We present the case of a patient whose monozygotic twin brother suffered a fatal myocardial infarction at the age of 40. The patient presented with similar symptoms as his brother. Given the family history, ischemic evaluation was undertaken and revealed similar coronary anatomy and severe coronary artery disease (CAD). We review the current literature regarding genetic and environmental factors regarding coronary anatomy, locations of atherosclerotic lesions, and screening in twins.

Calciphylaxis, or calcific uremic arteriolopathy (CUA), is a rare vascular calcific disease that is most often associated with renal dysfunction and warfarin, particularly end-stage renal disease (ESRD). This condition causes debilitatingly painful skin lesions, oftentimes plaques, throughout areas of cutaneous and subcutaneous adiposity. The progression of these lesions to black eschar with ulceration is the hallmark of CUA. In this report, we present the case of a Caucasian female with a past medical history of nephrogenic systemic fibrosis (NSF), ESRD, and mechanical aortic and mitral valves, anticoagulated with warfarin, who developed CUA. In the setting of mechanical prosthetic valves, vitamin K antagonists (VKA) and aspirin are the only evidence-based antithrombotic therapies. This case presents challenging decision-making when managing anticoagulant therapy in the absence of applicable guidelines.

Hypocalcemia is a common electrolyte derangement that is most associated with parathryoid hormone or vitamin D abnormalities. Less common causes that most providers are aware of include hyperphosphatemia, acute pancreatitis, chronic kidney disease, and sepsis. However, certain populations are at risk for less common, but no less dangerous, causes. One such cause is 1,1-difluoroethane, an organofluorine that is used as a propellant in aerosol sprays and is commonly abused. 1,1-Difluoroethane has been noted to cause severe hypocalcemia by accumulation of the metabolite fluorocitrate in tissues. Here, we present the case of a 51-year-old male with severe hypocalcemia and multiple rib fractures following a fall, with recent history of tibial fracture. The patient had a medical history of osteoporosis with numerous fractures and chronic steroid use. He admitted to using keyboard cleaner as an inhalant for the previous month, which was found to contain 1,1-difluoroethane. Previous case reports on 1,1-difluoroethane inhalation have not reported a patient with preexisting osteoporosis or refractory hypocalcemia.

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