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Cardiac troponin elevation in a middle-aged female consistent with COVID myocarditis
No full textBackground: Coronavirus (SARS-CoV-2) is known to cause severe acute respiratory syndrome, but more recently, it has been linked to increased cardiac involvement. It has recently been suggested by evidence that increased troponin levels seen in patients with severe COVID-19 reliably identifies myocardial damage. However, few longitudinal observations on troponin levels in mild COVID-19 cases over time have been published. Given its recent discovery, our understanding of the long-term effects of Coronavirus infections on individuals remains incomplete. The Center for Disease Control has recently estimated an overall incidence of myocarditis secondary to COVID-19 infection to be at around 150 cases per 100000 individuals in the United States alone.
Case Presentation: A 45 year-old caucasian female with past medical history of T2DM, HTN, HLD, CKD, PCOS, and past COVID-19 infection presented to the Emergency Department with recurrent chest pain associated with shortness of breath, left hand numbness, and diaphoresis while at rest. A month prior, this female was admitted for NSTEMI with cardiac catheterization showing normal coronary arteries, echo demonstrating EF of 50-55% without wall motion abnormalities, and CTA demonstrating no signs of PE. Patient had been compliant with all medications since discharge, states nitroglycerin helped with pain, and had not been taking aspirin due to scheduled hysterectomy. Initial troponin levels were 3.409 ng/mL (0.00-0.013), glucose level 107, and platelet count was 426. A focused cardiac ultrasound performed by the emergency physician demonstrated absence of pericardial effusion, normal LV function, mild LV dilation, absent RV dilation, and absence of pericardial tamponade. EKG showed no signs of acute ischemia and repeated EKG was normal. However, cardiology was consulted due to evidence of myocardial injury as indicated by elevated troponins. The patient received ASA, Plavix, and Lovenox in the ED and heparin was started as part of ACS protocol. Tylenol 650 mg Q6H PRN and Morphine 2mg Q30M PRN were added for pain. Troponin levels continued to trend upward to 7.115 over the course of 7 days. Normal studies and images led to the conclusion that this patient would benefit from a heart MRI and outpatient medical management.
Conclusions: This case highlights the long-term impact of Coronavirus infections on cardiac health, as indicated by notable elevations in troponin levels. It also demonstrates the atypical presentation of elevated troponin levels in the absence of acute ischemic myocardial injury
Redox Imbalance and Mitochondrial Abnormalities in Kidney Disease-Volume II
No full textThe kidney performs fundamental functions by eliminating metabolic waste and reabsorbing essential nutrients and electrolytes such as glucose, proteins, ions, and anions [...].L. J. Yan was supported in part by a grant from the Diabetes Action Research and Education Foundation and by a bridge grant (grant number 2400071) from the University of North Texas Health Science center
Elevated Troponins in a Middle-Aged Male Presenting with Cough, Dyspnea, and Chest Pain
No full textBackground: Respiratory complications from SARS-CoV-2 infection are most commonly reported; however, adverse cardiac events such as acute coronary syndromes, thromboembolic syndromes, and myocarditis have been described. A study by the Centers for Disease Control estimates an overall incidence of COVID-related myocarditis to be at around 150 cases per 100000 individuals in the United States.
Case Presentation: A 45-year-old male with a past medical history of exercise-induced asthma, obstructive sleep apnea, and gastroesophageal reflux disease was admitted to our hospital from the emergency department due to chest pain, shortness of breath on exertion, and cough. Patient reports having a cough that started three days prior to ED presentation. He managed his cough conservatively over the weekend, but his symptoms increased in severity and he developed a headache and chest pain radiating to his neck and jaw. Upon presentation to the ED, patient endorses the chest pain to be resolved. His vitals at the ED were temperature 97.8F, HR 97, RR 16, BP (MAP) 121/82 (95), O2 96% on room air. At the ED, his electrocardiogram showed ST depression in leads III and aVF, but no ST elevations to suggest STEMI. Initial workup shows unremarkable electrolytes, mild hyperglycemia with glucose 119 mg/dL, mild transaminase elevation with ALT 46 IU/L and AST 46 IU/L, and elevated troponin 0.308 ng/mL (normal: 0.00-0.013 ng/mL). Patient also tested positive for SARS-CoV-2 via rapid test. Serial troponins were monitored in the ED and rose to 0.910 ng/mL then 4.446 ng/mL before admission to inpatient floor. No radiographic evidence of acute pulmonary disease was identified. ACS protocol was initiated and patient received dual antiplatelet therapy, heparin, and metoprolol/lisinopril. Cardiology was consulted and an echocardiogram was performed which showed normal chamber sizes, normal left ventricular systolic function, and mild concentric left ventricular hypertrophy. Due to patient’s stable clinical presentation and echocardiogram results, the cardiologist recommended serial troponin measurements and felt that a stress test was not indicated. Troponins continued to trend upward to 16.7 ng/mL two days later.
