Giant Left Atrial Myxoma Masquerading as Cough-Syncope Syndrome

Left atrial myxomas are the most common type of benign primary cardiac tumor. Patients can present with generalized symptoms, such as fatigue, symptoms from obstruction of the myxoma, or even embolization of the myxoma causing distal thrombosis. We describe a case with several-month duration of syncopal episodes that occurred after coughing and with exertion. Computed tomography of the chest showed a 6.1 cm by 4.5 cm mass in the left atrium, later evaluated with an echocardiogram. Cardiothoracic surgery removed the mass, and it was determined to be an atrial myxoma. It is important for an internist to be able to diagnose an atrial myxoma because of the risks associated with embolization and even sudden death as myxoma can block blood supply from atrium to ventricle

Isometric Belt Squat Knee Position Affects Mediolateral Kinetics

The isometric belt squat has grown in popularity as a lower body strength assessment, given its reduction in spinal loading and limited involvement of the upper extremity compared to other whole-body isometric test variations. Previous research has identified knee angle ranges for the isometric belt squat that are more advantageous for vertical force generation. The relationship of knee angle and anteroposterior and mediolateral forces has not been established for the isometric belt squat. Since ground reaction force is three-dimensional, examination into anteroposterior and mediolateral forces will provide additional information on how force is developed for this movement as well as insight to optimal performance technique. PURPOSE: To determine the impact of knee positioning on isometric belt squat anteroposterior and mediolateral kinetics. METHODS: Thirty-three healthy, active collegiate female and male volunteers (n=33, male=9, 23.6 ± 3.7 years, 73.0 ± 16.3 kg, 1.69 ± 0.10 m) participated in this study. During familiarization, chain lengths were determined for positioning of knee angles for the maximal effort isometric belt squat: (A) 80-100, (B) 100-120, (C) 120-140, (D)140-160, and (E) 160-180 degrees. Participants completed a warm-up and 2 practice pushes. Then, participants completed 1, 5-second, maximal effort belt squat push for one of the five knee angle ranges mentioned above, followed by 2-minutes of rest. Similarly, maximal pushes for the remaining four angle ranges were completed in a random order. One-way repeated measures ANOVA were used to compare the difference in anteroposterior and mediolateral force range, absolute peak force, and time to absolute peak force between knee angle ranges. Post hoc analysis was done using Student’s LSD. RESULTS: No differences were found in the anteroposterior direction. Knee angle significantly affected the range of mediolateral force (F=9.639, p\u3c0.0001). Mediolateral force ranges were significantly larger for all knee angles greater than 100º compared to 80-100º. Force range for angles 100-120º and 160-180º were significantly less than 120-140º; additionally, 160-180º was significantly less than 140-160º. Knee angle had a significant effect on peak mediolateral force (F=6.90, p\u3c0.0001). Peak force at 120-140º and 140-160º was significantly greater than peak force at 80-100º, 100-120º, and 160-180º. In addition, peak force at 100-120º was significantly greater than at 80-100º. Lastly, knee angle had a significant effect on time to peak force in the mediolateral direction (F=2.993, p=0.0205). Time to peak force at angle 120-140º was significantly greater than 80-100º, 100-120º, and 160-180º. CONCLUSION: Alteration of isometric belt squat positioning by changing the knee angle did not significantly alter anteroposterior range, peak force, or time to peak force, likely due to restrictions from the apparatus set up and movement instructions. However, there were significant mediolateral force differences for range, peak force, and time to peak force based on positioning changes, suggesting this direction of force was more sensitive to knee position. All mediolateral findings had an inverted-u shape resembling the force-length relationship for active muscular contraction. It is likely the knee angles of 120-140 and 140-160 degrees resulted in a mid-range hip angle and provided peak force generation for this hip driven movement

