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Il SARS–CoV2 è trasmesso tra gli umani attraverso particelle respiratorie e l’infezione può determinare un largo spettro di manifestazioni cliniche. Precedenti studi hanno dimostrato il ruolo centrale dell’immunità cellulo–mediata nel limitare la gravità delle infezioni da virus respiratori. I linfociti T–helper CD4+ sono coinvolti in funzioni di coordinazione e regolazione dell’immunità anti–virale: determinano lo sviluppo di anticorpi neutralizzanti ad alta affinità e la differenziazione dei centri germinali a cellule B in cellule della memoria secernenti anticorpi con lunga vita. Nessun dubbio sul ruolo cruciale della risposta a cellule T durante l’infezione da SARS–CoV2 o dopo la vaccinazione. Descriviamo il caso di un paziente di 39 anni, vaccinato con ChAdOx1–S. Dopo due settimane il paziente accusava dispnea e febbricola. Il test molecolare per SARS–CoV2 era negativo; agli esami ematici la PCR era aumentata. La TC del torace escludeva embolia polmonare e rivelava pattern a vetro smerigliato bilaterale, come da flogisi. All‘ecocardiogramma i parametri erano nella norma. L’ECG mostrava tachicardia sinusale. Il paziente veniva dimesso dal PS con terapia cortisonica. Una settimana dopo i sintomi peggiooravano. Una nuova TC torace mostrava difetti di opacizzazione di rami secondari dell’arteria polmonare ed aspetto bilaterale a vetro smerigliato. Si iniziava terapia con EBPM ed antibiotici a largo spettro. Il test molecolare e la sierologia per SARS–CoV2 erano negativi. Negativi i test per Mycoplasma, Chlamydia, Legionella e CMV DNA. L’emocromo mostrava ridotti linfociti (6,8%) con neutrofilia relativa (90,4%), ma normale valore dei bianchi. La TC–HR mostrava aspetto “crazy paving” bilaterale suggestivo per infezione virale o micotica (pattern come da infezione da Pneumocystis Jiroveci). Il test per HIV aveva esito positivo; alla tipizzazione linfocitaria ridotti i livelli di linfociti T–Helper (CD3+/CD4+) e rapporto CD3+/CD4+ 0%. Per il rapido deterioramento del quadro clinico il paziente veniva trasferito in terapia intensiva. Dopo 30 giorni dalla diagnosi di AIDS il paziente giungeva ad exitus. Il ruolo dei linfociti T nello sviluppo di anticorpi neutralizzanti e di cellule della memoria durante l’infezione da SARS–CoV2 è la chiave nella strategia di vaccinazione per ridurre il dilagare della pandemia, tuttavia nel nostro paziente questo meccanismo non ha funzionato rivelando il deficit del suo sistema immunitario da una latente infezione da HIV.

The infective endocarditis (IE) has a significant impact on mortality rate in the first year after diagnosis, despite the improvements in early diagnosis and therapy. Embolic complications cause worsening of patient’s prognosis and they occur in the 20–50% of cases, with a risk of new embolic events after the initiation of antibiotic therapy rated between 6 and 12%. Echocardiographic characterization of vegetation has an important role in the definition of the embolization risk, it is documented that vegetation with dimension more than 10 mm are at higher risk. Several characteristic of the patient (diabetes, previous embolization, atrial fibrillation) determine the increase of the embolization risk, as well as the initiation of antibiotic therapy. We describe the case of a 64 y.o. man with chronic coronary syndrome (previous PCI) and previous Bentall–De Bono intervention for ascending aorta aneurysm. Patient was under anticoagulant therapy with DOAC due to atrial fibrillation. He was admitted to the emergency department for intermittent fever during the last three months, dyspnea and fatigue. Blood test showed neutrophilic leukocytosis and increased value of inflammatory markers. Transthoracic echography revealed an hyperechoic image on the ventricular side of the aortic prosthesis. The diagnosis of infective endocarditis was confirmed with transesophageal echocardiography, and empiric antibiotic therapy was initiated. Cardiac surgeon suggested follow up and new evaluation after three weeks of therapy. Clinical course was complicated by acute abdomen. The CT exam revealed dilation of a distal tract of superior mesenteric artery (maximum axial diameter was 10 mm) associated with distal thrombosis extended for 6 mm. The transthoracic echocardiogram showed absence of the vegetation on aortic prosthesis previous documented. Therapy with intravenous infusion of unfractionated heparin was administrated for three weeks, but the control TC showed persistence of the thrombotic occlusion of superior mesenteric artery so the case was discussed with Vascular Surgery team. They decided to treat patient with embolization and aneurysmectomy surgery (cultures were negative). This clinical case demonstrates that embolic complication of infective endocarditis, even on proper antbiotic therapy and close monitorization, are unpredictable and can cause the worsening of patient’s clinical course.

