Obstructive sleep apnea syndrome is a common disorder with significant health consequences and is on the rise in consonance with the obesity pandemic. In view of the association between sleep-disordered breathing and pulmonary hypertension as depicted by multiple studies, current clinical practice guidelines categorize obstructive sleep apnea as a risk factor for pulmonary hypertension and recommend an assessment for sleep disordered breathing in evaluating patients with pulmonary hypertension. The dysregulatory mechanisms associated with hypoxemic episodes observed in sleep related breathing disorders contribute to the onset of pulmonary hypertension and identification of these potentially treatable factors might help in the reduction of overall cardiovascular mortality.

O bstructive sleep apnea syndrome (OSA) affects 2-4% of the general population. 1 Irrespective of the type of sleep apnea (central versus obstructive), epidemiologic studies have indicated its independent association with hypertension 2 and cardiovascular disease. 3 Also, there is emerging evidence suggesting that sleep disordered breathing (SDB) has an association with fasting hyperglycemia, insulin resistance, and type 2 diabetes mellitus. 4,5 The impact of tracheostomy for severe obstructive sleep apnea syndrome on glycemic control has not been previously reported. CASE REPORTRR is a 58-year-old African American male with history of longstanding hypertension, obesity, type 2 diabetes mellitus, chronic kidney disease, congestive heart failure, sinus node dysfunction status post permanent pacemaker placement, coronary artery disease, and severe obstructive sleep apnea. He had a body mass index of 32. His baseline blood pressures were in the range of 140-160 mm Hg systolic and 70-90 mm Hg diastolic.An overnight sleep study prior to admission documented severe OSA, with an apnea-hypopnea index (AHI) of 54/hr and oxygen desaturation to 66%. He failed continuous positive airway pressure titration and was subsequently titrated to a bilevel (BiPAP ® ) setting of 15/9 cms of H 2 0 with 3 liters/minute of oxygen. Despite

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A 25-year-old male intravenous heroin user with Hepatitis C presented with a syncopal episode and left sided weakness. Examination revealed sub-conjunctival hemorrhages and diffuse bilateral petechiae on his lower extremities. He had multiple irregular, erythematous, painless macules on his hands and feet, and linear, red, subungal lesions bilaterally. These findings were consistent with Janeway lesions and splinter hemorrhages, respectively. His vital signs were stable on admission. Cardiac auscultation revealed a grade 2/6 holosystolic apical murmur radiating to the axilla. A brain MRI revealed multiple areas of hyperdensity, particularly in the right parietal lobe (Figure 1). Blood tests revealed leukocytosis and six of six blood cultures yielded methicillin sensitive Staphylococcus Aureus. The patient was treated with intravenous nafcillin and gentamicin.One week later the patient's neurologic status improved. A transesophageal echocardiogram was performed and revealed both a vegetation on the posterior leaflet of an otherwise normal mitral valve and moderate mitral regurgitation. The following day, the patient developed diarrhea that was positive for both heme and Clostridium difficile toxin. Metronidazole was started and an abdominal CT scan was ordered (Figure 2). Although there was no corresponding clinical presentation, imaging revealed bilateral renal infarcts, a splenic infarct, and sigmoid thickening. The patient regained full neurologic functioning within two weeks of initial presentation and was discharged after a 6 week course of intravenous nafcillin. He is currently awaiting a mitral valve replacement.In the setting of presumed septic emboli to both the skin and brain secondary to bacterial endocarditis, we were concerned that the heme positive stools were the result of embolization to the mesenteric arteries. Although the abdominal CT showed no evidence of bowel infarction and sigmoid thickening is non-specific, the renal and splenic infarcts were determined to be secondary to septic emboli. A previous case of bacterial endocarditis with simultaneous multiple organ involvement including the kidney, spleen, brain, skin, and intestines has not been documented. This case demonstrates that in the setting of diffuse symptomatic septic emboli, involvement of additional organ systems is likely but may be missed due to absence of clinical findings.Concomitant symptomatic emboli to more than one organ system are rare according to the literature. It is interesting to note that petechiae occur in only 20-40%, Osler nodes in only 10-25 % of patients, and Janeway lesions in less than 10% of patients with bacterial endocarditis. Splenic septic emboli in infective endocarditis are a common finding and incidental splenic infarcts were found in 38% of 29 asymptomatic patients in one study.Majumdar et al. found that 18% of 354 patients with infective endocarditis had renal involvement and 45% of that subpopulation was found to have localized renal infarction, making it the most common renal lesion. The authors o...

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