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BACKGROUND: As acute myocardial infarction (AMI) prevalence is increasing because of lifestyle changes, the incidence of atypical symptoms in acute coronary syndrome (ACS) is rising and making misdiagnosing of this fatal event more probable. To better approach the patients with atypical symptoms, we tend to present a rare case of AMI with wrist pain. CASE REPORT: A 41-year-old man presented to the emergency room (ER) with severe both-hand wrist pain and mild epigastric pain. His electrocardiogram (ECG) showed anterior ST-elevation myocardial infarction (MI) with an ejection fraction of 35-40%. His angiography showed severe left anterior descending artery (LAD), and first obtuse marginal artery (OM1) artery stenosis. He underwent Primary percutaneous coronary intervention (PCI). The patient recovered without serious complications and was discharged the day after PCI. DISCUSSION: In this rare case of AMI with wrist pain, it is important to know that atypical symptoms can be present at various levels of symptoms, which prevents future misdiagnosis.

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OBJECTIVES: Call-takers face a complex situation when assessing medical problems in emergency medical services calls. Patients with myocardial infarction experiencing atypical symptoms risk misinterpretation. We examined development in call-takers' decision-making process in telephone consultations with patients having imminent myocardial infarction. METHODS: Recording of 38 calls among 19 patients (two per patient) who contacted Copenhagen Emergency Medical Services (Denmark) at least twice within one week before myocardial infarction diagnosis. The penultimate and last call were compared using qualitative content analysis. RESULTS: Call-takers' assessment of the condition changed from unclear symptom picture and dismissal of heart disease in penultimate call to severe condition, not heart-related, and possible heart disease in last call. Call-takers recommended watchful waiting in the penultimate call. Both calls involved response negotiation, while caution regarding misinterpretation was only seen in the penultimate call. CONCLUSION: Call-takers used different decision-making approaches when the caller's symptom descriptions appeared unclear and not corresponding with the medical understanding of severe conditions. Call-takers did not negotiate the condition's assessment but engaged in discussions about the response choice. PRACTICE IMPLICATIONS: A protocol to negotiate response choice with callers having unclear clinical conditions should be developed. Clarifying watchful waiting as a recommendation may assist call-takers' decision-making.

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Introduction: The authors present a case of a delayed chronic subdural haematoma, a rare occurrence that manifested 3 years after a traumatic brain injury, accompanied by an unexpected symptom of urinary incontinence. Chronic subdural haematoma (CSDH) is a well-known condition characterised by the accumulation of old, liquefied blood under the dura mater, usually following minor head trauma. However, the atypical presentation of CSDH in a young patient without predisposing factors and the association with urinary incontinence challenge conventional understanding. This report explores the clinical manifestations, radiological findings, and management of this exceptional case, providing valuable insights into this unusual presentation. Case presentation: In this report, the authors present the case of a 23-year-old male with an unremarkable medical history, devoid of prior neurological deficits, who presented with persistent headaches, memory impairment, left-right disorientation, slurred speech, and urinary incontinence, troubling him for the past month. The patient had a history of a traumatic brain injury from a road traffic accident 3 years earlier, initially devoid of concerning symptoms. Imaging revealed a large heterogeneous mass lesion in the left fronto-parietal lobe consistent with a chronic subdural haematoma. The patient underwent surgical evacuation and excision of the haematoma, leading to the successful resolution of symptoms. Clinical discussion: Conventionally, chronic subdural haematoma is observed in elderly individuals following minor head trauma. However, this case challenges the traditional understanding by highlighting its delayed occurrence in a young patient without known predisposing factors. This case emphasises the need to consider delayed presentations even without immediate neurological deficits. The unexpected symptom of urinary incontinence underscores the necessity of comprehensive evaluations to understand the associated neurological effects of CSDH. A surgical approach was crucial for both diagnosis and treatment, underscoring the significance of prompt intervention in such atypical cases. Conclusion: This exceptional case sheds light on a delayed chronic subdural haematoma occurring years after traumatic brain injury in a young patient without known risk factors. The presence of urinary incontinence as a symptom further amplifies the uniqueness of this case. Understanding and recognising atypical presentations of CSDH is vital for accurate diagnosis and timely intervention. This report underscores the importance of vigilance and an integrated approach to managing patients with subdural haematomas, particularly in unexpected demographics and circumstances, to ensure optimal outcomes and patient well-being.

