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There is significant morbidity and mortality associated with the presence of coronary artery disease (CAD) in the setting of orthotopic liver transplantation in patients with end-stage liver disease. The prevalence of CAD in this cohort is similar to, if not higher, than the general population. Several studies show improved survival rates for patients with obstructive CAD who undergo percutaneous coronary intervention (PCI) and support a low threshold for PCI in these patients. However, a few studies have failed to show improved mortality associated with PCI in this cohort. This review hopes to highlight the current recommendations regarding the assessment of CAD in patients with end-stage liver disease who are orthotopic liver transplantation candidates and describe the outcomes of PCIs.

Cardiac lymphoma is a rare neoplasm involving heart, pericardium or both, usually seen in immunocompromised patients. We report a 61-year-old male presenting with worsening shortness of breath and 20-pound weight loss. Investigations showed right-sided tumor with interatrial septal wall perforation and left atrial expansion. The diagnosis was confirmed with mediastinal mass biopsy. After receiving the appropriate treatment, there was a steady improvement clinically and on the transesophageal echocardiography.

Degeneration of the cardiac conduction system resulting in complete heart block (CHB), ventricular arrhythmias (VA), and sudden cardiac death (SCD) is recognized in patients with Kearns-Sayre syndrome (KSS) and is potentially preventable with permanent pacemaker (PPM) implantation. However, other mechanisms for SCD have been proposed, and the efficacy of implanting a defibrillator instead of PPM remains to be investigated.We utilized the National Inpatient Sample (NIS) database 2016-2019 to investigate the risk of VA or dysrhythmic cardiac arrest (dCA) in KSS patients. We compared the outcomes of KSS to myotonic dystrophy (MD), a more common genetic disorder with similar clinical cardiac features and course.We identified 640 admissions for KSS. VA or dCA were lower in admissions for KSS than MD patients (2.3% vs. 4.5%, p = .009). Device implantation differed between study groups. Approximately, 70% of cases with KSS and conduction abnormalities had pacemaker (± defibrillator) on hospital discharge, compared to 35% in MD. Conduction abnormalities were associated with higher rates of VA or dCA in both study groups. None of the admissions for KSS patients who developed VA or dCA had a pacemaker, and all of them had conduction abnormalities. One-third of admissions for MD patients who developed VA or dCA had a device already implanted prior to the event.Despite its effectiveness in preventing VA, PPM remains underutilized in patients with KSS or MD who have conduction abnormalities. PPM alone do not fully prevent VA in MD patients; therefore, addition of defibrillator capacity might be necessary.

Ischemic gastropathy is a rare, underreported phenomenon that is associated with a poor prognosis. Patients often present with signs of shock, gastrointestinal bleeding, and anemia. We describe a patient with alcoholic cirrhosis who presented after a fall in hemorrhagic shock. Initial endoscopy revealed evidence of ongoing bleeding, with subsequent endoscopy revealing the “leopard skin” appearance in the stomach. The patient was treated supportively but eventually succumbed to his condition. Prompt diagnosis, treatment, and awareness of the delayed changes on upper endoscopy are imperative in diagnosing ischemic gastropathy. Patients with risk factors for the condition need to be given additional consideration for this diagnosis.

Tularemia has been well described clinically in the United States since the early 1900s. Worldwide, the infection has manifested in a variety of forms through various vectors with geography and local prevalence often considered in the diagnostic work-up. We present a case of a 57-year-old patient who lived in an area with low tularemia infection rates and presented with fever and a tender, swollen elbow. Though initially diagnosed with cellulitis, she was eventually found to have tularemia after further interviewing and questioning, followed by successful treatment with doxycycline. A thorough history including exposures and daily activities should always be considered in an effort to rule out rare infections, even in areas of low disease prevalence.

Diagnosing a stroke requires careful attention to clinical indicators on physical exam, especially the more subtle manifestations of cerebellar lesions. An 85-year-old male with vascular risk factors and new-onset atrial fibrillation was admitted for left upper extremity weakness, headaches, and tremors. The patient developed stridor during hospitalization and was found to have a new cerebellar infarct with hemorrhagic transformation on computed tomography (CT) of the head, with laryngoscopy showing bilateral vocal cord paresis. While strokes outside of the cerebellum are a known cause of unilateral vocal cord paresis, cerebellar strokes are a rare culprit and rarely cause bilateral cord paresis. Consideration beyond the more common pulmonary and iatrogenic causes of vocal cord paresis should be considered, with particular attention to stroke.

Cardiovascular conduction delay makes up part of the triad associated with Kearns-Sayre syndrome (KSS). Although there have been a few reported cases of prolonged Qtc and polymorphic ventricular tachycardia associated with this disease, despite the use of automatic implantable cardioverter defibrillators (AICD) for secondary prevention, some cases have been reported where the use of AICD did not help. We present a case of a 62-year-old male with KSS who came to the emergency department (ED) after two episodes of syncope. He already had an automatic AICD placed at the age of 34. Our patient had Qtc prolongation which is an unusual finding in KSS. He also had recurrent ventricular tachycardia (VT) refractory to medications and multiple shocks from his AICD, which progressed to a VT storm. He eventually passed away after the withdrawal of care, as his prognosis worsened. We recommend that a more clear guideline will help manage this devastating disease, resulting in mortality reduction.

e19546 Background: Plasmablastic lymphoma (PBL), a variant of diffuse large B-cell lymphoma, is a rare and aggressive malignancy. Minimal guidelines exist for its diagnosis and standard of care. Hence, we studied the epidemiological characteristics and survival variables of PBL patients by using the SEER 20 database. Methods: A total of 229 cases of PBL (WHO ICD-O-3 codes 9735/3) were identified between 2000 and 2015, after excluding 66 cases with unknown survival time or no microscopic confirmation. The epidemiological characteristics and the survival variables included were age, gender, ethnicity, Ann Arbor stage, B-symptoms, and site. The overall 5-year survival (OS), cause-specific 5-year survival (CSS), and cause-specific survival plots across different strata were plotted using the Kaplan Meier Method. The analysis was done using the Cox proportional hazard regression model (p < 0.05). Results: The incidence of PBL was 0.03 per 100,000 cases. It was more common in adults less than 60 years (61.57%), males (79.04%), and White ethnicity (72.49 %). There were more cases of patients with advanced Ann Arbor stages (3 or 4) PBL (52.84%), although some patients (5.68%) had unknown staging. There were 55.02% of extranodal cases, and 28.38% of patients had B-symptoms. The OS was 36.55%, and the CSS was 46.5%. CSS did not differ significantly based on age, race, or gender. However, the absence of B-symptoms was associated with better CSS (HR: 0.654, 95% CI: 0.455-0.941, p: 0.022). Nodal involvement (HR: 1.553, 95% CI: 1.135-2.124, p: 0.006) and advanced stages 3 or 4 (HR: 1.414, 95% CI: 1.018-1.962, p: 0.038) were also linked to a poor CSS. Conclusions: PBL patients with a primary nodal involvement and advanced staging (3 or 4) had poor CSS, and the absence of B-symptoms was associated with a better outcome. Age, gender, and ethnicity had no discernible effects on survival. We did not include therapeutic options in our study, and hence, further studies analyzing the impact of treatment options on PBL survival can be conducted.[Table: see text]