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Background One’s physical function and physical activity levels can predispose or protect from the development of respiratory infections. We aimed to explore the associations between pre-pandemic levels of physical function and physical activity and the development of COVID-19-like symptoms in Swedish older adults. Methods We analyzed data from 904 individuals aged ≥ 68 years from the population-based Swedish National study on Aging and Care in Kungsholmen. COVID-19-like symptoms were assessed by phone interview (March–June 2020) and included fever, cough, sore throat and/or a cold, headache, pain in muscles, legs and joints, loss of taste and/or odor, breathing difficulties, chest pain, gastrointestinal symptoms, and eye inflammation. Muscle strength, mobility, and physical activity were examined in 2016–2018 by objective testing. Data were analyzed using logistic regression models in the total sample and stratifying by age. Results During the first outbreak of the pandemic, 325 (36%) individuals from our sample developed COVID-19-like symptoms. Those with slower performance in the chair stand test had an odds ratio (OR) of 1.5 (95% confidence interval [CI] 1.1–2.1) for presenting with COVID-19-like symptoms compared to better performers, after adjusting for potential confounders. The association was even higher among people aged ≥ 80 years (OR 2.6; 95% CI 1.5–4.7). No significant associations were found between walking speed or engagement in moderate-to-vigorous physical activity and the likelihood to develop COVID-19-like symptoms. Conclusion Poor muscle strength, a possible indicator of frailty, may predispose older adults to higher odds of developing COVID-19-like symptoms, especially among the oldest-old.

Background: The pro-coagulable state in nephrotic syndrome is due to urinary losses of anti-coagulant proteins, including antithrombin III. Low molecular weight heparin (LMWH) is a common initial treatment for thrombosis and works by activating anti-thrombin III that itself inhibits factor Xa. In thrombosis in nephrotic syndrome, antithrombin levels are only infrequently checked and replacement is uncommon. We describe a case of thromboembolism due to an acquired antithrombin III deficiency and treatment with plasma derived anti-thrombin III (Thrombotrol-VF CSL ltd Australia) and LMWH. Case report: A 21-year-old male with focal segmental glomerulosclerosis, previously managed with rituximab, presented with a relapse of his nephrotic syndrome involving severe oedema and ascites, serum albumin <6 g/L, total cholesterol 17 mmol/L, UPCR 1.99 g/mmol, and right sided chest pain. A perfusion scan confirmed a large right segmental pulmonary embolus. He was commenced on intravenous methylprednisolone and rituximab and later cyclosporin. Given his impaired gut absorption and significant clot burden, his thromboembolism was treated with therapeutic enoxaparin. His initial anti-Xa and anti-thrombin III levels were low at 0.30 IU/mL (target range 0.50-1) and 0.29 IU/mL (normal 0.8-1.20) respectively. To ensure efficacy of LMWH he received Thrombotrol-VF with daily monitoring and replacement to achieve target levels. Owing to urinary losses, his anti-thrombin III levels were intermittently low even after achieving therapeutic anti-Xa levels. He was transitioned to warfarin once his gut absorption improved, evidenced by therapeutic oral cyclosporin drug levels and later his INR. Conclusion(s): Anti-thrombin III losses in severe nephrotic syndrome should be considered when treating its thrombotic complications. When using LMWH it may be prudent to check anti-thrombin III levels and replace as needed.

Objective: To quantify the burden of interstitial lung disease (ILD) in SSc. Method(s): Clinical data for SSc patients enrolled in the Australian Scleroderma Cohort Study were linked with healthcare databases for the period 2008-2015. ILD was defined by characteristic fibrotic changes on high-resolution CT (HRCT) lung, while severity was defined by the extent lung involvement on HRCT (mild <10%, moderate 10-30%, severe >30%). Determinants of healthcare cost were estimated using logistic regression. Result(s): SSc-ILD patients utilized more healthcare resources, including hospitalization, emergency department presentation and ambulatory care services, than those without ILD with a total cost per patient of AUD$48 368 (26 230-93 615) vs AUD$33 657 (15 144-66 905), P<0.001) between 2008-2015. Healthcare utilization was associated with an annual median (25th-75th) excess cost per SSc-ILD patient compared with those without ILD of AUD$1192 (807-1212), P<0.001. Increasing ILD severity was associated with significantly more healthcare utilization and costs with an annual excess cost per patient with severe ILD compared with mild ILD of AUD$2321 (645-1846), P<0.001. ILD severity and the presence of coexistent PAH were the main determinants of overall healthcare cost above median for this SSc-ILD cohort (OR 5.1, P<0.001, and OR 2.6, P=0.01, respectively). Furthermore, SSc-ILD patients reported worse physical HRQoL compared with those without ILD [34.3 (10.5) vs 39.1 (10.8), P<0.001], with a progressive decline with increasing ILD severity (P=0.002). Conclusion(s): SSc-ILD places a large burden on the healthcare system and the patient through poor HRQoL in addition to incremental healthcare resource utilization and associated direct cost.Copyright © 2019 The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Objectives To describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions. Design Prospective observational cohort study. Setting Two centre study in a Swedish county emergency medical services (EMS) organisation. Participants Unselected inclusion of 2917 patients with chest pain contacting the EMS due to chest pain during 2018. Primary outcome measures Low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge. Results Of included EMS missions, 68% concerned patients with a low-risk condition without medical need of acute hospital treatment in hindsight. Sixteen per cent concerned patients with a high-risk condition in need of rapid transport to hospital care. Numerous variables with significant association with low-risk or high-risk conditions were found. In total high-risk and low-risk prediction models shared six predictive variables of which ST-depression on ECG and age were most important. Previously known risk factors such as history of acute coronary syndrome, diabetes and hypertension had no predictive value in the multivariate analyses. Some aspects of the symptoms such as pain intensity, pain in the right arm and paleness did on the other hand appear to be helpful. The area under the curve (AUC) for prediction of low-risk candidates was 0.786 and for high-risk candidates 0.796. The addition of troponin in a subset increased the AUC to >0.8 for both. Conclusions A majority of patients with chest pain cared for by the EMS suffer from a low-risk condition and have no prognostic reason for acute hospital care given their diagnosis on hospital discharge. A smaller proportion has a high-risk condition and is in need of prompt specialist care. Building models with good accuracy for prehospital identification of these groups is possible. The use of risk stratification models could make a mor

