BACKGROUND: Immune checkpoint inhibitors (ICI) have changed the treatment scope for malignancies. The mechanism of ICIs is targeting of immune checkpoints that can suppress a response to a stimulus which can effect any organ. Adverse effects are usually mild but myocarditis, although rare, is becoming more recognized as a life threatening entity. The increase in mortality seen with ICI-induced myocarditis is more frequent with combination therapy. Most cases of ICI-induced myocarditis are limited to direct myocardial injury but there is a lack of evidence regarding conduction disease. CASE DESCRIPTION: We present a 74-year-old man with known metastatic malignancy recently started on ICI with ipilimumab and nivolumab who presented with complaints of abdominal pain, SOB and chest pain. His ED workup was consistent with colitis and acute PE without RV strain. Troponins and BNP were elevated and his ECG showed 3rd degree AV block. A coronary angiogram was negative for obstructive CAD and a temporary trans-venous pacemaker was placed. Cardiac MR showed LGE with active inflammation of the mid-myocardium. The patient had complex presentation as a side effect of ICI leading to myocarditis, 3rd degree AV block, colitis and PE. He was started on high dose methylprednisolone 1gm daily. Within 24 hours there was improvement evidenced by intermittent return of intrinsic conduction. At 48 hours there was marked improvement with restoration of sinus rhythm without evidence of AV block and/or use of the temporary pacemaker. Discussion: Early recognition of disease processes is difficult when there is minimal data to support a cause and effect. Increasing clinical awareness regarding adverse effects of ICI is paramount in decreasing the risk for unnecessary therapies, in our case, placement of a permanent pacemaker. Although there have been case reports of ICI-induced myocarditis, there has not been expert consensus regarding management of conduction pathway abnormalities.

Introduction: Allergic contact dermatitis to cardiac rhythm devices (CRD) has been reported sporadically from the early 1980s to present. Most of these cases involve allergic reactions to direct contact agents such as nickel, silicone, titanium, cobalt, epoxy resin, mercury, polysulfone, polyurethane and polychloroparaxylene. Our case is unique in that the strongest allergic reaction was with thiuram and P-phenylenediamine (PPD), which has only been documented once since the advent of permanent pacemakers (PPM) Case: 58-year old male with history of hypertension and coronary artery disease presented with palpitations and fatigue. Holter monitoring demonstrated tachybrady syndrome and he underwent dual chamber PPM implantation (L331 Accolade TM MRI - Boston Scientific Inc). Eight weeks later he presented with new onset rash around his neck and the surgical site. PPM allergy was suspected, as patient did not respond to empiric antibiotics. He underwent PPM and lead extraction. Decision was made to observe patient without immediate re-implantation of PPM. Skin patch testing was strongly positive to thiuram and PPD. Final diagnosis of allergic contact dermatitis was made and patient’s condition improved. Discussion: Thiuram and PPD, the raw materials used in the production of silicone rubber, encase pacemaker headers and leads. Individuals typically get sensitized to PPD by using hair dyes or temporary henna tattooing. The device used in our patient contained the same compounds. No studies to date document the true incidence and/or prevalence of allergic reactions to pacemaker components. One non-randomized retrospective trial reported benefits of skin patch testing before CRD implantation in patients who had a history of allergy to metals. Future trials are warranted to further evaluate the efficacy and benefits of pre-implantation skin testing and if it would benefit the population as a whole.

BACKGROUND: Acute pericarditis is the most common disorder affecting the pericardium. It accounts for less than 1% of patients who are admitted to the hospital for non-ischemic chest pain and 5% who present to the emergency department with non-ischemic chest pain. The most common etiology of acute pericarditis in developed countries is idiopathic although a pre-disposing viral illness has also been recognized as a common cause. Infectious etiologies in developed countries have been seen with commonly occurring viruses such as coxsackievirus, echovirus, adenovirus and less frequently EBV. CASE: We present a 41-year-old man who came in with fevers, rigors, shortness of breath and chest pain. Transthoracic echocardiogram was (TTE) demonstrated a large pericardial effusion without evidence of tamponade. He underwent a diagnostic pericardiocentesis followed by a pericardial window during his initial hospitalization without any complications and was discharged home on NSAIDs and colchicine. Serology results demonstrated positive EBV IgG and Nuclear Antigen, concerning for active EBV pericarditis. Pathology resulted as necrotizing pericardial tissue with diffuse inflammation. The patient was readmitted within 48 hours with worsening shortness of breath and leg edema. Repeat TTE revealed a large recurrent pericardial effusion with right ventricular collapse concerning for tamponade. The patient was ultimately transferred to a tertiary care center for pericardiectomy evaluation. DISCUSSION: Ebstein-Barr virus is rarely an etiology of acute pericarditis, much less necrotizing pericarditis. When identified it should raise concern for long term complications such as recurrent pericarditis and tamponade. We believe patients who have evidence of necrotizing pericarditis are at a high risk for constrictive pericarditis and should not only have closer follow while maintaining a low clinical threshold for definitive treatment with pericardiectomy.

