Acute limb ischaemia due to vasospasm: a rare presentation

A 30-year-old woman with active intravenous drug use presented with pain, blue discolouration, paresthesia and lack of grip strength of left hand for 1 week. Physical examination revealed blue discolouration, decreased sensation and cold to touch in the left hand. She had no palpable radial pulse. She admitted Heroin use only but the urine drug screen was also positive for amphetamine. CT angiogram of the left upper extremity was concerning for acute ischaemia due to arterial occlusion. The initial plan was for amputation. However, to salvage the limb with thrombolysis, an interventional radiology angiogram was performed. The angiogram demonstrated diffuse arterial spasm and response to nitroglycerin. She was treated with nitroglycerin drip and transitioned to a calcium channel blocker. She did improve significantly. To ensure no embolic sequelae, the patient was discharged with a month of oral anticoagulation.

COVID-19 Infection and Late Manifestation of Pulmonary Aspergillosis

We present the case of a 56-year-old woman who was diagnosed with severe coronavirus disease 2019 (COVID-19) pneumonia complicated by severe acute respiratory distress syndrome who was intubated for 19 days. She recovered from COVID-19 after a month. A computed tomography (CT) scan of the chest, after a month, showed improved infiltrates with a small residual cavity within the lingula. A CT angiogram showed a more confluent density in the lingular portion on follow-up 2 months later. She developed intermittent hemoptysis after 3 months in December 2020, which persisted for almost 6 months, and CT of the chest showed the lingular nodular with resolution of the cavitation. She underwent bronchoscopy with bronchoalveolar lavage, confirming Aspergillus fumigatus by galactomannan assay and histology showing branching hyphae. Once she started treatment with itraconazole, her hemoptysis resolved. The follow-up CT of the chest after 2 months of treatment did not show a cavity or a nodule in the lingula. Our patient developed invasive pulmonary aspergillosis (IPA) as a sequela of severe COVID-19 infection. COVID-19-associated invasive pulmonary aspergillosis (CAPA) is an underrecognized complication that needs to be investigated on whether prophylactic treatment is required. Our case also demonstrates that the diagnosis of IPA needs to be considered months after COVID-19 infection when a superimposed fungal infection can occur after a viral infection if the patient continues to have persistent symptoms.

Type A4 truncus arteriosus: series of 3 cases focused on dual source multidetector CT angiogram findings

Truncus arteriosus (TA) is a rare congenital cardiac anomaly caused by failure of normal conotruncal septation during the fetal development. This aberration leads to a common ventricular outflow artery over the malaligned large ventricular septal defect (VSD), supplying systemic, coronary and pulmonary circulation. People with such anomalous anatomy show variable presentation from early childhood to adult life depending on the severity of defects. We here present three cases of truncus arteriosus with aortic interruption / hypoplasia-coarctation (type A4 truncus arteriosus) with focus on relevant dual source MDCTA findings.

Tocilizumab and Renal Artery Stent—Therapeutic Strategy for Takayasu Arteritis

Takayasu vasculitis (TAK) is a form of large vessel vasculitis clinically manifesting as pulseless disease or hypertension. It is more common in South East Asia and Japan, India, and Mexico [1]. It is increasingly being recognized due to increased awareness among medical fraternity and better imaging modalities. Undetected hypertension, pulselessness, and syncope are more common symptoms and presentation during pregnancy is unusual and can lead to bad obstetric outcomes. Recent evidences support the use of tocilizumab for inducing remission in Takayasu arteritis. We report this rare case of vasculitis presenting in pregnancy as malignant hypertension. A 20-year-old pregnant woman (45 days) presented with headache and nausea but no fever. She had a history of intermittent claudication of legs for the past 3 years but not evaluated. During examination, pulses were felt normally and blood pressure (BP) 180/110, no murmurs in cardiac auscultation, but she had abdominal bruit (renal vessels). Other systems were normal. Echocardiogram (ECHO) showed dilated ascending aorta. Doppler of renal vessels showed narrowing of renal arteries. Unfortunately, she had to undergo termination of pregnancy (high BP in spite of antihypertensives). Her computed tomography (CT) angiogram showed features of TAK with type 5 pattern–she had methylprednisolone infusion 500 mg daily for 3 days, followed by injection tocilizumab 400 mg monthly 3 doses. Once remission was achieved, she had recanalization by percutaneous transluminal angioplasty of right renal artery. She is currently maintained on aspirin and telmisartan. Awareness of causes of high BP, inputs by radiologist, cardiologist, and rheumatologist and understanding by the patient and family helped to achieve good outcome albeit the miscarriage.