Long COVID-19 may be defined as patients who, four weeks after the diagnosis of SARS-Cov-2 infection, continue to have signs and symptoms not explainable by other causes. The estimated frequency is around 10% and signs and symptoms may last for months. The main long-term manifestations observed in other coronaviruses (Severe Acute Respiratory Syndrome (SARS), Middle East respiratory syndrome (MERS)) are very similar to and have clear clinical parallels with SARS-CoV-2: mainly respiratory, musculoskeletal, and neuropsychiatric. The growing number of patients worldwide will have an impact on health systems. Therefore, the main objective of these clinical practice guidelines is to identify patients with signs and symptoms of long COVID-19 in primary care through a protocolized diagnostic process that studies possible etiologies and establishes an accurate differential diagnosis. The guidelines have been developed pragmatically by compiling the few studies published so far on long COVID-19, editorials and expert opinions, press releases, and the authors' clinical experience. Patients with long COVID-19 should be managed using structured primary care visits based on the time from diagnosis of SARS-CoV-2 infection. Based on the current limited evidence, disease management of long COVID-19 signs and symptoms will require a holistic, longitudinal follow up in primary care, multidisciplinary rehabilitation services, and the empowerment of affected patient groups.

Background: Oral squamous cell carcinoma (SCC) with cardiac metastasis is a rare antemortem finding. A case demonstrating significant right ventricular (RV) cavity obliteration due to metastatic SCC in an asymptomatic patient is presented. Case Summary: A 46-year-old gentleman underwent routine preoperative electrocardiogram which raised concern of possible anterior and inferior ST elevation (Image 1A). Clinically he had no chest pain but a 2-week history of night sweats, anorexia and weight loss. This was on a background of meta-static floor of mouth SCC treated with neoadjuvant carboplatin/paclitaxel chemotherapy and wide local excision of the floor of the mouth, subtotal glossectomy, segmental mandibulectomy, left sided selective lymph node dissection, and right modified radical neck dissection. Histopathology revealed T4aN2cM0 locally advanced SCC. Clinical examination was unremarkable except for a JVP with a prominent 'a' wave and a pericardial friction rub. Investigations revealed a normal Troponin (<0.04 ng/ml). CT Pulmonary Angiogram demonstrated a large pericardial effusion, a large filling defect (49x45mm) within the RV, multiple enlarged mediastinal and anterior pericardial lymph nodes. Several lung nodules were found bilaterally (largest 14x17mm). FDG-PET scan demonstrated an intensely avid mass involving the myocardium, the interventricular septum and floor of the ventricle (Image 1D). Nodular FDG avid pericardial disease and bilateral pulmonary metastases were noted in addition to uptake in the subcutaneous soft tissues anterior to the left oropharynx (SUV max 6). Urgent transtho-racic echocardiogram revealed moderate right ventricular (RV) dilation, with a large lobulated echodense mass invading the RV free wall, occupying most of the RV cavity (Image 1B & C). Estimated RV systolic pressure was 32 mmHg. A moderate circumferential pericardial effusion was detected, measuring 25 mm in diameter posteriorly with no tamponade physiology. Management: A pres

Purpose: South Asian (SA) have been observed to have higher cardiovascular mortality rates compared to East Asians (EA) and Caucasians. Pericoronary adipose tissue (PCAT) attenuation around the right coronary artery (RCA) from coronary CT angiography (CTA) has been associated with coronary inflammation and cardiac death. We aimed to investigate i) the relationship between plaque characteristics and PCAT attenuation and ii) to assess gender and ethnic differences in PCAT attenuation using a matched cohort of SA, EA and Caucasians. Method(s): Three-hundred symptomatic patients who underwent CTA were matched for age, gender, BMI and diabetes (100 in each ethnic group). Semi-automated software was used to quantify the total volumes and burden of non-calcified plaque (NCP), low-density non-calcified plaque (LD-NCP) and calcified plaque (CP) in blinded core-lab analysis. PCAT CT attenuation was measured around the RCA (10-50 mm from RCA ostium), the most standardized model for PCAT analysis. Result(s): The total volumes and burden of NCP, LD-NCP and CP were comparable in the ethnic groups (each p > 0.05). PCAT attenuation was higher in patients with coronary plaque. PCAT attenuation correlated with the total volumes and burden of NCP, LD-NCP and CP (r>0.17; p < 0.003). Within the RCA this correlation persisted only for NCP features (r>0.39;p < 0.001). Males showed higher PCAT attenuation (p < 0.001). PCAT attenuation was similar between Caucasian, EA and SA (p = 0.32). Conclusion(s): PCAT CT attenuation correlated most with its surrounded NCP features further highlighting its role as surrogate measure of coronary inflammation. As coronary plaque burden and RCA PCAT attenuation did not differ between ethnic groups, causes of increased cardiac mortality in South Asians needs further investigations.Copyright © 2020

Hernia of Morgagni is an unusual congenital defect of the sternal portion of the diaphragm. Its concurrence with cardiac surgical pathology is rarely described in the literature. Notwithstanding, huge hernia of Morgagni have been noted to cause serious peri-operative impediment and complications. We report the case of a 50-year-old gentleman with a massive Morgagni hernia that threatened strangulation during cardiopulmonary bypass. We describe the combined surgical approach undertaken to repair this hernia, with an accompanying review of the literature relating to misadventure and management of similar large hernia coinciding with cardiac surgery.Copyright © The Author(s) 2019.