Conclusions: This case highlights the cardiac manifestations of COVID-19 in a patient with stable clinical presentation and markedly elevated troponin levels. The magnitude of troponin elevation in hospitalized patients with COVID-19 is typically associated with worse outcomes; however, this case illustrates the wide array of clinical cardiac presentation in patients with COVID-19-related myocardial injury
Iatrogenic Corticosteroid Atrophy Mimicking Bilateral Morphea en Coup de Sabre: A Case Report
No full textBackground: Corticosteroids affect numerous downstream cytokines to exert anti-inflammatory and immunosuppressive effects. Intralesional corticosteroid injection provides several advantages, including bypassing the stratum corneum to deliver a higher concentration of drug locally, while reducing systemic exposure. Intralesional corticosteroids are used in a variety of dermatologic conditions, and suboccipital steroid injection has been described as a novel treatment for cluster headaches.
Case Presentation: A 52-year-old Caucasian female presented to the outpatient dermatologic clinic with indented skin lesions on the scalp and forehead for six weeks. The indentation started on her left frontal scalp and spread down gradually to her forehead and temple. She later noticed the same indentation appearing on her right side. She reported severe pain and the “worst headache” before the lesions started, but there was no further pain after the lesions appeared.
Dermatologic examination demonstrated two symmetric hypopigmented linear atrophic plaques extending from the lateral forehead to the frontoparietal scalp on each side.
A punch biopsy from the left superior central forehead showed epidermal atrophy with compact orthokeratosis, and scattered telangiectasias within the papillary dermis. Elastin van Giesonstaining demonstrated a loss of elastic fibers in the papillary dermis. There was no dermal sclerosis. The adnexal structures, CD34 expression, and the elastic component of the reticular dermis were intact. Direct immunofluorescence studies were negative.
Upon further questioning, the patient revealed that she had injections with an unknown medication to the occipital and frontal scalps due to severe headaches from a motor vehicle accident. A diagnosis of steroid-induced skin atrophy was made from clinicopathologic correlation.
Conclusions: The adverse effects related to intralesional corticosteroid injections include hypopigmentation, telangiectasias, striae, and atrophy of the skin and subcutaneous fat. When present on the frontal and temporal scalp, atrophic plaques can mimic morphea en coup de sabre, a form of linear localized scleroderma with an autoimmune etiology. Several cases of bilateral morphea en coup de sabre have been previously reported. This case study highlights the importance of obtaining a comprehensive patient history in formation of a differential diagnosis. It also showcases the potential complications of intralesional corticosteroid injections, emphasizing the informed consent process for patients to fully understand possible adverse effects from treatment
Shaping Tomorrow’s Surgeons: Insights into PGY-1 Orthopaedic Training Across the United States
No full textPurpose
Orthopaedic surgery residency offers valuable opportunities for first-year residents to diversify their medical training beyond their specific field. The American Board of Orthopaedic Surgery (ABOS) mandates a five-year residency program for board certification, wherein the initial year, termed postgraduate year one (PGY-1), the curriculum is variable. ABOS permits up to six months in orthopaedic surgery rotations, with the remaining six months offering various educational experiences. Among the non-orthopaedic surgery months, at least three must be dedicated to either general surgery, trauma surgery, plastic/burn surgery, surgical or medical intensive care, or vascular surgery. The additional three months can encompass a range of hospital services. This study examined the rotations included in residency programs across the nation to analyze trends in PGY-1 orthopaedic resident experiences.
Methods
This study gathered data from the Electronic Residency Application Service (ERAS) list of participating orthopaedic programs across the United States for the 2023 application cycle. Program-specific information regarding PGY-1 rotations, both in orthopaedic and non-orthopaedic fields, as well as matriculated residents was gathered by utilizing each program’s publicly available internet resources. Programs with inadequate information regarding these variables were excluded from the study. Individual rotations were primarily divided into “month” intervals, which were defined on a program-to-program basis.
