Online Clinical Case Study (July 2017)

Clinical Cardiology Series
臨床心臟科個案研究

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

七月臨床心臟科個案研究之內容承蒙張玲玲醫生提供。

A 79-year-old lady with chest pain

A 79-year-old lady was admitted due to chest pain for two days. It was associated with sweating and nausea and increased in intensity with exertion. She was haemodynamically stable on admission. The blood pressure was 150/70 (left arm) and 157/72 (right arm). Physical examination was unremarkable.

The ECG on admission was shown as follows:

She was afebrile, however blood result showed raised white cell 15.5( 3.7-9.3x109/L),
ESR 116mm/hr. Therefore, she was empirically started on ceftriazone.
Her Chest X-ray was shown below:

Serial Troponin T came back to be normal.
CT thorax was ordered and shown below:

1. What was the Chest X ray abnormality?
  Left hilar shadow
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2.

What was the CT abnormality?

  Contained rupture of mid thoracic aorta
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3.

What will you do next after CT finding?

  Urgent consultation of cardiothoracic surgeon
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4.

What is the possible cause of the condition in 3)?

  Mycotic aneurysm
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Dermatology Series 皮膚科病例研究

Dermatology Series for July 2017 is provided by:
Dr. KWAN Chi Keung, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, Dr. LEUNG Wai Yiu and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology
七月皮膚科個案研究之內容承蒙關志強醫生鄧旭明醫生陳厚毅醫生梁偉耀醫生張苗醫生提供。

Sudden onset painful vesicles

A 68 year-old gentleman complained left neck and left shoulder pain for 3 days. The pain was sharp in nature. Subsequently, multiple vesicles were developed over left neck and shoulder region. Clinical examination revealed multiple vesicular rash over left neck and left shoulder.

Answers

1. What are the differential diagnoses?
The differential diagnoses include immunobullous diseases like bullous pemphigoid, infectious diseases like herpes simplex, chickenpox, herpes zoster, bullous impetigo, erysipelas, inflammatory dermatosis like contact dermatitis, insect bite and accidental or non-accidental injury like scalded injury.
 

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2. What is your diagnosis?
The diagnosis is herpes zoster (shingles) at left C3/4 dermatome.
 

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3. What is the cause?
Herpes zoster is caused by varicella zoster virus (VZV) which is belonged to herpes family - herpesvirus 3. VZV is the cause of chickenpox in primary infection following the initial exposure to the virus. Then VZV remains dormant in the sensory nerve root until reactivation of VZV when the host immune mechanism is compromised caused by medications, illness, malnutrition or advance aging.
 

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4. What investigation would you offer?
The diagnosis of herpes zoster is mainly from history and its characteristic clinical presentation and no investigation is required in usual situation. It is characteristically presented as painful erythematous rash first and then blisters or vesicular rash developed along the dermatome without crossing the midline. Swab can be sent for viral culture or polymerase chain reaction (PCR) to confirm varicella-zoster virus (VZV). In case of herpes zoster happens in multiple dermatomes, severe immunocompromised such as HIV infection, internal malignancy, diabetes should be considered.
 

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5. How do you manage this gentleman?
Anti-viral treatment such as acyclovir, famciclovir and valaciclovir can reduce the pain the duration of symptoms. Analgesic for pain relief is commonly required. Systemic antibiotic may be needed if secondary infection occurs.
 

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