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This case report presents an atypical instance of pediatric-onset multiple sclerosis (MS) in a 12-year-old male, a demographic less commonly affected by this condition. The patient's clinical course was marked by severe and progressive symptoms, including lower limb weakness and loss of bowel/bladder control, diverging from the typical relapsing-remitting pattern observed in pediatric MS. Despite initial resistance to high-dose steroid treatment, his condition was ultimately stabilized through plasmapheresis, following the detection of myelin oligodendrocyte glycoprotein antibodies. Unique aspects of this case included the patient's young age, male gender, and the occurrence of osteopenia, as identified by a dual-energy X-ray absorptiometry scan. This report highlights the variability in MS presentations among pediatric patients and underscores the importance of a personalized, multidisciplinary approach to diagnosis and treatment. It contributes to the growing body of knowledge on pediatric MS, emphasizing the need for heightened clinical vigilance and tailored management strategies in young patients with this complex and lifelong disease.

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Myasthenia gravis (MG) is often complicated by respiratory failure, an exacerbation known as myasthenic crisis. However, most patients with MG develop respiratory symptoms during the late course of the disease. Respiratory failure as an exclusive initial and primary complaint in patients with MG is rare and seldom reported. We herein describe a woman in her late 50s who presented with respiratory failure and was diagnosed with obesity hypoventilation syndrome at a local hospital. Her condition gradually worsened during the next 4 months and became accompanied by dysphagia. After 1 year of medical investigation, she was diagnosed in our hospital. A high level of anti-muscle-specific receptor tyrosine kinase antibody was found in her serum, and stimulation and electromyography results suggested MG. The patient's symptoms were improved by intravenous immunoglobulin and hormone therapy. This case reminds physicians to consider MG when encountering a patient who initially presents with respiratory failure.

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Background: Gastroesophageal reflux disease (GERD) is a challenging condition that involves different physicians, such as general practitioners (GPs), gastroenterologists, and ears, nose and throat (ENT) specialists. A common approach consists of proton-pump inhibitors (PPIs) administration. Adjunctive pharmacological treatment may have a role in the management of non-responders to PPIs. Objectives: We aimed to survey GPs and different medical specialists to investigate the medical approaches to patients reporting GERD symptoms. In addition, we examined the use of adjunctive pharmacological treatments in patients with GERD symptoms who do not respond to PPIs. Design: Retrospective observational study. Methods: A survey was conducted among a large sample of gastroenterologists, GPs, and ENT specialists. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life were explored with the GERD Impact Scale and with Reflux Symptom Index (RSI). All therapies administered usually for GERD were investigated. Results: A total of 6211 patients were analyzed in this survey. Patients with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p < 0.0001). The GSI was higher in patients followed by gastroenterologists (9 points) and GPs (9 points) than ENT specialists (8 points), but the RSI was higher in the ENT group (14.3 ± 6.93) than in GPs and gastroenterologist groups (10.36 ± 6.36 and 10.81 ± 7.30, p < 0.0001). Chest pain had the highest negative impact on quality of life (p < 0.0001). Of the 3025 patients who used PPIs, non-responders showed a lower GSI when treated with a combination of adjunctive pharmacological treatments and bioadhesive compounds, than with single-component drugs. Conclusion: Patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

Gastroesophageal reflux disease management: real-world perspectives from Italian gastroenterologists, primary care physicians and ENT specialists Gastroesophageal reflux disease (GERD) is a prevalent and chronic condition that affects millions of individuals worldwide, causing significant discomfort and impacting their overall quality of life. In the comprehensive management of GERD, a collaborative approach involving different physicians is essential to address the various aspects of this complex condition. Given the wide range of diagnostic and therapeutic possibilities in clinical practice, we aimed to investigate how GERD is managed in clinical practice by general practitioners and different medical specialists, including gastroenterologists and ears, nose, and throat (ENT) specialists. A total of 6,211 observations were carried out from a survey. The severity and impact of GERD on quality-of-life was higher in patients followed by gastroenterologists and general practitioners than ENT specialists. Non-cardiac chest pain had the highest negative impact on quality-of-life. Of the 3,025 patients who used PPIs, non-responders showed an improved quality of life when treated with a combination of adjunctive pharmacological treatments and bio adhesive compounds.