Results
A total of 174 orthopaedic residency programs out of 201 participating programs with sufficient public data regarding PGY-1 curriculum were included in this study (86.6%). On average, these programs took 4.63 residents per application cycle.In assessing the ABOS requirement of 3 months of non-orthopaedic surgical rotations, the utilization rates among orthopaedic programs were as follows: intensive care (72.1%), plastics/burn care (67.4%), trauma (61%), general surgery (52.3%) and vascular (47.7%). The threshold of six months of orthopaedic surgery rotations was met by 90.11% of programs, with general orthopaedics, trauma, spine, and joints being the mostcommon subspecialties with an average of 4.1, 2.4, 1.2, and 1.6 months spent in these areas, respectively.
Conclusions
Among nationally accredited orthopaedic programs, notable differences exist in PGY-1 rotations. Our data revealed that within non-orthopaedic rotations, intensive care, plastics/burn care, and trauma were the most common, whereas general orthopaedics, trauma, and spine predominated within orthopaedic rotations. Understanding these curriculum differences in the first year of orthopaedic residency iscrucialto applicants as they navigate the intricacies of this highly technical field, marked by significant variability in training. Moreover, this information is valuable to current orthopaedic residents and program directors as they shape their program’s educational direction, ensuring that rotations are comprehensive and aligned with national trends. Future directions for our study include surveying program directors regarding the philosophy of their PGY-1 curriculum, aiming to better categorize the factors influencing educational design
Carvedilol, an alternative for lowering liver stiffness in patients with cirrhosis and portal hypertension
No full textLiver cirrhosis, often associated with portal hypertension, presents a significant health burden globally. Carvedilol, a non-selective beta-blocker, has emerged as a promising therapeutic option for managing portal hypertension in patients with liver cirrhosis. This retrospective analysis assessed the effect of Carvedilol treatment on patients with liver cirrhosis and clinically suspected portal hypertension, focusing on its effects on liver function parameters, non-invasive fibrosis scores, and liver stiffness measurements. A total of 130 patients from the Liver Center of Texas were included in this retrospective analysis, comprising 65 patients in the treatment group receiving Carvedilol and 65 patients in the control group. Statistical analyses, including t-tests, were conducted to assess the differences between groups. Carvedilol treatment led to significant improvements in liver function parameters, including a reduction in AST levels, indicative of improved liver function. Non-invasive fibrosis scores, such as FIB-4, AGILE 3, AGILE 4, and APRI, showed notable improvements after Carvedilol treatment in the treatment group, suggesting a reduction in liver fibrosis and improved prognosis. Liver stiffness measurements using eKpa and CAP scores demonstrated significant reductions after Carvedilol treatment within the treatment group, indicating improved liver stiffness. The study suggests that Carvedilol is effective in managing portal hypertension in patients with liver cirrhosis. Further research is needed to confirm these findings in larger cohorts and evaluate the long-term efficacy, and safety of Carvedilol treatment. Additionally, addressing disparities in liver disease diagnosis and treatment is crucial for improving outcomes and reducing the burden of liver-related morbidity and mortality
Nutritional Management of IBS-complicated Exercise-Induced Gastrointestinal Syndrome
No full textBackground: The mechanism behind exercise-induced gastrointestinal syndrome (Ex-GIS) causing abdominal pain related to exercise is proposed to be due to altered gastrointestinal blood flow and neuroendocrine changes. Ex-GIS is found in up to 70% of athletes performing intense endurance exercise and can imitate the symptoms of Irritable Bowel Syndrome (IBS). However, the availability of research addressing the coexistence of IBS and Ex-GIS in athletes is limited. This is complicated by the underreported and underdiagnosed nature of IBS. Case Information: A 24 y/o male recreational triathlete presented with a chief complaint of chronic gastrointestinal distress both during and after endurance exercise. He described his abdominal pain as crampy with an excessive amount of bloating. High intensity long-distance running exacerbated his pain, but he obtained minor relief using OTC loperamide HCl 2mg with simethicone 125mg PRN and also by ceasing physical activity. Past medical history included painless hematochezia and Irritable Bowel