Ventricular premature beats are noted.

True

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Electrophysiology study is indicated.

False

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False

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False

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Ventricular premature beats is a common clinical problem. It is characterized by the premature occurrence of a QRS complex that is bizarre in shape and has a duration usually exceeding the dominant QRS complex, i.e. generally greater than 120 ms. Its prevalence increases with age and is associated with male sex and reduced potassium concentration. It is usually self limiting but, at times, can be very disturbing to the patient. The most important clinical question is, are the premature beats idiopathic/primary or secondary to structural or ischaemic heart disease?

A full 12-lead ECG is mandatory to document the baseline rhythm and electrical characteristics. A chest X-ray is useful to rule out any obvious pulmonary condition. Routine blood tests to rule out any electrolyte or thyroid abnormality are useful.

Echocardiography would be useful to rule out any structural heart disease including cardiomyopathy and valvular heart disease, which can sometimes cause ventricular premature beats.

Treadmill stress test would also be useful to rule out any coronary heart disease and to assess the relation of the premature beats to exercise. While some ventricular tachycardia is exercise-induced, in patients with benign isolated ventricular premature beats, very often the premature beats decrease with exercise.

A 24-hour Holter monitoring is useful to quantify the frequency of ventricular premature beats for surveillance purposes. It may also detect any subclinical runs of non-sustained or even sustained ventricular tachycardia.

In general, isolated ventricular premature beats with the standard preliminary investigations discussed above do not require active treatment. There is no evidence that suppressing the premature beats, either medically or via other means, will confer any benefit on the long-term outcome. Electrophysiology study or radiofrequency ablation is not indicated for simple benign ventricular premature beats. Similarly, medical treatment is rarely indicated. In symptomatic patients, a short course of beta-blockers such as inderal or betaloc may be helpful. Second-line anti-arrhythmic drugs such as amiodarone are generally not indicated and are usually reserved for refractory cases with their use limited to a short period of time.

What are the clinical diagnosis and differential diagnoses?

The clinical diagnosis is erythema multiforme minor. The differential diagnoses include secondary syphilis, acute dermatitis, urticaria and granuloma annulare.

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Describe the appearance of the typical target lesion.

The target lesion is said to be hallmark of this skin disorder. A typical target or “iris” lesion is characterized by a central dusky erythematous area surrounded by a pale oedematous ring with a peripheral erythematous margin.

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What are the common antigenic stimulants of this skin disorder?

Erythema multiforme is a type of hypersensitivity (allergic) reaction that occurs in response to one of the etiologic factors capable of generating foreign antigens. The three best documented and described associations include herpes simplex infection, mycoplasma infection and drugs (e.g. sulphonamides, phenytoin, barbiturates, penicillin and allopurinol).

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How does it differentiate from the severe form of this skin condition?

The eruptions of erythema multiforme minor are usually confined to the extensor aspects of the extremities. There were no systemic symptoms, and no or little mucosal involvement. It is most often associated with herpes simplex infection, as in this lady. The severe form of erythema multiforme (erythema multiforme major/ Stevens-Johnson syndrome), usually as a result of drug reaction, always occurs with mucosal involvement and more generalized cutaneous involvement.

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How should this woman’s condition be managed?

For the typical attack of erythema multiforme minor, symptomatic treatment will suffice, as it is a self-limiting condition lasting from 2 to 4 weeks. In those with HSV-associated EM with frequent recurrences, prophylaxis with oral acyclovir for 6–12 months may be considered.

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