Aim: To evaluate pain prevalence and characteristics in children and adolescents with predominant dyskinetic and mixed (dyskinetic/spastic) cerebral palsy (CP) motor types. Method(s): Seventy-five participants with a diagnosis of CP and confirmed dyskinetic or mixed (dyskinetic/spastic) motor type took part in a multisite cross-sectional study. The primary outcome was carer-reported pain prevalence (preceding 2wks) measured using the Health Utilities Index-3. Secondary outcomes were chronicity, intensity, body locations, quality of life, and activity impact. Result(s): Mean participant age was 10 years 11 months (SD 4y 2mo, range 5-18y). There were 44 males and 31 females and 37 (49%) had predominant dyskinetic CP. Pain was prevalent in 85% and it was chronic in 77% of participants. Fifty-two per cent experienced moderate-to-high carer-reported pain intensity, which was significantly associated with predominant dyskinetic motor types (p=0.008). Pain occurred at multiple body locations (5 out of 21), with significantly increased numbers of locations at higher Gross Motor Function Classification System levels (p=0.02). Face, jaw, and temple pain was significantly associated with predominant dyskinetic motor types (p=0.005). Poorer carer proxy-reported quality of life was detected in those with chronic pain compared to those without (p=0.03); however, chronic pain did not affect quality of life for self-reporting participants. Interpretation(s): Pain was highly prevalent in children and adolescents with predominant dyskinetic and mixed (dyskinetic/spastic) motor types, highlighting a population in need of lifespan pain management. What this paper adds: Chronic pain prevalence in children and adolescents with predominant dyskinetic and mixed (dyskinetic/spastic) motor types is high. Pain occurs across multiple body locations in predominant dyskinetic and mixed (dyskinetic/spastic) motor types. Less recognized locations of pain include the face, jaw, and temple for predo

Background: Patients who present to emergency departments (EDs) with chest pain (CP) are frequently discharged without diagnoses or follow-up. We hypothesise that unspecified CP (UCP) portends to increased future cardiovascular event risk. Aim(s): To examine major adverse cardiovascular event (MACE) prevalence among ED patients discharged with UCP compared with patients discharged with abdominal pain (AP). Method(s): Retrospective data review for patients discharged from three EDs between 2013-15 with UCP and AP, using linked data. The primary outcome was return to the health service within two years with MACE. Association between ED presentation and MACE return was determined using Chi-square test, stratified for sex, and quantified by crude (unadjusted) relative risk (CRR). Result(s): Over three years, 43361 ED patients were discharged with UCP (n=28534; 62% male) or AP (n=14827; 52% male). Overall, the 2-year MACE incidence was 3.2% (95% CI:3.0-3.4). MACE was identified among 1136 (82%) individuals with index UCP (MACE risk=3.4%) and 256 (18%) people with index AP (MACE risk=1.7%). Two-year CRR of MACE was 2.4x higher among individuals discharged with UCP (95% CI:2.02-2.64, p<0.001) compared with AP. When stratified by sex, MACE risk in males with index CP was 2.4x higher than males with AP (95% CI:2.0-2.9). In females, MACE risk was 2x higher after index CP compared to AP (95% CI:1.6-2.5). Conclusion(s): The 2-year MACE risk in ED patients discharged with UCP was significantly increased suggesting UCP may predict future MACE. Further research to quantify MACE risk is crucial to inform innovative programs to reduce risk and improve outcomes among individuals at high cardiovascular risk.Copyright © 2020

Introduction: We present the first case of triple coronary artery ectasia in a previously well Indigenous Australian presenting with ST-elevation myocardial infarction. Case Report: A 26 year old previously well Indigenous Australian male was admitted with anterior ST elevation myocardial infarction associated with an out of hospital ventricular fibrillation arrest. The patient was loaded with dual antiplatelet therapy and thrombolysed with 50mg tenecteplase prior transfer to our tertiary centre for rescue percutaneous coronary intervention due to <50% ST segment resolution and ongoing chest pain. Coronary angiography demonstrated thrombotic occlusion of the proximal left anterior descending artery with prominent vascular ectasia of all three arteries. Thrombus aspiration was not performed due to perceived high risk of systemic cardioembolic events. PCI was not attempted due to significant vascular ectasia preventing stent apposition within the grossly dilated vessel wall. He was managed with surgical thrombectomy and coronary artery bypass graft of the left anterior descending artery. Discussion(s): There is no consensus approach in the management of isolated coronary artery ectasia presenting with acute coronary syndrome due to the paucity of prospective trials in its management. The management principles currently are to administer aspirin and to relieve the underlying obstructive lesion by percutaneous coronary intervention and failing that, cardiac surgery.Copyright © 2020

Benign cardiac hemangiomas are rare tumors that may present in or out side of the heart, epicardium being the most common site. Echocardiography is the method of choice in diagnosing cardiac masses and though 3D TEE may seem to add exact information about the location, the time constraint in doing a comprehensive examination along with 3D rendering inside operation room may become an hindrance.Copyright © 2020 Annals of Cardiac Anaesthesia Published by Wolters Kluwer - Medknow.

Background: Invasive aspergillosis is rare in immunocompetent individuals. Aspergillus infection seldom results in cardiac involvement, but can be associated with pancarditis, myocardial abscess or granuloma formation, and typically occurs in patients who are immunocompromised, have undergone recent cardiac surgery, or have prolonged corticosteroid use. Case Presentation: A 32-year-old man presented with a three-day history of chest pain, dyspnoea, haemoptysis, and bilateral leg swelling. He had no significant past medical history, and regularly used anabolic steroids. Clinical examination revealed bilateral lung crepitations and pitting oedema. Computed tomography showed rapidly evolving bilateral pulmonary nodules with progressive central cavitation, and sputum cultures were positive for aspergillus fumigatus. Echocardiography demonstrated markedly increased wall thickness and impaired left ventricular long axis function. A diagnosis of invasive pulmonary aspergillosis with secondary myopericarditis was made, and the patient was successfully treated with anti-fungal therapy, with improvement in ventricular wall thickness and long axis function on repeat echocardiography after 12 weeks. Discussion/Conclusion: Cardiac manifestations of aspergillosis are a rare occurrence in immunocompetent patients, and is associated with a high risk of mortality. The majority of reported cases were diagnosed post-mortem, which highlights the importance of early diagnosis and treatment, particularly given the non-specific nature of symptoms and presentation, and the rarity of the disease.Copyright © 2020

