Online Clinical Case Study (January 2016)

Clinical Cardiology Series

The content of the January Cardiology Series is provided by:
Dr. CHEUNG Ling Ling
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology

A 27-year-old lady with shortness of breath

Ms. X was a 27-year-old lady who enjoyed good past health. She complaint of progressive shortness of breath on exertion in recent one week, associated with bilateral ankle swelling. On admission, her blood pressure was on low side 90/60. She was mildly tachypneic in room air. Physical examination was unremarkable except bilateral pitting oedema up to knees.

Her ECG (Figure 1) and CXR (Figure 2) were shown below.

Blood tests including complete blood picture, liver and renal function test were unremarkable. She had normal lipid and sugar profile. However, echocardiography showed very poor left ventricular ejection fraction of 20%, all chambers were dilated, there was moderate mitral and tricuspid regurgitation.

Figure 1

Figure 2

MRI was ordered for workup of congestive heart failure and images were shown below.

Figure 3

1. What is shown in Figure 1?
  Sinus tachycardia, poor R wave progression
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What is shown in Figure 2?

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3. What is shown in Figure 3?
  LV non compaction
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4. What is your management?
  Anticoagulation, ICD for primary prevention of sudden cardiac death, evidence based heart failure management, family screening
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Dermatology Series 皮膚科病例研究

Dermatology Series for January 2016 is provided by:
Dr. CHANG Mee, Mimi, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keung and Dr. LEUNG Wai Yiu
Specialists in Dermatology & Venereology

An elderly man with purplish papules on the leg

A 70-year-old man with background ischemic heart disease and diabetes presented with a few asymptomatic papules on his lower leg for 6 months. There was no history of trauma or insect bite. He had previous history of similar lesions which regressed with intralesional injection. He had no systemic symptoms otherwise. (Figure)

Multiple purplish papules with neighbouring yellowish-brown pigmentation on lower leg.


1. What is the most likely diagnosis?
The diagnosis is Kaposi's sarcoma (KS), classical type.

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2. What are the differential diagnoses?
The differential diagnoses are, lichen planus, prurigo nodularis, pyogenic granuloma, hemangioma, angiolymphoid hyperplasia with eosinophilia, cutaneous lymphoma and metastasis.

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3. What is the underlying cause of these lesions?
KS is a reactive cellular proliferation in response to angiogenic stimulus. HHV8 virus is known to be a causative trigger in all forms of KS. Classical KS occurs as slowly progressive violaceous maculopapules and nodules on the legs of the elderly. They become purple brown with greenish hemosiderin halo as they age. Other types of KS are associated with underlying immunosuppression (HIV positivity, treatment with immunosuppressives) or found in endemic population (African).

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4. How do you diagnose the skin disease?
The diagnosis of KS is confirmed on skin biopsy, showing endothelial proliferation causing slit-like vascular channels with extravasated red blood cells. It is also useful to exclude other differential diagnoses.

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5. What are the treatment options?
  Workup for underlying immunosuppression and staging investigations on major systems are needed before starting treatment. Solitary asymptomatic KS can be observed, or treated with tissue destruction (excision, cryotherapy, carbon dioxide laser) or allitretinoin gel. Second line therapy includes intralesional chemotherapy (vinblastine, vincristine, bleomycin or interferon), or radiation therapy. Disseminated disease warrants systemic chemotherapy (liposomal anthracyclines). In immunosuppressed patients, restoration of the immune system (highly active anti-retroviral therapy in HIV-positive patients, or reduction in immunosuppression therapy in transplant patients) is crucial, in addition to local therapy.
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