Central venous catheters including dialysis catheters are a potential source of venous thrombosis and pose a risk for paradoxical embolic events including ischemic stroke and systemic embolism in patients with a patent foramen ovale (PFO). The adult population with a PFO and patients with a central venous dialysis catheter (CVDC) are at increased risk of a paradoxical embolic event. Since bubble study is not routinely done during echocardiogram in a patient with CVDC, it is difficult to identify at-risk patients for paradoxical embolic events during catheter manipulation, especially for clogged CVDC.We report a rare case of a 79-year-old lady with end-stage renal disease on hemodialysis (HD) using a CVDC who developed a paradoxical embolic ischemic stroke following the use of tissue plasminogen activator (tPA) for unclogging a dialysis catheter. We aimed to highlight the existing risks of thromboembolism associated with the long-term use of central CVDC, especially the potential risk of paradoxical embolism and ischemic stroke with the use of tPA for management of clogged dialysis catheters. We emphasize the questionable need for a bubble study echocardiogram in all patients requiring long-term dialysis catheters.
Identifying risk factors for cardiovascular diseases in patients is key to reducing their resulting morbidity and mortality. Currently, risk factors are assessed using parameters that include and emphasize the role of the level of cholesterol carried by lipoproteins. Most providers focus on targeting cholesterol levels in patient management. However, recent research shows that lipoprotein particle number is more predictive of cardiovascular risk than cholesterol levels. The Nuclear Magnetic Resonance (NMR) LipoProfile test assesses the number of lipoprotein particles, sizes of lipoproteins, levels of cholesterol, and patient risk categories. Furthermore, it enables the identification of patients with underestimated cardiovascular risks—those with a discordant high number of low-density lipoprotein (LDL) particles (LDL-P) despite low cholesterol levels. While the NMR LipoProfile test requires a higher cost and longer waiting time for results in comparison to the lipid panel test, its advantages cannot be ignored. This review article focuses on exploring the routine use of NMR LipoProfile in clinical practice.
Kounis syndrome is an underdiagnosed medical condition and represents acute coronary syndrome in the setting of allergic reaction. With the increasing prevalence of allergic reactions, more cases of Kounis syndrome are being reported in the literature. Recognizing patients with acute coronary syndrome during an episode of anaphylaxis may be difficult due to symptom overlap; hence, a high index of suspicion must be maintained. This is vital as the management of Kounis syndrome requires meticulous use of medications as some pharmacological agents beneficial to acute coronary syndrome may be detrimental for the ongoing anaphylaxis and vice versa. We report a case of type 2 variant of Kounis syndrome following severe anaphylaxis to nuts to highlight the need for clinicians to suspect Kounis syndrome when managing patients with anaphylaxis and chest symptoms.
Baclofen is a commonly used medication for managing muscle spasticity with the potential of causing lifethreatening adverse effects, including encephalopathy as well as withdrawal symptoms including confusion and hallucinations following abrupt discontinuation. Severe toxicity with baclofen is common in patients with kidney disease, hence the importance of dose reduction and monitoring in patients with renal impairment. This article reports a case of encephalopathy with low-dose baclofen in an otherwise healthy young adult concurrently taking ibuprofen and baclofen and aims to underscore the importance of potential drug interaction and patient education when initiating baclofen.
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