Search

A post mortem examination was performed on a 45 year old white male who died suddenly during a competitive athletic swimming event. There were few clinical events seen in the year before his death. Clinical workup was negative and lung scan showed a small coin lesion was attributed to focal bacterial/fungal infection. Antibiotic treatment appeared to clear this condition on another follow up scan and he was sent home with an inhaler. On gross post mortem examination the lungs revealed diffuse pulmonary congestion, focal hemorrhage and edema. Small focal white areas of calcified lesions were also seen. In addition, an enlarged heart with left ventricular hypertrophy and thickened interventricular septum were seen. There was moderate atherosclerosis midway down the left anterior descending branch of the coronary artery observed. Histologic examination of lung tissue proved confirmatory for diffuse pulmonary ossification. Heart microscopic examination was consistent with cardiomyocyte hypertrophy. In conclusion, the diffuse pulmonary ossification was probably related to the sudden death with concomitant myocardial hypertrophy.

Amiodarone is an antiarrhythmic drug that is commonly used for the treatment of ventricular and supraventricular arrhythmias. It is an iodine-containing compound, and has a tendency to accumulate in certain organs, including in the lungs. We describe a case of amiodarone induced pulmonary toxicity with concurrent lung cancer which demonstrated good treatment response. A sixty nine-year old male smoker presented to our emergency department with a four-month history of progressive dyspnea, cough and 5 kilogram weight loss. Chest x-ray at admission showed enlarged heart shadow and prominent hilum bilaterally; CT revealed ground glass opacities in right lung and enlarged mediastinal lymph nodes. His past medical history was significant for dilated myocardiopathy and atrial fibrillation (for which he had been taking amiodarone for 5 years). Radiological findings, decrease in total lung capacity (TLC=84%), decrease in lung diffusing capacity (DLCOc=73%), and corneal epithelial opacities suggested amiodarone-induced pulmonary toxicity (APT) and/or advanced malignant disease. Amiodarone was eliminated from his medication profile due to suspicion of drug toxicity. The patient’s clinical condition promptly improved, and chest x-ray performed after 7 days showed corresponding improvement. Subsequent bronchoscopy included a transbronchial biopsy which revealed lung adenocarcinoma. The patient’s presumed APT was treated with methylprednisolone 40mg IV daily during the first two weeks, and subsequently with prednisone 20 mg/day orally for two months. One month after steroid therapy (and prior to chemotherapy) both lungs demonstrated radiographic improvement. Treatment response to chemotherapy was successful, with good performance status (ECOG1) after 10 months. This case with comorbid APT and lung cancer illustrates the importance of diligence in developing differential diagnoses for pulmonary infiltrates. Chest physicians should take care to remember that amiodarone induced pulmonary toxicity (APT) can sometimes mimic disseminated lung malignancy.

Background: The primary purpose of pre-participation screening is identifying the cohort of athletes affected by unsuspected cardiovascular diseases, such as coronary artery disease (CAD) as well as preventing sudden cardiac death (SCD) during sports competitions or training, through appropriate intervention. Case Report: This case report describes the recent history of a middle-aged marathon runner suffering from asymptomatic ischemic heart disease at high risk for SCD and illustrates the clinical pathway. An exercise ECG stress testing was positive for subendocardial ischemia. Computerized tomography (CT) coronary angiogram subsequently showed critical narrowing of the left anterior descending artery. Invasive coronary angiography was performed following angioplasty procedure. One month later an exercise ECG stress testing was normal, indicative of complete myocardial revascularization. Conclusions: Silent myocardial ischemia (SMI) is not such a rare event in athletes, especially in endurance sports athletes. In fact, even though they are asymptomatic this does not exclude the presence of a severe coronary artery disease. Exercise stress testing is safe and affordable non-invasive screening for detecting asymptomatic coronary artery disease in athletes. Myocardial revascularization procedure is to re-establish the athlete’s state of fitness for competitive sports.

U.S. Department of Veterans Affairs (VA) physicians receive guideline reminders to prescribe medications to patients recuperating from cardiac surgery. We examined whether these electronic clinical reminders were associated with a) medication fill rates and b) 6-month risk-adjusted survival after coronary artery bypass graft (CABG) surgery. This retrospective cohort study analyzed the national VA Pharmacy Benefits Management System and the Continuous Improvement in Cardiac Surgery Program data from 10/1/1999 to 9/30/2005. Medication fill rates for a 6 month period prior to the active use of the electronic clinical reminder were compared with fill rates for a 12 month period after electronic reminder use. We found no significant difference in fill rates between the pre- and post-reminder periods. An analysis of variance (ANOVA) model tested whether medication fill rates were affected by electronic reminders. Apparent differences in fill rates before and after implementing clinical reminders disappeared after controlling for multiple comparisons using false discovery rate; therefore data was pooled across years (antihypertensive medications (AH), p = 0.80 and lipid-lowering agent medication (LL), p = 0.30). Changes in fill rates for AH and LL were similar to each other (p = 0.37). A Cox Proportional Hazard Regression model was used to determine the predictors of survival between the 6-month time period prior to the clinical reminder versus the 6-month time period after the reminder was actively used. The clinical reminders for both AHM and LLA were not significantly associated with survival (p = 0.45, hazard ratio = 2.2, confidence intervals 0.29-16). These results do not support the use of electronic clinical reminders in this setting. Instead, these findings support questioning the utility of individual electronic record clinical reminders.

Coronary artery dissection is a common occurrence after percutaneous coronary intervention (PCI). We here firstly describe a interesting case of very rapid spontaneous recanalization associated with micro-dissection following PCI in the right coronary artery due to a total occlusion lesion that could not be stented but was associated with very early (a week) spontaneous healing and a favorable outcome.