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Kikuchi-Fujimoto disease (KFD), also called histiocytic necrotizing lymphadenitis, is more common in young women and typically presents with small, painful, localized cervical lymphadenopathy that resolves spontaneously within a few weeks. Laboratory findings are variable. As many as 40% of KFD cases are reported to be painless, and up to 22% to be generalized lymphadenopathy. Therefore, malignant lymphoma could be a differential diagnosis of KFD. A histopathologic diagnosis is needed when it is difficult to distinguish KFD from lymphoma. KFD typically shows small, highly accumulated cervical lymph nodes on fluorodeoxyglucose positron emission tomography (FDG-PET). This contrasts with malignant lymphoma, which tends to be associated with massive lymphadenopathy. In our case, a 40-year-old Japanese male presented with painless lumps in the right neck, accompanied by fever, night sweats, and loss of appetite. His symptoms and laboratory results worsened over a month. FDG-PET revealed highly accumulated uptake in cervical, mediastinal, and axillary lymph nodes. The PET imaging showed a small, high FDG uptake and contributed to the correct diagnosis of KFD. This case report highlights the importance of FDG-PET, which is a valuable diagnostic tool for KFD as it typically differentiates large clusters of small lymph nodes typical of KFD from normal lymph nodes. LEARNING POINTS: Kikuchi-Fujimoto disease (KFD) typically presents with small, painful, localised cervical lymphadenopathy.KFD has atypical patterns showing painless and generalised lymphadenopathy.Fluorodeoxyglucose positron emission tomography (FDG-PET) could be useful for diagnosing not only malignant lymphoma but also KFD.

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This case report presents a rare case of cardiac leiomyomatosis misdiagnosed initially as submassive pulmonary embolism in a 39-year-old woman. The patient presented with syncope and hypotension, leading to an initial diagnosis of submassive pulmonary embolism. However, further investigations revealed a right-sided heart mass on echocardiogram. Surgical intervention was carried out, and the patient's condition was successfully managed. This case emphasizes the importance of considering rare cardiac tumours in the differential diagnosis of pulmonary embolism. LEARNING POINTS: Given the rarity and diagnostic challenges associated with cardiac leiomyomatosis, it is important to raise awareness of this condition among healthcare professionals.Histopathological examination remains the gold standard for confirming the diagnosis of cardiac leiomyomatosis.Early recognition and accurate diagnosis are essential for timely intervention and optimal outcome.

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OBJECTIVE: To conduct an exploratory analysis of comorbidity patterns and the structure of depressive episodes among Russian patients with bipolar disorder (BD) and major depressive disorder (MDD). MATERIAL AND METHODS: This multicenter cross-sectional study included 178 patients with mood disorders, of which 78.1% (n=139) were women. The diagnosis of BD was made in 68.0% (n=121) patients, of them 37.1% (n=66) were diagnosed with BD type I. All study participants underwent a structured Mini International Neuropsychiatric Interview to verify the clinical diagnosis and identify concomitant mental disorders, and also filled out an electronic case report form. Statistical analysis was performed in RStudio v. 1.4.1717 using the standard R package and the «psych¼ package. RESULTS: According to the results of stepwise regression, comorbid diagnoses of panic disorder (OR=5.3; 95% CI 1.9-19.1) and eating disorders (OR=7.7; 95% CI 2.8-27.4) were more associated with BD. In addition, depressive episodes in BD were more associated with symptoms of hypersomnia (OR=2.5; 95% CI 1.2-5.3) and psychomotor retardation (OR=3.2; 95% CI 1.5-7.6). Symptoms such as increased appetite (47.1% (n=57) vs 26.3% (n=15); p=0.009), ideas of guilt (92.6% (n=112) vs 7.2% (n=44); p=0.006) and thoughts of self-harm or death (70.2% (n=85) vs 45.6% (n=25); p=0.003) were also nominally more common in depressive episodes within the BD compared to MDD. CONCLUSIONS: Mood disorders such as BD and MDD have significant differences in the patterns of comorbidity and the structure of depressive episodes, which is important to consider when conducting differential diagnosis of these disorders. The results also indicate the need for a comprehensive diagnostic interview with patients with mood disorders to assess the presence of comorbid mental disorders during life and the structure of depressive episodes throughout the clinical course from the moment of onset.

