Online Clinical Case Study (November 2002)

Office Cardiology Series
臨床心臟科個案研究

Will you consider permanent pacemakers for following patients after reversible causes excluded?

1.

A 60 year old lady presented with congestive heart failure. ECG showed advanced second degree AV block with a block of two consecutive P wave and ventricular rate of 50/min. Intermittent complete heart block was documented in Holter tracing during exercise.

 
2.

A 50 year old asymptomatic gentleman with ECG showing type II second-degree AV block with associated LBBB and QRS duration of 0.16s.

 
3.

A 60 year old gentleman presented with syncope. ECG one month ago showed sinus rhythm with complete RBBB. ECG today showed sinus rhythm with LBBB.

The content of the Office Cardiology Series is provided by:
Dr. Lam Chiu Wah
 M.B.,B.S.(H.K.), M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P., Specialist in Cardiology
Dr. Wong Shou Pang, Alexander
F.R.C.P., F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
Dr. Li Siu Lung, Steven
M.B.,B.S.(H.K.), M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P., F.R.C.P. (Glasg.), Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙林釗華醫生、王壽鵬醫生及李少隆醫生提供。

Answers

Answers

Permanent pacemakers are indicated for ALL above three patients after reversible causes are excluded.

Discussion

Recommendations for Pemanent Pacing in Acquired Atrioventricular (AV) Block in Adults*

  1. Third-degree and advanced second-degree AV block at any anatomic level, associated with any one of the following conditons:

    1. Bradycardia with symptoms (including heart failure) presumed to be due to AV block.

    2. Arrhythymias and other medical conditions that require drugs that result in symptomatic bradycardia.

    3. Documented periodes of asystole greater than or equal to 3.0 seconds or any escape rate less than 40 beats per minute in awake, symptom-free patients.

  2. Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardia.

Comments

  1. Advanced second-degree AV block refers to the block of two or more consecutive P waves but with some conduced beats. It is a new indication for permanent pacing.

  2. Heart failure is specifically introduced as a major symptom that merits consideration when dealing with AV block-induced bradycarda.

  3. Exercise induced AV block suggests disease in the His-Purkinje system when ischaemia is excluded.

Recommendation for Permanent Pacing in Chronic Bifascicular and Trifascicular Block*

  1. Intermittent third-degree AV block.

  2. Type II second-degree AV block.

  3. Alternating bundle-branch Block.

Comments

  1. Type II second-degree AV block and a wide QRS suggest diffuse conduction system disease and is indicated for pacing even in the absence of symptoms.

  2. Alternating bundle-branch block refers to block in all three fascicules in successive ECGs, e.g. right bundle-branch block with associated left anterior fascicular block on one ECG and associated left posterior fascicular block on subsequent ECG or alternating right bundle branch block with left bundle branch block. This is a new indication for permanent pacing.

*Reference

ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices - A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation Oct 15, 2002.

Dermatology Series 皮膚科病例研究

A 35 year old gentlemen reported a two weeks' history of itchy pubis. There was no urethral discharge, vesicles or ulcers on the genitalia. He admitted recent venereal exposures with commercial sex worker. Examination of the pubis and genitalia revealed multiple small grey materials (Figure) on the pubic hair shafts. Small excoriations were also noted on the lower abdomen and pubis. Genital examination was unremarkable and groin lymph nodes were not palpable. Systemic examination was normal.

The content of the Dermatology Series is provided by:
Dr. Tang Yuk Ming, William and Dr. Chan Loi Yuen
Specialists in Dermatology & Venereology
皮膚科病例研究之內容誠蒙鄧旭明醫生及陳來源醫生提供。

Answers

1. What is the diagnosis?

Pediculosis pubis. The condition is caused by the crab louse Phthirus pubis, and is transmitted through sexual or close body contact. Hairs below the umbilicus and those on the pubis are most commonly infested.
 

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2.

What additional clue would you look for to support your clinical diagnosis?

Black specks and blood spots could be demonstrated on an unchanged underpant. Lice feed by sucking blood.
 

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3. If facility is available in your office, how will you confirm your clinical diagnosis?

Low power microscopic examination of pubic hairs looking for nits and/or lice.
 

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4. What blood tests you would like to suggest to the patient?

The patient should be advised to take blood for syphilis serology and HIV test.
 

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5.

What is the management?

Shaving of pubic hair is unnecessary. 0.5% Malathion lotion applied to dry hair from umbilicus, to perineum, perianal areas and thighs. This is then washed after 12 hours. Gamma benzene hexachloride and permethrin are also effective. Underclothing, towels and bed linen should be washed and ironed. Screening for other coincident sexually transmitted infections should also be done. Current sex partners should be screened and treated.
 

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