A 72 year old man presented with generalized erythroderma, enlarged lymph nodes and atypical cells on peripheral smear and skin biopsy. This matches the diagnostic criteria for Sézary syndrome, an aggressive form of cutaneous T cell lymphoma characterized by erythroderma, lymphadenopathy and circulating atypical lymphocytes. A 70 year old woman experienced chest pain radiating to her shoulder and her ECG showed posterior wall myocardial infarction, likely due to occlusion of the right coronary artery, which supplies the posterior wall. A 83 year old man with congestive heart failure presented with pleural effusion on his chest x-ray. This resolved with treatment and reappeared with decompensation, representing a "phantom

1. DR SUBHASISH DEB
Burdwan Medical College and Hospital
Department of General Medicine
OSCE
DR SUBHASISH DEB 09/12/2014
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2. DR SUBHASISH DEB 09/12/2014
CASE 1
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3. DR SUBHASISH DEB 09/12/2014
 A 72 year old man presented with
generalized erythroderma with palmer and
planter hyperkeatosis and enlarged Lymph
nodes.
 WBC= 24,000/ul (mico lit)
 Peripheral smear shows the following
atypical cell.
 Skin biposy showed epidermotropism of the
atypical cells
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4. (A)Typical erythroderma of Sézary syndrome, and
(B) solitary mycosis fungoides plaque,
(C) tumour nodule of large cell lymphoma (LCL). Histology reveals
(D) an upper band-like infiltrate with epidermotropism of atypical
lymphocytes and
DR SUBHASISH DEB 09/12/2014
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5. SEZARY SYNDROME
 An aggressive form of CTCL (cutaneous T
cell Lymphoma)
 Triad:
1. Erythroderma (diffuse)
2. Lymphadenopathy
3. Circulating atypical lymphocytes (Sezary
cells)
DR SUBHASISH DEB 09/12/2014
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6. DR SUBHASISH DEB 09/12/2014
DIAGNOSTIC CRITERIA
 1 or more of the following should be present:
1. An absolute Sézary cell count of least 1000
cells/μL
2. Demonstration of an expanded CD4+ T-cell
population CD4/CD8 > 10; loss of any or all
of the T-cell antigens CD2, CD3, CD4, and
CD5; or loss of both CD4 and CD5)
3. Identical T-cell clone in blood and skin. (by
molecular assay like pcr)
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7. DR SUBHASISH DEB 09/12/2014
 Mycosis fungoides and SS are the m/c
CTCLs
 Lineage: Mature (peripheral) T cells
 SS differentiated from MF by presence of
atypical lymphocytes in blood.
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8. DR SUBHASISH DEB 09/12/2014
CASE 2
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9.  A 70 year old woman came with a c/o of
chest pain with radiation to left shoulder. She
has a medical h/o of hypercholesterolemia.
Her ECG showed the following.
 Trop T – positive
 CXR- NAD
 Ur-30, Cr-1.0
DR SUBHASISH DEB 09/12/2014
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10. DR SUBHASISH DEB 09/12/2014
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11. POSTERIOR WALL MI
DR SUBHASISH DEB 09/12/2014
 PMI also called ‘dead angle infarction’
 One of the m/c missed types of AMI
 The term PMI is used for necrosis of the
dorsal infraatrial part of the left ventricle
located between the atrioventricular sulcus
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12. DR SUBHASISH DEB 09/12/2014
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13. DR SUBHASISH DEB 09/12/2014
 Occurs due to stenosis/ occlusion of RCX
 Often accompanied by inferior and/or lateral
wall MI
 Pts with ecg of isolated PMI often do not
receive the appropriate reperfusion t/t due to
lack of classical ST-segment elevation in
normal 12 lead ecg
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14. ECG FINDINGS
DR SUBHASISH DEB 09/12/2014
 V1 and V2 are mirror images of V1 and V2 of
anterior wall MI
 Vector cardiogram points ventrally due to
loss of the electrical forces normally aimed
dorsally, resulting in a prolonged R wave –
R/S >1 in V1 and V2
 ST depression in precordial leads in acute
phase + tall upright T waves
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15. USE OF DORSAL LEADS
 Mortality reduction is max when reperfused
within 6hrs if pain onset
 POSTERIOR LEADS:
 V7 – at the level of V6 at post Axillary line
 V8 – left side of back at the tip of scapula
 V9 – half way between V8 and the left
paraspinal muscles
ST elevation >1mm in post leads is suggestive
of PMI
DR SUBHASISH DEB 09/12/2014
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16. DR SUBHASISH DEB 09/12/2014
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17. DR SUBHASISH DEB 09/12/2014
