Multisystem inflammatory syndrome in neonates due to severe acute respiratory syndrome coronavirus 2: An emerging entity

Severe acute respiratory syndrome coronavirus 2 was declared as a pandemic in March 2020. The virus has affected more adults than children, with disease severity being lesser in children. We present a case of a neonate who tested positive for coronavirus disease 2019 infection on day of life 3, 6, and 15. The baby had fever, respiratory distress, and shock. Laboratory investigations showed raised inflammatory markers, raised D dimer suggesting coagulopathy, coronary dilatation on 2D echocardiogram, and raised N terminal pro-brain natriuretic peptide. The neonate was successfully treated with good supportive care, lung-protective ventilatory strategies, early intravenous immunoglobulin administration, corticosteroids, and remdesivir.

Dilated Cardiomyopathy (DCM) in an Infant Due to Primary Carnitine Deficiency (PCD); A Rare Case

Dilated cardiomyopathy (DCM) is known to have ventricular dilatation and dysfunction in myocardium. Primary carnitine deficiency (PCD) is a not common but a reversible autosomal recessive phenomenon with supplementation of carnitine. Case presentation- 11-month male child was brought with complain of fever, cough, cold since 7 days and increased work of breathing for 15 days. 2 D echo was done suggestive of dilated cardiomyopathy. His initial investigations; chest Xray revealed significant cardiomegaly electrocardiography, (ECG) showed prolonged QT interval fraction. Patient was treated with syrup carnitine syrup empirically, as there is no way to determine a fatty acid oxidation profile. Repeated 2D echocardiogram (2 D ECHO) was suggestive of recovery. Conclusions: Carnitine deficiency could be the cause of cardiomyopathy and so treatment of carnitine supplementation can be considered empirically to avoid life-threatening complication related to cardiomyopathy.

Comprehensive Echocardiographic and Speckle Tracking Strain Analysis in Rheumatic Mitral Stenosis Patients before and after Transvenous Mitral Commissurotomy

PurposePercutaneous Transvenous Mitral Commissurotomy (PTMC) is the first line treatment for rheumatic mitral stenosis (MS). We sought to evaluate 1) changes in 2-dimensional (2D) echocardiographic and strain values and 2) differences in these values for patients in atrial fibrillation (AF) and sinus rhythm (SR) pre, immediately and 6 months post PTMC.MethodsRetrospective study of 136 patients who underwent PTMC between 2011 and 2021. We analyzed their 2D echocardiogram, Global Longitudinal Strain (GLS), Left Atrial Reservoir Strain (LAr-S) and Right Ventricle Free Wall Strain (RVFW-S) pre, immediately and 6 months post PTMC.ResultsAt 6 months, mitral valve area increases from 0.94 ± 0.23cm2 to 1.50 ± 0.42cm2. Ejection fraction (EF) did not change post PTMC (pre; 55.56 ± 6.62%, immediate; 56.68 ± 7.83%, 6 months; 56.28 ± 7.00%, p=0.218). Even though EF is preserved, GLS is lower pre-procedure; -11.52 ± 3.74% with significant improvement at 6 months; -15.16 ± 4.28% (p<0.001). Tricuspid annular plane systolic excursion (TAPSE) improved at 6 months from 1.95 ± 0.43 to 2.11 ±0.49 (p=0.004). RVFW-S increases at 6 months from -17.37 ± 6.03% to -19.75 ± 7.19% (p<0.001). LAr-S improved from 11.23 ± 6.83% pre PTMC to 16.80 ± 8.82% at 6 months (p<0.001) post PTMC. Pre-procedure patients with AF have lower strain values (More LV, RV and LA dysfunction) with statistically significant difference for LAr-S (p < 0.001), GLS (p <0.001) and RVFW-S (p <0.001) than patients in SR.ConclusionPatients with severe rheumatic MS have subclinical left and right ventricle dysfunction despite preserved EF and relatively normal TAPSE with significant improvement seen at 6 months post PTMC. AF patients have lower baseline strain values than SR patients.

