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Epipericardial fat necrosis (EFN) is an inflammatory process that occurs in the mediastinal fat surrounding the heart. It is a rare cause of acute chest pain and mimics more ominous clinical conditions such as acute coronary syndrome, aortic dissection, and pulmonary embolism. Clinicians are often not familiar with this condition due to its infrequent occurrence, and traditional textbooks of medicine and cardiology have not covered this topic adequately. In the past, EFN had been managed primarily with thoracotomy and surgical excision. This has changed with advances in imaging techniques and their more frequent utilization. Computed tomography (CT) of the chest is essential for the diagnosis of EFN as it allows for the evaluation of the nature and precise location of the lesion. Magnetic resonance imaging helps to differentiate EFN from other mediastinal fatty lesions such as lipomas or liposarcomas. The clinical presentation of acute chest pain along with CT findings of the encapsulated fatty pericardial lesion is adequate for diagnosis. Our review describes the emerging role of imaging in diagnosis and change in management over the last few years.

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Background: Cancer survivors with prior chest radiation therapy (C-XRT) frequently present with aortic stenosis (AS) as the first manifestation of radiation-induced heart disease. They are considered high-risk for surgical valve replacement. Transcatheter aortic valve replacement (TAVR) is as an attractive option for this patient population but the outcomes are not well established in major clinical trials. The authors performed a systemic review and metaanalysis of clinical studies for the outcomes after TAVR in cancer survivors with prior C-XRT. Methods: Online databases were searched from inception to April 2020 for studies evaluating the outcomes of TAVR in patients with and without C-XRT. We analyzed the pooled estimates (with their 95% confidence intervals) of the odds ratio (OR) for the all-cause mortality at 30-day and 1-year follow-ups, 4-point safety outcomes (stroke, major bleed, access-related vascular complications and need for a pacemaker), a 2-point efficacy outcome (mean aortic valve gradient and left ventricular ejection fraction) and worsening of congestive heart failure (CHF). Four studies were included following 2054 patients with and without prior C-XRT exposure (164 patients and 1890 patients respectively). Results: The C-XRT group had similar 30-day mortality compared to the control group (OR 1.29, 95% CI 0.64 to 2.58, p = 0.48). The 1-year mortality was higher in the C-XRT group (OR 1.97, CI 1.15 to 3.39, p = 0.01). Apart from higher congestive heart failure (CHF) exacerbation in the C-XRT group (OR 2.03, CI 1.36 to 3.04, p = 0.0006), TAVR resulted in similar safety and efficacy outcomes in both groups. Conclusion: TAVR in the C-XRT group has similar 30-day mortality, safety, and efficacy outcomes compared to the control group; however, they have higher 1-year mortality and CHF exacerbation. Including an oncologist to the cardiology team who considers cancer stage in the decision-making process and applying additional preoperative scores such as frailty indices may refine the risk assessment for these patients. The quality of analyzed data is modest, warranting randomized trials to assess the true benefits of TAVR in these patients.

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Drug reaction with eosinophilia and systemic symptoms (DRESS) is a life-threatening druginduced hypersensitivity reaction that is most closely associated with antiepileptics and antibiotics. While cases of DRESS are rare, here we present a case of DRESS in an adult male following administration of rosuvastatin who presented with fevers, generalized rash, and facial fullness. Vitals on presentation were temperature 102 o F, pulse 95/min, blood pressure 95/47 mmHg, and respiratory rate of 14/min. His physical examination revealed scleral icterus, generalized blanching maculopapular rash, facial fullness, and right upper quadrant tenderness. Laboratory investigations found hemoglobin 10 gm/dl, white blood cell count 16.0 K/uL, peripheral eosinophil count 1,700 K/uL, alkaline phosphatase 2,501 U/L, aspartate transaminase 620 U/L, alanine transaminase 680 U/L, total bilirubin 13.2 mg/dl with a direct component of 9 mg/dl, blood urea nitrogen 66 mg/dl, creatinine 5.20 mg/dl, glomerular filtration rate 8 ml/min, and immunoglobulin E level 623 IU/mL. Serology for viral hepatitis, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 was negative. Computed tomographic scan of chest, abdomen, and pelvis showed generalized lymphadenopathy. Over the next week, the patient deteriorated clinically with worsening transaminitis and oliguric acute renal failure requiring renal replacement therapy. As per the European Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR), the probability of rosuvastatin-induced DRESS syndrome was scored as "definite." He was treated with systemic and topical glucocorticoids leading to a gradual improvement in his symptoms. Skin biopsy was suggestive of DRESS syndrome as well. Since DRESS carries such a significant risk of mortality between 10% and 20%, DRESS must be recognized and treated as soon as symptoms present. Clinicians should also be aware that statins, one of the most commonly prescribed drugs, are also a potential cause DRESS.

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