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Khokher, Waleed

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Inhaled Pulmonary Vasodilators in COVID-19 Infection: 
A Systematic Review and Meta-Analysis 
W. Khokher, MD1*, S. Malhas, MD1, A. Beran, MD1, S. Iftikhar, MD1, C.
Burmeister, MD1, M. Mhanna, MD1, O. Srour, MD1, N. Kesireddy, MD1, R. Assaly,
MD2
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Pulmonary and Critical Care Medicine, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
*Corresponding author: Waleed.Khokher@utoledo.edu
Published: 05 May 2023 
Introduction: Inhaled pulmonary vasodilators (IPVD) have been previously studied in patients with 
non-coronavirus disease-19 (COVID-19) related acute respiratory distress syndrome (ARDS). The use 
of IPVD have been shown to increase PaO2/FiO2 (P/F) ratios in ARDS patients. However, the role of 
IPVD in COVID-19 ARDS is still unclear. Therefore, we performed this meta-analysis to evaluate the 
role of IPVD in COVID-19 patients.    
Methods: Comprehensive literature search of PubMed, Embase, Web of Science and Cochrane Library 
databases from inception through April 22, 2022 was performed. The single arm studies and case series 
were combined for a 1-arm meta-analysis, and the 2-arm studies were combined for a 2-arm meta-
analysis. Primary outcomes for the 1-arm and 2-arm meta-analyses were change in pre- and post-IPVD 
P/F ratios and mortality, respectively.    
Results: 13 single arm retrospective studies and 5 case series involving 613 patients were included in 
the 1-arm meta-analysis. 3 studies involving 640 patients were included in the 2-arm meta-analysis. The 
pre-IPVD P/F ratios were significantly lower compared to post-IPVD, but there was no significant 
difference between pre- and post-IPVD PEEP and lung compliance. The mortality rates, need for 
endotracheal intubation, and hospital LOS were similar between the IPVD and standard therapy groups.  
Conclusion: Although IPVD may improve oxygenation, our investigation showed no benefits in terms 
of mortality compared to standard therapy alone. However, randomized controlled trials are warranted to 
validate our findings. 
https://dx.doi.org/10.46570/utjms.vol11-2023-705 


English

Inhaled Pulmonary Vasodilators in COVID-19 Infection: : A Systematic Review and Meta-Analysis

Pasadyn, Vanessa

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Applications of Inhalational Nitrous Oxide in Patients as 
an Alternative to Traditional Narcotics and Sedation 
Agents in the Emergency Department 
Vanessa Pasadyn, BA1*, Mohamad Moussa, MD2, Sadik Khuder, PhD1 
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Department of Emergency Medcine, The University of Toledo, Toledo, OH 43614 
*Corresponding author: vanessa.pasadyn@rockets.utoledo.edu
Published: 05 May 2023 
This is the case of a 76-year-old woman who received nitrous oxide as analgesia for a shoulder reduction 
in the emergency department (ED). The goal of discussing this case is to emphasize the accessibility, 
efficacy, and safety of using nitrous oxide as a sedation agent in place of narcotics in the ED. From 
4/11/22-6/15/22, nitrous oxide has been used as an analgesic at two of ProMedica Toledo’s Hospital 
emergency departments 50 times for a variety of encounters ranging from laceration to open limb 
fracture repair. This effort is in support of the ProMedica Toledo’s PAIN (Prescribing Alternatives 
Instead of Narcotics) program with an overarching goal to reduce opioid use in the ED. Nitrous oxide 
can be used for analgesia, pain management, and anxiolysis. It is a colorless, odorless gas that has rapid 
onset of 1-2 minutes and a short duration of 3-5 minutes. Nitrous has minimal effects on respiration and 
hemodynamics and has a minimal side effect profile compared to other sedatives. Nitrous is easy to 
administer, thus there are a wide variety of indications such as being used as an adjunct in fracture 
reduction, cardioversion, or foreign body removal. The opioid epidemic is an ever present and growing 
issue in the United States and any effort to curb narcotic use is imperative to prioritize. It is the 
responsibility of caregivers to learn and understand the indications and contraindications of the use of 
nitrous oxide as an analgesic. This is a meaningful step in working to curb the opioid epidemic and 
optimizing patient care in the acute setting. 
https://dx.doi.org/10.46570/utjms.vol11-2023-709 


