BNP is released from the atria.

False

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Elderly and women have BNP levels higher than those in younger individuals or in men.

True

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BNP is elevated in patients with renal failure.

False

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BNP is elevated in patients with septic shock, pulmonary hypertension and acute pulmonary embolism as well as in decompensated heart failure.

True

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Atrial natriuretic peptide (ANP) and BNP are members of a structurally related family of peptides that are produced and released from cardiac myocytes. In healthy patients, ANP is produced primarily in the atria and BNP primarily in the ventricles. Increased cardiac filling is a potent stimulus for peptide secretion. The pro-peptide itself circulates and is cleaved into the biologically active fragment (C-BNP) and the N-terminal pro-B-type natriuretic peptide (NT-proBNP), both of which are measurable in the plasma. The biological half-life of NT-proBNP is 60-120 minutes higher than BNP, which is 20 minutes.

Both ANP and BNP have natriuretic, diuretic, vasodilator and antimitotic properties that served to counterbalance the volume retaining, vasoconstrictive, and ventricular remodeling effects of rennin-angiotension-aldosterone system activation. They act as counter-regulatory hormones that are thought to play a role in the stabilization of circulatory function during the early stage of the progression of ventricular dysfunction. BNP or NT-proBNP were shown to have greater sensitivity and specificity than ANP or N-terminal ANP for both systolic and diastolic dysfunction.

While studies have shown that a very low BNP or NT-proBNP makes acute heart failure unlikely and a very high level makes acute decompensated heart failure very likely, one needs to note that a significant proportion of patients have their values that fall into a non-diagnostic middle range. In addition, the levels increase with advancing age and are higher in women than men. Other conditions, such as atrial arrhythmias, acute pulmonary embolism, pulmonary hypertension, septic shock may also increase their levels. Only limited data are available in renal failure, but current observations suggest that renal failure without concomitant left ventricular hypertrophy is not associated with elevated BNP.

Measurement of BNP or NT-proBNP levels certainly would be of value in the setting of emergency department and primary care in assisting in the diagnosis of patients with non-specific symptoms such as dyspnea. Their levels may also provide information on therapeutic response and prognosis.

The diagnostic role of BNP or NT-proBNP is currently a work in progress. Additional studies are needed to define more exactly their clinical utility in the diagnosis and management of acute decompensated and chronic heart failure. Their levels should be interpreted cautiously in conjunction with history, symptoms, findings on physical examination and results of other basic investigations such as ECG and CXR. Such measurements should not be viewed as a 'Yes or No' diagnostic test for heart failure and physicians' own skill and clinical judgment are always more important.

What is the clinical diagnosis?

The diagnosis is wart.

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What are the clinical differential diagnoses?

The clinical differential diagnosis for warts includes seborrhoeic keratosis, naevi, acrochordons, corns, cutaneous horn, molloscum contagiosum, chronic hyperkeratotic eczema, and rarely squamous cell carcinoma.

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What is the pathogenesis?

Warts are caused by human papilloma virus (HPV). There are different types of warts including common warts, plantar warts, plane warts and genital warts. More than 100 types of HPV have been identified. Different HPV types tend to occur at different anatomical sites. Common warts are usually caused by HPV types 2 and 4. Plantar warts are usually caused by type 1. Plane warts are usually caused by type 3 and 10. HPV are transmitted by direct or indirect contact.

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What are the possible complications of this condition?

The complications include transmission of the virus, pain, secondary bacterial infection and nail deformity. Genital warts may be associated with malignant transformation such as cervical cancer. Complications may also be related to treatment such as scar formation.

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What are the treatments?

In general, two third of warts will regress spontaneously within two years and benign neglect is an option. Treatment is recommended when the warts are extensive, spreading or symptomatic. There are many treatment options but none is uniformly effective. Salicylic acid is a common first line treatment and can be available as an over the counter medication. Other topical agents used for warts include retinoic acid, trichloroacetic acid, podophyllotoxin and imiquimod. Those who failed topical agent may consider cryotherapy, electrocautery and laser.

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