Syndrome-Mixed (IBS-M). He endorsed consuming a high FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet of poorly digestible carbohydrates and lactose-intolerance that was poorly controlled with the inconsistent use of lactase enzyme supplements. On physical exam, the patient appeared well and was in no acute distress. The only physical exam findings were hyperactive bowel sounds on abdominal auscultation. The differential diagnoses included IBS, Ex-GIS, and Ex-GIS complicated by comorbid IBS. The patient received a colonoscopy in 2021 to rule out lower GI pathology. The colonoscopy results indicated internal hemorrhoids, which could help explain the painless hematochezia. However, the biopsy results and gross examination were otherwise normal. As a result, the patient received a diagnosis of IBS-mixed, by exclusion, and the patient was prescribed dicyclomine 10mg twice daily, but has been non-compliant due to unfavorable side effects. Searching for a non-medication based treatment, the patient turned towards dietary and behavioral modifications to seek relief. Preliminary research suggests that endurance athletes routinely eat up to 43g of FODMAPs/day, nearly twice the recommended amount, and that athletes suffering from Ex-GIS should consume a low FODMAP diet of 5-18g/day. Additionally, athletes who have Ex-GIS complicated by IBS should further reduce their FODMAP intake to under 3g/day. Conclusions: This case represents a unique presentation of exercise-induced gastrointestinal syndrome, further complicated by IBS symptoms. By consuming a low FODMAP diet, patients may be able to obtain significant symptom relief from IBS-complicated exercise-induced gastrointestinal syndrome. However, more research needs to be completed to address the dichotomy of high FODMAP foods being beneficial for athletic performance, while exacerbating symptoms in patients suffering from IBS-complicated Ex-GIS
A Rare Case of Anti-NXP2 Antibody Positivity in Juvenile Dermatomyositis – A Case Study
No full textBackground: Dermatomyositis (DM) is one of the many subcategories of Idiopathic Inflammatory Myositis (IIM), a treatable group of myopathies. Antibodies serve as a diagnostic tool with prognostic indicators. DM-specific antibodies include anti-NXP2, anti-MDA5, anti-TIF1gamma, Anti-Mi2, Anti- SAE, and anti-SRP. These DM-specific antibodies are mutually exclusive suggesting the idea that each plays a specific role in shaping different phenotypes. 1-17% of adult DM/ polymyositis (PM) and 23-25% of juvenile dermatomyositis (JDM) present with a positive anti-NXP2 antibody. Clinically, positive anti-NXP2 antibody DM patients present with a rash, debilitating muscle weakness, calcinosis, dysphagia, and a higher risk of malignancy. As compared to patients with negative anti-NXP2 antibody DM, positive anti-NXP2 antibody DM patients were younger at the age of onset, with shorter duration between symptom onset to diagnosis, and no significant sex diseases. The prognosis for positive anti-NXP2 antibody DM depends on the complications developed. The worrisome complications which lead to a poor prognosis are calcinosis and malignancies.
Case Information: 22 y/o female was referred to rheumatology for evaluation of Systemic Lupus Erythematosus (SLE). For 3 years prior, the patient experienced muscle and generalized weakness, and myalgia in the legs leading to difficulty climbing stairs. At the time of referral, the patient showed CPK 34, ANA positive anti-dsDNA +12, BUN 15, creatinine 0.70, GFR 123, albumin 4.6, AST 15, ALT 6, ESR 35, WBC 6.5, hemoglobin 10.8, platelets 320. On physical exam, upper and lower extremities showed 4/5 muscle strength. An autoimmune panel to test myositis specific antibodies was ordered. Which showed positive anti-NXP2 21, positive ANA screen IFA, actin antibody (IgG) 34, thyroid peroxidase antibodies 267 IU/mL, ANA titer 1:80.
20 days after, the patient had difficulty getting out of bed with profound generalized weakness. The patient had developed a rash in the upper chest and abdomen. The diagnosis of juvenile dermatomyositis (JDM) was made. Patient admitted to hospital treated with 1 g Methylprednisolone for 3 days and tapered 1 mg/kg body weight. Care with neurology was coordinated to start IVIG treatment at 2 g/kg body weight. The patient was found to have positive acetylcholine receptor antibodies and diagnosed with Myasthenia gravis. The patient was given IVIG for 5 days. The patient was also found to have thyroid nodule swelling s/p biopsy concerning Hurthel cell cancer. On follow-up one month later, the patient stated a return of muscle strength with no rashes. The patient was advised to get an EMG and follow up with neurology, the dose of prednisone was decreased to 40 mg daily and advised to take vitamin D 50,000 units weekly.
