Online Clinical Case Study (February 2008)

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王壽鵬醫生提供。

A 40-year-old gentleman was admitted to hospital because of progressive shortness of breath

A 40-year-old gentleman was admitted to hospital because of progressive shortness of breath in the past week. Three weeks ago, he experienced flu-like symptoms and has felt unwell ever since. There was orthopnea and he could not walk up stairs and slopes due to shortness of breath. Physical examination revealed a raised JVP with bilateral ankle oedema and basal crepitations. He was a non-smoker with no history of diabetes, hypertension, or hypercholesterolaemia. This was his ECG on admission:

 

Answers

1.

His ECG was abnormal.

2.

His symptoms were suggestive of heart failure.

3. Blood for cardiac enzymes would be useful.
4. Echocardiogram would be useful for diagnosis.
5. Cardiac MRI would be useful.
 

All are true. This gentleman has the classical history and symptoms of acute myocarditis. Acute myocarditis often follows an upper respiratory infection. It may present with pleuritic chest pain or frank heart failure. ECG may show T wave inversions or non-specific changes. CK and LDH are usually elevated. Chest X-ray often shows cardiomegaly and congested lung fields. Echocardiogram is the most convenient non-invasive test to assess the myocardial function and size. On the other hand, cardiac MRI may also reveal the contractile function as well as signals that are suggestive of active inflammatory process.

Viral myocarditis is the usual cause and is frequently caused by coxsackieviruses, although other agents are also possible (e.g. rickettsial myocarditis, diphtheritic myocarditis, Chagas’ disease, toxoplasmosis and HIV/AIDS). Paired serum viral titres and serological tests may identify the underlying cause.

While endomyocardial biopsy may reveal the typical round cell inflammatory response with necrosis, the patchy distribution of the abnormalities makes the test relatively insensitive. Due to its invasive nature and the low sensitivity, this test is now rarely performed for the sole purpose of diagnosing acute myocarditis.

Supportive treatment for heart failure and arrhythmia is the mainstay of treatment, which may include diuretics, ACEIs, beta-blockers and digitalis. While specific antimicrobial therapy may be needed when a particular agent is identified, no specific treatment is available for coxsackieviruses. Immunosuppressive therapy with steroids and other agents have been advocated but its benefits have not been supported by controlled trials.

While many cases recover fully with time, some may deteriorate progressively into dilated cardiomyopathy and end stage heart failure. No predictive factors have been identified and continuous monitoring is essential for progress.

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Dermatology Series 皮膚科病例研究

A 65-year-old gentleman has had a "mole" over his left earlobe for more than 5 years. The lesion has enlarged progressively over the recent few months. There was swelling and pain on one occasion, and he was referred by his family doctor for exclusion of skin cancer. Physical examination revealed a 1-cm diameter hard papule with warty surface and hetereogenous pigment.

The content of the Dermatology Series is provided by:
Dr. CHAN Loi Yuen, Dr. TANG Yuk Ming, William, & Dr. MAK Kam Har
Specialists in Dermatology & Venereology
皮膚科病例研究之內容誠蒙陳來源醫生、鄧旭明醫生及麥錦霞醫生提供。

 

Answers

1.

What is the clinical diagnosis?

The clinical diagnosis is seborrhoeic keratosis (SK), also called basal cell papillomas and senile warts. It is the most common benign tumour in older individuals. Typically SK is a slightly raised, light brown to black in colour, sharply demarcated papule or plaque. The lesion shows a warty surface and appears to be “stuck on” the skin surface.

 

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2.

What are the differential diagnoses?

Differential diagnoses for SK include common wart, epidermal naevus, melanocytic naevus, solar keratosis, pigmented basal cell carcinoma and malignant melanoma.

 

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3.

What is the pathophysiology?

It is considered to be a degenerative or ageing change.

 

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4.

How can it be differentiated from malignant melanoma?

SK has a regularly shaped warty appearance, while melanoma usually has a smooth surface and slightly infiltrating pattern. However, SK may be caught on clothing and become red and swollen. Irritated SK may resemble a skin cancer.

 

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5.

What are the treatment options?

Most small lesions do not require treatment. Treatment options include removal by cauterization and curettage, cryotherapy, laser or shave excision. Diagnostic skin biopsy should be considered if the lesion appears atypical.

 

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