Background: The aetiology of post-partum chest pain range from benign to life-threatening. Concerning causes include pulmonary embolism, pneumothorax, myocardial infarction, peripar-tum cardiomyopathy, aortic dissection, and oesophageal rupture. Case: A 24-year-old primigravid, antenatally well lady arrived fully dilated in spontaneous labour. She commenced pushing and at 1 h suddenly developed right-sided facial, eyelid, and neck swelling. She progressed to deliver a male liveborn baby. Day 1 post-partum she developed worsening throat swelling, dysphonia, chest tightness, and subcutaneous emphysema along her trachea and anterior chest with normal air entry and vital signs. An ECG was norma and chest x-ray showed pneumomediastinum and bilateral supraclavicular subcutaneous emphysema. A follow-up CT scan showed a moderate to large volume pneumomediastinum encircling the oesophagus, trachea, and thyroid. Gas was also tracking bilaterally within the bronchovascular interstitium, the oblique and right horizontal fissure, lower cervical soft tissues and bilateral supraclavicular regions with no signs of oesophageal perforation. She was diagnosed with Hamman's syndrome (spontaneous pneumomediastinum and subcutaneous emphysema) and managed conservatively. The patient's condition gradually stabilized prior to discharge. Discussion(s): Hamman's syndrome is an uncommon cause of spontaneous pneumomediastinum and subcutaneous emphysema. Pneumomediastinum occurs when air leaks through smal alveolar ruptures, the upper respiratory, or gastrointestinal tracts. Predisposing factors include prolonged labour, forceful coughing or vomiting, or asthmatic bronchospasm. Common presenting symptoms of pneumomediastinum include chest pain, dyspnoea, cough, neck pain, odynophagia, dysphagia. Exclusion of other serous causes of pneumomediastinum including pneumothorax and Boerhaave's syndrome (spontaneous transmural perforation of the oesophagus) is essential.

The prognosis of AML in elderly patients is poor and research into novel therapeutic approaches is urgently needed. This study examined the use of low-dose chemotherapy with cytarabine and thioguanine administered in repetitive cycles in 62 elderly patients with newly diagnosed or relapsed/refractory AML. The overall response rate was 58% in the total cohort. Response rates (CR/CRi) were significantly higher in patients with newly diagnosed AML (74%) compared to patients with relapsed/refractory disease (25%, p =.0004). Kaplan-Meier estimate of overall survival was 289 days (95% CI; 183-395 days) with a relapse rate of 65.7%. The induction mortality rate was 16.1% with treatment successfully undertaken in the outpatient setting. Similar clinical outcomes were observed in a retrospective analysis of a second cohort of 25 AML patients treated at a different site. These results support the use of a sustained low intensity chemotherapy approach as a therapeutic option for elderly patients with AML.Copyright © 2019, © 2019 Informa UK Limited, trading as Taylor & Francis Group.

Fractional flow reserve derived from coronary computed tomography enables anatomical and haemodynamic assessment of coronary artery disease in a single non-invasive test. Its diagnostic performance has been established against invasive fractional flow reserve in multi-centre trials, and a growing body of evidence has demonstrated its utility in predicting clinical outcomes. The purpose of this article is to describe the physiological principles, review its diagnostic performance, and describe the role of this technology in a real world clinical application.Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Objective: To find out frequency and outcomes of undiagnosed diabetes mellitus in patients presenting with acute ST elevation myocardial infarction (STEMI). Study Design: Descriptive / Cross-Sectional Study Place and Duration of study: This study was conducted at the Cardiology Department, Lady Reading Hospital, Peshawar from November 2018 to May 2019. Materials and Methods: Patient of either gender having age ranging between 30-75 years old with acute STEMI who present within 12 hours of symptoms and with no past history of documented diabetes mellitus were included in the study. Venous blood samples for laboratory data, including random blood sugar, two fasting blood sugar and HBA1c using hitachi modular evo p800 machine was done. Results: A total of 158 patients having acute STEMI were studied. Males were 68.4% (n=108).The mean age was 59.65 ±10.80 years. Frequency of undiagnosed diabetes mellitus was 31.64 % (n = 50). In non-diabetics stress hyperglycemia was found in 51.85 % (n=56) patients. Among various types of STEMI, anterior STEMI was more common presentation 34.1 % (n=54. p= 0.85). Mean HBA1C was 6.19 ± 1.87%. Frequency of Ventricular tachycardia (VT) was 22.2 % in which undiagnosed diabetics were n=18 (p=0.004).Ventricular fibrillation was present in 13.3 % patients with undiagnosed diabetics were n=14 (p=0.001). Frequency of AF was 13.9% (n=22) with undiagnosed diabetics having AF in n=13 (p=0.003). SVT was present in 5.7% (n=9) patients with not significant difference between two groups (p=0.017). Among various mechanical complications VSR was present in 10 % (n=16) of patients (p=0.001), cardiogenic shock in 11.1 % (n=18) patients (p=0.004), acute LVF was present in 15.8 % patients (p=0.017). Conclusion: In our study we concluded that one third of patients having acute ST elevation myocardial infarction have undiagnosed diabetes mellitus (31.64 %, n = 50). The most common complication was ventricular tachycardia among electrical complication and LVF a, QC 20211011

Objective: An observational study on the current diagnostic and procedural utility, as well as impact of point-of-care ultrasound (POCUS) in the emergency department (ED). Background(s): Point-of-care ultrasound (POCUS) has been recognised as a useful non-invasive bedside tool in providing valuable information, as well as its utility in procedural guidance for clinicians. However, its current prevalence and utility in ED remain unknown. Method(s): In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified. Result(s): A total of 390 (2.1%) POCUS examinations were performed among 18,355 presentations in the three Monash Health EDs during the study period. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural guidance in 46 (11.8%) cases. eFAST/AAA and bedside echocardiography were the two most frequently utilised diagnostic modules. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma mainly traffic accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. The majority of the cases were performed by FACEMs (Fellows of Australasian College of Emergency Medicine) (66.4%). Conclusion(s): Despite known diagnostic and procedural values, the prevalence of POCUS in ED was found to be lower than what was expected. The prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians and trainees should be further advocated and supported.Copyright © 2019 Australasian Society for Ultrasound in Medicine

