The American journal of emergency medicine
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Case Reports
Patent foramen ovale appearance with association of left ventricular assist device and mechanical ventilation.
We report on a 62-year-old man referred to the cardiac intensive care unit less than 24 hours after anterior ST-segment elevated myocardial infarction. The patient developed cardiogenic shock requiring elective intubation, vasopressor, and inotropic support. Emergency coronary angiography, revascularization, and insertion of an intraaortic balloon pump were performed. ⋯ The shunt resulted from abnormal left-to-right pressure gradient due to left ventricular unloading and increased right ventricular afterload induced by mechanical ventilation. Transesophageal echocardiography was used to regulate both LVAD output and positive end-expiratory pressure settings to optimize oxygen transport. Because patent foramen ovale is common in humans, transesophageal echocardiography should be performed systematically after LVAD insertion.
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Case Reports
HIV-positive patient with herpes zoster: a manifestation of the immune reconstitution inflammatory syndrome.
Herpes zoster is a common illness that can lead to serious morbidity. There is now evidence that HIV-infected patients who have been treated with antiretroviral therapy are at greater risk of developing herpes zoster not when they are severely immunocompromised but, paradoxically, when their immune system is recovering. This is a manifestation of the immune reconstitution inflammatory syndrome. ⋯ Emergency department physicians should be aware that HIV-infected patients treated with HAART may have clinical deterioration despite immune system strengthening. This immune reconstitution inflammatory syndrome can present with infectious, autoimmune, or oncological manifestations. Our case patient, an HIV-positive man with immune system recovery after treatment with HAART, presented with an infectious manifestation, herpes zoster.
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Elevated S100B level in cerebrospinal fluid could predict poor outcome of carbon monoxide poisoning.
S100B is a calcium-binding protein produced by astroglia in the brain and has been used as a marker of neuronal damage after brain trauma. We investigated the utility of S100B in cerebrospinal fluid (CSF) measured during the early phase of carbon monoxide (CO) poisoning in predicting the subsequent clinical course. ⋯ Early elevation of S100B in CSF after CO poisoning could be a suitable predictor of subsequent development of PVS.
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Hiccups, which are usually benign and self-limited, occasionally serve as markers of a serious underlying pathology. We present this case report to inform emergency physicians about the potential for hiccups to serve as the only presenting symptom of a myocardial infarction. The patient, a 68-year-old man with a history of diabetes mellitus, hypertension, and current tobacco use, was first seen in the emergency department after 4 days of intractable hiccups with no other complaints or symptoms. ⋯ Stents were placed in these sites, and the patient recovered uneventfully. This is the first case in which hiccups were the single presenting symptom of a myocardial infarction in the last 50 years. Although extremely common and usually benign, hiccups can occasionally be a sole symptom of serious underlying pathology, which in this case, was a non–ST-segment elevation myocardial infarction.
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The diagnosis of acute coronary syndrome relies on clinical history, electrocardiographic (ECG) changes, and cardiac biomarkers; but within the spectrum of acute coronary syndrome, there exist subtle presentations that cannot afford to be overlooked. Wellens syndrome is one such example, in which a patient can present with both ECG changes that are not classic for myocardial ischemia and negative cardiac biomarkers. ⋯ The associated critical stenosis of the proximal left anterior descending artery carries an immediately life-threatening prognosis if not recognized promptly (Am Heart J. 1982;103[4 Pt 2]:730-736). We describe a case of a less common manifestation of Wellens syndrome (type 1) followed by a discussion of its implications and management.