Applications of Inhalational Nitrous Oxide in Patients as an Alternative to Traditional Narcotics and Sedation Agents in the Emergency Department

Sajdeya, Omar

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
The Rate of Adverse Events of Sodium-
Glucose Cotransporter 2 Inhibitors: A 
Meta-Analysis of Randomized Clinical 
Trials 
Omar Sajdeya, MD1*, Ziad Abuhelwa, MD1, Wasef Sayeh, MD1, Said Malhas, MD1, 
Clarissa Pena, MD1, Ehab Eltahawy, MD2
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Cardiovascular Medicine, Department of Medicine, The University of 
Toledo, Toledo, OH 43614 
*Corresponding author: Omar.Sajdeya@utoledo.edu
Published: 05 May 2023 
Introduction: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have proven cardiovascular benefits 
in diabetics and in patients with heart failure in the presence or absence of diabetes. We sought to assess 
the rate of adverse events with the use of SGLT2 inhibitors compared to placebo. 
Methods: We included all randomized, double-blinded, placebo-controlled trials of SGLT2 inhibitors 
regardless of the indication. Data were pooled using the Mantel-Haenszel random-effects model to 
calculate the relative risk (RR) and 95% confidence interval (CI). 
Results: We included a total of 62 trial comprising 95,594 patients (55,739 patients in the SGLT2 arm 
and 39,855 patients in the placebo arm). Compared to placebo, use of SGLT2 inhibitors was associated 
with a statistically significant increased rate of overall infections (9.6% vs. 5.7%, RR: 1.28, 95% CI: 
1.18 - 1.40), and diabetic ketoacidosis (0.2% vs. 0.08%, RR: 2.7, 95% CI: 1.62 - 4.50). The increased 
rate of overall infections was primarily driven by higher rates of genital infections (3.6% vs. 0.7%, RR: 
3.23, 95% CI: 2.73 - 3.82). The rates of hypoglycemia, bone fracture and amputation were not 
significantly different between both treatment arms (10.0% vs. 7.3%, RR: 1.06, 95% CI: 0.98 - 1.14), 
(3.6% vs. 3.6%, RR: 1.02, 95% CI: 0.94 - 1.10), and (1.5% vs. 1.3%, RR: 1.09, 95% CI: 0.94 - 1.27), 
respectively. 
Conclusion: SGLT2 inhibitors increase the risk of diabetic ketoacidosis and genital infections. The 
overall rate of diabetic ketoacidosis was, however, low. 
https://dx.doi.org/10.46570/utjms.vol11-2023-720 


The Rate of Adverse Events of Sodium-Glucose Cotransporter 2 Inhibitors: : A Meta-Analysis of Randomized Clinical Trials