Autoimmune Pancreatitis Type 2: Case Report

© 2017, © 2017 American Federation for Medical Research. A middle-aged man presents with acute pancreatitis of unknown etiology and is found to have a presentation consistent with the diagnosis of type 2 autoimmune pancreatitis (AIP). AIP is a group of rare heterogeneous diseases that are challenging to diagnose. There are 2 types of AIP. Type 1 disease is the more common worldwide than type 2 AIP. While type 1 AIP is associated with IgG4-positive antibodies, type 2 AIP is IgG4 antibody negative. Both types of AIP are responsive to corticosteroid treatment. Although type 1 AIP has more extrapancreatic manifestations and more commonly relapses, this is a case of a patient with type 2 AIP with inflammatory bowel disease and relapsing course

Inflammatory Breast Cancer and Warm Antibody Autoimmune Hemolytic Anemia: A Rare Paraneoplastic Syndrome

Autoimmune hemolytic anemia (AIHA) is a disease process that involves the destruction of red blood cells mediated by the humoral immune system. It can be characterized as a cold agglutinin syndrome, paroxysmal cold hemoglobinuria, and warm, mixed type, and drug-induced AIHA. Although a well-established relationship exists between the presence of AIHA and lymphoproliferative malignancy, AIHA rarely presents in association with solid malignancies. An analysis of the limited number of published cases of AIHA in association with solid malignancies performed showed that AIHA may present before the diagnosis of a solid malignancy, concurrently with the presence of a solid malignancy, or even on resolution of a solid malignancy. Few cases of solid cancers associated with AIHA have been reported. AIHA rarely presents as a paraneoplastic syndrome indicating existence of a solid cancer. We report a case of inflammatory breast cancer with AIHA

Acute Kidney Injury, Immune Thrombocytopenic Purpura, and the Infection That Binds Them Together: Disseminated Histoplasmosis

Untreated human immunodeficiency virus (HIV) can be complicated by opportunistic infections, including disseminated histoplasmosis (DH). Although endemic to portions of the United States and usually benign, DH can rarely act as an opportunistic infection in immunocompromised patients presenting with uncommon complications such as acute kidney injury and idiopathic thrombocytopenic purpura. We report a rare presentation of DH presenting with acute kidney injury and immune thrombocytopenic purpura in an immunocompromised patient with HIV

Assessing Dual Task Gait Asymmetries in Older Adults Using Wireless Instrumented Shoe Insoles

Gait asymmetries have been suggested to be indicators of pathology. Walking while simultaneously completing a secondary cognitive task, or dual task, has been found to alter gait parameters such as stride time and stride length in aging populations. Gait asymmetries are commonly exacerbated in older adults under dual task conditions as attention is diverted away from walking. Although clinically relevant, assessing gait biomechanics outside of traditional laboratory settings can be challenging, but is possible using lightweight wireless sensors. PURPOSE: Our aim was to assess the influence of a cognitive load on gait asymmetries in older adults using wireless instrumented shoe insoles. METHODS: Thirteen participants, six females and seven males (age: 78.3 ± 7.1 years, BMI: 27.1 ± 6.6 kg/m2) participated in the study. Participants were fitted with OpenGo 16-pressure sensor insoles with embedded inertial measurement units in each shoe (Moticon GmbH, Munich, Germany). Participants completed five overground walking conditions, spanning 7 meters in distance: (1) self-paced walking, (2) walking while verbally stating as many animals as possible, (3) walking while spelling the word “world” backwards, (4) walking while counting backwards from 100 by 7s, and (5) walking while balancing a cup full of water on an opaque tray in their dominant hand. We calculated stride time and stride length asymmetry while excluding the initial and final steps of each condition. Gait asymmetries relative to the self-paced walking condition were evaluated among dual task gait conditions using a one-way ANOVA. RESULTS: We did not observe statistically differences among dual task walking conditions based on stride time asymmetry (F(3) = 1.3, p = 0.30), and length asymmetries (F(3) = 0.5, p = 0.65). CONCLUSION: Our approach to measure dual task walking conditions using instrumented in-shoe insoles with minimal participant preparation or recording equipment is a promising approach that can be used in larger trials. Future assessments of step width asymmetry and variability should be considered given the importance of mediolateral balance during overground walking

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes