From the Department of Dental Specialties, Birmingham Children's Hospital. This case study describes a rare case of oral carcinoma cuniculatum in a 7 year old female. She presented with an enlarged mass of the anterior maxilla arising from the gingiva. An anterior maxillectomy with immediate prosthetic replacement and obturation of the residual defect were carried out. The management of this case was challenging given the rare nature of the disease, unclear etiology, the patient's young age and the mutilating effects of surgery. The treatment involved a large multidisciplinary team. The provision of obturators was particularly difficult due to poor patient compliance and the extent of surgery carried out in a growing child. Oral cancer in children under 15 years old is extremely rare and this is the youngest case of oral carcinoma cuniculatum reported in the literature.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has shown an association with acute myocardial injury, cardiomyopathy, and myocarditis. Individuals with myocardial involvement in association with the coronavirus disease 2019 (COVID-19) may be at increased risk of developing severe illness. Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually exhibit inappropriate ventricular hypertrophy or dilation and are due to a variety of causes that frequently are genetic. It has been primarily divided into three subsets: genetic, mixed, and acquired cardiomyopathy. We anticipate that, because of the high inflammatory response, other cardiovascular complications may also occur in COVID-19 patients with severe symptoms. This review explores new information as it pertains to COVID-19 and cardiac complications.

Pericardial decompression syndrome (PDS) is an exceedingly rare complication of pericardial fluid removal characterized by paradoxical hemodynamic deterioration which may present with hypotension, pulmonary edema, uni or bi-ventricular failure and cardiogenic shock. A 59-year-old female presented to the ED with sudden-onset dyspnea. Her medical history was significant for stage III breast cancer status-post right-sided mastectomy 5 years prior. She had additionally noted a non-healing wound on her right breast 2 months prior. She was hemodynamically stable, heart sounds were normal without murmur or rub, neck veins were flat. Right breast was notable for an ulcerating, purple lesion. EKG was low voltage but without electrical alternans. CXR revealed an abnormal cardiac contour. CT confirmed a large pericardial effusion. Echocardiography revealed a circumferential pericardial effusion measuring 2.2 cm (Image 1). LVEF was 65% without RV diastolic collapse or tamponade physiology. Breast biopsy confirmed recurrence of malignancy and bone scan suggested metastatic spread. She remained dyspneic on hospital day 5, pericardial window was performed; 450 cc of pericardial fluid was evacuated. Eight hours after intervention she became profoundly hypotensive and suffered a PEA arrest; CPR was successful. CXR revealed pulmonary edema. Stat echocardiography revealed an ejection fraction of 10-15%, global hypokinesis and biventricular failure. No ST-changes were seen on EKG and blood cultures were negative. Her deterioration was attributed to PDS. Pericardial fluid analysis revealed presence of carcinoma cells. Despite maximal inotrope and pressor support, she remained hypotensive and developed sequela of profound cardiogenic shock. Her family chose to withdraw care and she expired. The incidence of PDS is 4.8% with mortality estimated at 29% in the general population. Notably, the incidence of PDS is significantly higher at 11% in patients with underlying malignancy and carries an alarming in-hospital mortality of 58%. In patients who developed PDS, 57% had a history of malignancy and 40% of pericardial effusions in cases of PDS were found to be positive for malignancy. Furthermore, the presence of malignant cells in pericardial fluid is significantly associated with development of PDS with an odds ratio of 5.8 (p-value 0.029). While the pathophysiology of PDS is unclear, tamponade physiology may play a role as 16% of patients with tamponade develop PDS compared to 4% of patients without tamponade. Given the staggering mortality and increased incidence of PDS in patients with malignancy, we urge clinician awareness and encourage judicious fluid removal and intensive monitoring when pericardial fluid drainage is warranted.

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