Yassen, Mohammand

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
The Efficacy of Cardiac Myosin Inhibitors 
Versus Placebo in Patients with 
Symptomatic Hypertrophic 
Cardiomyopathy 
Mohammad Yassen, MD1*, Khalid Changal, MD1 
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614
*Corresponding author: mohammand.yassen@utoledo.edu
Published: 05 May 2023 
Introduction: Given the interplay between hypertrophic cardiomyopathy, elevated resting LVOT 
gradients (≥ 50 mm Hg) and heart failure and cardiovascular death, cardiac myosin inhibitors have 
recently emerged as a promising novel therapy to improve HCM-related outcomes by regulating 
myocardial relaxation and contractility, and thereby reducing intracavitary gradients.  
Methods: We performed a literature search using PubMed, Embase, and Cochrane Library from 
inception through May 2022 to assess the impact of novel cardiac myosin inhibitors (Mavacamten and 
Aficamten) on LVOT gradient and functional capacity in patients with symptomatic hypertrophic 
cardiomyopathy. The co-primary outcomes were mean percent change from baseline in resting LVOT 
gradient, Valsalva LVOT gradient, and NYHA Class Improvement ≥ 1. Secondary outcomes included 
mean percent change from baseline NT ProBNP, Troponin I, and LVEF.  
Results: 4 studies (all randomized-control trials, including 3 Mavacamten-focused and 1 Aficamten-
focused trials) involving 463 patients were included in the meta-analysis. Compared to patients receiving 
placebo, the cardiac myosin inhibitor group demonstrated statistically significant differences in percent 
change in mean resting LVOT gradient (MD -62.48, CI -65.44, -59.51, p <0.00001), Valsalva LVOT 
gradient (MD -54.21, CI -66.05, -42.36, p <0.00001), and mean percentage in NYHA Class 
Improvement ≥ 1 (OR 3.43, CI 1.90, 6.20, p <0.0001). Regarding secondary outcomes, the intervention 
group demonstrated statistically significant reductions in meant percent change from baseline in NT-
proBNP (MD -69.41, CI-87.06, -51.75, p < 0.00001), Troponin I (MD, -44.19, CI -50.59, -37.78, p < 
0.00001), and LVEF (MD -6.31, CI -10.35, -2.27, p = 0.002). 
Conclusion: The use of cardiac myosin inhibitors in patients with symptomatic hypertrophic 
cardiomyopathy may confer both clinical and symptomatic benefits, at the possible expense of LV 
ejection fraction. Further trials with large sample sizes are needed to confirm our findings. 
https://dx.doi.org/10.46570/utjms.vol11-2023-727 


The Efficacy of Cardiac Myosin Inhibitors Versus Placebo in Patients with Symptomatic Hypertrophic Cardiomyopathy

Zerihun, Kirubel

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Efficacy and Safety of Insulin Icodec Versus 
Glargine U100- A meta-analysis of 
randomized controlled trials 
Kirubel Zerihun, MD1*, Mohammed Mhanna, MD, MPH2, Hazem Ayesh, MD1, 
MPH, Sami Ghazaleh, MD3, Yasmin Khader, MD1, Azizullah Beran, MD1, 
Abdulaziz Aldhafeeri, MD1, Sadikshya Sharma, MD1, Amna Iqbal, MD1, Juan 
Jaume, MD1
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Department of Surgery, The University of Toledo, Toledo, OH 43614 
3Division of Gastroenterology and Hepatology, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
*Corresponding author: Kirubel.Zerihun@utoledo.edu
Published: 05 May 2023 
Background: Insulin Icodec is a once-weekly basal ultra-long-acting insulin that is currently in 
development.  
Methods: We conducted a meta-analysis of randomized controlled trials that investigated the efficacy 
and safety of insulin icodec compared to glargine U100. From each clinical trial, we collected the 
number of patients who received icodec insulin and glargine U100. The primary outcome was change in 
hemoglobin A1C (HBA1C) from baseline. Secondary outcomes included percent of time in range (TIR) 
of blood glucose (3.9-10.0 mmol/L or 70-180 mg/dL) measured via continuous glucose monitoring 
during weeks 15 and 16 as well as occurrence of hypoglycemic episodes during treatment. The random-
effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence 
intervals (CI). A p-value <0.05 was considered statistically significant.  
Results: Three randomized controlled trials involving 552 patients with type 2 diabetes were included in 
the meta-analysis. The difference in change in HBA1C between the icodec and glargine U100 groups 
was not statistically significant (Standard difference in means: -0.068, 95% CI: -0.388, 0.253, P-
value=0.679, I2=67%). Furthermore, TIR percentage was comparable between the two groups (RR: 
1.04, 95% CI: 0.898, 1.206: P-value=0.593, I2=0%). However, treatment with icodec was associated 
with lower risk of combined level 2 (< 3 mmol/L or < 54 mg/dL) and 3 (severe) hypoglycemia (RR: 
0.69, 95% CI: 0.674, 0.713: P-value <0.05, I2=99.9%)  
Conclusion: Our meta-analysis demonstrated that in comparison to once daily insulin glargine U100, 
once weekly treatment with insulin icodec had similar glucose lowering efficacy but a better safety 
profile. 
https://dx.doi.org/10.46570/utjms.vol11-2023-730 


