Author: Kristopher Maday PA-C

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Takotsubo Cardiomyopathy

Other Known Aliases – Broken-Heart Syndrome

Definition – stress-induced cardiomyopathy

Clinical Significance – this syndrome is characterized by transient regional systolic dysfunction of the left ventricle, that mimics a myocardial infarction, but with an absence of angiographic evidence of coronary artery involvement.

History – Named after Japanese word for “octopus trap” as the left ventricle takes the shape of this unique hunting vessel. This condition was first studied in Japan by Hikaru Sato in 1991, but it was not “introduced” to the western medical world until 1997.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Tofield A. Hikaru Sato and Takotsubo cardiomyopathy. European Heart Journal, Volume 37, Issue 37, 1 October 2016, Page 2812
  7. Pavin D, Breton HL, Daubert C. Human stress cardiomyopathy mimicking acute myocardial syndrome. Heart. 1997;78:509-511.

PAINE #PANCE Pearl – Cardiology

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Question

73yo man, with a history of hypertension and coronary disease, is brought into the emergency room after a witnessed syncopal episode at home. He reported some mild exertional chest pain over the past few days, but states that it improved with rest. Vital signs are BP-180/98, HR-74, RR-12, and O2-100%. He is currently in no distress and not diaphoretic. Physical examination revealed a systolic murmur over the 2nd right intercostal space. A CT was ordered to rule-out PTE in the setting of chest pain and syncope and is below, along with the murmur.

  1. What is the diagnosis?
  2. How would you describe this murmur?
  3. Where would you expect this murmur to radiate?
  4. What is the classic triad associated with this condition?

Answer

  1. Aortic Stenosis due to a calcified aortic valve
  2. High-pitched, crescendo-decrescendo (diamond shaped), midsystolic, ejection murmur with a soft S2
  3. AS murmurs transmit well and equally to the carotid arteries
  4. The classic triad of AS is exertional angina, exertional dyspnea, and dizziness/syncope

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Kerley Lines

Other Known Aliases – none

Definition – lines seen on chest radiography due to interstitial edema

Clinical Significance – Kerley lines are thin pulmonary opacities caused by fluid or cellular infiltration into the interstitial of the lungs. There are three distinct types that are seen:

  • Kerley A lines – linear opacities extending from the periphery to the hilum caused by distention of anastomotic channels between peripheral and central lymphatics
  • Kerley B lines – short horizontal lines situated perpendicularly to the pleural surface at the lung base and represent edema of the interlobar septa
  • Kerley C lines – reticular opacities at the lung base representing Kerley B lines en face
White Arrows (A lines); White Arrowheads (B lines); Black Arrowheads (C lines)

History – Named after Sir Peter James Kerley (1900-1979), who was an Irish radiologist and received his medical doctorate from Cambridge University in 1932. He went on to study in Vienna, which was the center of the new and blossoming specialty of heart and lung radiography. He assisted to editing “A Textbook of X-ray Diagnosis” in 1939, which was a major radiology textbook at the time, and later became director of radiology at Westminster Hospital in 1939. He first described his eponymonic findings in an article entitled “Radiology in heart disease” in 1933, and further elaborated on them in the second volume of his textbooks in 1951. During this year, he was also a key figure in the diagnosing of King George VI’s lung cancer due to his review of the King’s radiographs. He received several Royal awards for mass radiological screening for tuberculosis and his diagnosis of King George VI cancer, leading up to his Knight Commander of the Royal Victorian Order by Queen Elizabeth in 1972.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Koga T, Fujimoto K. Images in clinical medicine. Kerley’s A, B, and C lines. The New England journal of medicine. 2009; 360(15):1539. [pubmed]
  7. Kerley P. Radiology in heart disease. BMJ. 1993;2:594-597 [Link]
  8. Shanks SC, Kerley P. A Text-Book Of X-Ray Diagnosis: Vol II. Saunders. 1951 pp403–415

PAINE #PANCE Pearl – Cardiology

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Question

73yo man, with a history of hypertension and coronary disease, is brought into the emergency room after a witnessed syncopal episode at home. He reported some mild exertional chest pain over the past few days, but states that it improved with rest. Vital signs are BP-180/98, HR-74, RR-12, and O2-100%. He is currently in no distress and not diaphoretic. Physical examination revealed a systolic murmur over the 2nd right intercostal space. A CT was ordered to rule-out PTE in the setting of chest pain and syncope and is below, along with the murmur.

