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Heyde syndrome is the association between gastrointestinal (GI) bleeding from intestinal angiodysplasia (IA) and aortic stenosis (AS). Although the course of disease progression that links AS and GI bleeding has not been determined, overlaps among AS, intestinal dysplasia, and acquired von Willebrand's syndrome is thought to result in GI bleeding. Proper repair of the aortic valve can result in significant improvement of GI bleeding and its recurrence. Herein, we are reporting this rare case, in which a patient with moderate AS on echocardiogram presents with recurrent GI bleeding from multiple IA in the setting of elevated factor VIII levels, to propose a theory that angiodysplasia could potentially develop due to intermittent, recurrent low-grade obstruction of submucosal veins at the level of the muscularis propria secondary to venous thrombosis related to elevated factor VIII levels.

Esophagogastroduodenoscopy (EGD) is one of the forefronts of minimally invasive modalities with excellent safety records and tremendous capability but despite its accolades and functions, there are still very rare complications including air embolism. It is a life-threatening condition that could lead to a significant increase in morbidity and mortality. However, there are limited data for incidence of air embolism in association with gastrointestinal endoscopy. Diagnosis of air embolism after or during gastrointestinal endoscopy might be a difficult task due to overlapping presentations with anesthesia effects on the cardiopulmonary and the neurological systems, as a result, there should be increased awareness allowing clinicians to quickly rule out air embolism in patient with altered mental status or cardiopulmonary changes after or during gastrointestinal endoscopy. Herein, we report a unique case of cerebral air embolism after EGD in a 79-year-old female patient. In addition, we also performed a systematic review of cases based on PRISMA guideline, with the aim to investigate the demographics and clinical outcomes associated with this complication. This systematic review of cases hopes to increase the awareness about this rare entity. J Med Cases. 2021;12(3):119-125 doi: https://doi.org/10.14740/jmc3639

Spontaneous coronary artery dissection (SCAD) is a grave medical condition that is defined as a separation of the coronary artery wall layer. This presentation is rare in males and can be triggered by cardio-circulatory stress, such as exercise and emotional stress. Sexual intercourse is considered potent cardiovascular stress that can be strenuous and cause rapid and significant changes in the heart rate and blood pressure which can predispose SCAD. Herein, we are reporting a very rare case of a 41-year-old male gentleman who presented with SCAD after vigorous sexual intercourse. We are reporting this case to encourage physicians to educate their patients on the topic.

Thyrotoxicosis manifests when excess levels of thyroid hormone act on different tissues throughout the body. Excess hormone levels can be related to endogenous production or exogenous ingestion and can present differently in patients. It has been theorized that high levels of thyroxine can irritate the neuroanatomical hiccup center leading to persistent hiccups. Although extremely rare, physicians should be aware of this entity to allow for proper diagnosis and management. Here, we discuss a rare case of thyrotoxicosis after an epidural steroid injection presenting with intractable hiccups.

Hypothermia defined as a core body temperature less than 35°C causes hundreds of deaths annually in the United States. It can occur in a variety of clinical settings, including environmental exposure, shock, infection, metabolic disorders, alcohol, or drug toxicity, and malnutrition. This condition can affect many different organ systems and may lead to serious complications including cardiac arrhythmia. Hypothermia is extremely rare in people living with HIV but can be seen in severely malnourished patients or those who are not receiving antiretroviral therapy (ART). It is a life-threatening situation that should be treated aggressively. To the best of our knowledge, there are only a few cases that have been reported for people living with HIV presenting with hypothermia and sinus bradycardia. Herein, we are reporting a very rare case of people living with AIDS who presented with hypothermia complicated by sinus bradycardia. In addition, we also performed a systematic review of cases based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, to investigate the clinical characteristics and outcomes associated with this rare complication. This systematic review of cases hopefully can increase the awareness of this rare entity and help improve its outcome.

