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

1. Case Report
Ahmed Taha Hussein
Assisstant Lecturer
M.Sc. cardiology
Zagazig University

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

8. Imaging
• CXR :
• Encysted pleural effusion
on the right side .
• Pleural wall thickening and
interlobar pleural
thickening.
• Cardiomegally
• Increased Bronchovascular
markings.

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. LAB
• CBC : • Ca+2 :
• Microcytic anaemia • 11.5 mg/dl
• ESR :
• Moderate elevation .
• Normal LFTs , RFTs.
• Urinanalysis :
• ++ proteinuria

11. A4CV

12. A4CV

13. PLAV

14. MV FLOW

15. TV FLOW

16. 2nd step for diagnosis?
Pleurocentesis : failed
US guided also failed .
CT ch est with IV contrast

17. CT
• Moderate
pericardial effusion
• Thick pericardium
with calcification
• Thick pleural wall

18. CT
INTERLOBAR THICKENING

19. Other investigations were
recommended to reach the
diagnosis
of the
polyserositis

20. XR of the hands
• Lytic lesions of
the heads of
metcarpal bones

21. MRI spine

22. • MRI of the vertebral
column :
• Multiple lytic lesions
involving the bodies
of the lumbar thoracic
and cervical region.

23. LAB
• Tuberclin test :
• Equivocal
• RF :
• Mild +ve
• coomb’s test :
• +ve
• Reticulocyte count :
• 2 % ( within normal ) inproportionate .

24. Differential Diagnosis
• Accordinig to :
• Pleauropericardial thickening
• Proteinuria
• Multiple osteolytic lesions
• Anaemia
• Weight loss .

25. Differential Diagnosis
Idiopathic
Irradiation
Post-surgical
Infectious
Neoplastic ( MM , local tumor , metastatic )
Autoimmune (connective tissue) disorders
Uremia
Post-trauma
Sarcoid
Methysergide therapy

26. According to the data of
investigations and clinical
correlation ….
•Multiple Myeloma?
•TB?
•Malignancy with
metastatic lesions?

27. Plasma protein Electrophoresis
• Albumin : 36%
• Alpha 1 : 2% polyclonal
• Alpha 2 : 8%
gammopathy
• Beta : 10%
• Gamma : 44%
• Diffuse band at
gamma region

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. 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. Thank you