Online
Clinical Case Study (April
2007)
Clinical
Cardiology Series
臨床心臟科個案研究
The
content of the Office Cardiology Series is provided by:
Dr. LI Siu Lung, Steven
F.H.K.A.M. (Med), F.R.C.P. (Glasg), F.R.C.P. (Edin), F.R.C.P.
(Lond), 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
臨床心臟科個案研究之內容誠蒙李少隆醫生及王壽鵬醫生提供。
An 84 year old gentleman
was admitted because of recurrent dizziness and near syncope. This was his ECG.
Answers
| 1. |
What
are the abnormalities?
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The ECG showed
isolated ventricular premature beat, fi rst degree heart block, right
bundle branch block and left posterior hemiblock.
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| 2. |
What
is the diagnosis?
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The ECG diagnosis
is trifascicular block. The conduction system consists of three fascicles:
right bundle branch and the left anterior and posterior fascicles of the
left bundle branch. Tri-fascicular block is present when there is a combination
of bifascicular block and fi rst degree atrioventricular block. Bifascicular
block, in turn, refers to conduction disturbances affecting two of the
fascicles, most commonly right bundle branch block plus left anterior
fascicular block. Left posterior hemiblock is much rarer than left anterior
hemiblock and its typical features include: right axis deviation in the
frontal plane (>+100 degrees), rS complex in lead I, qR complexes in lead
II, III, aVF, with R in lead III>lead II.
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| 3. |
What
treatment is needed? |
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More than
5% of patients with trifascicular block may progress to complete heart
block. The recurrent symptoms of this gentleman may be related to intermittent
complete heart block, although it may sometimes be diffi cult to obtain
ECG documentation. To prevent the associated hazard of complete heart
block (e.g. bradycardia related hypotension and fall/head injury), prophylactic
placement of permanent pacemaker may be helpful if no other causes of
recurrent dizziness/syncope can be identifi ed.
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Dermatology
Series 皮膚科病例研究
A 54 year old gentleman
presented with papules on scalp, chest and upper back for two months. The papules
turned into "hard scales" later on. The lesions on scalp were mildly
pruritic but those on body were painful. There was appearance of single blister
of the oral cavity once about a month after onset of the skin lesions. The blister
spontaneously ruptured and healed that day. There was no systemic upset. He
was diagnosed to have seborrheic dermatitis by general practitioner but the
treatment was not effective. He enjoyed good health all along and there was
no history of intake of medication or herb prior to the onset of skin lesions.
On examination, there was large area of thick crusting over the frontal scalp.
Multiple erythematous patches with crusting or scabbing were found scattering
over the chest and upper back. One small blister was detected on his right scapular
region. Oral mucosa was intact.
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The
content of the Dermatology Series is provided by:
Dr. MAK Kam Har, Dr. TANG Yuk Ming, William, Dr. CHAN Loi Yuen & Dr.
CHOW Ka Yuen
Specialist in Dermatology & Venereology
皮膚科病例研究之內容誠蒙麥錦霞醫生、鄧旭明醫生、陳來源醫生及周家源醫生提供。 |
Answers
| 1. |
What
is the most likely diagnosis and what are the differential diagnoses?
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This patient
suffered from pemphigus vulgaris. It is a chronic immunobullous disorder
of skin and mucous membranes that histologically shows clefting between
the basal cell layer of the epidermis and the suprabasilar epidermis.
Other differential diagnoses include erythema multiforme, impetigo, other
immunobullous disorders such as bullous pemphigoid and pemphigus foliaceus.
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| 2. |
How
could one confi rm the diagnosis?
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Diagnostic
skin biopsy for histology with immunofl uoresence is mandatory for immunobullous
disorders. Circulating anti-skin antibody should also be checked to confi
rm the diagnosis of pemphigus vulgaris and to monitor the disease activity.
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| 3. |
Where
is the more commonly affected site when this disease begins?
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More typically,
pemphigus vulgaris starts as painful erosions in the mouth and months
may elapse before skin lesions occur.
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| 4. |
What
is the mainstay of treatment for this skin disorder?
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High dose
of oral corticosteroids is required initially to stop formation of new
blisters. It is then tapered slowly over months. Other immunosuppressants
such as azathioprine, cyclophosphamide are often given concomitantly for
their steroid-sparing effect.
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| 5. |
What
is the prognosis?
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Before the
introduction of corticosteroids, the mortality was 99% by 5 years. Nowadays
the mortality rate is markedly reduced and death is almost invariably
due to complications of the immunosuppressive therapy.
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