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Coronary artery fistulas (CAFs) are found in 0.3–0.8% of patients who undergo coronary angiography. CAFs are defined as single or multiple, small or large direct communications that arise from one or more coronary arteries and enter into one of the four cardiac chambers or major vessels. We present two cases of multiple coronary artery fistulas arising from diagonal and left anterior descending (LAD) branches of left coronary artery draining into the left ventricle. In both the cases, No intervention was performed. Of the congenital fistulas, two major groups are identified: solitary CAFs or coronary artery-left ventricular multiple micro-fistulas (CALVMMFs). Noninvasive techniques such as transthoracic echocardiography, transesophageal echocardiography and magnetic resonance imaging are becoming increasingly popular for diagnosis and follow-up of CAFs. Despite the advent of these newer non-invasive modalities, coronary angiography remains the gold standard for diagnosis. Treatment of CAFs is indicated when the patients are symptomatic with left ventricular volume overload, myocardial ischemia, left ventricular dysfunction or in the presence of a large or increasing left-to-right shunt. If the fistula is small and hemodynamically insignificant, it can be managed with conservative management. Multiple left anterior descending to left ventricle (LV) fistulas are extremely rare and, as per our literature review, we noted only a few case reports of coronary artery fistulas between branches of LAD and left ventricle.

The goal of this study was to determine the utility of hydrocortisone in septic shock and its effect on mortality. We performed a systematic search from inception until March 01, 2018, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines comparing hydrocortisone to placebo in septic shock patients and selected studies according to our pre-defined inclusion and exclusion criteria. Four reviewers extracted data into the predefined tables in the Microsoft Excel (Microsoft Corp., New Mexico, US) sheet. We used RevMan software to perform a meta-analysis and draw Forest plots. We used a random effects model to estimate risk ratios. A two-sided p-value of ≤ 0.05 was considered statistically significant. A total of five randomized control trials (RCTs) with 5,838 patients were included in our analysis. The primary outcome was mortality at 28 days. Secondary outcomes were intensive care unit (ICU) and in-hospital mortality, mortality at 90 days and one year, reversal of shock, intensive care unit (ICU) and hospital length of stay, incidence of superinfections, and incidence of limb and/or cerebral ischemia. The 28-day mortality was significantly reduced with hydrocortisone, 808 vs. 880 with placebo, Risk Ratio (RR)=0.92, confidence interval (CI) =0.85-0.99, p=0.04, I2=0%. There was no difference in ICU mortality (RR=0.93, CI=0.81-1.08), in-hospital mortality (RR=0.95, CI=0.84-1.08), 90-day mortality (RR=0.93, CI=0.84-1.02, p=0.10), and one-year mortality (RR=0.97, CI=0.84-1.12). Superinfections were significantly common with hydrocortisone, RR=1.16, CI=1.05-1.28, p=0.003. In conclusion, the use of hydrocortisone showed a significant reduction in mortality at 28 days and a trend toward reduced ICU mortality. This mortality reduction was observed at the cost of significantly higher superinfections.

OBJECTIVES Intravenous balanced crystalloid fluid therapy may improve mortality and other outcomes in critically ill adult patients, but data are conflicting. We conducted a meta-analysis and literature review to evaluate the impact of intravenous balanced crystalloid, as compared with normal saline, fluid therapy on outcomes in critically ill adult patients. METHODS We searched PubMed, Scopus, MEDLINE, and the Cochrane Register of Clinical Trials for relevant studies. Randomized controlled trials comparing the effects of balanced intravenous crystalloids with normal saline on intensive care unit (ICU) or hospital mortality were included. Pooled risk ratios (RRs) were calculated using a fixed effects model. Heterogeneity was calculated using the I2 statistic. The risk of bias was assessed using the Cochrane tool. RESULTS Seven randomized controlled trials with 20,171 patients (10,179 participants received balanced crystalloids and 9992 participants received normal saline) were included. For hospital mortality, the pooled RR (95% confidence interval [CI]) was 0.92 (0.85-1.00). For ICU mortality, the pooled RR (95% CI) was 0.91 (0.82-1.00). For major adverse kidney events at 30 days, pooled RR (95% CI) was 0.95 (0.88-1.01). For stage ≥2 acute kidney injury, the pooled RR (95% CI) was 0.94 (0.86-1.02). For receipt of new renal replacement therapy, the pooled RR (95% CI) was 0.91 (0.77-1.07). None of these findings reached statistical significance. CONCLUSIONS Intravenous balanced crystalloid use, compared with normal saline, does not result in a statistically significant reduction in hospital or ICU mortality, major adverse kidney events at 30 days, stage ≥2 acute kidney injury, or receipt of new renal replacement therapy in critically ill adult patients.

Patient: Male, 57 Final Diagnosis: Left atrial to esophageal fistula Symptoms: Chest pain • syncope Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Unusual clinical course Background: Left atrial to esophageal fistula (LAEF) is a rare fatal complication of radiofrequency ablation (RFA) for atrial fibrillation and is associated with high mortality. Clinical features can be nonspecific and include fever, dysphagia, upper gastrointestinal (GI) bleeding, sepsis, and embolic stroke a after recent history of RFA for atrial fibrillation. Case Report: A 57-year-old Caucasian male was brought to the emergency department (ED) by his family because of an altered mental status. He had undergone a radiofrequency ablation for paroxysmal atrial fibrillation three weeks earlier. Several hours after admission to the ED, the patient transiently became unresponsive and had a right sided hemiplegia. A brain MRI revealed multiple cerebral infarcts. On the following day, the patient had an episode of melena, and an esophagogastroduodenoscopy (EGD) was performed which did not reveal any source of bleeding. While the patient was being monitored in the intensive care unit (ICU), he had an episode of hematemesis and went into cardiac arrest from which he was successfully resuscitated and transferred to another facility. He had another EGD, which uncovered a flap of mucosa covering the lower third of his esophagus and a 1 cm fistulous opening was seen with fresh blood oozing out of it. The patient had another cardiac arrest during the endoscopy and died despite all measures. Conclusions: We present this case to stress the importance of early diagnosis of LAEF. LAEF can be fatal if diagnosis is delayed or missed. Early surgical intervention can reduce LAEF morbidity and mortality. Newer diagnostic modalities such as endoscopic ultrasound (EUS) can be helpful in cases where conventional imaging is unclear.

