, affected by arterial hypertension in treatment with angiotensin-receptor blocker (cardesartan 32 mg), was admitted to emergency department for fever and dyspnoea. The molecular swab for SARS-CoV-2 was positive. Chest CT showed bilateral interstitial pneumonia with Chung severity score index 15/20. The laboratory examinations showed: PCR 21 mg/dl, IL-6 17 pg/ml, d-dimer 374 ng/ml, lymphopenia, glycaemia 218 mg/dl, total cholesterol 245 mg/dl. At COVID-19 diagnosis he started the following therapy: Azithromycin 500 mg once a day, Methylprednisolone 20 mg twice a day, Remdesivir 200 mg once a day, Enoxaparin 6000 UI twice a day, Insulin Lispro 6/8/8 UI three times a day, High FlowNasal Cannula (FiO2 45%). No lipid-lowering therapy was prescribed. During the hospitalization, the patient experienced a progressive improvement in clinical and laboratory parameters. On the 28th day, there was a sudden worsening of dyspnoea with evidence of ST-elevation in DI, aVL, V2–V6 leads. A primary percutaneous coronary intervention at COVID-19 HUB hospital (2.9 km away) was required. Because of massive demand for emergency vehicles, the patient was admitted to the Chat Lab 3 h and 23 min later. Due to evidence of critical stenosis of the proximal and intermediate left anterior descending artery, a PTCA with stenting was performed. 12 h later, the patient developed left hemiplegia (NIHSS score: 7). The brain CT revealed an acute right frontal ischaemic lesion; no indication to fibrinolysis was given by the consultant neurologist. Our case report describes the rare concomitance of two thrombotic events in a COVID-19 patient with many cardiovascular risk factors, offering the opportunity to underline the need of their appropriate treatment during the hospitalization for SARS-CoV-2 infection. Moreover, a dedicated treatment pathways should be provided for COVID-19 patients in order to ensure the timely and correct application of the protocols suggested by the international guidelines. 659 Figure 1ECG performed at the onset of acute dyspnoea.659 Figure 2Critical stenosis on LAD and subcritical stenosis on first and second obtuse marginal arteries.

An Unusual Case of Acute Dyspnoea: Acute Intrathoracic Gastric Volvulus with Probable Tension Gastrothorax

Acute gastric volvulus is a rare complication affecting 4% of hiatal hernias. It is described as an abnormal rotation of the stomach around a transverse or longitudinal axis and can be intra-abdominal or intrathoracic. Intrathoracic gastric volvulus can lead to tension gastrothorax, which is defined as the presence of a massive gastric distension in the chest cavity causing a mediastinal shift with haemodynamic instability and a risk of cardiorespiratory arrest. We report a case of intrathoracic gastric volvulus with probable tension gastrothorax. Early diagnosis of gastrothorax with computed tomography and immediate insertion of a nasogastric tube resulted in rapid clinical improvement. Surgical intervention is the treatment of choice.

CMV enteritis as unusual source of bleeding to GIT

Introduction: Cytomegalovirus disease affecting the gastrointestinal tract is a rare but severe disease presenting particularly in people under immunosuppression, solid organ transplant recipients and AIDS patients with CD4 count under 100/mm3. When colon or small intestine are affected, the disease may be complicated by severe bleeding. CMV therapy includes antivirals and, in case of bleeding, methods of therapeutic endoscopy or interventional radiology. Case description: We present a case of a 74-year-old woman 3 years after kidney transplantation owing to vascular nephrosclerosis, treated with belatacept, mycophenolate mophetile and prednisone. She was admitted to hospital for acute dyspnoea. During hospitalisation, she presented with intestinal bleeding, but the endoscopic intervention at the first colonoscopy was not successful. She was referred to the Department of Hepatogastroenterology of the Institute of Clinical and Experimental Medicine and subsequent colonoscopy revealed a 15 cm long part of ileum with ulcerations as the source of bleeding. The histological assessment described a severe CMV enteritis. The CMV DNA blood level established by PCR was higher than 10 000 000 U/ml. The patient was treated with intravenous ganciclovir and she underwent selective embolization of the inferior mesenteric artery with an excellent clinical effect. Conclusions: CMV enteritis may be associated with a high mortality. The approach to therapy is multidisciplinary and needs collaboration of gastroenterologist, endoscopist and interventional radiologist. Key words: CMV – GIT bleeding – immunosuppression – transplantation

Immersion pulmonary oedema in a triathlete – a diagnostic challenge in sports cardiology

Immersion pulmonary oedema, also referred to as swimming-induced pulmonary oedema, is a form of pulmonary oedema which usually occurs during swimming in cold water. The condition is most common in triathlon athletes; it was first reported in military divers. The main symptoms include acute dyspnoea, cough, and occasionally haemoptysis, which usually subside within approximately 48 hours. The pathomechanism is not fully understood, but oedema is suspected to be due to an increased systemic vascular resistance that overloads the left ventricle. The diagnostic process can be challenging and require multiple stages to rule out a number of other possible conditions. In view of the circumstances in which incidents typically occur, immersion pulmonary oedema poses an immediate life threat to individuals involved in selected forms of physical activity, where survival is often determined by appropriate training of medical services.