Introduction: To describe a case of nitrofurantoin associated organising pneumonia. Background(s): Nitrofurantoin is an antibacterial agent indicated for treatment of uncomplicated urinary tract infection (UTI) or for prophylaxis in those patients with recurrent UTIs. It is rarely used as a first line agent owing to its potential for adverse reactions such as pulmonary toxicity.1 Organising pneumonia is a pathological syndrome associated with dyspnoea, non-productive cough, bilateral crackles on chest examination and hypoxaemia at rest.2 We report a case of nitrofurantoin associated organising pneumonia responsive to drug withdrawal and corticosteroid initiation, this is a rare occurrence, with only a few reported cases worldwide. Interventions, Case Progress and Outcomes: A 73-year-old female ex-smoker with a history of multiple allergies, Graves' disease, and recurrent UTIs who was treated with long-term nitrofurantoin presented with an 8- week history of worsening dyspnoea on exertion, pleuritic chest pain when coughing, nausea, decreasing appetite, weight loss and increasing lethargy. Computed Tomography (CT) of the chest revealed widespread bilateral airspace and peribronchovascular ground glass opacities indicative of organising pneumonia. Following diagnosis of organising pneumonia, nitrofurantoin was ceased and high dose prednisolone commenced. After rapid clinical response to treatment, the patient was discharged long-term on high dose prednisolone. On routine 4-week follow up, the patient's symptoms had improved significantly. A repeat CT chest demonstrated dramatic reduction in ground glass changes. Conclusion(s): Nitrofurantoin associated organising pneumonia is a rarely reported adverse reaction and is often associated with poor outcomes. 3 This case report highlights that nitrofurantoin associated organising pneumonia can improve dramatically with prompt withdrawal of the causative agent and commencement of corticosteroids. It also reinforces the impor

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

Background: When compared with Caucasian populations, East Asians (EA) have a lower prevalence of coronary artery disease, myocardial infarction and cardiovascular mortality. Ethnic differences in coronary atherosclerotic burden and plaque composition are not known. Objective(s): To compare CT-assessed coronary atherosclerotic burden, plaque composition and quantitative high risk plaque features in a matched cohort of Caucasian and EA patients with stable chest pain. Method(s): Two-hundred symptomatic patients (age 58.8+/-7.9, male 51%) underwent clinically mandated CT coronary angiography (CTA) were matched for age, gender, BMI and diabetes (100 for each ethnic group). Visual CTA assessment and quantitative plaque analysis using dedicated semiautomatic software was performed by a blinded core laboratory to measure plaque volume and burden. Plaque composition was determined from measurement of total, calcified and non-calcified plaque (NCP) volumes. NCP was further separated by differences in Hounsfield Units (HU). Quantitative high risk plaque features were defined as low attenuation necrotic core (-30 to 30 HU) and intermediate fibrofatty plaque (31-130 HU). Favourable plaque was defined as high attenuation fibrous plaque (131-350 HU). Result(s): Segment Involvement Score, percent diameter and area stenosis were comparable in both groups. Similarly, there was no significant difference in total plaque, calcified and non-calcified plaque volume and burden. Compared with Caucasians, plaque composition in East Asians was associated with significantly less high risk features of necrotic core (3.47 vs 5.09%, P=0.003) and fibrofatty plaque (29.28 vs 37.20% P=0.002). Fibrous plaque composition was highest in East Asians (65.65 vs 57.58% P=0.009). Conclusion(s): Based on this matched cohort with comparable overall plaque volume and burden, East Asians exhibited significantly lower composition of high risk plaque features and had higher favourable plaque composition compare

Background: Late gadolinium enhancement (LGE) with cardiac magnetic resonance (CMR) is commonly assumed to represent myocardial fibrosis; however, comparative human histological data are limited, and there is no consensus on the most accurate method for LGE quantitation. We evaluated the relationship between CMR assessment of regional fibrosis and infarct size assessment using serial biomarkers after ST elevation acute myocardial infarction (STEMI). Method(s): Ninety-three patients treated for STEMI (59 +/- 10 years, 86% male) underwent CMR 6 months after infarction. Infarct size was quantified by CMR-LGE using manual and range of semi-automated thresholds (range: 2-10 standard deviations [SD]) above reference myocardium and the full width-half maximum (FWHM) technique, and compared with the rise in serum biomarkers. The agreement between CMR and biomarker in the identification of large infarcts based on peak troponin (TnI) levels was also analysed. Result(s): Quantification methods had a strong influence on the infarct size assessment with CMR-LGE. Significant correlations were observed between LGE and biomarkers across all of the signal intensity thresholds. Whilst there was a wide variation with respect to the estimation of total LGE size (from 6.8 +/- 7.7 to 32.1 +/- 11.3 grams), the variation in the correlation with peak troponin level was much smaller (r-values ranging from 0.670 to 0.876). There was good agreement between CMR-LGE and biomarker assessment of infarct size; the best agreement between CMR-LGE and large infarction using a threshold of 8SD for peak TnI > 50 ng/mL (Cohen's kappa (kappa) = 0.722), and a threshold of 4SD for peak TnI > 95 ng/mL (kappa = 0.761). Conclusion(s): The correlation between CMR-LGE quantification of infarct size and biomarker release following STEMI at a range of semi-automated thresholds was consistently strong, with good agreement between measures across a range of thresholds.Copyright © 2018

