Elevated troponin levels have been observed in a wide spectrum of patients who do not have ischemic heart disease, including nonacute coronary syndrome and cardiovascular and noncardiovascular conditions. The cases of two patients with diabetic ketoacidosis who had elevated troponin levels in the absence of coronary artery disease are presented. This clinical scenario can pose a diagnostic dilemma for the physician. The objective of the present report is to highlight the mechanism of troponin elevation in patients with diabetic ketoacidosis, in addition to the clinical and prognostic significance of this finding.

A 26-year-old woman presented with a 1-week history of epigastric and left upper quadrant pain associated with nausea and vomiting. She also described 3 weeks of constant substernal chest pain, dyspnea, and decreased exercise tolerance.Her medical history was significant for a pituitary macroadenoma diagnosed 6 years previously that had been treated with cabergoline. She had a miscarriage 7 years ago but gave birth to a healthy child 5 months prior to admission. She had smoked 2 cigarettes per day for the last 7 years. She denied alcohol or illicit drug use. Her mother had sickle cell trait.On admission, her heart rate was 112 beats/minute, blood pressure was 110/80 mm Hg, and respiratory rate was 26 per minute. Jugular venous distension was not appreciated. She had decreased breath sounds over the right lung base. The apical impulse was palpated in the left sixth intercostal space 1 cm lateral to the midclavicular line, and a 2/6 holosystolic murmur was auscultated at the left lower sternal border. No other murmurs or S3 or S4 gallop could be appreciated. There were no vascular or immunological phenomena suggestive of infective endocarditis. She had abdominal tenderness in the epigastrium and bilateral upper quadrants. There was no lower extremity edema, and the extremities were well perfused.Complete blood count, electrolytes, and liver, renal, and coagulation profiles were normal. Her chest x-ray revealed cardiomegaly and bilateral pleural effusions. EKG showed sinus tachycardia and nonspecific T-wave changes. To further evaluate her abdominal pain, a CT scan of the abdomen and pelvis (Fig.1) was ordered. This revealed a 3 by 1.8 cm splenic infarct. Because of her respiratory symptoms and tachycardia, a pulmonary embolism was suspected but was ruled out with a CT angiogram of the chest.She was diagnosed with new-onset heart failure and a splenic infarct. However, it was unclear if the 2 problems were linked. Possible etiologies of the splenic infarct included thrombus from hypercoagulable state (given her prior miscarriage, postpartum state), infarct from hemoglobinopathy (given her family history), septic emboli from infective endocarditis, and peripartum cardiomyopathy associated with embolism to the spleen.Pain control, empiric antibiotics, and intravenous diuretics were started. Twelve hours later, the patient's dyspnea and chest pain resolved. Her blood culture results were negative, and hemoglobin electrophoresis was normal. Results of a hypercoagulable workup for an arterial thrombus that included lupus anticoagulant, anticardiolipin antibodies, and antibodies to ␤2-glycopro- C A S E R E P O R T

Factor X deficiency is the most common coagulation factor deficiency amongst patients with AL amyloidosis. It presumably occurs due to adsorption of factor X to amyloid fibrils. The deficiency of this factor, in conjunction with other hemostatic defects, can cause bleeding complications. A case of acquired factor X deficiency due to AL amyloidosis is reported, where abnormal coagulation parameters were the only presenting feature.

No abstract

Pyomyositis is an acute or sub-acute primary infection of the striated muscles. It is commonly misdiagnosed in its early stages due to its nonspecific presentation and lower suspicion among physicians when it comes to diagnosis. It has been historically associated with tropical climates but is being seen with increasing incidence in temperate regions. In both tropical and temperate areas, Staphylococcus aureus is the most common causative organism; gram-negative organisms are rare and traditionally only seen in immunocompromised patients. We report a case of Klebsiella pneumoniae pyomyositis in an immunocompetent patient with no risk factors. The awareness of the possibility of gram-negative pyomyositis in immunocompetent patients will broaden initial empiric antibiotic treatment, especially in those patients not responding to traditional empiric treatment.