Background The presence of bifascicular block on electrocardiography suggests that otherwise-unexplained syncope may be due to complete heart block. European Society of Cardiology (ESC) recommends investigating it with electrophysiology study (EPS). PPM is indicated if high-degree atrioventricular block is inducible. Long term rhythm monitoring with implantable loop recorder (ILR) is recommended if EPS is negative. We evaluated adherence to these guidelines. Methods This is a single-center retrospective audit of adult patients with bifascicular block hospitalized for unexplained syncope between January 2018 and August 2019 under general medicine service. Patients with an alternative explanation for syncope were excluded. Guideline adherence was assessed by formal cardiology consult and whether EPS followed by ILR and/or PPM were offered. Results 65 out of 580 adult patients (11.2%) admitted to general medicine service for syncope had a bifascicular block; 29 (5%) were identified to have bifascicular block and unexplained syncope. Median age was 77 ±10 years; 9 (31%) were female, and 6 (20.7%) patients had at least one prior hospital visit for syncope at our academic medical center. Cardiology was consulted on 17 (58.6%) patients. Two patients were evaluated by EPS (1 refused) followed by ILR. Overall, 3 out of 29 patients (10.3%) received guideline-directed evaluation during the hospitalization based on ESC guidelines. None of the patients received empiric PPM during the index hospitalization. Conclusion Among patients admitted to the general medicine service with unexplained syncope and bifascicular block, a minority (10.3%) underwent guideline-directed evaluation per ESC recommendations. Cardiology was consulted in 58.6% of cases.

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INTRODUCTION: Invasive Klebsiella pneumoniae Syndrome is characterized by liver abscesses, bacteremia, and metastatic infection – particularly endogenous endophthalmitis. First described in Southeast Asia in the 1980s, this syndrome has been increasingly identified in North America and is linked to virulent strains defined by hypermucoviscosity specific capsular serotypes, especially serotype K1 and K2. Following the development of a liver abscess, bile leak is a potential complication that may benefit from endoscopic management. CASE DESCRIPTION/METHODS: A 68-year-old female presented with 5 days of fevers, rigors, & chills. Blood cultures grew mucoid Klebsiella pneumonia, and a large hepatic abscess was noted on abdominal imaging. Shortly after admission, she developed left-sided visual deficits, with floaters and decreased visual acuity. She was found to have endogenous endophthalmitis and received intravitreal antibiotics. A percutaneous hepatic drain was placed, and she was treated with IV ceftriaxone. At a one-week follow-up, she reported decreased drain output and right flank pain. The drain had bilious output and was concerning for bile leak. ERCP showed a contrast leak at the level of the common bile duct, and a stent was placed. Repeat cultures were sterile, with no output following stent placement, so the drain was removed. She completed 6 weeks of antibiotics, and follow up imaging demonstrated marked improvement. She underwent vitrectomy with anterior chamber washout. Despite the resolution of abscess and bacteremia, she had no recovery of vision in the affected eye. Although the Klebsiella strain was of mucoid nature, the traditional K1 hypermucoviscosity serotype was negative. Only K1 serotype was tested for in our patient. DISCUSSION: Klebsiella pneumoniae is known to result in highly invasive community-acquired infection in immunocompetent patients without underlying hepatobiliary or intestinal disease, particularly the K1 and K2 subtypes, which are the most virulent of the known serotypes. Their capsules essentially protect the bacteria from phagocytosis. Endophthalmitis is a common complication, with high morbidity. Liver abscesses are treated with antibiotics and percutaneous drainage. Development of bilious drain output may signal the development of a bile leak, which can be successfully managed with endoscopic stenting.

A 43-year-old man with history of non-Hodgkins’ lymphoma presented with unilateral eye swelling, pain and vision deficits which had been progressive over 2 months. Symptoms followed a presumed bacterial pneumonia 4 months prior. Imaging demonstrated retro-orbital soft tissue swelling with bony erosion concerning for a mass; surgical decompression was performed with histology confirming disseminated Blastomyces dermatitidis. Symptoms responded rapidly to antifungal therapy with amphotericin followed by itraconazole. Orbital dissemination of blastomycosis is extremely rare; accurate diagnosis requires tissue biopsy to facilitate timely targeted therapy and minimise morbidity.

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