Recent evidence suggests plaque morphology evaluated on coronary computed tomography angiography has prognostic implications. East Asians have a lower prevalence of myocardial infarction and cardiovascular mortality compared with European-origin Caucasians. We aimed to compare coronary atherosclerotic burden and plaque composition in a matched cohort of Caucasian and East Asians patients with stable chest pain who underwent computed tomography angiography. Two-hundred symptomatic patients (age 58.8 +/- 7.9, male 51%) were matched for age, gender, body mass index, and diabetes (100 each ethnic group). A blinded core-laboratory quantified calcified and noncalcified plaque (NCP) volume and burden. Components of NCP were differentiated by plaque hounsfield unit (HU) thresholds which defined high-risk necrotic core (-30 to 30HU), fibrofatty plaque (31 to 130HU); and low-risk fibrous plaque (131 to 350HU). Composition of NCP components was derived as (NCP component volume/total NCP volume) x 100%. Segment Involvement Score, percent diameter and area stenosis were comparable in both groups. Similarly, there was no difference in the volume and burden of total, calcified and NCP. Compared with Caucasians, East Asians demonstrated lower composition of plaque attenuation corresponding to necrotic core (3.5 vs 5.1%; p = 0.004) and fibrofatty plaque (29.6 vs 37.3%; p = 0.005), and higher fibrous plaque (65.7 vs 57.6%; p = 0.004). On multivariable analysis East Asian ethnicity was independently associated with lower composition of high-risk plaque after adjustment for risk factors and scan parameters. These findings were consistent in a propensity-matched sensitivity-analysis. In conclusion, based on this matched cohort, East Asian ethnicity is associated with significantly less composition of high-risk NCP (necrotic core and fibrofatty plaque) and a higher composition of low-risk fibrous plaque compared with Caucasians; which may confer a lower risk of cardiovascular events.Copy

Aneurysmal bone cysts are uncommon bony abnormalities that most often affect those in the third decade of life, but are rarely seen in the thoracic cage. This study reported the case of a recurrent lesion in a 37-year-old gentleman who had undergone initial curettage of the aneurysmal bone cyst 14 years earlier. The lesion involved the anterior right chest wall, in particular arising from the third rib, and presented with intermittent chest pain over a 12-month period. Computed tomography scan demonstrated a large mass deep to the pectoral muscles, which expanded both inward into the pleural space as well as externally. Histopathology confirmed the diagnosis, with a similar appearance to the original tumour. This case highlighted the importance of complete resection whenever possible, rather than curettage. The literature relating to the thoracic manifestations of these tumours was reviewed with a focus on typical clinical manifestations, radiological and histological identifiers, and the key elements of management to avoid problems of recurrence and malignant transformation.Copyright © 2019

Background Coronary computed tomography angiography (CCTA) is often avoided in elderly patients due to a presumption that a high proportion of patients will have heavily calcified plaque limiting an accurate assessment. We sought to assess the image quality, luminal stenosis and utility of CCTA in elderly patients with suspected coronary artery disease (CAD) and stable chest pain. Methods Retrospective analysis of elderly patients (> 75 years) who underwent 320-detector row CCTA between 2012-2017 at MonashHeart. The CCTA was analysed for degree maximal coronary stenosis by CAD-RADS classification, image quality by a 5-point Likert score (1-poor, 2-adequate, 3-good, 4-very good, 5-excellent) and presence of artefact limiting interpretability. Results 1011 elderly patients (62% females, 78.8 +/- 3.3 years) were studied. Cardiovascular risk factor prevalence included: hypertension (65%), hyperlipidaemia (48%), diabetes (19%) and smoking (21%). The CCTA was evaluable in 68% of patients which included 52% with non-obstructive CAD (< 50% stenosis), 48% with obstructive CAD (> 50%) stenosis. Mean Likert score was 3.1 +/- 0.6 corresponding to good image quality. Of the 323 (32%) of patients with a non-interpretable CCTA, 80% were due to calcified plaque and 20% due to motion artefact. Male gender (P = 0.009), age (P = 0.02), excess motion (P < 0.01) and diabetes mellitus (P = 0.03) were associated with non-interpretable CCTA. Conclusion Although CCTA is a feasible non-invasive tool for assessment of elderly patients with stable chest pain, clinicians should still be cautious about referring elderly patients for CCTA. Patients who are male, diabetic and >78 years of age are significantly less likely to have interpretable scans.Copyright © 2019 JGC All rights reserved

Objective: An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments. Background(s): POCUS has been recognised as a readily available, non-invasive imaging tool; providing prompt clinical information at the bedside, as well as a useful guiding tool during procedural interventions. However, its current use and clinical impact in ED remain unknown. Method(s): In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were archived and analysed. Factors associated with diagnostic impacts were identified. Result(s): A total of 390 (2.82%) POCUS examinations were performed among 18,355 (13,822 adults) presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. The POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were in patients presented with abdominal pain (35.3%), chest pain (14.0%) and trauma mainly motor vehicle accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. Most of the cases were performed by Senior Medical Staffs (66.4%). DiagnosticPOCUS overall sensitivity and specificity were 94.1% (95% CI 85.6 - 98.4%) and 99.6% (97.5 - 100%); positive and negative predictive values were 98.5% (95% CI 90.1 - 99.8%) and 98.2% (95% CI 95.6 - 99.3%), respectively. Conclusion(s): Despite known diagnostic and procedural p

Background: Malignant Pleural Mesothelioma (MPM) is a rare but fatal disease related to asbestos exposure, with historic survival in the order of 9 to 17 months. Chemotherapy is associated with only a modest benefit. The advent of immunotherapy has heralded significantly improved outcomes using checkpoint inhibitors in an as yet ill-defined cohort. We aim to identify predictive and prognostic biomarkers in a series of patients (pts) with MPM and describe survival data. Method(s):A retrospective audit was undertaken of pts with MPM diagnosed between 2013 and 2017 at a single tertiary centre in Melbourne, Australia (Monash Health). Data relating to patient outcomes and clinicopathological features were obtained through medical reports. Further immunostains are being performed on archived tissue for PDL-1 status. Result(s): 65 pts were identified, of whom 52 (80.0%) were male. Median age was 73 years (range 44-90). 52 pts were noted to be ECOG 0-1. 42 pts (64.6%) were noted to have suspected asbestos exposure. Epithelioid MPM was the most common subtype, noted in 41 pts (63.1%) (table 1). 8 pts (12.3%) presented with stage IV disease. 16 pts (24.6%) received checkpoint inhibitor therapy, with 10 (63 %) in the second/third line setting. Median overall survival (OS) was 19.8 months (95% CI 13.3-26.3) in the whole cohort.Patient characteristics associated with poor OS were: presence of weight loss (P = 0.001), chest pain (p = 0.08) and ECOG 2 (p = 0.04). Pts with sarcomatoid histology who received immune checkpoint inhibitors in any line of treatment had significantly prolonged OS compared to other histologies. 3-year survival was 80% in this group while median OS was not reached (p = 0.04). This difference was not seen with other histologies. Conclusion(s): The evolving landscape of treatment in MPM appears to show promise in improving OS. In this unselected case series, our data is consistent with historic controls in terms of survival and prognostic factors. The findin

