Case ReportCase Report

AhmedAhmed TahaTaha HusseinHussein

M.Sc. cardiologyZagazig University

Assisstant Lecturer

Basic DataBasic Data

•• Female patient 60 years old , widow ,not Female patient 60 years old , widow ,not DM nor HTN ,DM nor HTN ,

•• with relevant past history of cervical and with relevant past history of cervical and lumbar pain 1 year ago .lumbar pain 1 year ago .

•• Weight loss within 6 month.Weight loss within 6 month.•• Co.: shortness of breathe since 4 month.Co.: shortness of breathe since 4 month.

HPIHPI

•• the condition started 6 m ago by acute the condition started 6 m ago by acute dyspneadyspneaassociated with associated with coughtcought and expectoration of and expectoration of yellowish sputum and fever for 2 weeks .yellowish sputum and fever for 2 weeks .

•• Later on the condition ameliorated with Later on the condition ameliorated with antibiotic antibiotic tttttt..

•• 1 m later the 1 m later the dyspneadyspnea recurred but was recurred but was progressive in nature and accompanied with dry progressive in nature and accompanied with dry cough and cough and pleuriticpleuritic chest pain . chest pain .

HPIHPI

•• DyspneaDyspnea progressed in progressed in orthopneaorthopnea and and patient preferred the Prayerpatient preferred the Prayer’’s position .s position .

•• 1 week later patient developed 1 week later patient developed periorbitalperiorbitalodeamaodeama progressed into progressed into generalisedgeneralisedodeamaodeama within 2 weeks .within 2 weeks .

•• generalisedgeneralised boneacheboneache allover the body allover the body especially the chest wall and vertebrae. especially the chest wall and vertebrae.

Clinical examinationClinical examination

•• Vital examination :Vital examination :•• Pulse : 100 Pulse : 100 BpmBpm regular regular threadythready pulse.pulse.•• BlBl. Pr.: 90 / 70 .. Pr.: 90 / 70 .•• L.L : mild pitting L.L : mild pitting oedemaoedema•• N.V. : congested pulsating up to N.V. : congested pulsating up to ½½ neck in 45*.neck in 45*.

•• GereralisedGereralised bony tenderness .bony tenderness .•• No apparent No apparent LymphadenopathyLymphadenopathy. .

Clinical ExaminationClinical Examination

•• Chest Examination :Chest Examination :–– Dullness on percussion on the right side up to Dullness on percussion on the right side up to ½½

chest. chest. –– Diminished air entry on the right side . Diminished air entry on the right side .

•• Cardiac Examination :Cardiac Examination :–– Distant heart sounds , S4 .Distant heart sounds , S4 .

ECGECG

•• ECG: ECG: •• Low voltage Low voltage •• Non specific T wave changes.Non specific T wave changes.

ImagingImaging

•• CXR :CXR :•• Encysted pleural effusion Encysted pleural effusion

on the right side .on the right side .•• Pleural wall thickening and Pleural wall thickening and

interlobarinterlobar pleural pleural thickening.thickening.

•• CardiomegallyCardiomegally•• Increased Increased BronchovascularBronchovascular

markings.markings.

PelviPelvi--AbdAbd USUS

•• Mild free peritoneal fluids.Mild free peritoneal fluids.•• Within normal size liver and spleen.Within normal size liver and spleen.•• No masses or foci can be identified either No masses or foci can be identified either

in the spleen or the liver.in the spleen or the liver.•• Within normal size and shape of both Within normal size and shape of both

kidneys.kidneys.

LABLAB

•• CBC :CBC :•• MicrocyticMicrocytic anaemiaanaemia•• ESRESR ::•• Moderate elevation .Moderate elevation .•• Normal Normal LFTsLFTs , , RFTsRFTs..•• UrinanalysisUrinanalysis ::•• ++ ++ proteinuriaproteinuria

•• Ca+2Ca+2 ::•• 11.5 mg/dl11.5 mg/dl

A4CVA4CV

A4CVA4CV

PLAVPLAV

MV FLOWMV FLOW

TV FLOWTV FLOW

22ndnd step for diagnosis?step for diagnosis?PleurocentesisPleurocentesis : failed : failed US guided also failed . US guided also failed .

CT chest with IV contrast

CTCT

•• Moderate Moderate pericardial effusion pericardial effusion

•• Thick pericardium Thick pericardium with calcificationwith calcification

•• Thick pleural wallThick pleural wall

CTCT

INTERLOBAR THICKENING

Other investigations wereOther investigations wererecommended to reach therecommended to reach the

diagnosisdiagnosisof theof the

polyserositispolyserositis

XR of the handsXR of the hands

•• LyticLytic lesions of lesions of the heads of the heads of metcarpalmetcarpal bonesbones

MRI spineMRI spine

•• MRI of the vertebral MRI of the vertebral column :column :

•• Multiple Multiple lyticlytic lesions lesions involving the bodies involving the bodies of the lumbar thoracic of the lumbar thoracic and cervical region.and cervical region.

LABLAB

•• TuberclinTuberclin test :test :•• Equivocal Equivocal •• RF :RF :•• Mild +Mild +veve•• coombcoomb’’ss test :test :•• ++veve•• ReticulocyteReticulocyte count :count :•• 2 % ( within normal ) 2 % ( within normal ) inproportionateinproportionate ..

Differential DiagnosisDifferential Diagnosis

•• AccordinigAccordinig to :to :•• PleauropericardialPleauropericardial thickening thickening •• ProteinuriaProteinuria•• Multiple Multiple osteolyticosteolytic lesionslesions•• AnaemiaAnaemia•• Weight loss .Weight loss .

Differential DiagnosisDifferential Diagnosis

IdiopathicIdiopathicIrradiationIrradiationPostPost--surgicalsurgicalInfectiousInfectiousNeoplasticNeoplastic ( MM , local tumor , ( MM , local tumor , metastaticmetastatic ))Autoimmune Autoimmune ((connective tissueconnective tissue) ) disordersdisordersUremiaUremiaPostPost--traumatraumaSarcoidSarcoidMethysergideMethysergide therapytherapy

According to the data ofAccording to the data ofinvestigations and clinicalinvestigations and clinical

correlationcorrelation ……..

••MultipleMultiple MyelomaMyeloma??

••TB?TB?

••Malignancy withMalignancy withmetastaticmetastatic lesions?lesions?

Plasma protein ElectrophoresisPlasma protein Electrophoresis

•• Albumin : 36%Albumin : 36%•• Alpha 1 : 2%Alpha 1 : 2%•• Alpha 2 : 8%Alpha 2 : 8%•• Beta : 10%Beta : 10%•• Gamma : 44% Gamma : 44% •• Diffuse band at Diffuse band at

gamma region gamma region

polyclonalpolyclonalgammopathygammopathy

effusiveeffusive--constrictiveconstrictivepericarditispericarditis

a failure of the right atrial pressure to decline by at least 50 percentto a level below 10 mm Hg when

the pericardial pressure was reduced to near 0 mm Hg by pericardiocentesis

Take home messageTake home message

•• Systemic rare diseases are present and Systemic rare diseases are present and should be in mind .should be in mind .

•• Pericardium is Pericardium is emberyologicallyemberyologically derived derived from the same mesoderm as pleura and from the same mesoderm as pleura and peritoneum .peritoneum .

•• Even if the pathology is in the heart Even if the pathology is in the heart ,general body examination must be ,general body examination must be fulfilled .fulfilled .

Thank youThank you