Case Report


Ahmed Taha Hussein
           Assisstant Lecturer
            M.Sc. cardiology
          Zagazig University
Basic Data

• Female patient 60 years old , widow ,not
  DM nor HTN ,
• with relevant past history of cervical and
  lumba...
HPI

• the condition started 6 m ago by acute dyspnea
    associated with cought and expectoration of
    yellowish sputum...
HPI

• Dyspnea progressed in orthopnea and
  patient preferred the Prayer’s position .
• 1 week later patient developed pe...
Clinical examination


• Vital examination :
    •   Pulse : 100 Bpm regular thready pulse.
    •   Bl. Pr.: 90 / 70 .
   ...
Clinical Examination

• Chest Examination :
  – Dullness on percussion on the right side up to ½
    chest.
  – Diminished...
ECG




•   ECG:
•   Low voltage
•   Non specific T wave changes.
Imaging
• CXR :
• Encysted pleural effusion
    on the right side .
•   Pleural wall thickening and
    interlobar pleural...
Pelvi-Abd US

• Mild free peritoneal fluids.
• Within normal size liver and spleen.
• No masses or foci can be identified ...
LAB
•   CBC :                  • Ca+2 :
•   Microcytic anaemia     • 11.5 mg/dl
•   ESR :
•   Moderate elevation .
•   Nor...
A4CV
A4CV
PLAV
MV FLOW
TV FLOW
2nd step for diagnosis?
  Pleurocentesis : failed
  US guided also failed .



        CT ch est with IV contrast
CT
• Moderate
    pericardial effusion
•   Thick pericardium
    with calcification

• Thick pleural wall
CT




INTERLOBAR THICKENING
Other investigations were
recommended to reach the
         diagnosis
           of the


   polyserositis
XR of the hands



• Lytic lesions of
  the heads of
  metcarpal bones
MRI spine
• MRI of the vertebral
    column :
•   Multiple lytic lesions
    involving the bodies
    of the lumbar thoracic
    and...
LAB
•   Tuberclin test :
•   Equivocal
•   RF :
•   Mild +ve
•   coomb’s test :
•   +ve
•   Reticulocyte count :
•   2 % (...
Differential Diagnosis

•   Accordinig to :
•   Pleauropericardial thickening
•   Proteinuria
•   Multiple osteolytic lesi...
Differential Diagnosis
Idiopathic
Irradiation
Post-surgical
Infectious
Neoplastic ( MM , local tumor , metastatic )
Autoim...
According to the data of
investigations and clinical
      correlation ….

  •Multiple Myeloma?
         •TB?
   •Malignan...
Plasma protein Electrophoresis

•   Albumin : 36%
•   Alpha 1 : 2%       polyclonal
•   Alpha 2 : 8%
                     ...
effusive-constrictive
                           pericarditis
    a failure of the right atrial pressure to decline by at ...
Take home message
• Systemic rare diseases are present and
  should be in mind .
• Pericardium is emberyologically derived...
Thank you
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Case report

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rare case with questionalbe diagnosis ...need thorough examination and follow up

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Case report

  1. 1. Case Report Ahmed Taha Hussein Assisstant Lecturer M.Sc. cardiology Zagazig University
  2. 2. Basic Data • Female patient 60 years old , widow ,not DM nor HTN , • with relevant past history of cervical and lumbar pain 1 year ago . • Weight loss within 6 month. • Co.: shortness of breathe since 4 month.
  3. 3. HPI • the condition started 6 m ago by acute dyspnea associated with cought and expectoration of yellowish sputum and fever for 2 weeks . • Later on the condition ameliorated with antibiotic ttt. • 1 m later the dyspnea recurred but was progressive in nature and accompanied with dry cough and pleuritic chest pain .
  4. 4. HPI • Dyspnea progressed in orthopnea and patient preferred the Prayer’s position . • 1 week later patient developed periorbital odeama progressed into generalised odeama within 2 weeks . • generalised boneache allover the body especially the chest wall and vertebrae.
  5. 5. Clinical examination • Vital examination : • Pulse : 100 Bpm regular thready pulse. • Bl. Pr.: 90 / 70 . • L.L : mild pitting oedema • N.V. : congested pulsating up to ½ neck in 45*. • Gereralised bony tenderness . • No apparent Lymphadenopathy.
  6. 6. Clinical Examination • Chest Examination : – Dullness on percussion on the right side up to ½ chest. – Diminished air entry on the right side . • Cardiac Examination : – Distant heart sounds , S4 .
  7. 7. ECG • ECG: • Low voltage • Non specific T wave changes.
  8. 8. Imaging • CXR : • Encysted pleural effusion on the right side . • Pleural wall thickening and interlobar pleural thickening. • Cardiomegally • Increased Bronchovascular markings.
  9. 9. Pelvi-Abd US • Mild free peritoneal fluids. • Within normal size liver and spleen. • No masses or foci can be identified either in the spleen or the liver. • Within normal size and shape of both kidneys.
  10. 10. LAB • CBC : • Ca+2 : • Microcytic anaemia • 11.5 mg/dl • ESR : • Moderate elevation . • Normal LFTs , RFTs. • Urinanalysis : • ++ proteinuria
  11. 11. A4CV
  12. 12. A4CV
  13. 13. PLAV
  14. 14. MV FLOW
  15. 15. TV FLOW
  16. 16. 2nd step for diagnosis? Pleurocentesis : failed US guided also failed . CT ch est with IV contrast
  17. 17. CT • Moderate pericardial effusion • Thick pericardium with calcification • Thick pleural wall
  18. 18. CT INTERLOBAR THICKENING
  19. 19. Other investigations were recommended to reach the diagnosis of the polyserositis
  20. 20. XR of the hands • Lytic lesions of the heads of metcarpal bones
  21. 21. MRI spine
  22. 22. • MRI of the vertebral column : • Multiple lytic lesions involving the bodies of the lumbar thoracic and cervical region.
  23. 23. LAB • Tuberclin test : • Equivocal • RF : • Mild +ve • coomb’s test : • +ve • Reticulocyte count : • 2 % ( within normal ) inproportionate .
  24. 24. Differential Diagnosis • Accordinig to : • Pleauropericardial thickening • Proteinuria • Multiple osteolytic lesions • Anaemia • Weight loss .
  25. 25. Differential Diagnosis Idiopathic Irradiation Post-surgical Infectious Neoplastic ( MM , local tumor , metastatic ) Autoimmune (connective tissue) disorders Uremia Post-trauma Sarcoid Methysergide therapy
  26. 26. According to the data of investigations and clinical correlation …. •Multiple Myeloma? •TB? •Malignancy with metastatic lesions?
  27. 27. Plasma protein Electrophoresis • Albumin : 36% • Alpha 1 : 2% polyclonal • Alpha 2 : 8% gammopathy • Beta : 10% • Gamma : 44% • Diffuse band at gamma region
  28. 28. effusive-constrictive pericarditis a failure of the right atrial pressure to decline by at least 50 percent to a level below 10 mm Hg when the pericardial pressure was reduced to near 0 mm Hg by pericardiocentesis
  29. 29. Take home message • Systemic rare diseases are present and should be in mind . • Pericardium is emberyologically derived from the same mesoderm as pleura and peritoneum . • Even if the pathology is in the heart ,general body examination must be fulfilled .
  30. 30. Thank you
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