Accuracy of lung ultrasound and chest X-rays in diagnosing acute pulmonary oedema in patients presenting with acute dyspnoea in emergency department

To determine the diagnostic accuracy of lung ultrasound and chest X-ray in diagnosing Acute Pulmonary Edema (APE) in patients presenting with acute dyspnea in emergency department. This study was conducted at the emergency department of Shifa International Hospital, Islamabad from 31st July 2018 to 31st January 2019. A total of 225 patients presenting with dyspnoea and satisfying inclusion criteria were assessed by clinical examination, lung USG and chest X-ray. The results of chest X-ray and lung USG were compared with clinical diagnosis. The current study revealed sensitivity of chest X-ray and LUS ( 60.16% versus 91.05%), specificity (66.67% versus 91.18%), positive predictive value (68.52% versus 92.56%) and the negative predictive values (58.12% versus 89.42%) respectively. Present study revealed that the LUS has better accuracy than chest X-ray for diagnosis of APE. Continuou...

Intravascular lymphoma presenting with hypoxaemia, platypnoea and lactic acidosis

Intravascular large B-cell lymphoma (IVLBCL) is an aggressive and rare type of diffuse extranodal B-cell lymphoma. Diagnosis and treatment are challenging and clinical presentation is variable. Physicians should be aware of this rare but life-threatening lymphoma without adenopathy and treatment should be promptly started. We describe the case of a 70-year-old woman who presented with general malaise, acute dyspnoea, platypnoea and lactic acidosis. Echocardiography revealed an extracardiac shunt, the cause of her orthodeoxia. The patient developed rapid liver failure and underwent liver biopsy. Anatomopathological findings suggested IVLBCL, non-germinal center type. She achieved complete remission after rituximab, cyclophosphamide, doxorubicin, vincristine, methylprednisolone chemotherapy but relapsed 1 year after initial presentation with multiple organ involvement. The patient’s relapsed disease was treated with rituximab, iphosphamide, carboplatin, etoposide and she is still in complete remission 2 years later.

Brain natriuretic peptide in differentiating cardiogenic and non- cardiogenic dyspnoea in patients with renal dysfunction: a single centre study

Background: Both BNP (Brain Natriuretic Peptide) and renal function are prognostic indicators of survival in patients with congestive heart failure. However, relationship between BNP, renal function and heart failure as an emergency diagnosis are unknown. The usefulness of BNP as a diagnostic tool in patients with renal dysfunction is thus explored in this study.Methods: The present study was prospectively designed diagnostic test evaluation study conducted in Banaras Hindu University, Varanasi. Out of 166 participants with renal dysfunction defined as creatinine >1.5mg/dl who presented with acute dyspnoea, clinical history, BNP, 2D Echo and baseline estimated glomerular filtration rate were assessed. Patients with severe anaemia, eGFR less than 15 ml/min/1.73 m2 and those on dialysis therapy were excluded from the study. The final diagnosis was adjudicated by cardiologist who was blinded to BNP values.Results: The final diagnosis of CHF was in 104 (62.7%). The correlation between BNP and eGFR values were r=-0.49 for those with CHF (p<0.001) and r=-0.279 (p<0.028) for those without CHF. Median BNP in patients with renal dysfunction with CHF was 1206 pg/ml and without CHF was 186 pg/ml. The area under the receiver operating characteristic curve and optimal cutpoints for EGFR categories 59-30 ml /min/1.73 m2 and EGFR less than 30 ml/min/1.73m2 were 0.992 and 491.5 pg/ml (sensitivity 97% and specificity 95%) and 1.000 and 512pg/ml (sensitivity 100% and specificity 95.5%) respectively.Conclusions: Renal function weakly correlates with BNP in patients without CHF (congestive heart failure). BNP is an important bed side tool for distinguishing cardiogenic and non-cardiogenic dyspnoea in patients with renal dysfunction requiring higher diagnostic cut points. Thus the present study emphasises BNP is the strong and independent predictor of CHF even after taking renal function into considerations.

Biomarkers in acute heart failure

Acute heart failure continues to be a worldwide medical problem, associated with frequent readmissions, high mortality, and a profound economic impact on national health care systems. Biomarkers have shifted the way in which acute heart failure is managed by the cardiologist. The search for the ideal biomarker to aid in the diagnosis, prognosis, and treatment of acute heart failure is ongoing. The natriuretic peptides have come close to an ideal biomarker and prove extremely useful in determining whether acute dyspnoea has a cardiac aetiology. Furthermore, they are useful for prognosis and may have a role in guiding management of heart failure. Additionally, high-sensitivity troponin, sST2, and galectin-3 are increasingly used with mounting clinical evidence for utility. Other emerging acute heart failure biomarkers include mid-regional pro-adrenomedullin, bio-adrenomedulin, mid-regional proatrial natriuretic peptide, and procalcitonin.

Echocardiography in acute critical care in cardiology

Diagnostic opportunities of echocardiography in the acute cardiac care are reviewed. It is shown in detail how to perform echocardiography in different scenarios of critical conditions, especially in acute chest pain, acute hypotension and shock, in acute dyspnoea, in chest trauma, in post-procedural and post-surgical complications. The advantages and disadvantages of the echocardiographic method in acute myocardial infarction with complications, in acute aortic dissection, in cardiac tamponade, in pulmonary embolism, in systolic left ventricular dysfunction and in acute valvular dysfunction are analyzed. Key words: critical care, echocardiography, dyspnoea, shock, chest pain, tamponade, pulmonary embolism, aortic dissection.