A Case Report on Ischaemic Cardiomyopathy with Severe Left Ventricular Dysfunction

Ischaemic cardiomyopathy is a condition that arises when heart muscle is weakened because of coronary artery disease or a heart attack. Left ventricular (LV) dysfunction occurs when the left ventricle is either defective or damaged, thus disrupting healthy function. Normal LV function can be perturbed because of several causes. Some cardiac defects such as valvular malformations or conditions block the passage of blood into the body. Effective and cost-effective treatment is available for such patients that can reduce both morbidity and mortality. Herein, the authors present the case of a 69-year-old male who was brought to the emergency department with a history of hypertension on medication. Later, the patient was transferred to the cardiology department. The patient was brought to the hospital after midnight and had bleeding gums, and experienced bleeding from the site of needle puncture. Earlier reports showed that the international normalised ratio was >6.0, and the 2D echocardiogram showed large LV blood clots, mild LV dysfunction, mild mitral regurgitation, and aortic valve stenosis. Finally, the patient was diagnosed with ischaemic cardiomyopathy associated with LV dysfunction. During discharge, the patient and patient’s representative were counselled in layman’s language about the conditions and prognosis of the disease, the use and adherence to medications, lifestyle modifications, and were advised to review back to the cardiologist.

A rare case of mobile ball-like mass in right atrium associated with dilated cardiomyopathy

Mobile thrombus in the Right Atrium (RA) is a rare condition. Here, we described a case of a 59-year-old male who presented in emergency room with complaints of progressively worsening dyspnea for 7 years. He was normotensive, had elevated jugular venous pressure and clear lungs. ECG revealed ventricular tachycardia. After successfully electrical defibrillation, an urgent 2D echocardiogram was obtained and revealed the enlargement of all heart chambers and a ball-like, mobile mass in the right atrium. An emergent CT scan revealed no sign of pulmonary embolism. Based on morphological features on echocardiogram, we highly suspected it as RA thrombus. The patient was treated with anticoagulant therapy comprising of low molecular heparin and warfarin since he rejected surgical treatment. Repeat echocardiogram was performed 7 days after anticoagulant therapy and showed disappearance of the RA mass. He was subsequently maintained on warfarin (INR=2.4- 3.0) and other medications for heart failure. The patient was followed up as outpatient and kept in good clinical condition. We concluded that early recognition of this rare situation and prompt management can help in preventing life-threatening complications, and anticoagulant therapy was a therapeutic option for RA thrombus.

Abstract 13313: Venous Thromboembolism as a Presenting Finding and Complication of Covid-19: A Case Series

Background: Although not yet fully understood, the pathogenesis of the novel RNA betacoronavirus2 currently named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is thought to involve thrombotic microangiopathy, as evidenced by autopsy. To date, the number of pulmonary embolism (PE) reports in the setting of COVID-19 is increasing, with many presenting in acute cor pulmonale. In this case series, we aim to describe our center’s experience with COVID-19 and PE. Methods: A total of 10 patients with a diagnosis of PE in the setting of positive qualitative SARS-CoV-2 through RT-PCR were identified and managed by our service. Results: The mean age was 58 years old with 60% being males. The majority of the population was Hispanic (70%) with 30% self-identifying as black. All of our patients were middle-aged except for one elder and one young adult, and they had other risk factors for thromboembolism, (e.g. obesity, heart failure, COPD, and HIV). The mean time from presentation to diagnosis of PE was 100 hours. Hemodynamic instability was present in 30% of the cases. There was a whole spectrum of PE involvement, the vast majority of which were segmental and subsegmental (60%) compared to distal main arteries (20%) and saddle PE (20%). Mortality rate was 10% and the rest of the patients were successfully discharged on oral anticoagulation. Although our cohort comprised low-to-intermediate pretest probability for PE per Wells criteria (1.5-3), high clinical suspicion prompted further imaging studies with computed tomography angiography and 2D-echocardiogram. Currently, many hospital systems are avoiding advanced imaging for concerns of infection control, which likely contributes to the underdiagnosis of VTE in patients with COVID-19. Conclusion: As we continue to understand the pathophysiology of this emerging disease, clinicians should maintain a high degree of suspicion to differentiate causes of hypoxemic respiratory failure and hemodynamic instability in the setting of COVID-19. Overt PE may increase inpatient mortality and post-discharge mobility due to the burden of pulmonary hypertension in this population. Further research is required to elucidate the relationship between these entities and the best management approach.