Coronary artery fistula (CAF) is defined as anomalous communication between coronary arteries and cardiac chamber or a major thoracic vessel. CAF are a rare coronary anomaly, mostly congenital, first described by Krause in 1856. In literature the incidence in general population is approximately 0,002%. Detection of CAF during coronary angiography is usually accidental. In 50% of cases CAF originate from right coronary artery, in 30% they originate from LAD, while in the rest of the percentage CAF originate from left circumflex artery. CAF drain into low–pressure chamber (right ventricle or right atrium, superior Vena Cava or pulmonary artery). We can distinguish CAF into little or medium sized, usually with silent clinical course, and large sized CAF, with variable clinical signs, depending on the extent of the shunt and on the hemodynamic overload of the receiving chamber. We describe the case of a 57 y.o woman with hypertension, admitted for femur fracture. ECG showed bifasic T waves in the anterior leads, already described in a previous ECG. Normal systolic function and no valvular defect were found on the echocardiogram. Patient was asymptomatic. Coronary angiography documented normal coronary arteries, with a double coronary fistula: the first from a septal branch of posterior descending and the second one from distal branches of the first diagonal. Even if CAF have often a favorable clinical course with no relevant consequences for the patient, it’s crucial to obtain more information about their functional implication and their anatomic connections. Indeed, rare cases of sudden cardiac death have been described in patients with CAF involved in myocardial ischemia based on the theft syndrome mechanism. Echocardiographic evaluation of the patient to detect associated congenital abnormalities, pressure overload of the receiving chambers and the extent of the shunt on the coronary angiography are crucial for the proper management of CAF. In the case described above we decided to optimize therapy adding beta–blocker (to reduce the overload caused by the two coronary fistula).

Coronary artery kink is a variant of anomalous coronary artery, not related to vessel disease. Often it is associated with coronary artery tortuosity (CAT) and fibromuscular dysplasia. The pathogenesis and clinical implications are not fully understood. Kinks are hypothesized to cause coronary blood flow alterations that can results in ischemia and even in acute coronary syndrome. It is speculated that coronary artery kinks are most often caused by guide wire straightening and seen after wiring the artery, but that is not always the case. We describe the case of a 55 years old woman, with familiar history of CAD. In 2019 she had percutaneous Patent Foramen Ovale closure intervention. She presented to the Emergency Department complaining chest pain radiating into the neck. The ECG was normal, but Troponin I levels were mildly elevated (2,1 ng/ml) and ipokinesia of basal and mid segment of the anterior intraventricular spetum was found at the ecoscopy. The patient was admitted to Cardiology department with diagnosis of unstable angina and urgent coronary angiography was performed. At a first glance the coronary arteries did not exhibit significant arteriosclerotic or thrombotic changes. However, upon a closer review, a focal kink of the mid left descending coronary artery was found. This coronary kink folded the LAD during systole causing a transient stenosis that resolved during diastole. Management of coronary kinks is controversial. In the past, literature suggested treatment with coronary stenting as one of the management options. However there are reported cases of adverse outcomes, such as shifting of kink proximally, requiring an additional stenting. We decided to treat patient with medical approach: beta–blockers at the tolerated doses was initiated, in addition to ACE–Inibithor, Aspirin and statin. Stenting of the coronary artery was not a choice, due to the possibility of shifting (as described in literature) and stent fracture. At a one month follow up the patient presented asymptomatic for angina, palpitation or dyspnea. Even if rarely coronary artery kink is a potential cause of myocardial ischemia and its treatment is often challenging to improve patient quality of life and to prevent adverse cardiac event.