Efficacy and Safety of Insulin Icodec Versus Glargine U100- A meta-analysis of randomized controlled trials

Nigro, Anthony

The University of Toledo Translation Journal of Medical Sciences 
Haematology and Oncology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Immunotherapeutic Interventions in Carcinoid Tumors 
Anthony Nigro, M31*, J. Creeden, PhD, L. Dworkin, MD, S. Varatharajan, M3, S. Vellani, M4 
1Division of Nephrology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
*Corresponding author: Anthony.Nigro@rockets.utoledo.edu
Published: 05 May 2023 
Introduction: Management of carcinoid tumors consists of pharmacological treatment and surgical resection. 
Pharmacologic treatments have side effects and are often limited in their scope. Though surgical intervention can 
be curative, carcinoid tumors are asymptomatic and are not detected until they metastasize. Immunotherapy has 
the potential to overcome the limitations both surgical and pharmacologic options face. Active and passive 
immunotherapeutic options for treatment of carcinoid tumors are summarized here.   
Methods: A PubMed search was conducted yielding studies focused on carcinoid tumor characteristics, standards 
of care, and immunotherapeutic approaches. Carcinoid tumor immunotherapy clinical trial results and other 
relevant data was extracted from each study.   
Results: The search yielded 16 studies encompassing 6 immunotherapies. Two studies reported overall response 
rates (ORR) to combined ipilimumab-nivolumab as 25% and 26%. ORR to pembrolizumab monotherapy was 
reported by two studies as 3.7% and 12%. Pembrolizumab combined with lanreotide produced stable disease in 
40% of patients. Spartalizumab ORR was 7.4%. Lu-Dotatate ORR was 14.7% with 65.2% progression-free 
survival after 20 months. Tidutamab achieved stable disease in 27% of patients. AdVince was tumoricidal to 
100% of resected metastatic carcinoid tumor cells and delayed subcutaneous carcinoid tumor growth in mice.   
Conclusion: All immunotherapeutic agents achieved significant antitumor activity defined by their respective 
studies, with the exception of spartalizumab. However, immunotherapy demonstrated limited benefit as a 
monotherapy to carcinoid tumor management. Treatment related-adverse events may require future monitoring 
and evaluation. Further investigation is warranted to assess immunotherapy efficacy as an adjunct to 
chemotherapy and surgical resection. 
https://dx.doi.org/10.46570/utjms.vol11-2023-738 


Immunotherapeutic Interventions in Carcinoid Tumors

Kammeyer, Joel

The University of Toledo Translation Journal of Medical Sciences 
Infectious Diseases Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
An Alprostadil Intracavernosal Injection 
Leading to a Psoas Muscle Abscess 
K.K. Girdhar, MPH1*, M. Deutsch, J.A. Kammeyer, MD, MPH 
1Division of , Department of Medicine, The University of Toledo, Toledo, OH 43614 
2Division of, Department of Medicine, The University of Toledo, Toledo, OH 43614 
3Division of, Department of Medicine, The University of Toledo, Toledo, OH 43614 
*Corresponding author: joel.kammeyer@utoledo.edu
Published: 05 May 2023 
Introduction: Alprostadil is a synthetic prostaglandin E1 that can be self-administered via 
intracavernosal injection as a vasodilatory treatment for erectile dysfunction. The psoas muscle has close 
anatomical relationships such as to the ureters and renal pelvises, and is vulnerable to infection from 
regional structures. Lumbar artery derivatives supply the muscle. Primary psoas abscess is often 
associated with trauma, while Crohn’s disease is linked to secondary abscess.  
Case Presentation: A 59-year-old male presented with a three-week history of fevers, chills, and body 
aches. Eight months prior, the patient had undergone laparoscopic prostatectomy with bilateral pelvic 
lymph node dissection and nerve sparing as prostate cancer therapy.  Since, the patient had reported 
stress incontinence with heavy lifting but denied hematuria, dysuria, flank pain, or testicular pain. The 
patient was diagnosed with erectile dysfunction related to prostatectomy and received intracavernosal 
alprostadil and combination treatment with sildenafil six months.  Imaging revealed a loculated, 
peripherally-enhancing fluid collection in the hemipelvis along the inferior margin of the right psoas 
muscle.  Blood and urine cultures were negative.  An abscess aspirate sample revealed methicillin-
sensitive Staphylococcus aureus. The patient was treated with cefazolin 2g IV every eight hours for six 
weeks.   
Discussion: The case offers an example of intracavernosal injection of alprostadil precipitating psoas 
muscle abscess, as opposed to more common cavernous or penile abscesses. Psoas abscess can arise 
from contiguous spread from adjacent structures or by the hematogenous route from a distant site. This 
case highlights the importance of considering intracavernosal injections as potential local introduction 
mechanisms for psoas infection. 
https://dx.doi.org/10.46570/utjms.vol11-2023-752 