Metoprolol-induced hyperkalemia – A case report

Hyperkalemia is a condition that increased serum potassium levels, which can lead to life-threatening cardiac conditions. A 59-year-old female patient admitted to an emergency medicine ward with complaints of gradually progressive retrosternal chest pain. She was a known case of diabetes mellitus (DM), hypertension, and ischemic heart disease with a positive family history of DM and hypertension. She has treated with tablet metoprolol 12.5 mg twice daily from 20 days. On examination, the patient was restless due to unstable angina BP in the range of 110/70–180/90 mm of Hg, PR range 84–86 bpm, and SPO2 – 98%. Laboratory investigation revealed that the HbA1c was 7.19, and mean blood glucose of the past 90 days was in average control. Ultrasonography shows the Grade I renal parenchymal disease. The serum blood sugar level was elevated. Serum troponin I was 0.91 ng/ml. Ultrasonography abdomen was normal. Electro cardiogram: Sinus tachycardia suspected left inferior hemiblock, poor R-wave progression, inverted T- wave, and slide ST segments elevation and 2D-echocardiogram: IHD and RWMA at rest (basal inferior moderate left ventricle dysfunction). On hospital admission, the patient was treated with antiplatelet agents, anticoagulant, insulin, anti-ischemic agents, hypolipidemic agents, and potassium binder resins and diuretics. Patients with diabetes and kidney dysfunction have a higher risk of hyperkalemia in concomitants therapy with beta-blockers, so the health care workers should be aware of life-threatening events due to hyperkalemia secondary to beta-blockers. This case-report adds the evidence on the electrolyte related adverse drug reactions due to the beta-blockers.

Williams-Beuren syndrome presenting as pulmonary edema with pleural effusion: a new pulmonary manifestation of elastin vasculopathy

Introduction: Williams-Beuren syndrome (WBS) is a gene deletion disorder characterized by distinct facial features, cardiovascular anomalies, and intellectual disability. Many genes are involved in WBS, of which the elastin (ELN) gene deletion is almost present in all cases. Limited data exist about pulmonary diseases in children with WBS. Furthermore, pleural effusion (PE) has not been reported in these patients. Case Presentation: A term, small-for-gestational-age (SGA) male Caucasian newborn presented with respiratory distress shortly after vaginal birth. A chest radiograph showed significant pulmonary edema with bilateral pleural effusion. A 2D Echocardiogram demonstrated supravalvular aortic stenosis and branch pulmonary stenosis suspecting WBS. A genetic evaluation revealed an interstitial 1.5Mb deletion in the long arm of chromosome 7 involving band q11.23 confirming the diagnosis of WBS. The child underwent surgical repair at 4 months for age due to cardiac disease progression. Conclusions: An unexplained finding of pulmonary edema and PE in a newborn can be associated with genetic disorders and warrants investigation for WBS, especially in SGA newborns.

Syncope in children clinicoetiological correlation

Background: Syncope is the abrupt cessation of cerebral blood flow leading to temporary loss of consciousness. Identification of etiology is utmost important as any syncopal event may be life threatening. Aim was to correlate the clinical and etiological causes of syncope in children and to note their investigational profile.Methods: Among 40 patients presenting with syncope and presyncope were studied. History of the event, precipitating factors were noted. They were investigated with the help of blood pressure, Electrocardiogram (ECG), 2D Echocardiogram and Electroencephalogram (EEG).Results: Out of the 40 patients of syncope 65% were above the age of 10 years with male preponderance (60%). Vasovagal syncope (57%) was the most common cause of syncope followed by orthostatic hypotension (15%), neurological (15%), and cardiac etiology (6%). In the neurological etiology the EEG showed diffuse slow background with occasional sharp bursts in right frontal area in 2 patients while in 4 patients sharp bursts were present in the centero-temporal region. 17% were classified as presyncope, 60% as mild and 22% as having severe syncope. There was a significant correlation of etiology of syncope with duration of hospitalization of more than 4 days and with recurrence of syncope. There was significant correlation of Evaluation of Guidelines in Syncope (EGSYS) score >3 with cardiogenic syncope. On follow up, neurological syncope patients had significant decrease in the number of syncopal episodes as they were immediately started on antiepileptics.Conclusions: Electrocardiogram, 2D Echocardiogram and Electroencephalogram are important tools for the early management and treatment of cardiac and neurological etiology of syncope.