What did the ECG during chest pain show when compared with that at rest?

The ECG showed ST elevation at aVR and widespread ST depression at V2-6 and leads I,II,III,aVL and aVF.

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What diagnosis should you consider based on this finding?

Left main coronary artery disease or severe triple coronary disease must be considered in this patient.The widespread ST depression indicated that extensive ischemia was present and triple vessel disease must be considered. There have been reports showing that ST elevation at aVR was associated more frequently with left main artery disease with up to 81% sensitivity and 80% specificity.

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What was the investigation as shown in Fig. 3 and what was the major finding?

This was a picture of her coronary angiogram showing a critical distal left main artery stenosis (Fig.4). She also has a 60% proximal right coronary artery stenosis that was not shown here.

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How would you treat this patient?

Coronary artery bypass surgery is the gold standard for the revascularization of left main artery disease, although percutaneous coronary intervention (PCI) is now emerging as a promising alternative in selected patients. In general, ostial or mid left main diseases pose less technical concern for PCI when compared with distal left main lesions, which involve bifurcation or trifurcation branches.

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Clinicians should keep a high alert for ECG signs that signify a high probability of triple vessel disease or left main artery disease when treating patients with acute coronary syndrome. In general,patients with acute coronary syndrome who are scheduled for coronary angiogram would usually receive Clopidogrel beforehand to facilitate subsequent PCI should this be needed.However, bypass surgery under the effect of Clopidogrel would encounter great hemostasis problem and in general, Clopidogrel should preferably be taken off for a few days before bypass surgery is performed. Identifying patients at risk of left main disease might minimize such delay by withholding the initial loading of Clopidogrel.

What is the clinical diagnosis?

The clinical diagnosis is erythema nodosum (EN). EN is a delayed hypersensitivy reaction to some antigenic challenge. Most commonly females aged 15 to 30 years are affected.Clinically there are tender erythematous nodules and plaques on both legs, especially pretibial region. Histologically, there is septal panniculitis (inflammation of connective tissue septa between fat lobules). There may be fever, malaise and arthralgia.

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What are the clinical differential diagnoses?

Clinical differential diagnoses include erythema induratum, erysipelas, insect bite reaction, cellulitis and acute urticaria.

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What are the possible causes for this dermatosis?

EN may be caused by infective agents such as streptococcus, tuberculosis, leprosy, yersinia, mycoplasma, coccidioidomycosis and histoplasmosis. Drugs causing EN include oral contraceptive, sulfonamide, phenytoin, and halide. Other causes include sarcoidosis, inflammatory bowel disease, Behcet's disease, pregnancy and malignancies such as lymphoma. Among these, the most likely causes of EN are streptococcus and tuberculosis. In western population, sarcoidosis is also a common cause. However, about 40%EN cases are idiopathic.

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What are the investigations?

Investigations include erythrocyte sedimentation rate, antistreptolysin titre,throat swab for culture,chest X-ray and tuberculin test.Skin biopsy may be required.

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What are the treatments?

Possible underlying causes should be identified and treated. Treatment is with bed rest and leg elevation. Non-steroidal anti-inflammatory drug is the first line treatment. Potassium iodide and colchicine are alternative choice. Systemic steroid can be used in severe cases if infection is excluded. The condition usually resolves within six weeks although idiopathic cases may persist for six months.

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