Background: Patients on systemic anticoagulation are at increased risk for gastrointestinal bleeding (GIB). Guidelines recommend endoscopy within 24 hours for diagnostic and therapeutic purposes. Unfortunately, lack of resources and/or gastroenterologists in small, community centers limit the ability to perform timely endoscopy. Conservative management is used in this setting with delayed or outpatient endoscopy, specifically in those who respond to medical therapy. There is minimal data on the outcomes of patients managed in this fashion. Objective : To compare outcomes of patients on systemic anticoagulation who present with non-variceal upper GIB in a small community hospital. Design: We conducted a retrospective cohort chart review. Participants : 115 adult patients who met the inclusion criteria for non-variceal upper GIB on systemic anticoagulation. Excluded patients were those on dual antiplatelet therapy, history of decompensated cirrhosis, variceal bleeds, active GIB identified on imaging (defined as contrast extravasation on CT angiogram or positive tagged RBC nuclear scan), and those with gastrointestinal malignancy. Interventions : Resuscitative medical therapy (MT) alone vs inpatient endoscopy with resuscitative MT. Main Measures: Outcomes included red blood cell (RBC) transfusions, re-admission for GIB, and 30-day all-cause mortality. Sub-group analysis was also performed based on endoscopy timeline and anticoagulation type. Key Results : Patient in MT group required less RBC transfusions compared to endoscopy group (1.4 vs 2.5 average units, [95% CI 1.01-1.87]; P=0.004). There was no statistical significance for re-admission for gastrointestinal bleeding or mortality between both groups. Moreover, there was no significant difference in RBC transfusions based on EGD timing. Most patients were on warfarin (n=47) and there were no differences in re-admission for GIB or mortality based on anticoagulant use. Conclusion : Our study suggests that there is no significant therapeutic benefits to inpatient endoscopy in comparison to medical management alone in anticoagulated patients who present with non-variceal UGIB.

INTRODUCTION: Patients on systemic anticoagulation are at increased risk for gastrointestinal bleeding (GIB). In those that present with GIB, resuscitation and support remain the standard of care. Guidelines also recommend endoscopy within 24 hours for diagnostic and therapeutic purposes. Unfortunately, lack of resources and/or gastroenterologists in small, community centers limit the ability to perform timely endoscopy. Conservative management is used in this setting with delayed or outpatient endoscopy, specifically in those who respond to medical therapy. There is minimal data on the outcomes of patients managed in this fashion. We look to compare presentation and outcomes of patients on anticoagulation who present with non-variceal upper GIB in a small community hospital. METHODS: We conducted a retrospective review of 115 patients with non-variceal upper GIB who underwent medical therapy (MT) alone vs inpatient endoscopy with MT. Outcomes included red blood cell (RBC) transfusions, re-admission for GIB, and 30-day all-cause mortality. Sub-group analysis was also performed based on endoscopy timeline and anticoagulant type. RESULTS: The MT group was comprised of 54 patients while 61 patients underwent inpatient esophagogastroduodenoscopy (EGD). There were no difference in age, gender, baseline laboratory values, or co-morbidities between both groups. Patient in the MT group required less RBC transfusions compared to EGD group (1.4 vs 2.5 average units, P = 0.004). There was no significant difference in the re-admission for GIB and overall mortality. There were 3 deaths, one in the endoscopy group (<24 hours) and 2 in the MT group (P = 0.60). Most patients were on warfarin (n = 47) and there were no differences in re-admission for GIB or mortality based on anticoagulant type. CONCLUSION: We aimed to evaluate outcomes in patients on chronic anticoagulation with non-variceal UGIB at a small, community medical center where urgent endoscopy cannot always be performed. In this retrospective study, we found that patients receiving MT only required significantly fewer blood transfusions than those undergoing endoscopy with no difference in recurrent GIB or mortality. Our study suggests that in a small, community center, conservative management could be employed safely if urgent endoscopy is not available. Nevertheless, a randomized, large study is needed to substantiate this claim.Table 1.: Demographic data comparing endoscopy group with Medical Therapy only groupFigure 1.: Average number of packed red blood cell transfusions was greater with endoscopy.Table 2

Ventricular fibrillation is a fatal arrhythmia due to its detrimental impact on cardiac output. Managing patients in V-Fib arrest is often challenging, but newer mechanical support devices such as Impella CP 5.0 (Abiomed, Danvers, MD) are proving to be an excellent adjunct to inotrope and vasopressor therapy. We present a 75-year-old female with a medical history of atrial fibrillation and obstructive sleep apnea that presented to the ER unresponsive. On arrival, the patient was pulseless and initial rhythm on telemetry revealed ventricular fibrillation. The patient demonstrated minimally reactive pupils to light, negative corneal reflex, and lower extremity clonus. ROSC was achieved with electric defibrillation and two rounds of CPR. Chest radiograph revealed mild bilateral pulmonary congestion. Head CT revealed no acute intracranial pathology. The patient was placed on targeted temperature management protocol for the next 48 hours. Emergent left heart catheterization revealed no signs of occlusive coronary disease. TTE revealed left ventricular ejection fraction 5-10%, likely from stunned myocardium. The patient continued to clinically decline and decision was made to place an Impella device for further hemodynamic support. Unlike ECMO, the Impella fully unloaded the LV and allowed diastolic coronary filling. The patient ultimately demonstrated significant improvement and repeat TTE revealed an improved EF of 45-50%. Prior to hospital discharge, an AICD was placed for primary SCD prevention. The patient maintained close outpatient follow-up with her cardiologist and PCP. This case illustrates the importance life-saving mechanical support devices such as Impella in the setting of cardiogenic shock, even from non-ischemic ventricular fibrillation.

Rituximab is a chimeric monoclonal antibody against the protein CD20 which is predominantly found on the surface of B cells. Malignant B cells express higher levels of CD20. Rituximab not only induces cellular apoptosis but also down regulates the B cell receptor and mediates antibody dependent