Bordetella bronchiseptica is a rare cause of respiratory tract infection in humans, most commonly found in immunocompromised individuals exposed to infected animals. It colonizes the respiratory tract and can lead to infection in dogs, cats, rabbits, and others. In immunocompromised patients, it has been reported to result in life-threatening infections but rarely affects immunocompetent individuals. Here, we are the first to report a case B. bronchiseptica bacteremia in a patient with decompensated liver cirrhosis without known animal exposure.

Vitamin E deficiency can be observed in patients with malabsorption syndromes or inherited diseases such as ataxia. It is unusual for it to be a result of dietary insufficiency due to its presence in a wide variety of foods. Patients with vitamin E deficiency can present with neuromuscular disorders such as ataxia, hyporeflexia, spinocerebellar syndrome, as well as loss of vibration and proprioceptive sensation. Herein, we are presenting a case in which a previously healthy adult with no family history of genetic defects and malabsorption syndrome presented with a characteristic sensory axonopathy associated with vitamin E deficiency without any evidence of fat malabsorption. Patient reported a markedly improvement of symptoms after three-month supplementation of vitamin E. The unique part of this case was that the patient presented with neuropathic pain associated with vitamin E deficiency without any family history of inherited deficiency or any malabsorption syndrome.

Background: Coronary artery disease (CAD) has emerged as an important cause of death in PLWH. T-lymphocyte cells has been shown to regulate the inflammatory response and have an inhibitory effect on atherosclerosis. NLR and PLR has been studied as severity prediction for CAD. However, to our knowledge, there were no studies to date that identify the relationship of NLR and PLR with CAD severity and outcome in PLWH. The aim of the study is to determine if NLR and PLR can be used as independent predictors of CAD severity in PLWH in our population in the United States. Methods: A retrospective cohort study of PLWH 18-year-old who underwent cardiac percutaneous coronary intervention was conducted between 2010 and December 2019. Their demographic, clinical and biochemical characteristics were extracted from the electronic medical record. Univariate and multivariate analysis were employed to identify the markers that can be used to predict CAD severity in PLWH. The study end point was number of coronary artery stenosis (85%) vessels involved. Results: A total of 74 PLWH were included in this retrospective cohort study. The median age was 60 years old (range from 30 to 79 years old). The male to female ratio was 2:1 (49 males and 25 females). As for ethnicities, 59 (80%) were African American, 9 (12%) were Caucasian and 6 (8%) were Hispanics. Comorbidities present in 64 patients (86%), with hypertension being the most common (77%), followed by CKD/ESRD (39%), diabetes mellitus (27%) and dyslipidemia (24%). Smoking and alcohol use were reported in 56 (76%) and 23 (31%) patients respectively. Female gender (p=0.042), higher triglycerides (r=0.29; p=0.014), history congestive heart failure (p=0.041) and higher CD4/CD8 ratio (r=0.30; p=0.011) were significantly correlated with greater number of coronary artery vessels involved. NLR (p=0.205) and PLR (p=0.567) are otherwise not significant. In multivariate analysis, NLR (odds ratio [OR] 1.553; 95% confidence interval [CI], 0.928-3.611), PLR (OR 0.997, CI 0.983-1.011) and CD4/CD8 ratio (OR 0.676, CI 0.042-1051) were not independently associated with the severity of CAD. Conclusion: This cohort study demonstrated that there is no relationship between the NLR and PLR with the severity of CAD in PLWH in our population in USA.

