Malaria is a vector-borne disease that is endemic in 91 countries. South East Asia is the second most affected region in the world, with India carrying the highest burden of the disease. Four species of Plasmodium are known to cause malaria in humans. Plasmodium vivax and Plasmodium falciparum are the most common species found in India, but Plasmodium malariae have also been reported. Severe complications of malaria have been more commonly seen in P. falciparum infections, and those caused by P. vivax have been considered benign. However, the literature has alarming reports of complicated malaria seen in vivax infections in recent times. This article reports three such cases of P. vivax infection with severe manifestations of malaria such as are found in P. falciparum. This recent evidence indicates that it is important to suspect complicated malaria in P. vivax infection and initiate the appropriate treatment as early as possible to avoid morbidity and mortality.

Objective: Post-systolic shortening (PSS) has been shown to be sensitive in detecting ischemia on stress echocardiography. In this study, we aimed to assess the diagnostic potential of resting PSS and post-systolic index (PSI) in patients with suspected unstable angina (UA). Methods: A total of 159 participants with suspected UA without any wall motion abnormalities were recruited. They all underwent speckle tracking echocardiography (STE) and coronary angiogram (CAG). Global longitudinal strain (GLS); presence or absence of pathological PSS; PSI 17 and PSI 12 , and PSI in left anterior descending, left circumflex, and right coronary artery territories were assessed. On the basis of CAG, those who had more than 70% stenosis were labelled to have obstructive CAD. Results: Obstructive disease was noted in 54.7% patients. The prevalence of PSS (62.1% vs. 13.9%), mean PSI 17 (5.4 vs. 3.3), and PSI 12 (6.2 vs. 3.7) were significantly higher in those with CAD compared with patients without obstructive disease. Both PSS [odds ratio (OR) 10.145; 95% confidence interval (CI) 4.577-22.489; p=0.001] and PSI 17 (OR: 1.217; 95% CI: 1.064-1.393; p=0.004) were predictors of CAD by multivariate regression analysis. PSS had a sensitivity of 62.1% and specificity of 86.1% with a positive predictive value of 84.4%. PSI 17 [area under curve (AUC): 0.637; p=0.003] and PSI 12 (AUC: 0.661; p=0.001) have moderate accuracy in identifying obstructive CAD. Conclusion:In patients presenting with suspected UA, STE derived PSS has reasonable sensitivity and good specificity in diagnosis of obstructive CAD. Patients identified to have PSS can be subjected to CAG without further stress testing because of its high positive predictive value.

Background Acute myocardial infarction (AMI) secondary to coronary embolization is one of the rare complications of atrial myxoma. Takotsubo cardiomyopathy (TCM), a close mimic of AMI, is extremely rare in the setting of atrial myxoma. We report a patient with atrial myxoma presenting with features leading to a clinical dilemma between these two entities. Case summary  A 60-year-old woman presented with acute chest pain with ST segment elevation. Echocardiogram revealed left ventricular (LV) apical ballooning which is typical of TCM, coexisting with a fragile left atrial mass. Emergency coronary angiogram showed a hazy lesion in the circumflex ostium and an intermediate lesion in ramus without any obstruction. Surgical excision of the tumor was done due to features of recurrent coronary embolism. The histopathology examination confirmed it as a myxoma. Regional wall motion abnormalities reversed within a month and LV function normalized. Cardiac magnetic resonance (CMR) imaging at follow-up suggested myocardial infarction. Discussion TCM can occur very rarely in the setting of atrial myxoma. In a patient with atrial myxoma presenting with features of TCM, differentiating it from coronary embolization is important.

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Congenital portosystemic shunts (CPSSs) are rare developmental vascular anomalies which are classified into extrahepatic and intrahepatic malformations. Here, we report a 7-year-old girl who presented with a history of progressive dyspnea, pandigital cyanosis, and clubbing. On evaluation, she was found to have a rare combination of both type II extrahepatic and intrahepatic portosystemic shunts which were closed endovascularly in the same setting. Diagnosis of CPSS needs a very high index of clinical suspicion. Timely diagnosis with specific imaging modalities will help in deciding the treatment strategy and may prevent long-term complications.