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This case report presents a complex clinical scenario involving a 71-year-old female with aortic dissection accompanied by hypotension. The patient's initial presentation of sudden loss of consciousness unveiled a large pericardial effusion and cardiac tamponade, leading to emergency surgery. Subsequent diagnostic findings revealed an intramural haematoma with an intimal tear in the ascending aorta. Postoperatively, the patient experienced an ischaemic stroke, necessitating prompt neurology consultation and treatment. This report underscores the significance of early recognition and collaborative management in achieving positive patient outcomes. LEARNING POINTS: Early identification of aortic dissection symptoms, such as sudden loss of consciousness and hypotension, is crucial for effective management.Managing aortic dissection involves a multidisciplinary effort with emergency medicine, cardiology and surgical teams working together for optimal patient outcomes.After aortic dissection surgery, staying attentive to potential neurological complications such as ischaemic strokes is essential.

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OBJECTIVES: Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers. METHODS: Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied. RESULTS: Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see". CONCLUSION: Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response. PRACTICE IMPLICATIONS: Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

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We present the case of a 74-year-old woman, functionally independent in her daily activities, with a medical history notable for hypertension and dyslipidemia. She presented to the emergency room with an altered level of consciousness, opening her eyes only to pain, no verbal response, and flexion withdrawal from pain coupled with a Glasgow Coma Scale of 7. The intensive care unit was promptly summoned, and the patient was intubated and admitted to intensive care. Comprehensive laboratory assessments revealed no abnormalities and an initial cerebral CT scan showed no acute changes. A subsequent CT scan performed 24 hours post-event disclosed bilateral ischemia affecting the territories of the anterior and middle cerebral arteries. Regrettably, this catastrophic event precluded any potential for recovery. Consequently, the decision was made not to pursue further investigations to determine the underlying cause. The medical team opted for supportive treatment and comfort measures. Tragically, the patient died on the 37th day of hospital admission.

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Background: Primary mucinous lung adenocarcinoma, a subtype of lung adenocarcinoma, is extremely rare. Currently, as there are no specific diagnostic features, it is easy to delay the diagnosis or even to misdiagnose when atypical symptoms are present. Case summary: This case details a patient with primary mucinous lung adenocarcinoma and metastasis to the femoral head. The sole symptom was left hip pain and the initial diagnosis was isolated femoral head necrosis. Conclusions: By presenting this rare case report and the experiences learned from it, we hope to assist clinicians to identify bone metastasis cases with non-typical symptoms in order to make the correct diagnosis as soon as possible.

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Introduction: Dengue fever (DF) is endemic in numerous regions of Indonesia with primary clinical features such as high fever as well as pullout of intravascular fluid and albumin leakage, which provokes pleural effusion, hypoproteinemia, and blood hemoconcentration. However, the incidence of abdominal pain as a clinical manifestation of DF, which refers to acalculous cholecystitis, is rare. Case presentation: An 11-year-old female was admitted to the to hospital with fever, headache, and myalgia. Blood examination resulted in low platelet coua nt and positive IgM Dengue antibody test. On the third day, the patient felt sharp abdominal pain. Abdominal ultrasound showed cholecystitis, cholestasis, pleural effusion, ascites, and laboratory finding showed increased C-reactive protein. The management was conservative and discharged at the 7th day. Discussion: The acalculous cholecystitis in Dengue Fever/Dengue Hemorrhagic fever (DF/DHF) is challenging in diagnose due to atypical presentations. Several proposed mechanisms are critical illness, including direct invasion of the gallbladder epithelial cells, vasculitis, stasis of biliary flow, obstruction of the biliary tree, ischemia, and sequestration. The actual mechanism of the dengue virus has been proposed that direct viral incursion of the gallbladder may yield edema and exudation. Abdominal ultrasonography is considered to diagnose acute acalculous cholecystitis (AAC) in children. Conclusion: Understanding pathophysiology of the acalculous cholecystitis in DF/DHF patients and atypical presentation of sharp abdominal pain help physicians for early diagnosis and management both in monitoring and patient care management. Abdominal ultrasonography can help physicians to diagnose AAC.