Introduction: SARS-CoV-2 infection has been associated with a multiple cardiovascular complications. It is not known if cardiac markers can be used for outcome prediction in the US population. Methods: We conducted a retrospective study on patients ≥ 18 years old with confirmed COVID 19, who were admitted to our hospital between 03/15/2020 and 05/25/2020. Individuals were included if they had a baseline troponin and brain natriuretic peptide (BNP) available, and if their outcome by the end of the study period was well defined as discharge alive, or deceased. Univariate and multivariate logistic regression methods were employed to identify the cardiac markers associated with mortality in COVID-19 patients. Results: The total number of confirmed COVID-19 hospitalized patients during the study period was 348, after excluding patients who did not have cardiac markers available, 233 patients were included in the study, 75 (32%) expired, and 158 (68%) were discharged alive. The median age was 65 years old, and ranged from 22 to 101 years old. 140 males and 93 females. Comorbidities were present in 201 (86%) patients, with hypertension (65%) being the most common, followed by obesity (55%), diabetes mellitus (DM) (44%) and coronary artery disease (27%). Mechanical ventilation was required for 61 patients of whom 42 expired. In univariate analysis, we found a significant difference in history of chronic kidney disease defined by eGFR Conclusions: This retrospective cohort study of hospitalized patients with COVID-19 suggests an independent association of increased troponin as risk factor for death in COVID-19 patients. Cardiac troponin has been reported as potential prognostic marker in the China cohort. To our knowledge, we are first to demonstrate the utilization of troponin as mortality predictor in the US population.

The global pandemic of severe acute respiratory syndrome coronavirus 2 has caused significant morbidity and mortality, not only causing devastating lung injury but also has an enormous effect on the cardiovascular system. The hypercoagulable state associated with coronavirus 2019 plays a major role in the disease manifestation. Venous thromboembolism including pulmonary embolism remains the most common thrombotic manifestation of the disease as compared to arterial thrombosis. Nonetheless, the co-occurrence of both venous and arterial thrombosis in a coronavirus 2019 patient, to our knowledge, has rarely been reported. Herein, we are presenting a case of co-occurrence of left ventricular thrombosis with pulmonary embolism in the setting of coronavirus 2019 with successful treatment with apixaban.

COVID-19 is a global public health emergency with more than one million positive cases across the globe. COVID-19 has a multifaceted presentation. We are herein to report two cases of SARS-CoV-2 induced rhabdomyolysis with an initial presentation of weakness and elevated creatinine kinase (CK). Both patients had no respiratory symptoms, they only complained of generalized weakness and were found to have elevated CK. Routine chest X-ray showed bilateral infiltrates in both cases and subsequently reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 was positive. To the best of our knowledge, there was only one literature to date documented SARS-CoV-2 induced rhabdomyolysis as a late complication of COVID-19 patient. Our cases showed that elevated CK and rhabdomyolysis can be the sole initial presentation of patients with COVID-19 and total CK should be ordered in every patient on admission.

Pulmonary embolism (PE) is considered a major cause of morbidity and mortality in both inpatient and outpatient settings. PE can be presented in different clinical pictures. However, the association between PE and right atrial thrombus is not frequently reported. PE is categorized based on size, location and clinical presentation. Although management changes between different PE sub-types, optimal medical therapy is not well established for coexisting PE with right atrial thrombus. Herein, we present a unique case of a 58-year-old male with bilateral PE and atrial thrombus, with no known underlying risk factors.

Background Data on risk of thromboembolism in PLWH is limited. HIV is often recognized as a chronic inflammatory disease and has been recognized as a prothrombotic condition. We aimed to analyze the incidence and demographic of venous thromboembolism such as pulmonary embolism and deep vein thrombosis in PLWH admitted to our hospital. Methods We conducted a retrospective hospital cohort study on PLWH ≥ 18 years old who were admitted to our hospital between 09/01/2018 and 09/01/2019. Study individuals were recruited if they had complete laboratory profile and well-defined clinical outcomes. Demographic, clinical and laboratory data were reviewed and retrieved. Descriptive analysis was employed to describe the demographic profile of PLWH with venous thromboembolism. Results Out of the 192 hospitalized PLWH during the study period, 15 (8%) patients had documented deep vein thrombosis (DVT) and/or pulmonary embolism (PE). History of DVT/PE was present in 5 (33%) patients while the rest had new onset of DVT/PE. Out of the 15 patients, 4 (27%) had DVT and PE, 4 (27%) had only DVT and 7 (46%) had only PE. The median age was 57 years, ranged from 40 to 74 years; 4 males and 11 females. As for ethnicities, 2 Caucasian, 12 were African American and 1 Hispanic. The average D-dimer was 4491. The median CD4 count for PLWH with venous thromboembolism was 487 and a median viral load of 900. In contrary, the median CD4 count of PLWH without venous thromboembolism was 420 and median viral load of 140. Though not statistically significance, higher viral load seems to associate with risk of venous thromboembolism. Surprisingly, female gender is an independent risk factor for venous thromboembolism in PLWH (z-score 2.75, p=0.0059; odds ratio [OR], 4.67; 95% confidence interval [CI], 1.56-13.69). Conclusion Our observation of PLWH with venous thromboembolism suggest that this population has an increased risk of venous thromboembolism as compared to general population. Female gender is an independent risk factor for venous thromboembolism in PLWH and higher HIV viral load seems to associate with higher risk. Larger prospective studies in this population are needed to dissect the interplay between HIV and venous thromboembolism. Disclosures All Authors: No reported disclosures

