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and occupational therapy. Antioxidant therapy with co-enzyme Q10, vitamin E, and vitamin C were initiated. He was discharged with multi-modal support for cognitive impairment, central dysautonomia, decerebrate posturing, and spastic tone.
Discussion
“Chasing the dragon” is a subtype of TLE. The term refers to the mode of heroin inhalation by which powder is heated on aluminum foil and vapor is then inhaled. It is speculated that an impurity or additive in the drug becomes activated by heat, causing toxicity. Since this is a diagnosis of exclusion, other neurological conditions should be ruled out before making the diagnosis. This case also hyperactivity (seen with TBI, seizure, and spinal cord injury) manifesting here as a complication of TLE. Heroin inhalation leukoencephalopathy typically occurs in three stages, with some cerebellar signs such as ataxia and motor restlessness. Weeks later, a terminal phase displaying akinetic mutism and central pyrexia. abnormalities of the cerebellar hemispheres, the posterior limb
of the internal capsule, and often the corpus callosum, while sparing subcortical white matter, are characteristic of heroin inhalation toxicity. Treatment is supportive in regards to symptom management, and enzymes CoQ10 and vitamin E have shown some success in a few case studies. Care strategies are aimed
at controlling muscle spasms, reducing sympathetic nervous system activity by keeping hemodynamics within normal limits and improving functionality through physical and occupational therapy. Prognosis is variable but grim and patients usually require lifelong support.
RESIDENT POSTER HONORABLE MENTION 2
When Exercise is Deadly! — A Rare Case of ARVC
By Steven Cetel, DO; Ania Rodney, MD; Chelsea Walton and Hamid Deliri, MD
Case Presentation
to the cardiac ICU as an out-of-hospital witnessed cardiac arrest.
He hit a double and rounded home when he lost consciousness. He was pulseless and CPR was initiated with return of spontaneous circulation. En route to the hospital, he exhibited a wide complex tachycardia that resolved with chemical and electrical cardioversion. Upon arrival to the cardiac ICU, the patient had a Glasgow
Coma Scale score of 14. He was initially hypotensive, requiring vasopressors, but within 12 hours was able to be weaned off of these medications. His physical exam was benign.
During a similar presentation one year prior during a basketball
game, he had unremarkable ECG and transthoracic echocardiogram (TTE). Cardiac MRI was equivocal for Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D). TTE on this sinus rhythm showed deep T-wave inversions in leads V1 through V3. Another in-hospital episode of wide complex tachycardia had characteristics of ventricular tachycardia (VT), with left bundle branch block morphology. We also learned in this admission that criteria for ARVC/D diagnosis.
(AICD) implant for secondary prevention. Following discharge, he had appropriate anti-arrhythmic drug use and ablation to control his VT burden. In the follow-up, he had genetic testing positive for Pkp2 c.235C>T, which is the same causative mutation daughter. His left ventricular systolic function was improved
to low normal with guideline-directed medical therapy, and he remained arrhythmia-free.
Discussion
ARVD/C is an inherited cardiomyopathy that presents as ventricular arrhythmias due to ventricular pathological changes prevalence in the adult population is approximately 1 in 2000- 50001 ARVC/D is an important cause of sudden cardiac death
in young adults that accounts for around 11% of cases overall
and 22% in athletes in a study from northern Italy.2,3 In contrast, ARVD/C has been rarely diagnosed in the United States and therefore may be underdiagnosed here.
This case demonstrates the importance of thinking about ARVC,
strong genetic component of this disease needs to be recognized
cousin having the diagnosis was a missed opportunity for genetic screening that now has further implication for his daughter and her activity level. Our goal is to prevent these instances when exercise becomes deadly.
REFERENCES
1. Corrado, Domenico, and Gaetano Thiene. Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia. Circulation, vol. 113, no. 13, 3 Apr. 2006, doi:https://doi.org/10.1161/CIRCULATIONAHA.105.616490
2. Corrado, Domenico, et al. Screening for Hypertrophic Cardiomyopathy in Young Athletes. New England Journal of Medicine, vol. 339, no. 6, June 1998, pp. 364–369., doi:10.1056/nejm199808063390602
3. Corrado, Domenico. Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy. Circulation, vol. 101, no. 11, 21 Mar. 2000, doi: https://doi.org/10.1161/01.CIR.101.11.e101
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