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History: A 40 year old male with c\o fever, cough productive of mucoid sputum without haemoptysis and chest pain for four months. He also reported weight loss for two months and abdominal and lower limb swelling for one month. In addition he had fatigue, palpitations and exertional dyspnoea but denied orthopnoea. Chest X-ray showed a massively enlarged cardiac silhouette and bilateral pulmonary infiltrates or oedema. An urgent bedside ultrasound showed a large pericardial effusion of about 2 cm, right atrial collapse and right ventricular collapse in diastole. What’s the diagnosis?

Answer: The patient presented with cardiac tamponade, the most severe complication of TB pericarditis. Cardiac tamponade occurs when fluid in the pericardial space accumulates faster than the pericardial sac can stretch and so causes high pressure compressing the heart and preventing the heart from expanding fully. However, if the fluid accumulates more slowly as with TB pericarditis, the pericardial sac can expand to hold over one litre of fluid before critical compression arises.

Signs & Symptoms: The three classical signs of cardiac tamponade (Beck’s triad) are hypotension, jugular venous distention, and muffled heart sounds. Hypotension results from decreased cardiac output, jugular-venous distension results from impaired venous return to the heart and, muffled heart sounds are due to pericardial fluid. There are other physical signs that may indicate cardiac tamponade. On inspiration the central venous pressure (jugular venous pressure) would normally fall but with tamponade this rises. Pulsus paradoxus is the finding of a fall in the systolic blood pressure of more than 10mmHg when the patient inspires.

Causes: Infection- viral, TB, bacterial, fungal, HIV, Malignancy, Post-cardiac injury syndrome (after trauma or cardiothoracic surgery), Acute myocardial infarction (acute, delayed), Metabolic-uremia, hypothyroidism, Collagen vascular diseases- rheumatoid arthritis, lupus erythematosus, Radiation, Idiopathic.

Investigation: The chest Xray of a patient with large pericardial effusion shows a large “boot-shaped” cardiac silhouette but it can be difficult to tell if a large heart is due to dilated cardiomyopathy or pericardial effusion. Ultrasound easily detects a large pericardial effusion: the fluid appears anechoic or black around the heart. The right atrium and right ventricle appear collapsed with dilation of the inferior vena cava.

Treatment: Emergency pericardiocentesis by a subxiphoid approach using ultrasound guidance.

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History: A 30-year-old man presented with an 11-year history of coarse facial features and progressive enlargement of hands and feet. On physical examination, his height was 1.70 m and his weight was 65 kg. Coarse facial features included enlarged frontal and nasal bone, thickened facial and scalp skin including the periorbital area, and thickened lips. His lower jaw shows the classic spacing of teeth. Funduscopic examination revealed the absence of papilloedema. Hands and feet are noted to be enlarged but non-oedematous. What’s the diagnosis?

Answer: Acromegaly is a disorder that results from excess growth hormone (GH) after the growth plates have closed.

Symptoms: The initial symptom is typically enlargement of the hands and feet. There may also be an enlargement of the forehead, jaw, and nose. Other symptoms may include joint pain, thicker skin, deepening of the voice, headaches, and problems with vision. Complications of the disease may include type 2 diabetes, sleep apnea, and high blood pressure.

Cause: Acromegaly is usually caused by the pituitary gland producing excess growth hormone due to a benign pituitary adenoma.

Diagnosis: Measuring insulin-like growth factor I in the blood. After diagnosis MRI of the pituitary is carried out to determine if an adenoma is present. If excess growth hormone is produced during childhood, the result is the condition gigantism rather than acromegaly, and it is characterized by excessive height.

Treatment: Surgery to remove the tumor, radiation therapy, somatostatin analogues or GH receptor antagonists may be used. Radiation therapy may be used if neither surgery nor medications are completely effective.

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History: A 60 yr male k/c/o of HTN, Type2DM, and hyperlipidemia presents to the ER with the first episode of rapid palpitations, sob, and chest discomfort. Physical exam shows an irregularly irregular radial pulse at a rate 130 bpm, BP 110/70 mmHg, and RR 20 bpm. Heart sounds are irregular, but no third or fourth heart sound gallop or murmurs are audible. What’s the diagnosis?

Answer: Acute atrial fibrillation (AF) is a episode of a chaotic and irregular atrial arrhythmia. Prevalence increases progressively with age. AF causes significant morbidity and mortality including palpitations, dyspnea, angina, dizziness or syncope, and features of congestive heart failure, tachycardia-induced cardiomyopathy, stroke, and death. ECG shows absent P waves, presence of fibrillatory waves, and irregularly irregular QRS complexes. Treatment in hemodynamically unstable patient is DC cardioversion. In stable patient do rate control with beta-blocker and/or calcium-channel blocker +/- anticoagulation +/- electrical cardioversion or chemical cardioversion with drugs. If the precise timing of the onset of AF is unclear, a transesophageal echocardiogram must be performed to exclude left atrial clots before cardioversion.

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Question: Which of the following tests can be used to make the definitive diagnosis of this disease?

1.  Biopsy showing Donovan bodies
2.  Giemsa stain showing intracytoplasmic inclusion bodies
3. Potassium hydroxide preparation (KOH prep)
4.  Serology
5. Tzanck smear

Answer: This picture shows lesions of Molluscum contagiosum. These lesions may occur in single or multiple lesions. It is spread skin-to-skin contact and is most common in infants, sexually active adults, and immunocompromised individuals. A Giemsa stain of the keratotic core will show intracytoplasmic inclusion bodies or “molluscum bodies.” These lesions usually resolve in 6–24 months without specific treatment. Tape may be applied after showers to prevent friction and spread of the lesions. Other treatments that could be prescribed by a dermatologist include topical cantharidin (blister beetle fluid) applied in the office or imiquimod (Aldara) every day three to five times per week at home to speed the resolution of the lesions. Donovan bodies are seen with granuloma inguinale. KOH prep is used to help visualize the hyphae seen in fungal etiologies of skin lesions. Serology is used for syphilis diagnosis. Tzanck smear is used to help diagnose herpes lesions.

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History: A 19-year-old male presents with a rapid onset of shortness of breath. There is no history of trauma or chronic medical disease. The patient has no risk factors for thromboembolic disease. The following x-ray is consistent with which of the following conditions?

1. Atypical pneumonia
2. Spontaneous pneumothorax
3. Metabolic bone disease
4. Hampton hump

Anwer: The x-ray demonstrates a spontaneous pneumothorax on the right with a small hemothorax in an otherwise healthy young individual. Management of primary pneumothorax includes aspiration of pleural air either by needle thoracostomy or small catheter with or without Heimlich valve. A Hampton hump is a classic sign of pulmonary embolism with pulmonary infarction that is described as a pleural-based triangular wedge with base along the pleural surface and the top of the triangle pointing toward hilum. This is opposed to Westermark sign that is a sign of vascular oligemia distal to the location of a pulmonary embolism and is described as dilation of proximal pulmonary arteries and collapse of distal vessels. An atypical pneumonia would have a different radiographic appearance including patchy or subsegmental infiltrate. There is no evidence of cortical irregularities or displaced rib fractures on this chest radiograph and there is no history of trauma. Metabolic bone disease would likely manifest with some bony lesion either as lytic lesions or osteopenia.

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