Online Clinical Case Study (February 2017)

Clinical Cardiology Series

The content of the February Cardiology Series is provided by:
Dr. TAN GuangMing
MBChB, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology
Dr. CHEUNG Shing Him, Gary
MBBS, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology

A Patient with Renal Failure and Fluid Overload

A 40-year-old female with end staged renal failure on continuous ambulatory peritoneal dialysis was admitted for fluid overload. Dialysis regime was intensified but without significant improvement in fluid status. She was also found to have persistent sinus tachycardia and hypotension. Physical examination showed elevated JVP up to earlobes, and positive Kussmaul sign. Heart sound was not muffled but a vague rub was heard. Echocardiography was arranged with images of Tissue Doppler Imaging (TDI) and hepatic venous flow Doppler shown below.

TDI of Medical and Lateral Mitral Annulus

Pulse Wave Doppler of Hepatic Venous Flow

1. What other investigation may be considered?
A. Autoimmune marks to rule out rheumatological disease
B. QuantiFERON GOLD test to rule out tuberculosis disease
C. CT scan of the thorax
D. Right heart catheterization
E. All of the above
  Back to top

What did the TDI show?
A. Annulus paradoxus
B. Annulus reversus
C. Diastolic dysfunction
D. Normal TDI
E. A and B

  Back to top

What did the Hepatic Vein Flow show?
A. Hepatic congestion
B. Cardiac tamponade
C. Tricuspid regurgitation
D. Right ventricular failure
E. Expiratory diastolic reversal suggestive of constrictive pericarditis

  Back to top

How would you manage this patient?
B. Diuretics
C. Colchicine
D. Pericardiectomy
E. All of the Above except B

  Back to top


1 E, 2 E, 3 E, 4 E.

This patient suffers from constrictive pericarditis (CP) as evidenced by the typical echocardiographic finding of annulus paradoxus, annulus reversus, and expiratory diastolic reversal of hepatic vein. CP occurs when a thickened fibrotic pericardium, of whatever cause, impedes normal diastolic filling. Patients usually present with symptoms mimicking that of right ventricular failure and fluid overload. Commonest cause of CP is idiopathic. However, in this patient, the likely etiology is uremia. Other causes including infection such as viral or tuberculosis, autoimmune disease or radiation. Echocardiography remains an important tool for diagnosis of CP. Typical Echo findings of CP are: 1) respiration-related ventricular septal shift, (2) variation in mitral inflow E velocity, (3) preserved or supernormal medial mitral annular e' velocity, (4) reversed ratio of medial mitral annular e' to lateral e', and (5) hepatic vein expiratory diastolic reversal ratio. Treatment include a trial of anti-inflammatory drugs such as NSAID or Colchicine. Diuretics might be useful to relieve the symptoms. However, aggressive diuretics treatment may cause a drop in intravascular volume and hypotension. Surgical Pericardiectomy remained a definitive therapy for patients who remain symptomatic despite medical therapy.


  1. Imazio M; Brucato A; Mayosi BM; Derosa FG; Lestuzzi C; Macor A; Trinchero R; Spodick DH; Adler Y. Medical therapy of pericardial diseases: part II: Noninfectious pericarditis, pericardial effusion and constrictive pericarditis. J Cardiovasc Med (Hagerstown). 2010; 11(11):785-94.
  2. Welch TD, Ling LH1, Espinosa RE. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging. 2014 May;7(3):526-34. doi: 10.1161/CIRCIMAGING.113.001613. Epub 2014 Mar 14.
    Gonulkula SR, Spodik DH. Pericardial disease in renal patients. Semin Nephrol. 2001;1:52-58.
  3. Kleynberg RL, Klynberg VM, Kleynberg LM, Farahmandian D. Chronic constrictive Pericarditis in association with end stage renal disease. Int J Nephrol. 2011;2011:469602.
  Back to top

Dermatology Series 皮膚科病例研究

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

A nurse with itchy hand rash

A 25-year-old female nurse complained of itchy rash over both hands for a few days/weeks. The rash was worsening. She enjoyed good past health. Physical examination showed erythematous papules over both hands, wrists and distal forearms. The proximal border of the rash was sharply defined. Skin elsewhere was unaffected.


1. What is the clinical diagnosis?
The clinical diagnosis is allergic contact dermatitis. It is an acute allergic reaction caused by contacting a certain allergen to the skin. This nurse is suffering from allergic contact dermatitis to the latex.

Back to top


2. What are other common causes of this skin disease?
Apart from causing by the Latex, allergic contact dermatitis is commonly caused by:
1. Metal like nickel
2. Perfumes or chemicals in cosmetics and skincare products
3. Plants like poison ivy and oak

Back to top


3. What are the other daily used items that can cause this same skin disease for her?
Other possible causes that can cause allergic contact dermatitis include other latex medical products include: elastic bandages; urinary catheters; electrode pads; wound drains, stomach and intestinal tubes; Foley; protective sheets; etc.

Back to top


4. How do you diagnose this skin disease?
This skin disease is usually diagnosed clinically and no further investigation is needed. The rash usually completely clears up if no further contact to the allergen. Patch testing may be needed to confirm the cause of certain non-specific condition.

Back to top


5. What are the treatments and managements?
Most cases of allergic contact dermatitis will subside by itself. Potent topical steroid and oral antihistamine may be used to treat serious medical cases. It is also important to educate the patient to avoid contact with latex gloves and products and avoid places where she might inhale the powder from the latex gloves worn by other healthcare professional. Latex free gloves made of materials like vinyl and nitrile should be used instead to prevent future attack of allergic contact dermatitis.

Back to top


Back to Online Clinical Case Study