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Patients with heart failure with preserved ejection fraction have reduced cyclic guanosine 3',5'-monophosphate (cGMP) levels compared to those with reduced ejection fraction. Phosphodiesterase-5 inhibitors may play a cardioprotective role by potentiating the cGMP pathway. To address this question, we conducted a systematic search for randomized trials using the electronic databases of PubMed, Embase, and Google Scholar and used RevMan (version 5.4) for the data analysis. We included 221 subjects in the phosphodiesterase group (mean age 69.2 ± 3.43 years; 58.82% male) and 202 subjects in the control group (mean age 70.4 ± 4.96 years; 53.46% male). The mean follow-up duration was 5.85 ± 3.43 months. The pooled results showed no significant differences in peak oxygen consumption, 6-minute walking distance, mitral annular E/e' ratio, left ventricular ejection fraction, mean pulmonary artery pressure, pulmonary artery systolic pressure, and pulmonary vascular resistance between the phosphodiesterase group and the control group., (Copyright © 2022 Baylor University Medical Center.)

Brugada syndrome is an autosomal dominant genetic disorder that primarily affects myocardial sodium channels and has been associated with an increased risk of ventricular tachyarrhythmias and sudden cardiac death. Here, we report a case of a 58-year-old Hispanic male with a history significant for prior pulmonary tuberculosis infection who presented with pleuritic left-sided chest pain associated with body aches, productive cough, fevers, and chills and was found to be positive for SARS-CoV-2 by real-time reverse-transcription-polymerase chain reaction (rRT-PCR). Electrocardiogram (ECG, EKG) on presentation demonstrated a coved ST-segment elevation in V1-V2, suggesting Brugada pattern type 1 without evidence of ischemic changes. EKG changes normalized once fever and hyponatremia improved., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Ayad et al.)

Azithromycin is a broad-spectrum antibiotic of the macrolide class and has multiple effects on the cardiovascular system, including prolonged corrected QT (QTc) interval. However, there is limited literature on the association between azithromycin and bradyarrhythmias. Monitoring the patient via telemetry can detect bradycardia. The diagnosis of azithromycin-induced bradycardia is usually made by the exclusion of other causes of bradycardia. We report a case of a 44-year-old female with past medical history of obstructive sleep apnea who presented to our hospital due to polysubstance drug overdose with possible aspiration pneumonia. The patient received azithromycin and subsequently developed symptomatic bradycardia two days post-onset of antibiotic treatment. This case raises awareness amongst physicians about the possibility of azithromycin-induced bradycardia and explains the different mechanisms that can cause it., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Abdelazeem et al.)

Diabetic ketoacidosis (DKA) is a significant complication of poorly controlled diabetes. In diabetics, it typically occurs due to insulin deficiency resulting in lipolysis and subsequent ketone body formation and acidosis. The emergence of the COVID-19 infection has been associated with several complications, with the most prominent being pulmonary and cardiovascular-related. However, in some cases, patients with COVID-19 infection present with diabetic ketoacidosis. The pathophysiology of DKA in COVID-19 infection is different and currently not completely understood. The manifestation of DKA in COVID-19 patients is associated with increased severity of mortality and length of stay in these patients. Here, we describe a patient with no past medical history who presented with COVID-19 symptoms and was found to be in DKA. This case report highlights the possible underlying pathophysiology associated with this complication., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Patel et al.)

In patients who are critically ill and in circulatory shock, substantial dosages of vasopressors including norepinephrine and Neosynephrine are often required to sustain blood pressure. While these medications are necessary and can be lifesaving, they are often associated with several complications related to severe vasoconstrictions. One of these known but underreported side effects is digital ischemia (DI). DI refers to a decrease in digital perfusion. It is a rare and uncommon phenomenon that can lead to significant consequences and unfortunately can result in amputation of the digits. Herein, we report an unfortunate female with septic shock secondary to acute bowel ischemia who developed bilateral digital necrosis while on norepinephrine., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Jesani et al.)