An Alprostadil Intracavernosal Injection Leading to a Psoas Muscle Abscess

Waack, Andrew

The University of Toledo Translation Journal of Medical Sciences 
Infectious Diseases Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Herpes Simplex Virus-1 Encephalitis 
Secondary to Whole Brain Radiation 
Therapy 
Andrew Waack, M21*, Sarah Jaggernauth, M21, James Iordanou, DO1, Venkatramana 
Vattipally, MD1, Claudiu Georgescu, MD1
1Division of Infectious Diseases, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
*Corresponding author: Andrew.waack@rockets.utoledo.edu
Published: 05 May 2023 
Background: Encephalitis is inflammation of the brain parenchyma with associated neurological 
dysfunction. Herpes simplex virus-1 (HSV-1) encephalitis (HSE) is the most common cause of 
encephalitis. HSV-1 characteristically remains dormant in the trigeminal ganglion and reactivates during 
states of immunosuppression, including stress, cancer or chemotherapy. There have been few reported 
cases of HSE following whole brain radiation therapy (WBRT) for treating intracranial tumors. 
Importantly, reported HSE cases following WBRT demonstrate an atypical presentation of encephalitis. 
We report a case of HSE following WBRT to treat brain metastases of renal cell carcinoma.   
Case Presentation: A 67-year-old female patient who recently underwent WBRT to treat brain 
metastases from renal cell carcinoma presented with an elevated temperature, weakness and altered 
mental status. The patient was admitted, and baseline CT imaging did not demonstrate any acute 
abnormalities. The next day the patient’s neurological status declined substantially, prompting MR 
imaging that revealed lesions in the temporal lobes, encompassing the amygdala and hippocampus 
bilaterally. Extra limbic lesions were also demonstrated. Empirical intravenous acyclovir was initiated 
upon suspicion of possible HSE. Later imaging revealed cerebellar folia enhancement, suggesting 
probable leptomeningeal carcinomatosis. CSF PCR was positive for HSV-1, confirming the diagnosis of 
HSE. The patient’s condition significantly improved and ultimately returned to baseline.   
Conclusion: We present a case of HSE following WBRT. HSE must be promptly treated to avoid 
catastrophic outcomes. However, rapid treatment may be difficult due to a delay in diagnosis, which is 
difficult due to the atypical presentation of HSE secondary to WBRT. 
https://dx.doi.org/10.46570/utjms.vol11-2023-762 


