Online Clinical Case Study (January 2017)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the January Cardiology Series is provided by:
Dr. CHEUNG Ling Ling
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
Dr. LI Ying Wah, Andrew
MBBS (HK), FHKAM (Med), Specialist in Cardiology
Dr. LO Ka Yip, David
MBChB (CUHK), FHKAM (Med), Specialist in Cardiology

一月臨床心臟科個案研究之內容承蒙張玲玲醫生李英華醫生盧家業醫生提供。

A 34-year-old man with dizziness and syncope

A 34-year-old Chinese man presented to the Accident and Emergency department for dizziness and one episode of syncope. He was a non-smoker and non-drinker. His past medical history included biopsy-proven minimal change glomerulonephritis since his teenage. He was put on cyclosporine A and oral steroid treatment, but the patient defaulted follow-up since 2013. On arrival to the Accident and Emergency department, he was found to be hypotensive with SBP 75mmHg and bradycardia with a pulse rate of 35 beat per minute. Moreover, he reported fever for 2 days. The travel history was unremarkable and the patient did not report any chest pain. His CXR was normal without features of pulmonary congestion. Figure 1 showed the ECG on admission.

Investigation showed relapse of nephrotic syndrome, with proteinuria 7.6g/day. His white cell count, renal and liver function tests were normal; ESR was 30mm/hr (normal <10); CRP was 57 ng/L (normal <5); creatine kinase was elevated to 596IU/L (normal 39-308) and high-sensitive troponin T was 1622ng/L (normal <14). Serum serology for Borrelia burgdorferi antibody was negative. Initial bedside echocardiography showed low-normal left-ventricular systolic function (LVEF ~50%) with mildly hypokinetic lateral wall. Coronary angiogram was normal. Cardiac MRI performed 20 days later showed no myocardial scar but a mass lesion inside RV cavity, which was only evident in repeated echocardiography but not the first one (Figure 2). Doppler USG of legs did not reveal any deep vein thrombosis.


Figure 1. ECG


Figure 2
A & B. No delayed enhancement of the core of RV mass following administration of gadolinium in short axis and four chamber view respectively.
C. No edema revealed in T2 weighted MRI.
D. The mass adjacent to RV free wall in off-axis four chamber view of repeated echocardiography.

1. What was the ECG diagnosis?
a. Acute ST-segment elevation myocardial infarction
b. Complete heart block
c. Second degree heart block
d. Right bundle branch block
   
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2.

Which was the most likely etiology for the diagnosis in question one?
a. Acute myocardial infarction
b. Myocarditis
c. Lyme disease
d. Idiopathic degeneration

   
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3.

What's the mass lesion inside the right ventricle?
a. Myxoma
b. Granuloma
c. Thrombus
d. Amyloid deposit

   
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Answer

Q.1 - b
Q.2 - b
Q.3 - c

Our patient was admitted to the coronary care unit and he was put on temporary transvenous pacing. The elevated inflammatory markers, regional cardiac motion abnormality and elevated cardiac enzymes established the clinical diagnosis of myocarditis. The complete heart block persisted for 4 weeks after presentation and permanent pacemaker was implanted.

Patients with myocarditis can develop both tachy- and bradyarrhythmias. Complete heart block and/or symptomatic bradycardia are indications for pacing during the acute phase of myocarditis. This conduction abnormality is often transient; as a result, use of a temporary pacemaker should be the first step and therapy is generally supportive.

High-grade AV blocks are uncommon in young or middle-aged adults, but when identified pose a dilemma. Decision for permanent pacemaker implantation in young adults should be judged with the anticipation of repeated device replacement in future. Therefore, it is very important to look for a cause for the AV block, which will help in adoption of appropriate treatment strategies. Common causes of complete heart block in young adults include:

1. Myocardial ischaemia or infarction
2. Infectious or noninfectious myocarditis
3. Infiltrative disease (e.g. amyloidosis)
4. Cardiomyopathies
5. Iatrogenic (e.g. medications or invasive procedures)
6. Idiopathic degeneration of the conduction system

MRI diagnoses myocarditis with an accuracy of 78% and may exceed that of other available invasive and noninvasive approaches, especially in early disease phase [1,2]. Studies evaluating the clinical course of myocarditis have demonstrated that hyperenhanced signals corresponding to tissue edema typically disappear within first 1-2 weeks in uncomplicated cases, whereas their persistence may indicate less favorable prognosis in terms of recovery of contractility.

Studies have demonstrated that MRI has at least twofold greater sensitivity for the detection of thrombi than echocardiography [3,4] . Due to their lack of contrast uptake, thrombi demonstrate low signal intensity on inversion recovery delayed-enhancement images. Hypercoagulability in nephrotic syndrome, even in absence of stagnant cavity blood flow, provide a nidus for thrombus formation. In this case, incidental finding of clot in RV by MRI would guide pacemaker implanter in cautious manipulation of pacing lead, so as not to dislodge the clot.

Reference:

  1. Liu PP, Yan AT. Cardiovascular magnetic resonance for the diagnosis of acute myocarditis: prospects for detecting myocardial inflammation. J Am Coll Cardiol. 2005;45:1823-1825
  2. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC white paper. J Am Coll Cardiol. 2009;53:1475-1487
  3. Srichai MB, Junor C, Rodriguez LL, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J. Jul 2006;152:75-84.
  4. Barkhausen J, Hunold P, Eggebrecht H, et al. Detection and characterization of intracardiac thrombi on MR imaging. AJR Am J Roentgenol. 2002;179:1539-1544
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Dermatology Series 皮膚科病例研究

Dermatology Series for January 2017 is provided by:
Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keung and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology

一月皮膚科個案研究之內容承蒙梁偉耀醫生鄧旭明醫生陳厚毅醫生關志強醫生張苗醫生提供。

A middle-aged gentleman with skin-colored growth on his forehead

A middle-aged man presented with 4-month history of asymptomatic skin colored growth on his forehead. There is no discomfort except occasional itchiness and bleeding. The patient was otherwise healthy and no medications were taken. On examination, there was a narrow skin colored frond-like growth on his forehead. No other skin manifestations were found.

Answers

1. What is the clinical diagnosis?
The clinical diagnosis is filiform wart, a variation of the common wart which is commonly found around the eyelids, face, neck or lips. It is caused by the human papilloma virus (HPV). Young adults and teenager are more commonly affected. They are usually asymptomatic and there might be itchiness or bleeding after scratching.
 

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2. What are the differential diagnoses?
The differential diagnoses included cutaneous horn, actinic keratosis, seborrhoic keratosis and squamous cell carcinoma.
 

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3. What are the causes and how are they transmitted?
Filiform wart is caused by HPV and strains 1, 2, 4, 27, and 29 are thought to be responsible for the cause. HPV is transmitted by direct skin-to-skin contact or autoinoculation, and the spread is much influenced by local and systemic immune factors in our body.
 

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4. How are they diagnosed?
The diagnosis of filiform wart is usually made on clinical basis, rarely, a skin biopsy may be considered in doubtful case. Dermoscopy may be used to distinguish other diagnosis.
 

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5. What are the treatment options?
Patients are advised against any scratching or picking which may make it spread. Despite spontaneous regression may occur in months, treatment is always recommended because of its contagious nature. Treatments include topical lotions and destructive methods such as electrocautery, cryosurgery and laser surgery. Salicylic acid lotion is a commonly used topical lotion, but it should be generally avoided or used with extreme caution when applied to the face and neck area due to its irritating side effects. Other treatments may include Imiquimod, intralesional bleomycin injections and systemic retinoids for recalcitrant warts and extensive warts respectively.
 

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