(P44) Between a Hydatid and a Heart Place

62 y.o. Albanian-speaking male with a past medical history of HFrEF ( LVEF 25%, ischemic CM), s/p PCI with 2 DES in 2014, DM, HLD, and HTN. He was brought in by EMS from home due to bilateral shoulder pain. He traveled to the US from Montenegro the day before presenting to the ED. Before leaving his home, he had one episode of sweating. In the airplane, he had bilateral shoulder pain and felt fatigued, symptoms had resolved by the time he arrived in the US. He had remained free of chest pain, shoulder pain, fatigue, diaphoresis, and lightheadedness in the interim. His daughter was concerned about a possible heart attack and thus called an ambulance. He endorsed good adherence to medications, is a nonsmoker, and had not experienced abdominal pain, nausea, vomiting, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity swelling. VS wnl. EKG revealed STE in V1-4, I and aVL w/ q wave, ST depression in III. POCUS Cardiac revealed reduced LVEF, diffuse hypokinesis, apical dyskinesis w/ no apparent thrombus, and minimal MR/TR. Troponin T 1.260 ug/L uptrend to 1.350 ug/L 4 hrs later. Pro BNP 2091.0 pg/mL. CK 426 U/L downtrend to 293 U/L 4 hrs later. Cr 1.2 mg/dL. The patient was treated for ACS and admitted for further cardiac work-up. LHC showed 100% CTOs of L-sided circulation and 50% RCA with R to L collaterals. Cardiac MRI showed no myocardium viability of LAD territory. CABG was deferred and he was placed on GDMT with a plan for eventual ICD. The cardiac MRI incidentally found multiple liver/renal cysts. CT abdomen found a new 11x11x13 cm thick-walled multiseptated cystic hepatic lesion in contact with the IVC/hepatic veins. Further investigation revealed the patient had a history of cystic echinococcosis (CE - one of the four forms of Echinococcosis) and had undergone surgical right hepatic resection 13 years prior. (There is about 6.5% relapse rate after surgical intervention) A multidisciplinary team evaluated the case and deemed the patient was a moderate-risk candidate for a high-risk procedure such as liver cyst removal (there is a 2.2% postoperative death rate for CE surgical patients). The Infectious Disease (ID) specialist decided to hold treatment with albendazole due to the risk of rupture, specifically due to the large size of the cyst. ID followed in the outpatient clinic and the patient was eventually referred to a quaternary care center where he underwent open partial hepatectomy w/ fenestration and evacuation of cysts. The operative note confirmed the disease was isolated to the liver only and the pathology report was consistent with an echinococcal cyst. He was started on albendazole 400 mg BID. The patient eventually returned to Montenegro, where he had no access to Albendazole. ID specialist clinic was able to procure the medication and give him enough to complete the 6-month treatment. He continued to be in contact with the ID specialist in the US for routine laboratory work and monitoring. He is recovering well.