Hypercalcemia from cosmetic injections can be severe and life threatening and can present years after the initial procedure. Cosmetic injection-associated granuloma should be considered a cause of hypercalcemia, especially in middle-aged females presenting with non-PTH-mediated, non-malignant hypercalcemia, which is often associated with elevated calcitriol; however, it should be noted that calcitriol level may be normal as well.
Primary hyperparathyroidism in pregnancy can result in significant maternal and fetal complications. When indicated, prompt parathyroidectomy in the early second trimester is considered the treatment of choice. Pregnant patients with primary hyperparathyroidism who have an indication for parathyroidectomy during the first trimester represent a therapeutic challenge. We present the case of a 32-year-old primigravida who presented with symptomatic hypercalcemia from her primary hyperparathyroidism. She remained symptomatic despite aggressive conservative management and underwent parathyroidectomy in her first trimester with excellent outcomes.
Statins are widely prescribed medications to prevent cardiovascular events. While self-limited statin myopathy is relatively common, statin-induced necrotizing autoimmune myopathy (SINAM) is extremely uncommon, with incidence of two cases per million per year. We present a case of SINAM after a decade of atorvastatin use, leading to debilitating weakness. A 71-year-old male presented with recurrent falls due to extreme bilateral lower-extremity weakness without pain or sensory changes. No fever, chills, rash, joint pain, recent infection or medication changes were reported. Reported taking atorvastatin 80 mg daily for 10 years. Physical examination revealed significant muscle wasting on right deltoid and proximal muscle weakness in all extremities. Lab tests included elevated creatinine kinase, aldolase, ESR, CRP and transaminases. Anti-HMGCR antibody was significantly elevated. TSH, serum protein electrophoresis and RPR were unremarkable. ANA, Anti-Jo-1, anti-Mi2, anti-SRP, anti-ds-DNA, anti-SSA and anti-SSB antibodies were negative. MRI of thigh revealed diffuse myositis. Electromyogram revealed an acute myopathic process. Muscle biopsy showed muscle necrosis and C5b-9 sarcolemmal deposits on non-necrotic fibers without rimmed vacuoles. He was diagnosed with SINAM. Statin was discontinued, and steroid, immunoglobulins and azathioprine were started with gradual improvement. Unlike the self-limiting statin myopathy, SINAM is more severe and is associated with significant proximal muscle weakness, markedly elevated CK and persistent symptoms despite statin discontinuation. Anti-HMGCR antibodies are present in 100% of cases. Immunosuppressants are the mainstay of treatment, and statin rechallenge should never be done in these cases. Although relatively rare, physicians should be cognizant of SINAM.
Introduction: Transcatheter mitral valve-in-valve (ViV) & valve-in-ring (ViR) are relatively novel
therapeutic alternatives for patients with degenerated bioprostheses or failed annuloplasty rings
whose reoperative risk is too high. The predominant procedural access for both procedures is
transapical or transseptal. However, whether there are differences in outcomes of this procedure
using transseptal versus transapical access has not yet been defined.
Methods: We conducted a systematic review of all published articles from MEDLINE and
EMBASE to explore the outcomes of these two procedural approaches.
Results:total of 55 studies including 183 patients (154 ViV and 29 ViR) were included. Patients
that underwent ViV (101 transapical and 53 transseptal) using the transseptal approach required
more iatrogenic atrial septal defect (ASD) closure (19% versus 0.0 %; P < 0.001) and hence had a
lower device success rate (68% versus 89%; P = 0.001). However, there was no significant difference
between the two groups in procedural success and all-cause mortality at 30 days. Overall severe
bleeding complications (major or life threatening) were not different the two groups (3.7% versus
7.9%; P = 0.321). In the ViR group (19 transapical and 10 transseptal), no difference in procedural
success, device success or 30-day outcomes were identified between transseptal and transapical
groups, although sample size was small.
Conclusion: In conclusion, mitral ViV and ViR using the two different procedural approaches appear to confer equal and reasonable 30-day outcomes.
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