No abstract

Post-myocardial infarction ventricular septal defect (post-MI VSD) is a rare complication of ST-elevation myocardial infarction (STEMI) with an incidence of <1% in early revascularization era. Here we present the case of a 66-year-old woman with post-MI VSD owing to delay in her presentation in the current pandemic. Patient presented with worsening back pain and chest pain with confusion, and an EKG positive for inferior wall STEMI. She underwent emergent percutaneous intervention with placement of drug-eluting stent in her right coronary artery. She developed worsening heart failure and new-onset heart murmur and was found to have a VSD on a transthoracic echo. Because of her poor prognosis, family decided to pursue comfort care and patient unfortunately passed. Delay in seeking health care during the pandemic, as seen in our patient, is multifactorial including fear of contracting infection, decreased emergency medical services members, and concerns for overburdening healthcare systems. Lack of standardized in-hospital approach to emergencies while ensuring adequate protection from infection to healthcare workers, especially during the initial phase of the pandemic, led to increased door-to-balloon times in addition to the increased time to first medical contact. The importance of media outreach ensuring availability of health care in emergencies, changing emergency response algorithms to ensure safety of patients and healthcare providers, and including thrombolytic therapy where there is a delay due to stringent screening or delayed COVID-19 testing can be used to prevent worsening complications following STEMI.

Postinfectious generalised myoclonus has been reported after many viral and bacterial infections in the past. Recently, some case reports have described it in the context of COVID-19 infection. Most patients described in these case reports are either critically ill and intubated or have concurrent respiratory symptoms. Herein, we present a case of a 79-year-old man, who was recovering from a recent COVID-19 infection, presented with isolated generalised myoclonus. The patient was treated with levetiracetam, a short course (10 days) of dexamethasone, and required extensive rehabilitation. Outpatient follow-up at 2 months suggested complete resolution of symptoms and levetiracetam was subsequently discontinued. This case highlights that generalised myoclonus can occur as a delayed complication of COVID-19 infection.

A 42-year-old woman with a remote history of smoking and recently diagnosed anorectal cancer presented with typical anginal chest pain, dyspnea, palpitations, and hallucinations. She was started on continuous 5flurouracil (5-FU) infusion five days before presentation. Her physical examination was significant for bilateral bibasilar crackles and tachycardia. Her bloodwork was significant for an increased troponin and brain natriuretic peptide (BNP). Electrocardiogram (EKG) showed sinus tachycardia with ST elevation in multiple contiguous leads, whereas transthoracic echocardiogram (TTE) showed estimated ejection fraction of 17% with severe global hypokinesis with apical akinesis and matted thrombus at the apex. Coronary angiogram showed 20% occlusion of the left anterior descending artery. She was diagnosed with 5-FU induced Takotsubo cardiomyopathy complicated by left ventricular (LV) thrombosis. 5-FU was discontinued, uridine triacetate was given as reversal agent. Aspirin and apixaban were started for three months for LV thrombosis. Her six-week TTE showed return of normal heart function with resolution of LV thrombosis.