Conclusion: Anti-NXP2 antibody positive JDM has a poor prognosis compared to other subcategories. This stems from increased risk of malignancies and calcinosis leading to fatalities.
Our patient was a rare case with anti-NXP2 antibody positive JDM, Myasthenia gravis, and Hurthle cell cancer. There is an increased need in data and research regarding NXP2 antibody and its heterogenous prognosis with DM patients
Suppression of host humoral immunity by Borrelia burgdorferi varies over the course of infection
No full textBorrelia burgdorferi, the spirochetal agent of Lyme disease, utilizes a variety of strategies to evade and suppress the host immune response, which enables it to chronically persist in the host. The resulting immune response is characterized by unusually strong IgM production and a lack of long-term protective immunity. Previous studies in mice have shown that infection with B. burgdorferi also broadly suppresses host antibody responses against unrelated antigens. Here, we show that mice infected with B. burgdorferi and concomitantly immunized with recombinant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein had an abrogated antibody response to the immunization. To further define how long this humoral immune suppression lasts, mice were immunized at 2, 4, and 6 weeks post-infection. Suppression of host antibody production against the SARS-CoV-2 spike protein peaked at 2 weeks post-infection but continued for all timepoints measured. Antibody responses against the SARS-CoV-2 spike protein were also assessed following antibiotic treatment to determine whether this immune suppression persists or resolves following clearance of B. burgdorferi. Host antibody production against the SARS-CoV-2 spike protein returned to baseline following antibiotic treatment; however, anti-SARS-CoV-2 IgM remained high, comparable to levels found in B. burgdorferi-infected but untreated mice. Thus, our data demonstrate restored IgG responses following antibiotic treatment but persistently elevated IgM levels, indicating lingering effects of B. burgdorferi infection on the immune system following treatment.Funding for this work was provided by University of North Texas Health Science Center and the State of Texas to the Tick-Borne Disease Research Laboratory
The effects of esmolol on the control of coronary blood flow and myocardial oxygen supply-demand balance in sepsis
No full textPurpose: Sepsis is an acute organ dysfunction secondary to infection that results in tachycardia, tachypnea, fever, decreased blood pressure, and lactic acidosis. This results in an overall myocardial oxygen supply-demand imbalance leading to cardiac dysfunction and ultimately death. The current treatment for sepsis is antibiotic therapy, vasopressors, and fluid therapy. However, this regimen does not address the tachycardia that leads to cardiovascular decompensation. Beta-blocker therapy addresses this myocardial oxygen supply-demand imbalance and is expected to promote survival in sepsis. We hypothesize that treatment with beta-blocker therapy during acute sepsis will address the myocardial oxygen supply-demand imbalance to maintain coronary perfusion pressure, improve myocardial oxygen delivery, and promote survival.
Methods: Female and male Yorkshire pigs were used as the animal model for this project. Pigs were anesthetized, intubated, and a rectal thermometer and oximeter were placed. Catheters placed in ear vein, great cardiac vein, femoral artery, and bilateral femoral veins. Pressure transducer placed in the femoral artery. A transonic flow transducer placed around the left anterior descending artery. After instrumentation, baseline values were collected. Then, infusion with Escherichia coli lipopolysaccharide (LPS) at 10 µg/kg over the course of 2 hours was used to induce sepsis. LPS was infused via the femoral vein at a rate of 0.5mL/min. After 2 hours, intervention began depending on the treatment group. Intervention lasted 4 hours. Experiment groups included Sham (without LPS, fluids, norepinephrine (NE), or esmolol), Control (with LPS, no fluids, NE, or esmolol), Standard (with LPS, fluids, and NE), and Experimental (with LPS, fluids, NE and esmolol). Doses: LPS 10 µg/kg, esmolol escalating from 100mg/hr, and NE escalating from 0.4 µg/kg/min. Goals during the intervention included keeping the mean arterial pressure (MAP) above 65mmHg and heart rate below 100.
Results: All control pigs died during the 4-hour follow-up. 1 out of 3 standard treatment pigs survived. All esmolol-treated pigs survived. The esmolol group had better MAP, coronary blood flow, myocardial oxygen delivery, and oxygen extraction than the standard treatment group.
Conclusion: Esmolol improves survival, coronary perfusion pressure, and myocardial oxygen delivery. This data provides support for our hypothesis and the clinical use of esmolol in sepsis