Background A few COVID-19 related retrospective studies have established that older age, elevated neutrophil-lymphocyte ratio (NLR), and decreased lymphocyte-CRP ratio (LCR) were associated with worse outcome. Herein, we aim to identify new prognostic markers associated with mortality. Methods We conducted a retrospective hospital cohort study on patients ≥ 18 years old with confirmed COVID-19, who were admitted to our hospital between 03/15/2020 and 05/25/2020. Study individuals were recruited if they had a complete CBC profile and inflammatory markers such as CRP, ferritin, D-dimer and LDH, as well as a well-defined clinical outcomes (discharged alive or expired). Demographic, clinical and laboratory data were reviewed and retrieved. Univariate and multivariate logistic regression methods were employed to identify prognostic markers associated with mortality. Results Out of the 344 confirmed COVID-19 hospitalized patients during the study period, 31 who did not have a complete blood profile were excluded; 303 patients were included in the study, 89 (29%) expired, and 214 (71%) were discharged alive. Demographic analysis was tabulated in Table 1. The univariate analysis showed a significant association of death with absolute neutrophil count (ANC, p=0.022), NLR (p=002), neutrophil-monocyte ratio (NMR, p=< 0.0001), LCR (p=0.007), lymphocyte-LDH ratio (LLR, p=< 0.0001), lymphocyte-D-dimer ratio (LDR, p=< 0.0001), lymphocyte-ferritin ratio (LFR, p=< 0.0001), and platelets (p=0.037) with mortality. With multivariable logistic regression analysis, the only values that had an odds of survival were high LDR (odds ratio [OR] 1.763; 95% confidence interval [CI], 1.20–2.69), and a high LFR (OR 1.136, CI 1.01–1.34). We further build up a model which can predict >85% mortality in our cohorts with the utilization of D-dimer (>500 ng/ml), Ferritin (>200 ng/ml), LDR (< 1.6), LFR (< 4) and ANC (>2.5). This new model has a ROC of 0.68 (p< 0.0001). Conclusion This retrospective cohort study of hospitalized patients with COVID-19 suggests LDR and LFR as potential independent prognostic indicators. A new model with combination of D-dimer, Ferritin, LDR, LFR and ANC, was able to predict >85% mortality in our cohort with ROC of 0.68, it will need to be validated in a prospective cohort study. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericardial fluid. There are multiple risk factors for cardiac tamponade, nephrotic syndrome is an uncommon one, especially in adults. Herein, we are reporting a 35-year-old African American woman with membranoproliferative glomerulonephritis secondary to human immunodeficiency virus-associated immune complex kidney disease (HIVICK), who presented with cardiac tamponade. The patient had pericardiocentesis and was discharged, with outpatient follow-up with cardiology, nephrology, and infectious disease. To the best of our knowledge, this is the first report of HIVICK nephrotic syndrome associated with cardiac tamponade.

