In this controlled study, migraine, especially with aura, is more frequent in subjects with PFO. PFO closure is associated with a reduction in migraine frequency and severity, as well as an improvement in MIDAS scores. PFO closure was associated with a significant reduction in the use of abortive medications.

The Food and Drug Administration has banned the sale of ephedrine-based weight-loss products because of their association with many cardiovascular adverse effects. Bitter orange is now being used as a stimulant in "ephedra-free" weight-loss supplements but was recently implicated in adverse cardiovascular sequelae. To our knowledge, this report describes the first case of variant angina associated with bitter orange in a dietary supplement.

A 54-year-old man was evaluated for a 6-month history of intermittent palpitations with associated shortness of breath, fatigue, and lightheadedness. The episodes would last several hours and were triggered by exertion, although he never experienced syncope. He had no prior medical problems, and he had no family history of heart disease or unexplained sudden death.He was normotensive and had no abnormalities on physical examination. A 12-lead electrocardiogram showed sinus arrhythmia, left bundle-branch block, and left ventricular (LV) hypertrophy with associated ST-and T-wave strain abnormalities ( Figure A). A 2-dimensional echocardiogram demonstrated hyperdynamic LV systolic function with an ejection fraction of 65% (online-only Data Supplement Movie I). There was concentric LV hypertrophy, with the ventricular septum and free wall measuring 17 mm at end diastole. Biatrial enlargement was noted, but no valvular disease or LV outflow tract obstruction was present.A 1-month loop monitor recorded bursts of rapid atrial fibrillation and atrial tachycardia, which corresponded to his Figure. A 54-year-old man with Anderson-Fabry disease and cardiac involvement. A, Twelve-lead electrocardiogram showing sinus arrhythmia, left bundle branch block, and LV hypertrophy with strain ST-and T-wave abnormalities. B and C, Cine CMR at end diastole in the long-axis 4-chamber view (B) and the basal LV short-axis view (C) demonstrating concentric LV hypertrophy (17 mm maximal wall thickness in ventricular septum and LV free wall) with biatrial enlargement. D, Contrast-enhanced CMR image of the basal LV short axis with an area of late gadolinium enhancement confined to the midmyocardium of the inferolateral wall (arrows). LA indicates left atrium; RA, right atrium; and RV, right ventricle.

KEY WORDS: autoimmune hepatitis; autoimmune thyroiditis; rifampin prophylaxis; pyrazinamide prophylaxis.Drug-induced autoimmune hepatitis (DIAH) and thyroiditis with rifampin and pyrazinamide has not been reported to our knowledge. We report on a 25-year-old male who presented with signs of acute anicteric hepatitis and subclinical thyroiditis 3 weeks after starting antituberculosis (anti-TB) prophylaxis. After discontinuation of the rifampin and pyrazinamide prophylaxis, his symptoms of hepatitis resolved, and liver enzymes and thyroid tests returned to normal after several months. Since neither rifampin nor pyrazinamide has been described so far as a triggering factor for autoimmune hepatitis and thyroiditis, the case is discussed and the literature reviewed. CASE REPORTA 25-year-old man in otherwise excellent health presented 3 weeks after the start of anti-TB prophylaxis. He was found to have a positive purified protein derivative (PPD) in May 2002 that was performed as part of a routine employment physical examination. A PPD 2 years earlier had been negative. He was unable to recall any exposure to TB, but he was a medical student at an urban medical center. A chest x-ray taken after the PPD was found to be unremarkable. The patient chose not to start anti-TB prophylaxis at this time, as he was asymptomatic. However, in October 2002, he was convinced to start a 2-month regimen of rifampin and pyrazinamide prophylaxis, which was the guideline at that time for treatment of latent TB (1). Three weeks after beginning prophylaxis, he presented with anorexia, fever, fatigue, and right upper quadrant pain. Physical examination was unremarkable except for mild right upper quadrant tenderness on deep palpation. No organomegaly or tenderness Manuscript . was noted. No skin eruption was present. The patient was a nonsmoker, but did consume alcohol, up to two six-packs of beer on the weekends. He had no other comorbid conditions. Aminotransferases at presentation were elevated, with an ALT of 749 IU/L (normal, 0-40 IU/L) and an AST of 938 IU/L (normal, 0-40 IU/L). Preprophylaxis baseline ALT and AST had been normal (12 and 22 IU/L, respectively). Serum total protein was 6.7 g/dL (normal, 6.0-8.5 g/dL), serum albumin was 3.8 g/dL (normal, 3.5-5.0 g/dL), and serum globulin was 2.9 g/dL (1.5-3.0 g/dL). Blood work also revealed an eosinophil count of 15%. Serological studies showed a positive antinuclear antibody (ANA) of >1:640 in a speckled pattern. Anti-smooth muscle antibody (ASMA) was elevated, at 1:80. Tests for acute and chronic viral infection, including hepatitis A, B, and C, mononucleosis, and cytomegalovirus, were all negative. Iron and copper studies were normal, and an abdominal ultrasound was unremarkable with normal echogenicity of the liver. One week after discontinuation of rifampin and pyrazinamide, the ALT was further elevated, to 1256 IU/L, and AST was 695 IU/L. INR was slightly prolonged, at 1.4 (normal, 0.9-1.1), but the bilirubin level was normal at 0.4 mg/dL (normal, 0.1-1.0 mg/dL). No liver biopsy w...

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