Determination of Sensitivity and Specificity of High Resolution CT Scan in Evaluation of Cardiac and Extra-Cardiac Anomalies among Bangladeshi Children

Congenital heart disease (CHD) is one of the important causes of morbidity and mortality in the pediatric age group. Invasive angiography is considered as gold standard method for the diagnosis of pediatric cardiovascular diseases. Multi-detector CT cardiac angiogram by using 64 slice scanner is a useful modality and suitable alternative to previous invasive procedure in evaluation of congenital heart disease. The present study was conducted in the Department of Cardiology of NICVD during the period of September 2019 to August 2020 (One year). We selected 40 patients presenting in the outpatient department of National Institute of Cardiovascular Diseases and Hospital (NICVD) who were diagnosed to have congenital heart disease clinically and radiologically. CT angiogram revealed ASD in 10%, coarctation of aorta in 5%, Pentalogy of Fallot in 2.5%, Tetralogy of Fallot (TOF) in 32.5%, Ventricular septal defect (VSD) in 30.0%, PAH in 2.5%, PS in 5%, RVH with PS in 2.5%, PDA in 5% and Tricuspid atresia with ASD with VSD with PS in 2.5% patients. Conventional catheter angiogram revealed ASD in 5%, VSD in 32.5%, TOF in 30%, PS in 12.5%, Coarctation of aorta in 5% and Pentalogy of Fallots in 5%. The diagnostic performance of MDCT in the diagnosis and evaluation of congenital heart disease was high.

Vascular involvement in chronic thromboembolic pulmonary hypertension is associated with spirometry obstructive impairment

Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension caused by persistent thromboembolism of the pulmonary arteries. In clinical practice, CTEPH patients often show obstructive ventilatory impairment, even in the absence of a smoking history. Recent reports imply a tendency for CTEPH patients to have a lower FEV1.0; however, the mechanism underlying obstructive impairment remains unknown. Methods We retrospectively analyzed CTEPH patients who underwent a pulmonary function test and respiratory impedance test to evaluate their exertional dyspnea during admission for right heart catheterization from January 2000 to December 2019. We excluded patients with a smoking history to rule out the effect of smoking on obstructive impairment. Results A total of 135 CTEPH patients were analyzed. The median FEV1.0/FVC was 76.0%, %FEV 1.0 had a negative correlation with the mean pulmonary artery pressure and pulmonary vascular resistance and the CT Angiogram (CTA) obstruction score. A multivariate regression analysis revealed that the CTA obstruction score was an independent factor of a lower %FEV1.0. In the 54 patients who underwent pulmonary endarterectomy, %FEV1.0 was improved in some cases and was not in some. Mean PAP largely decreased after PEA in the better %FEV1.0 improved cases, suggesting that vascular involvement in CTEPH could be associated with spirometry obstructive impairment. Conclusion %FEV1.0 had a significant correlation with the CTA obstruction score. Obstructive impairment might have an etiological relationship with vascular involvement. Further investigations could shed new light on the etiology of CTEPH.

Extensive subcutaneous emphysema from scalp to lower limbs in a 44-year old

A 44-year-old man was admitted after being found suspended by his ankles from a bridge for 5 days. The events leading to it was not clearly known initially. On examination, the patient was hypotensive and hypothermic, airway was oedematous and both lower limbs were mottled with dusky feet. Both foot pulses were impalpable, with prolonged capillary refill time and sensation barely present. Doppler signals were not heard in the feet, but groin pulses and popliteal signals were present. On CT, the patient had bilateral pneumothoraxes, extensive subcutaneous emphysema throughout the body from the subcutaneous tissue of the scalp to both lower limbs and pneumomediastinum and pneumoperitoneum. CT angiogram showed opacification up to proximal crural vessels and absence beyond. After multispeciality input and optimisation of his physiology, he underwent bilateral below knee amputations as they were non-salvageable.