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The left main disease is significant stenosis of the left coronary artery, which is responsible of supplying blood to a major portion of the left ventricle. In this report, we describe a unique case of critical left main disease with a special clinical presentation. A 66-year-old male with insignificant past medical history presented with dyspepsia. Patient presented twice to the emergency department seeking for help for his persistent complaint. During his second visit, patient was diagnosed with type one myocardial infarction and underwent coronary angiography which showed 90% stenosis in the left main coronary artery. Patient underwent successful coronary artery bypass grafting and was sent home. This case is a unique representation of type 1 myocardial infarction as the peak troponin I level does not correlate with the extent of the myocardium being jeopardized. A big portion of the heart is at risk of injury with the 90% stenosis found in this patient's left main coronary artery, yet the peak troponin I level is minimum. This report provides a possible explanation of the discrepancy between the peak troponin I level and the extent of the myocardium being jeopardized and describes a common yet easily missed clinical presentation of acute coronary syndrome. Left main disease is a relatively uncommon presentation of acute coronary syndrome, with potentially serious detrimental consequences. Discrepancies do occur among patients of critical left main disease, and promptly diagnosing and managing is of great importance.

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Myasthenia gravis (MG) is an acquired autoimmune disease. Its clinical manifestations comprise ptosis, diplopia, dysarthria, dysphagia, limb weakness, and in severe cases, respiratory muscle involvement. Dysarthria as an exclusive initial and primary complaint in MG is rare and seldom reported. In this paper, we report a case of type IIIb MG with isolated dysarthria as the only clinical manifestation and we review the relevant literature. The patient was a 62-year-old man who presented with episodes of slurred speech for 20 days that had worsened in the previous 9 days. His medical history comprised hypertension, diabetes mellitus, and coronary heart disease. The initial diagnosis on admission was transient ischemic attack. Careful re-examination of the patient's history revealed that his symptoms mainly involved increasingly worse slurred speech episodes without drinking or swallowing difficulties, and no significant improvement with rest was observed. Electromyography and autoantibody profiling led to a diagnosis of type IIIb MG. His symptoms improved after the oral administration of pyridostigmine bromide 60 mg. Laryngeal MG is important to differentiate from stroke. It is necessary to perform a computerized voice analysis when encountering patients with atypical symptoms of MG.

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BACKGROUND AND PURPOSE: Patients with cervical spondylosis often present with concurrent 'atypical symptoms' of unknown etiology that have been associated with cervical spondylotic disease, including dizziness, headache, nausea, tinnitus, blurred vision, palpitations, and memory and gastrointestinal disturbances. Few studies have addressed whether surgical intervention to treat classic symptoms of cervical spondylosis can also effectively alleviate atypical symptoms. Accordingly, the purpose of this study is to compare the ability of cervical arthroplasty (CA) and anterior cervical discectomy and fusion (ACDF) to alleviate atypical symptoms associated with cervical spondylosis. MATERIALS AND METHODS: A retrospective analysis of 140 patients with cervical spondylosis and associated atypical symptoms was performed. Atypical symptoms were defined vertigo, headache, nausea and vomiting, tinnitus, blur vision, palpitation, hypomnesia, and gastroenteric disturbances not otherwise explained by medical comorbidities. Seventy-eight patients (55.7%) underwent ACDF and 62 (44.3%) patients underwent CA. Demographics, surgical characteristics, patient reported outcome measures (PROMs), radiographs, complication rates, and resolution in atypical symptoms were recorded and compared between groups. Atypical symptoms were assessed using a 20-point system. All the patients had a minimum of five years follow-up. RESULTS: VAS, SF-36, JOA, and NDI scores improved significantly in all the patients (p < 0.001). At the last follow-up, the fusion rate was 97% in the ACDF group. Atypical symptoms improved in both groups (p < 0.001), although the ACDF group demonstrated greater improvement in headache and vertigo resolution compared to the CA group (p < 0.0001). CONCLUSIONS: While both ACDF and CA are effective in alleviating atypical symptoms associated with cervical spondylosis, ACDF demonstrated greater improvements in atypical symptoms.

