What are the abnormalities?

Right axis deviation with QRS +173^o. Decrease R wave amplitude from V1 across to V6.

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What is the diagnosis?

Dextrocardia. Make sure that the limbs leads of the ECG are not reversed before establishing the diagnosis.

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What further investigations are needed and what are other possible associated problems?

A chest X-ray to confirm dextrocardia. An echocardiogram to rule out any structural heart disease and congenital abnormalities. An abdominal ultrasound to establish any situs inversus. Dextrocardia with complete situs inversus occurs in about 2 per 10,000 live births. The incidence of congenital heart disease is relatively low in this group and is estimated to be around 3 percent. Dextrocardia with situs solitus or situs ambiguous is considerably less common and occurs in about 1 in 20,000 live births. However, the incidence of congenital heart disease is extremely high in this group, probably more than 90 percent. Cardiac malformations usually, although not invariably, are severe and complex, such as transposition of the great arteries; double-outlet right ventricle; ventricular septal defect; single ventricle; and pulmonary stenosis or atresia. Tetralogy of Fallot is uncommon. Polysplenia or asplenia is found in about one-third of patients with dextrocardia and almost invariably with situs ambiguous. Kartagener’s syndrome, the triad of situs inversus, sinusitis, and bronchiectasis, results from impaired ciliary movement. It is present in approximately 20 percent of patients with dextrocardia and situs inversus totalis.

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How to follow up this patient?

Medical management of patients with cardiac malposition is similar to that of patients with normally located hearts. For patients with asplenia, continuous daily antibiotic coverage and pneumococcal vaccine is recommended.

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References:

1. Hurst The Heart. 10th Edition. McGraw Hill.

What is the clinical diagnosis?

The clinical diagnosis is lymphangioma circumscriptum as the lesions persist for a long period and are localized. This condition is characterised by persistent, multiple clusters of vesicles measuring 2-4 mm in diameter. The vesicles represent superficial saccular dilations from underlying lymphatic vessels. They are usually clear although they may be discoloured by haemorrhage.

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What are the differential diagnoses?

Differential diagnoses for grouped vesicles include herpes simplex, herpes zoster, dermatitis herpetiformis, molluscum contagiosum and insect bite reaction. These are unlikely in this case because they are either more widespread or last for short duration.

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What are the investigations?

Skin biopsy for histology will confirm the diagnosis. Ultrasound and/or MRI scan should be performed to define the depth and extent of involvement before surgical intervention is performed.

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What are the possible complications of this condition?

Possible complications include pain, functional disturbance, bleeding and recurrent infection. There is no risk of malignant transformation.

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What are the treatments?

There is no satisfactory treatment for this condition. Antibiotics may be given for secondary infection. Individual lesion may be destroyed by cryotherapy, cautery, carbon dioxide vaporization and sclerotherapy. Radical surgery may be done but recurrence of lesions may occur due to the presence of deep component.

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