JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Introduction: Cor triatriatum is a congenital cardiac anomaly in which the left (sinister) or right (dexter) atrium is divided into two compartments by residual embryonic tissue, resulting in a tri-atrial heart. As cor triatriatum dextrum can present clinically in various ways and have multiple associated cardiac anomalies, this report attempts to contribute to what is known about this exceedingly rare disorder. Case: A 40 year oldHispanicmanwith amedical history of gastritis presentedwith complaints of palpitations, dizziness and bilateral lower extremity edema. He was found to have atrial fibrillation and new onset heart failure. The patient was admitted for rate control and further evaluation, which revealed several cardiac anomalies. Initial 2D echocardiography demonstrated severe right atrial enlargement, right ventricular hypertrophy and an engorged coronary sinus, which prompted further assessment of the patient’s cardiovascular anatomy. Transesophageal echocardiography (TEE) revealed a severely enlarged, septated right atriumwith a possible unroofed coronary sinus and a small patent foramen ovale (PFO). Left- and right-heart catheterization established a coronary-cameral fistula between the right coronary artery (RCA) and right atrium, as well as left-to-right shunt. The patient improved clinically with conservative management including diet modification, furosemide and digoxin for fluid and rate control, and was referred to cardiothoracic surgery for further evaluation. Discussion: Cor triatriatum dextrum is an extremely rare cardiac condition: In high-volume echocardiographic laboratories, prevalence is <0.01%. This case highlights the association between cor triatriatum and other congenital cardiac anomalies, including persistent left superior vena cava with an unroofed coronary sinus, PFO and left-to-right shunt; all of which were found in this patient. While cases of cor-triatriatum sinistrum often require correction in infancy (due to left sided heart failure, pulmonary edema and cyanosis), cor-triatriatum dextrum is sometimes diagnosed in adulthood due to the lack of left heart and pulmonary involvement.
Transthoracic echocardiogram revealed a dilated left ventricle with global hypokinesis and severely depressed systolic function with an ejection fraction less than 15%. The patient was diuresed, and subsequent left and right heart catheterizations were normal. CT chest showed a small nodule in the right upper lobe. Tests for Coccidiosis, Trypanosoma cruzi, andMycobacterium tuberculosis were negative; however the acid fast bacilli culture grew Mycobacterium fortuitum. A Strongyloides stercoralis antibody test was positive, and the patient was treated with two doses of oral ivermectin with one dose of intravenous ceftriaxone, and discharged. Two months later, his eosinophilia resolved, but he remained symptomatic with productive cough and weight loss, andwas started on an outpatient course of oral ciprofloxacin and trimethoprim-sulfamethozole for M. fortuitum. Discussion: Strongyloides-infectedpatientsmay carry the parasite for years without prominent symptoms. Endemic throughout South America, Strongyloides persists in its hosts through a lifecycle of autoinfection, which, over time, increases parasite burden and can lead to a hyperinfection syndrome whereby filiariform larvae penetrate organ tissue, most commonly: heart, central nervous system, lungs and liver. We suspect chronic eosinophilia and disseminated filiaria to be the etiology of the non-ischemic dilated cardiomyopathy in this patient. Standard treatment of strongyloidiasis is ivermectin, however, mortality owing to transient bacteremia in the setting of hyperinfection syndrome is high. Therefore, bacteremia prophylaxis with gram negative rod coverage should be considered before antiparasitic agent initiation.
PURULENT PERICARDITIS DUE TO AN INFECTED PACEMAKER LEAD
Teresa Backes, MD Department of Internal Medicine, LSU Health Sciences Center, New Orleans, LA Introduction: Intravenous drug users have a substantially increased risk of infective endocarditis, especially in the setting of implanted cardiac devices. Purulent pericarditis is a rare occurrence that can occur iatrogenically or through direct or hematogenous spread. Case description: A 75 year old man with a past medical history significant for hepatitis C, IV drug abuse, and sick sinus syndrome status post pacemaker was brought in by EMS with a chief complaint of diaphoresis and chest pain. Initial EKG revealed atrial fibrillation with ST elevations in multiple leads. The patient was taken urgently to the cardiac catheterization lab due to concern for STEMI. Left heart catheterization revealed nonobstructive CAD; bedside echo was significant for a pericardial effusion and a pacemaker lead vegetation. CT of the chest revealed extension of the ventricular pacemaker lead through the anterior right ventricular wall and pericardium and into the pleural cavity. Cardiothoracic surgery performed a pacemaker removal as well as pericardial window due to early tamponade; approximately 900 mL of purulent fluid was drained from the pericardial space. The patient was septic with initial blood cultures growing
A STRONG AND FORTUITOUS CASE OF DYSPNEA
R. Hammer, MD; M. Sciaudone, MD. Department of Internal Medicine, Tulane Health Sciences Center, New Orleans, LA Case: A 48 year-old man with no past medical history was sent to our emergency department (ED) from a primary care clinic for hypertensive urgency of 200/130. The man reported an intermittent non-productive cough of approximately one year’s duration and worsening dyspnea on exertion and orthopnea over the last month with lower extremity swelling. Of note, he emigrated from Honduras twenty years ago. Blood pressure normalized with administration of Lasix in the ED. Physical exam revealed rales in lung bases bilaterally, jugular venous distension, lower extremity pitting edema with serpiginous patches of erythema and excoriation, and a cardiac gallop. Labs showed peripheral eosinophilia, thrombocytopenia, elevated creatinine, hyperbilirubinemia, hyperglycemia, and mild transaminitis.
J La State Med Soc VOL 169 MARCH/APRIL 2017 51
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