Patient: Male, 57 Final Diagnosis: Infective endocarditis vegetation attached to the congenital foramen ovale location Symptoms: Dysuria • fatigue • fever Medication: — Clinical Procedure: Trans thoracic echocardiography • trans esophageal echocardiography • redosternotomy Specialty: Cardiology Objective: Rare disease Background: Non-valvular mural infective endocarditis (IE) is a rare bacterial growth on cardiac walls. Several risk factors have been reported. Echocardiography is an important diagnostic modality for diagnosing vegetation attached to the intracardiac walls. Case Report: We present the case of a 57-year-old man admitted with Staphylococcus aureus bacteremia due to an infected tunnelled hemodialyses catheter. Transthoracic echocardiogram did not show any abnormality, but transesophageal echocardiogram (TEE) revealed a 1.7×0.8 cm mobile echo-density attached to the surface of the interatrial septum in the left atrium, where the foramen ovale (FO) exists in utero. The patient was transferred to another facility for re-do sternotomy cardiac surgery, where these findings were confirmed intraoperatively. A biopsy of the mass was taken, which confirmed it to be a vegetation attached to the FO. Conclusions: We report the first case in the literature of vegetation attached to the surface of the interatrial septum in the left atrium at the congenital location of the foramen ovale. There have been no previously reported cases in the literature with such novel imaging findings.

Drug induced lupus erythematosus (DIL or DILE) is an autoimmune disorder caused by chronic use of certain drugs. We report a unique case of hydralazine induced lupus syndrome (HILS) with a negative antinuclear antibody in a female patient who was on hydralazine for a period of 1.5–2 years and developed recurrent pericardial effusion as a result of it. Initially her condition was managed with a pericardial window. The recurrence of a massive pericardial effusion necessitated a right hemipericardiectomy. After hydralazine was stopped, she never had any further episodes of pericardial effusion or tamponade.

Left atrial myxomas are rare primary cardiac tumors. Their incidence is estimated to be about 0.1% of total cases. Neurological complications resulting from cardiac myxomas are seen in 20–35% of patients. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram for evaluation of left atrial myxoma. Three-dimensional (3D) echocardiography ensures better visualization of intracardiac structures. It has been used prior to surgery for diagnostic support in the surgical treatment of cardiac masses. We present a case of a 46-year-old Hispanic male who developed acute ischemic stroke of left frontal lobe and was also found to have multiple ‘silent’ cerebral infarcts in the MRI of the brain. On further workup, he was found to have a left atrial myxoma on 3D TEE. This was resected with the assistance of intra-operative 3D TEE imaging. We present this case to increase awareness and to stress at early evaluation of secondary causes of ischemic cerebrovascular accident, outside the realm of hypercoagulability. This case also exhibits the need for basic cardiac workup in young individuals who present with symptoms of intermittent palpitations or chest pain to minimize significant morbidity or mortality.Keywords: left atrial myxoma; three-dimensional transesophageal echocardiogram; acute stroke(Published: 17 February 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 29604 - http://dx.doi.org/10.3402/jchimp.v6.29604

Ventricular septal defect (VSD) is a rare complication of right ventricular infarction (RVI) which is associated with significant mortality, if not treated appropriately. It typically occurs within the first 10–14 days after myocardial infarction. Surgical repair has been shown to reduce in-hospital mortality from 90% to 33–45%. Early surgical VSD repair has also been associated with high 30-day operative mortality of 34–37%. Furthermore, after an acute MI the friable myocardium enhances the risk of recurrent VSD with early surgical repair. We present a case of a middle-aged woman who developed VSD after an RVI. Her surgical repair was delayed by 2 weeks due to development of Staphylococcus aureus bacteremia. During this period, she was managed medically and later on underwent percutaneous repair with an amplatzer VSD occluder device. Keeping this patient encounter in mind, we would like to emphasize on the limited recommendations available for early against late surgical repair of VSD.Keywords: right ventricular myocardial infarction; ventricular septal rupture; early against late repair(Published: 17 February 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 30460 - http://dx.doi.org/10.3402/jchimp.v6.30460

Acquired thrombotic thrombocytopenic purpura (TTP) usually presents as severe microangiopathic hemolytic anemia (MAHA) and thrombocytopenia in a previously healthy individual. It occurs in approximately three in one million adults and 1 in 10 million children annually. The incidence is increased in females and blacks. Diagnosing TTP and initiating therapy with plasma exchange is a must to avoid preventable complications. Acquired thromotic microangiopathy has been linked to collagen vascular diseases, use of certain medications, organ transplants, infections, pregnancy and cancer. We report a rare case of a 56-year-old African American male diagnosed with TTP who found to have an asymptomatic adenocarcinoma of the lung. Prompt cancer management resulted in completed remission of the thrombotic microangiopathy.