Background: Following corrective surgery in infancy/childhood for tetralogy of Fallot (TOF) or its variants, patients may eventually require pulmonary valve replacement (PVR). Debate remains over which valve is best. We compared outcomes of the Medtronic Freestyle valve with that of the pulmonary allograft valve following PVR. Method(s): A retrospective study was undertaken from a single surgical practice of adult patients undergoing elective PVR between April 1993 and March 2017. The choice of valve was at the surgeon's discretion. There was a trend toward the almost exclusive use of the more readily available Medtronic Freestyle valve since 2008. Result(s): One hundred fifty consecutive patients undergoing 152 elective PVRs were reviewed. Their mean age was 33.8 years. Ninety-four patients had a Medtronic Freestyle valve, while 58 had a pulmonary allograft valve. There were no operative or 30-day mortality. The freedom from reintervention at 5 and 10 years was 98% and 98% for the pulmonary allograft and 99% and 89% for the Medtronic Freestyle. There was no significant difference in the rate of reintervention, though this was colored by higher pulmonary gradients across the Medtronic Freestyle despite its shorter follow-up. Conclusion(s): Pulmonary valve replacement following previous surgical repair of TOF or its variants was found to be safe with no significant differences in mortality or reintervention between either valve. Although the Medtronic Freestyle valve had a greater tendency toward pulmonary stenosis, additional follow-up is needed to further document its long-term outcomes.Copyright © The Author(s) 2019.

A 75-year-old male presented to the Emergency Department with chest pain and anterior ST segment elevation. He had previously had a left anterior descending (LAD) stent (CYPHERTM sirolimus-eluting) implanted in 2006 for angina. Coronary angiography revealed stent fracture with thrombo-sis, displacement of the distal half of the stent, and a coronary aneurysm between fractured segments. Stent fracture in first-generation drug-eluting stents (DES) is an uncommon but recognised complication of DES implantation. Most cases are minor, but aneurysm formation at the site of fracture is rare. Image A demonstrates the stent in the LAD with the proximal (red arrow) and distal (yellow arrow) portions angulated relative to each other; the coronary wire is in the proximal LAD. Image B shows the coronary aneurysm (blue arrow) with TIMI0 flow in the LAD distal to the aneurysm; the coronary wire is seen in a septal branch. The vessel was unable to be revascularised. [Figure Presented].

Objective: The primary aim of our study was to evaluate the prevalence of ultrasound use in patients presenting to ED. The secondary aims were to assess the purpose, indication, and the therapeutic impact of USS in the ED. Background(s): Ultrasound scan (USS) has been recognised as a great imaging tool owing to its non-invasive, nonradioactive nature, with rapid provision of clinical information at the bedside without the use of ionising radiation. Although the utility of USS has been extensively advocated in the emergency setting, the actual rate and indication of utility remain unknown. Method(s): A 31-day, prospective observational study in three Emergency Departments of the Monash Health Network, Victoria, with approximately 200 000 Monash ED attendances annually (Monash Medical Centre Clayton, tertiary adult and paediatric EDs; Dandenong Hospital and Casey Hospital; both with mixed adult and paediatric EDs) was performed in October, 2016. Data in regard to the frequency and indications of utility, the mode of POCUS use, its diagnostic values, and the corresponding operator were achieved and analysed across these three sites. Factors associated with diagnostic impacts were also identified. Result(s): In the 31-day study period in ED, the prevalence of POCUS was 2%. POCUS was utilised for assessing diagnosis in 87.6% of cases and procedural guidance in 12.4% cases. Majority of the diagnostic POCUS cases were indicated for abdominal pain (73%), chest pain (14%) and multi-trauma/injury (6%); while most procedural POCUS cases were indicated for IV access (85%). The most frequently used modality were eFAST/AAA (46%) and BELS (17%).The sensitivity and specificity of diagnostic POCUS were found to be 91.3 and 94.7%, respectively. Majority of cases were performed by the senior medical staff (51.9%). Conclusion(s): The prevalence of POCUS in ED was found to be low, despite that fact of it being highly recommended. The utility was mainly for diagnostic assessment of intra

Appropriate deliberate clinical inertia refers to the art of doing nothing as a positive clinical response. It includes shared decision-making to improve patient care with the use of clinical judgement. We discuss common clinical scenarios where the use of deliberate clinical inertia can occur. The insertion of peripheral intravenous cannulae, investigating patients with suspected renal colic and the investigation of low risk chest pain are all opportunities for the thoughtful clinician to 'stand there' and use effective patient communication to avoid low value tests and procedures. Awareness is key to identifying these opportunities to practice deliberate clinical inertia, as many of the situations may be so much a part of our environment that they are hidden in plain view.Copyright © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Background: Improving quality of care with a clinical pathway is an ongoing process and requires continuing feedback, monitoring along with staff training. A large body of our epidemiological evidence suggests Australian Indigenous (Aboriginal and Torres Strait Islander people) are at higher risk of having a major coronary event and cardiac mortality. Method(s): This was a multifaceted quality research, conducted five discrete but inter-related studies using audit (n = 14), incidence review (n = 4), direct observation of patient's journey (n = 14), chart review, and an anonymised interview (n = 3) between Feb 2014-Aug 2016 at multi-sites within Queensland Health. Result(s): There were no considerable differences in the action of chest pain pathway delivery in Indigenous versus non-Indigenous patients. However, several factors were identified as clear barriers in applying chest pain pathway for the Indigenous population including compromised communications via "000" during the emergency situation, lack of reliable transportation to adequate health facilities either primary or tertiary care and ineffective education mainly perpetuated by unfamiliarity with Western medicine. It was also highlighted the crucial role of involving a local "Indigenous Health Professionals" from the get-go not only improved efficacy but resulted with increased further compliance. Conclusion(s): A special consideration should be taken to evaluate chest pain symptoms in Indigenous patients due to mentioned barriers and carrying a higher risk. The authors suggest it is critical to apply a "wellness improvement system model" with a holistic approach to engaging the community to develop cultural competency for successful outcomes.

