more information, stating she had been having left ear pain with an exam revealing tenderness in the left mastoid region. On further review of the CT of the head following the spinal fluid results and new history, mastoiditis was discovered, and suspected to be the cause of her bacterial meningitis. Given these findings, the patient was transferred to a facility with Otolaryngology services. The final spinal fluid cultures were positive for Haemophilus influenza and antibiotics were switched to Rocephin monotherapy. After 6 weeks of antibiotics, the patient made a full recovery without significant neurological
deficits and was discharged with therapy.
Discussion: Haemophilus influenza meningitis is most commonly seen in unvaccinated children under the age of five. However, it can affect the elderly, unvaccinated or incompletely vaccinated population. Since the Hib vaccine was first marketed in the US in 1985 for use in infants and asplenic patients, its prevalence has decreased. However, in this case the patient did not receive the vaccine as she had no prior indication to be vaccinated and therefore was at risk, leading to the patient's presentation in this case
SHORT OF BREATH? JUST SQUAT. A CASE OF PARTIAL ANOMALOUS PULMONARY VENOUS RETURN Eric Arthur Pace MD; Roxanne Nemati MD; Lee Arcement MD; Vishal Vyas MD; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Partial anomalous pulmonary venous return encompasses a spectrum of malformations and is a rare cause of pulmonary hypertension. It is an important consideration in patients presenting with signs of heart failure or shortness of breath. Case: A 52-year-old man with no past medical history presented with a complaint of exertional dyspnea for the past three months. His symptoms occurred only at his job as a carpenter and were relieved by taking deep breaths while in the squatting position. He had no significant family history of lung or heart disease and denied ever smoking cigarettes. The physical examination was unrevealing. ECG showed right axis deviation, bi-atrial enlargement, incomplete right bundle branch block, and right ventricular hypertrophy. Laboratory results were significant only for elevated nt-proBNP elevation of 3 times normal levels. Chest Xray was suggestive of scimitar sign. Subsequent Computed Tomography Angiogram demonstrated an anomalous vessel extending from the junction of the right atrium and inferior vena cava into the right lung. Transthoracic echocardiogram showed
right ventricular enlargement, septal dynamics consistent with right ventricular volume and pressure overload, severe right atrial enlargement, severe tricuspid regurgitation, and an estimated pulmonary artery systolic pressure of 75 mmHg. Patient was referred to the adult congenital heart disease clinic and is currently awaiting their evaluation. Discussion: Congenital malformations in pulmonary venous return causing shortness of breath as seen in this patient are rare. In general shunts with Qp:Qs ratios above 1.5 – 2 are considered for repair as these are more likely to cause right sided heart failure and pulmonary hypertension. Malformations arising from the right side can be repaired with several techniques directed at restoring blood flow to the systemic circuit. In the setting of long-standing pulmonary hypertension vascular remodeling may have already occurred, and shunt correction may provide little relief. While squatting is classically associated with tetralogy of Fallot, this patient may experience relief secondary to increased preload compensating for right ventricular failure.
TWO IS COMPANY, THREE IS A CROWD: A CASE OF COR TRIATRIATUM Eric Arthur Pace MD, Roxanne Nemati MD, Vishal Vyas MD, Lee Arcement MD; Department of Medicine, Leonard J. Chabert Medical Center, Houma LA.
Introduction: Cor Triatriatum is an exceedingly rare congenital malformation of the atria caused by persistence of membranous tissue dividing an atrium into two compartments. It accounts for 0.4% of all patients with congenital heart disease.
Case: A 51-year-old female with hypertension and type 2 diabetes presented to cardiology clinic for shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea for the past several months. On examination, an S4 was auscultated. EKG 36
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