 Sensitivity increases from 32% to 57% and
specificity 98% for RCX on the 15 lead ecg
instead of the normal 12 lead ecg
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18. DR SUBHASISH DEB 09/12/2014
CASE 3
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19. DR SUBHASISH DEB 09/12/2014
 A 83 year old man with h/o heart disease
with repeated symptomatic episodes of CHF
presented with c/o cough and progessive
orthopnea and 3 weeks of PND. CXR
showed A
 Pt was treated with iv furosemide, t. digoxin,
iv nitroglycerine and captopril. He improved
in 3 days and 6 days later, repeat CXR
showed B
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20. DR SUBHASISH DEB 09/12/2014
A B
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21. PHANTOM TUMOUR
DR SUBHASISH DEB 09/12/2014
 The term phantom tumour is applied to a
transudative interlobar pleural fluid collection
in CHF which disappears spontaneously with
compensation and may reappear on
decompensation
 USUALLY SEEN IN:
 CHF
 Renal Failure
 Hypoalbuminemia
Due to transudation from pulmonary
vasculature
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22. PATHOGENESIS
DR SUBHASISH DEB 09/12/2014
 Involves the adhesion and obliteration of the
pleural space due to pleuritis that may be
transient, thereby preventing the free
accumulation of fluid.
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23. DR SUBHASISH DEB 09/12/2014
CASE 4
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24. DR SUBHASISH DEB 09/12/2014
 A 56 year old woman with past h/o of HTN
presented with flue like symptoms that were
ongoing for last 3 days. While waiting in the
observation room for 6 hrs, she developed
chest pain. No family h/o of any cardiac
problems.
 ECG - showed the follwing
 TROP t – positive
 ECHO – hypokinetic walls with EF – 35%
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25. DR SUBHASISH DEB 09/12/2014
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26. MYOCARDITIS
DR SUBHASISH DEB 09/12/2014
 NON ISCHEMIC myocardial inflammation
resulting from a variety of infectious, immune
and toxic insults.
 DCM and Chronic Heart Failure are the
mojor long term sequla of myocarditis.
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27. DR SUBHASISH DEB 09/12/2014
 M/c/c in Europe and North America – VIRUS
 m/c/c Worldwide – chagas disease
 Less common non viral pathogens:
1. Borrelia Burgdorferi
2. Trypanosoma Cruzi
3. Hypersensitivity to drugs
4. Autoimmune reaction
(Streotococcal M protein and Coxsakie virus B
epitopes are similar to cardiac myosin)
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28. DR SUBHASISH DEB 09/12/2014
 As definitive diagnosis requires a heart
biopsy,which doctors are reluctant to do,
statistics on the incidence of myocarditis vary
widely.
 Among HIV patients, myocarditis is the m/c
cardiac pathological finding at autopsy.
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29. SIGNS AND SYMPTOMS
1. Chest pain (stabbing)
2. CHF
3. Palpitation
4. Sudden death
5. Fever
6. Flue like symptoms
DR SUBHASISH DEB 09/12/2014
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30. DIAGNOSIS
DR SUBHASISH DEB 09/12/2014
 ECG- diffuse t wave inversions, saddle
shaped ST-segment elevations (also in
pericarditis)
 Gold standard – biopsy of myocardium
Generally done in a setting of angiography. A
small tissue sample of te endoand
myocardium is taken
Also useful are IgM against virus, ESR, CRP
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31. TREATMENT
DR SUBHASISH DEB 09/12/2014
 Viral infections cannot be treated with direct
therapy – symptomatic
 People who do not responf to convesional
therapy are candidayes for bridge thrapy with
Left ventricular assist device
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32. DR SUBHASISH DEB 09/12/2014
CASE 5
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33. DR SUBHASISH DEB 09/12/2014
 A 20 years old man presented with this
rash and 1st degree heart block.
What is the diagnosis and what is the
treatment ?
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34. DR SUBHASISH DEB 09/12/2014
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35. LYME DISEASE
DR SUBHASISH DEB 09/12/2014
 Borrelia burgdorferi is transmitted to humans
by the bite of infected hard ticks.
 Early symptoms may include fever, headache,
fatigue, depression, and a characteristic
circular skin rash called erythema migrans
(bull's eye rash) .
 Left untreated, later symptoms may involve
the joints, heart, and central nervous system.
 Treatment: antibiotics-doxycycline, if have
later complications- cefotaxime or ceftriaxone.
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