Pickering syndrome is an under recognised cardio-renal syndrome where life threatening flash pulmonary edema develops in the setting of diastolic dysfunction of the heart. Renal artery stenosis induced activation of sympathetic nervous system and renin-angiotensin-aldosterone system result in fluid retention; such fluid retention in the setting of diastolic dysfunction results in flash pulmonary edema. Most patients who present with pickering syndrome have normal coronary circulation and left ventricular systolic function. We here present a case of pickering syndrome that was precipitated by initiation of angiotensin converting enzyme inhibitor therapy in a patient with undiagnosed unilateral renal artery stenosis. The incidence of flash pulmonary edema decreases on revascularization of renal artery stenosis. Underlying renal artery stenosis should be suspected in a patient with recurrent flash pulmonary edema as such patients merit from revascularization of renal artery stenosis. To the best of our knowledge we are the first to report angiotensin converting enzyme inhibitors as a precipitator of pickering syndrome.
Uncontrolled diabetes and acute coronary syndrome share a complex dynamic that results in significant ambiguity when interpreting biomarker elevations in this setting. This is concerning because myocardial infarction has been shown to be the most common cause of death in the first 24 hours of admission for uncontrolled diabetes. Literature shows that elevation in cardiac biomarkers in patients with uncontrolled diabetes could be from viral myopericarditis, although a clear clinical significance is still lacking.1 It is, however, clear that elevation in cardiac biomarkers portends a poor long-term prognosis in patients with uncontrolled diabetes mellitus. We present a rare case of myopericarditis in a middle-aged patient with uncontrolled diabetes. The patient had elevated troponin I level reaching a peak of 7.3 ng/mL with associated ST elevations on electrocardiography. Coronary angiogram was subsequently done revealing clean coronaries. To our knowledge, this is the first description of myopericarditis in uncontrolled diabetes without a known cause.
Studies have showed that nearly 100% of morbidly obese men and 60–70% of women have obstructive sleep apnea (OSA). A polysomnography (PSG) study is used to establish the diagnosis and parameters for continuous positive airway pressure (CPAP) therapy. PSG is commonly recommended prior to bariatric surgery to assess for the presence of OSA and possible anesthetic complications. After surgery patients are to continue CPAP until a repeat sleep study is done to re-evaluate the need for CPAP. Currently there are not many studies that look at the prevalence of CPAP in the pre/post-op period in minority patients in an urban tertiary care center. Observational cohort study of morbidly obese patients who had polysomnography (PSG), received diagnosis of OSA and were prescribed CPAP treatment prior to bariatric surgery. Follow-up was done at 5 years post procedure. From 2010–2011, 121 patients had PSG prior to bariatric surgery at Brookdale Hospital. 100 patients were female and 21 were male. 70 of patients were black, 42 patients were Hispanic, and 8 were other ethnicities. 61 patients used CPAP consistantly prior to surgery. In the group using CPAP average age was 36.7 years and BMI was 49.8. The non-compliant group had an average age of 39.7 years and BMI of 48.0. None of the patients in the study had immediate complications post-surgical procedure. After 5 years, 15 patients continued to use CPAP and 2 patients in this group had a repeat PSG after surgery. Chi-squared and student t-test were used to analyze sex, age, ethnicity, BMI and there were no statistically significant differences between the two groups. Our study showed that there was no correlation between OSA and post-op complications which calls into question the need for PSG prior to bariatric surgery. Roughly half of the patients were compliant with CPAP prior to surgery and only 2 patients followed up for a repeat PSG. Possible reasons for lack of compliance with therapy include nasal discomfort, cost and lack of knowledge. More studies need to be done regarding the utility of PSG before and after bariatric surgery. None.
Atrial septum aneurysm (ASA) is a saccular aneurysm of the interatrial septum, bulging into either atrium during the cardiac cycle. It is mostly congenital in natures and is often associated with patent foramen ovale (PFO). ASA is increasingly gaining attention as a possible cause of cryptogenic stroke. We here present a case of ASA in an elderly female in whom ASA possibly contributed to atrial fibrillation and mitral valvular prolapse; she denied any thromboembolic event. Transesophageal echocardiography remains the imaging modality of choice for diagnosis of ASA. Management guidelines for initiation of antiplatelet therapy, anticoagulation and the need for endovascular or surgical closure of associated PFO are lacking.
Gastrointestinal sarcoidosis is a rare clinical entity. Diagnosis of isolated gastric sarcoidosis is difficult as it is usually asymptomatic; when symptomatic it presents with non-specific symptoms such as abdominal pain, nausea and vomiting. We here present a case of a 32-year-old black lady who presented with non-specific abdominal complaints; a diagnosis gastric sarcoidosis was established following endoscopic biopsy. Here symptoms resolved promptly with steroidal therapy as with most cases. Gastric sarcoidosis should be suspected in sarcoid patients who present with nonspecific abdominal complaints. This case serves as an important clinical reminder of the atypical manifestations of sarcoidosis.
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