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clinical manifestations are diverse and can vary from mild respiratory symptoms to severe hypoxic respiratory failure. In severe cases, infection can cause gastrointestinal, renal, cardiac, neurological and haematological complications and result in multi-organ failure. There are very few reports of parapneumonic effusion in patients with COVID-19. We describe two patients with COVID-19 who had loculated empyema and discuss the clinical course and therapeutic options., Learning Points: The clinical manifestations of COVID-19 vary from mild to severe disease and can result in multi-organ failure.Pleural empyema is usually treated with a combination of antibiotics and surgical drainage of the pleural cavity., Competing Interests: Conflict of interests: The authors declare there are no competing interests., (© EFIM 2021.)

The use of highly active antiretroviral therapy (HAART) in the management and treatment of human immunodeficiency virus type 1 (HIV-1) has dramatically changed the course of the disease and improved overall survival. HAART results in significant decrease in viral load and enhancement of CD4 cells and gradual restoration of the immune system. However, a subset of patients may experience a paradoxical worsening after the initiation of HAART due to a heightened and dysregulated immune response. This phenomenon is termed immune reconstitution inflammatory syndrome (IRIS). The manifestation of Graves' disease (GD) after the introduction of HAART has been identified as IRIS manifestation in some patients. Thus, this occurrence should be suspected and further investigated in patients with HIV on antiretroviral therapy (ART) who present with symptoms consistent of hyperthyroidism to avoid overt hyperthyroidism. We report a case of IRIS associated Graves' disease. Our case adds to the very limited literature about this phenomenon., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Ayad et al.)

The importance of this review lies in its study of the risk of sudden cardiac death (SCD) and sudden cardiac arrest (SCA) in people living with the human immunodeficiency virus (PLWH). To the best of our knowledge, this is the first review investigating the effect of the human immunodeficiency virus (HIV) on SCD and SCA. The review's objective was to determine the risk of SCD and SCA in PLWH. To do this, the electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar were systematically searched to identify eligible studies published before January 31, 2021. Reference lists of the included studies were searched for further identification of relevant studies. The search terms included: "Sudden Cardiac Death," "Sudden Cardiac Arrest," "Human Immunodeficiency virus," "HIV," "Acquired immunodeficiency syndrome," and "AIDS." Only observational studies that assessed the association between SCD and SCA in PWLH were selected.  Data were extracted by two independent authors who screened titles, abstracts, and articles to meet the inclusion criterion. Quality assessment was done by using modified Downs and Black checklist. A total of seven studies were included in this review. Five studies revealed a higher incidence of SCD in PLWH, two of which focused on patients with HIV and low left ventricular ejection fraction (LVEF). The other two studies were about the association of HIV and SCA. Studies reported that PLWH had a three- to five-fold higher incidence of SCD as compared to non-HIV patients. HIV patients with low LVEF had a higher incidence of SCD than HIV patients with normal LVEF. PLWH had a higher incidence of SCA and less successful cardiopulmonary resuscitation (CPR) as compared to patients without HIV. After adjusting for various confounders in multiple studies, all the studies reported a higher incidence of SCD in PLWH. To conclude, PLWH is at an increased risk of SCD and SCA. Some risk factors for this include LVEF, viral load (VL), and the cluster of differentiation 4 (CD4) count. There is a paucity of data on the mechanisms involved, although a higher prevalence of cardiac fibrosis and interstitial fibrosis in PLWH may play a role. Because of the general suboptimal quality of the heterogeneous nature of the current evidence, further, rigorous studies are needed to determine the association of increased risk of SCD and SCA in PLWH., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Abdelazeem et al.)

The spread of the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has resulted in a global health pandemic and caused profound morbidity and mortality worldwide. The virus is known to cause severe hypoxemic respiratory failure and has been associated with extrapulmonary manifestations and end-organ dysfunction in the setting of extensive inflammatory response. Recently, the association between COVID-19 and pneumococcal pneumonia co-infection or superinfections has gained increasing interest. In this report, we present the case of a 58-year-old man with a past medical history significant for pulmonary tuberculosis, diagnosed over two decades ago, who presented with pleuritic chest pain, myalgia, intermittent fevers, chills, and productive cough and was found to have invasive pneumococcal disease and COVID-19. To our knowledge, this is the first reported case of invasive pneumococcal infection in a patient with COVID-19., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Ayad et al.)