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The patient is a 50-year old man with Hepatitis C, HIV, and pneumonia who recently became homeless and presented with 3 days of worsening palpitations and shortness of breath. Initially the palpitations were sporadic; however, they had become more frequent over the three days prior to admission. He had a corresponding increase in shortness of breath along with significant decreases in his exercise tolerance. He presented to the Emergency Department (ED) when he could no long perform his usual activities of daily living. In the ED, patient was found to have a narrow complex tachycardia with a rate of 234 beats per minute (bpm) (Figure 1).His past history is significant for HIV diagnosed in 1979 with a recent CD4 Count of 16. The patient was not on HAART medication due to noncompliance resulting from financial issues. He also has a history of Hepatitis C secondary to remote intravenous drug abuse. He had pneumonia approximately three weeks prior to admission, which was incompletely treated with antibiotics. The patient also noted a 30-pack year history of tobacco use.In the ED, the patient was given large volumes of normal saline followed by 3 sequential doses of adenosine, all of which failed to terminate his tachycardia. He was then started on an esmolol infusion with resultant hypotension to a systolic blood pressure (SBP) of 80mmHg. The esmolol infusion was subsequently stopped and patient received diltiazem. Following the diltiazem infusion, the patient still had no decrease in his rapid heart rate. A cardiology consultation was requested and procainamide was recommended for chemical cardioversion; however, the patient's blood pressure had deteriorated to SBP of 70mmHg with a heart rate of 240 bpm and the patient was urgently electrically cardioverted. Sinus rhythm was restored at a rate of 110 bpm and the SBP improved to 130 mmHg. He was then referred to the Electrophysiology (EP) service in order to evaluate for a more durable and definitive management of his supraventricular tachycardia (SVT). An EP study was performed and revealed an atrioventricular accessory pathway on the left lateral mitral annulus that was responsible for his SVT. The accessory pathway was successfully ablated as evidenced by intracardiac electrograms and by a lack of initiation of supraventricular tachycardia following isoproteronol administration after ablation (Figure 2).

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A 31 year-old Caucasian male with no significant past medical history presents with increasing dizziness, chest pain, and shortness of breath of one day duration. On returning from a camping trip to Northern Pennsylvania three weeks prior to admission, he noted high fevers, "joint pains all over," and a pink blotchy rash all over his chest and back. He did not recall any insect, tick or animal bites. His primary physician, who clinically suspected Lyme disease, ordered Lyme serologies and offered a prescription for doxycycline which the patient declined. Two weeks later, the patient presented to the emergency department after the onset of chest pain that he described as sharp, radiating to both arms, occurring with exertion and relieved by rest. The chest pain was associated with worsening shortness of breath and dizziness.The patient denied taking any medications, herbal or other supplements. He admitted to smoking half a pack of cigarettes per day, drinking 20 alcoholic beverages per week and occasionally smoking marijuana. He denied any intravenous drug use. He also denied any recent travel outside the United States or exposures to new chemicals or pets. The patient's mother had leukemia; his father had hypertension, diabetes, and hyperlipidemia; and his brother died from an anaphylactic reaction to shellfish.On physical exam, the patient had a temperature of 99.6° Fahrenheit, heart rate of 50 beats/minute, blood pressure of 155/77 mm Hg, respiratory rate of 14 breaths/minute with an oxygen saturation of 100% on room air. The exam also revealed a regularly irregular rhythm with no murmurs, rubs or gallops. His lungs were clear to auscultation bilaterally. He had no focal neurological deficits nor was he orthostatic. Large, well demarcated macular erythematous lesions were noted on his back and thorax. Initial labs showed a white blood cell count of 10,000 cells/mm3 with a normal differential, normal serum chemistries, and a negative troponin. Peripheral smear was negative for babesiosis. The patient's admission chest radiograph showed clear lungs without evidence of infiltrate or effusion. His initial EKG (Figure 1) showed a sinus rhythm at an atrial rate of approximately 100 beats/minute and a highgrade atrioventricular (AV) block with a variable ventricular response of about 40 beats/minute. The patient was admitted to telemetry, and a transcutaneous pacer was placed. Empiric intravenouis ceftriaxone was begun to treat for a clinical diagnosis of Lyme carditis.