Background Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can lead to many different cardiovascular complications, we were interested in studying prognostic markers in patients with atrial fibrillation/flutter (A. Fib/Flutter). Methods A retrospective cohort study of patients with confirmed COVID-19 and either with existing or new onset A. Fib/Flutter who were admitted to our hospital between March 15 and May 20, 2020. Demographic, outcome and laboratory data were extracted from the electronic medical record and compared between survivors and non-survivors. Univariate and multivariate logistic regression were employed to identify the prognostic markers associated with mortality in patients with A. Fib/Flutter Results The total number of confirmed COVID-19 patients during the study period was 350; 37 of them had existing or new onset A. Fib/Flutter. Twenty one (57%) expired, and 16 (43%) were discharged alive. The median age was 72 years old, ranged from 19 to 100 years old. Comorbidities were present in 33 (89%) patients, with hypertension (82%) being the most common, followed by diabetes (46%) and coronary artery disease (30%). New onset of atrial fibrillation was identified in 23 patients (70%), of whom 13 (57%) expired; 29 patients (78%) presented with atrial fibrillation with rapid ventricular response, and 2 patients (5%) with atrial flutter. Mechanical ventilation was required for 8 patients, of whom 6 expired. In univariate analysis, we found a significant difference in baseline ferritin (p=0.04), LDH (p=0.02), neutrophil-lymphocyte ratio (NLR) (p=0.05), neutrophil-monocyte ratio (NMR) (p=0.03) and platelet (p=0.015) between survivors and non-survivors. With multivariable logistic regression analysis, the only value that had an odds of survival was a low NLR (odds ratio 0.74; 95% confidence interval 0.53–0.93). Conclusion This retrospective cohort study of hospitalized patients with COVID-19 demonstrated an association of increase NLR as risk factors for death in COVID-19 patients with A. Fib/Flutter. A high NLR has been associated with increased incidence, severity and risk for stroke in atrial fibrillation patients but to our knowledge, we are first to demonstrate the utilization in mortality predictions in COVID-19 patients with A. Fib/Flutter. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

LV thrombus is a possible complication of anterior wall MI. It is imperative to recognize and understand the difficulty in management in the event of stenosis or requirement of percutaneous intervention in the presence of a LV thrombus. 59 y/o male with history of HTN, CAD, HIV presented to the

Background The Center for Disease Control and Prevention recommends strict contact isolation precautions (CP) that include hand hygiene (HH) and barrier (gloves and gown) precautions upon entering and leaving the rooms of patients diagnosed with multidrug-resistant organism or Clostridium difficile infections. Although this policy has been in place for several years, compliance rate among HCW is rarely studied. The aim of our study was to covertly monitor, analyze, and compare the overall bundle compliance (OBC) and individual (HH, glove and gown) component compliance (ICC) among HCWs during routine patient care. Methods A prospective observational study was done in six Detroit Medical Centers (July 2017 to February 2018). Trained observers audited both inpatient and intensive care units on random days and time. Components audited (1) HH before donning and after doffing (2) gowning and gloving techniques before entering and after existing the patient room. A mobile application (speedy audit) was used to record all data. A pilot targeted education program (TEP) was also conducted in one of the hospitals where education was focused only on strict HH practice before donning. Results A total of 6,274 observations were collected. The OBC was 38%. Common HCWs observed included nurses (registered nurse and nursing student) 47%; physicians (attending’s, residents, fellows) 28%; service workers including Environmental Service, Food service, Patient transporter, Social worker, Pastoral care- 14%; Allied Health Professions including Dietician, Blood Collection, Physiotherapist, Radiology Tech, Respiratory Therapist 4%; The OBC among all HCW were below 50%. For the ICC, HH (49%) was way below the gloving (80%,) and gowning (62%) compliance. HH compliance before donning was strikingly lower (40%) than the compliance after doffing (62%). This trend was similar in all HCW. Within a month of TEP, a drastic increase in both HH [↑ to 75% from 26% (P < 0.001)] and OBC [↑ to 68% from 16% (P < 0.001)] was seen. Conclusion Common misconception that gloves are substitute to HH could explain the low HH rates before donning. Recognition of this gap and focused education on HH before donning has led to improved compliance in all HCW. Disclosures All authors: No reported disclosures.