Meet the killers of Thoracic park; A review of the utility of point of care / Bed side ultrasound (including bed side Echo) in diagnosis of major life threatening conditions in patients presenting with cardiorespiratory symptoms ie arrest, chest pain, dyspnea etc Presentation involves multiple videos and case series as well as a review of ultrasound modalities that can be used (Lung, Echo, Vascular, etc).

Background/Aims: Stress myocardial perfusion imaging (MPI) has established superior sensitivity and specificity to exercise ECG in diagnosing myocardial ischaemia. However, the impact of chest pain or ECG changes during MPI remains unclear. This study aimed to define the relationship between chest pain or ischaemic ECG changes during MPI and the amount of myocardial ischaemia. Method(s): 161 consecutive patients with no cardiac history who presented with chest pain for investigation and underwent exercise stress MPI between July 2014 and March 2015 were analysed retrospectively. The presence of chest pain or ischaemic ECG changes (1 mm or more of ST depression) during the study, as well as the subsequent diagnosis of no, mild, moderate or severe ischaemia was recorded, using visual semiquantitative scoring. Quantitation was by consensus from two experienced readers, blinded to all other information. Result(s): Chest pain during exercise stress testing was significantly associated with severe ischaemia, defined as summed difference score (SDS) > 8 (OR = 14.6, 95%CI = (1.3,169.2), P < 0.05). Whilst a trend was seen for an association between chest pain and moderate ischaemia (SDS = 5- 8) (OR = 3.5, 95%CI = (0.3,39.8), p = 0.34), it is only for severe ischaemia that this association was significant. No association was seen between chest pain and either mild ischaemia (SDS = 2-4), or no ischaemia (SDS < 2) (OR = 0.4, 95%CI = (0.05,2.9), p = 0.47 for mild ischaemia). Conversely, ischaemic ECG changes during exercise stress testing were not associated with severe, moderate, mild or no ischaemia (OR = 4.2, 95%CI = (0.7,26.1), p = 0.13 for severe ischaemia). Conclusion(s): Chest pain occurring during exercise is significantly correlated with ischaemia on MPI, but only when severe, while ischaemic ECG changes during exercise are not. This may assist in the diagnosis of prognostically significant coronary artery disease.

Coronary artery aneurysms are rare. We present an unusual case of an isolated coronary artery aneurysm in the obtuse marginal artery detected on a computed tomographic coronary angiogram, which is unlikely to be significant for the patient. A Medline literature search did not find a similar case.Copyright © 2018

Advances in computed tomography (CT) technology now allow definitive imaging of the coronary arteries. Non-enhanced CT is used to perform coronary artery calcium scoring, which is useful to stratify the risk of future coronary events but does not allow assessment of stenosis. Contrast-enhanced CT coronary angiography (CTCA) enables angiographic evaluation of both the coronary artery lumen and wall. The high negative predictive accuracy of CTCA makes it a useful test to rule out the presence of significant coronary stenoses, especially in patients with an intermediate pre-test likelihood of coronary artery disease. CTCA also has potential to aid the triage of patients with acute chest pain in the emergency department. CTCA can determine the approximate degree of stenosis as well as detect high-risk plaque characteristics. Coronary artery bypass grafts can be assessed reliably using CT. Intracoronary stent evaluation is possible because of advances in temporal resolution. Myocardial perfusion imaging using cardiac CT is the subject of current investigation.Copyright © 2018 Elsevier Ltd

We present a rare case of polyarteritis nodosa coronary vasculitis with pericardial tamponade and severe ischaemic cardiomyopathy. A 34 year old lady presented with acute chest pain, dyspnoea and syncope. She had no previous medical conditions. She had a systolic blood pressure of 60mmhg on arrival. Examination revealed raised jugular venous pressure and pulsus paradoxus. Electrocardiogram revealed low voltage complexes. Urgent echocardiography showed moderate pericardial effusion (maximal 2 cm apically) with features of pericardial tamponade. Pericardiocentesis drained 250ml which normalised of her vitals. Subsequent echocardiography revealed dilated left ventricle with moderately reduced left ventricular ejection fraction and non-left anterior descending coronary artery territory hypokinesis. Left heart catheterisation revealed all coronary arteries were severely aneurysmal with features of intra-aneurysmal thrombus in the right coronary artery aneurysms. The first obtuse marginal and first diagonal branch had aneurysmal segments followed by chronic total occlusions. Laboratory analysis revealed that the pericardial fluid was exudative but had negative microbiology and cytology screen. Her erythrocyte sendiment rate was elevated at 50mm/hr but a c-reactive protein of 6mg/L and negative autoimmune screen. Subsequent computed tomography angiography confirmed liver and renal artery aneurysms, consistent with polyarteritis nodosa (ANCA-negative). She was treated with intravenous cyclophosphamide and high dose corticosteroids. Her erythrocyte sediment rate subsequently improved. A subcutaneous implantable cardioverter-defibrillator was inserted for primary prevention. Follow-up computed tomography coronary angiogram at 5months revealed persistence of coronary aneurysms and intra-aneurysmal thrombus. At 8 month review her immunosuppressants were successful weaned, her functional status improved with heart failure treatment and repeat echocardiography revealed mildly imp