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Aortic dissection is a relatively uncommon, although catastrophic, disease which requires early and accurate diagnosis and treatment for patient survival. Aortic dissection can be difficult to diagnose due to the diverse symptom presentation, which can lead to later diagnosis, resulting in a higher mortality rate. Here we present a case of type A aortic dissection with a varied symptom presentation, highlighting the importance of early detection and the Bentall procedure for management of such cases. A 50-year-old man with no known medical history presented with bilateral lower extremity swelling and fatigue for 2 weeks. The patient denied any chest pain or dyspnoea. Vital signs showed blood pressure of 160/76 mmHg, pulse of 103 bpm, respiratory rate of 18, and temperature of 36.7°C. Laboratory findings indicated a BNP of 1901 pg/ml and troponin of 0.5 ng/ml. An initial diagnosis of decompensated heart failure was made, and IV Lasix was started. Subsequently, an echocardiogram indicated an EF of 50-55% and ascending dissection of the aorta. A CT angiogram of the chest and abdomen confirmed this diagnosis. This patient presented with unusual symptoms of aortic dissection without the typical presentation of chest pain. It is important to consider aortic dissection in a cardiac-related case as prompt imaging can help confirm the diagnosis. We explore the risks and benefits of the Bentall procedure for the management and early detection of aortic dissection. LEARNING POINTS: The absence of chest pain does not rule out aortic dissection as 50% of patients are pain free.It is critical to diagnose aortic dissection early in the disease course as mortality increases by 1% per hour from symptom onset.The aim of this study is also to raise awareness among healthcare professionals about the Bentall procedure in patients with type A aortic dissection involving the aortic valve.

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Clinical presentation is one of the factors that can influence how quickly a patient with an acute coronary syndrome is treated, particularly if it is atypical. The purposes of this study are to explore gender-related differences in patients presenting with non-ST elevation acute coronary syndromes (NSTEACS) from the perspective of a series of common risk factors as well as treatment strategies and to evaluate the prevalence of atypical clinical presentation of NSTEACS in the study group. In addition, we explored the differences between the two entities that define NSTEACS: unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI). We conducted a retrospective study by reviewing discharge documents of patients admitted in the cardiology department of the Clinical Rehabilitation Hospital in Cluj-Napoca with NSTEACS between January 2014 and December 2015. We retrieved demographic data, clinical presentation and history, laboratory tests, and coronary angiography records as well as the implemented treatment strategies. Women in the study group were more frequently hypertensive than men (89.5% vs. 75.4%; p = 0.043), had a higher mean serum HDL cholesterol value (43 vs. 38 mg/dL p = 0.022), were more frequently diagnosed with microvascular coronary heart disease (32% vs. 9.8%, p = 0.036), and were more often treated conservatively (49.1% vs. 30.8%, p = 0.038), while men were significantly more prone to smoking than women (30.8% vs. 14%, p = 0.028) and had higher mean serum creatinine (1.2 vs. 0.8 mg/dL; p = 0.022) and uric acid values (6.9 vs. 6.2 mg/dL; p = 0.048). Out of the 122 included patients, 109 had documented information regarding symptoms. The prevalence of atypical presentation was 4.6% (95% CI 0.7-8.5%). In our study group, patients with UA had a more frequent history of cardiovascular ischemic diseases (77.4% vs. 56.7%, p = 0.015), the mean value for BUN was higher in NSTEMI patients compared to patients with UA (47 vs. 39 mg/dL, p = 0.038) and NSTEMI patients more frequently received interventional treatment compared to patients with UA (60% vs. 41.9%; p = 0.046).

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Malignant hyperthermia (MH) is an autosomal dominant genetic condition of the skeletal muscle triggered by inhaled general anesthetic agents or succinylcholine and associated with a hypermetabolic state and skeletal muscle rigidity. Tachycardia, increased carbon dioxide production, hypercarbia, hyperthermia, acidosis, hyperkalemia, cardiac arrhythmias, muscle rigidity, and rhabdomyolysis are common symptoms of MH. As the progression of the syndrome could be rapid or less evident, even experienced physicians have difficulty in diagnosing MH, which can lead to delays in treatment and increased mortality. We report a rare case of a 36-year-old man, who underwent open reduction and internal fixation of the left clavicle after inhaled anesthetics. The patient developed dyspnea, hypotension, unremitting hyperthermia, tachycardia, and elevated serum myoglobin, and finally died of pyemia and disseminated intravascular coagulation. We reviewed the process of disease development, summarized the steps of diagnosis, and improved genetic testing. Exome sequencing revealed a new mutation c.8519G>A (p.arg2840 GLN) in the RYR1 gene that could be associated with MH. The gene mutation was also found in his daughter's genetic test. This case emphasized the importance of the awareness of MH and its atypical clinical symptoms. The presence of dyspnea, hypotension, unremitting hyperthermia, tachycardia, and raised myoglobin in serum might further strengthen the clinical diagnosis of suspected MH.