Herpes Simplex Virus-1 Encephalitis Secondary to Whole Brain Radiation Therapy

Zhang, Shungang

The University of Toledo Translation Journal of Medical Sciences 
Nephrology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Disruption of CD40 Results in Significantly 
Attenuated Renal Inflammation Following 
Glycerol-Induced Acute Kidney Injury 
Shungang Zhang, PhD1*, Prabhatchandra Dube, PhD1, Jerrin George, BS1, Xiaoming 
Fan, PhD1, David J. Kennedy, PhD2, Steven T. Haller, PhD2
1Division of Nephrology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Cardiovascular Medicine, Department of Medicine, The University of 
Toledo, Toledo, OH 43614 
*Corresponding author: Shungang.Zhang@rockets.utoledo.edu
Published: 05 May 2023 
Introduction: We have shown that disruption of the prominent pro-inflammatory receptor CD40 
attenuates renal tubular atrophy and tubular cell death following high salt diet in our CD40 knockout 
(KO) model in addition to significantly reduced renal fibrosis following experimentally induced 
ischemic renal injury. We have also demonstrated significantly reduced pro-inflammatory and pro-
fibrotic signaling in human CD40 KO renal proximal tubule epithelial cells. We performed the following 
study to test the hypothesis that disruption of CD40 significantly attenuates acute kidney injury (AKI). 
Methods: Age matched (8-week-old) C57/BL6 wild-type and C57/BL6 CD40 KO male mice (n=8) 
were administered glycerol (7.5 ml/kg in 50% glycerol) to induce AKI. After 24h, animals were 
euthanized and kidneys were assessed for evidence of renal injury.   
Results: Renal expression of CD40 was increased in the proximal tubules of wild-type mice in response 
to AKI. CD40 KO mice demonstrated reduced renal inflammation compared with wild-type mice 
following AKI. In addition, CD40 KO mice demonstrated significantly attenuated renal cortex gene 
expression of inflammatory markers IL1β, TGFβ1, and the fibrosis marker Col3a1 following AKI 
compared to wild-type (all p<0.05).  
Conclusion: Disruption of CD40 results in significant attenuation of renal inflammation following 
experimentally induced AKI. Our results indicate that disruption of CD40 signaling may be a promising 
therapeutic target for the treatment of AKI. 
https://dx.doi.org/10.46570/utjms.vol11-2023-769 


Disruption of CD40 Results in Significantly Attenuated Renal Inflammation Following Glycerol-Induced Acute Kidney Injury

Al-Ataby, Harith

The University of Toledo Translation Journal of Medical Sciences 
Pulmonology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Spontaneous Second Intercostal Artery 
Bleeding Complicated with Massive 
Hemothorax after Lower Limb Angioplasty 
Procedure 
Harith Al-Ataby, MD1*, Mohamed Omballi, MD1 
1Division of Pulmonology and Critical Care Medicine, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
*Corresponding author: Harith.Al-Ataby@utoledo.edu
Published: 05 May 2023 
Introduction: This is an extremely rare case of left massive hemothorax secondary to a spontaneous 
rupture of an intercostal artery. Presenting with a combination of hypovolemic and obstructive shock. 
Case: A 42-year-old male with PMHx of polysubstance, and Buerger's disease presented with right 
lower limb ischemia. Patient underwent RLE angiogram and balloon angioplasty. Intraoperatively, he 
received 11,000 unit of heparin. In the PACU, he became unresponsive and went into a severe shock 
state, intubated and resuscitated with IV fluid and vasopressors. Examination showed absence breath 
sounds in the left lung. CTA chest showed large left hemothorax with linear contrast extending from the 
posterior second intercostal artery compatible with acute hemorrhage with right mediastinal shift. 
Massive transfusion protocol was initiated. Angiogram showed bleeding from the Lf posterior 2nd 
intercostal artery. Transthoracic arterial coil embolization was performed and successfully stopped the 
bleeding. Two left-sided chest tubes were placed and 1 L of frank blood was drained. Next day, his 
vitals were stable, and was extubated to room air.  
Discussion: Spontaneous intercostal artery bleeding is extremely rare and reported in patients with 
underlying disorders, such as neurofibromatosis type 1, SLE, coarctation of aorta, Kawasaki disease, or 
Ehler-Danlos. High blood pressure or physical can trigger intercostal artery bleeding. We believe that 
our patient is the first reported case of spontaneous second intercostal artery bleeding in absence of 
underlying disorders. Being fully anticoagulated with high-dose heparin during the angioplasty and 
being agitated with forceful movement directly after weaning off the sedation might have caused the 
spontaneous rupture. 
https://dx.doi.org/10.46570/utjms.vol11-2023-771 


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