  1. What is the diagnosis?
  2. How would you describe this murmur?
  3. Where would you expect this murmur to radiate?
  4. What is the classic triad associated with this condition?

PAINE #PANCE Pearl – Dermatology

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Question

A 29yo patient is seen for a severe drug reaction after starting lamotrigine (Lamictal) for new-onset epilepsy. She has significant desquamation of her mucous membranes as well as large patches of denuded epidermis with multiple bullae present.

  1. What is the clinically distinguishing feature between Steven-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)?

Answer

The main clinical difference between SJS and TEN is the severity and degree of involvement. SJS classically is < 10% TBSA involvement, where as TEN is > 30% TBSA.

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Nikolsky’s Sign

Other Known Aliases – none

Definition – Exfoliation of the outermost layer and elicitation of blistering as a result of gentle mechanical pressure on the skin

Clinical Significance – This sign is classically associated with pemphigus vulgaris and is used to differentiate vulgaris (where it is present) and bullous (where it is absent). It is also present in Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and scalded skin syndrome.

History – Named after Pyotr Vaseilyevich Nikolsky (1858-1940), who was a Russian dermatologist and received his medical doctorate from the Saint Vladimir Imperial University of Kiev in 1884. His doctoral dissertation and thesis was on pemphigus foliaceus, where he described his now famous eponym. He went on to have a career in academic medicine becoming professor at the Imperial University of Warsaw and establishing the Department of Dermatology and Venerology at the future Southern Federal University.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Grando SA, Grando AA, Glukhenky BT, Doguzov V, Nguyen VT, Holubar K. History and clinical significance of mechanical symptoms in blistering dermatoses: a reappraisal. Journal of the American Academy of Dermatology. 2003; 48(1):86-92. [pubmed]

#54 – Dacryocystitis

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Definition

  • Infection of the lacrimal sac usually due to obstruction of the nasolacrimal systems

Anatomy

The lacrimal apparatus is responsible for tear production and drainage of the eye and consists of 3 main structures:

  • Lacrimal gland
    • Serous gland located in the superiorlateral corner of the orbit in the lacrimal fossa
    • Responsible for tear secretion onto the globe
  • Lacrimal canaliculi
    • Drainage ducts located in the medial corner of the eye and drain into the nasolacrimal duct
  • Nasolacrimal duct
    • Drains into the inferior nasal meatus of the nasal cavity

Pathophysiology

  • The most common cause of dacryocystitis is obstruction of the nasolacrimal duct
  • Adults
    • Chronic inflammation leading to fibrosis/stenosis of the duct
    • Most commonly in postmenopausal women
  • Infants/Children
    • Persistent membrane covering the Valve of Hasner
      • Occurs in up to 90% of newborns
        • Becomes patent by the end of the first month of life in 90%

Microbiology

  • Pediatric
    • Streptococcus pneumoniae
    • Staphylococcus species
    • Haemophilus influenza
    • Entrobacteriaceae species
  • Adults
    • Staphylococcus aureus
    • Staphylococcus epidermidius
    • Pseudomonas aeruginosa
    • Propionibacterium species

Clinical Findings

  • The main clinical finding is tearing and discharge
  • Acute
    • Inflammation, pain, swelling, and tenderness beneath the medial canthal tendon around the lacrimal sac
      • Purulence can be expressed through the lacrimal puncta with direct pressure on the lacrimal sac
  • Chronic
    • Tearing and matting of the eyelashes is most common
    • Mucoid material can be expressed occasionally

Diagnostic Studies

  • Although this is clearly a clinical diagnosis and the majority do not need further studies, you can do a bedside test called “Dye Disappearance Test”
    • Apply a drop of topical anesthetic
    • Place a drop of fluorescein stained saline in the inferior cul-de-sac of each of the patient’s eyes
    • Wipe away excess tears from eyelids
    • Observe patient for 5 minutes with careful instructions that the eye should not be rubbed and cheeks should not be wiped
    • After 5 minutes inspect eye, nose, and cheek
      • All of the fluorescein should have drained into the nose within 5 minutes if there is no obstruction
      • If any fluorescein remains in eye or drained down the cheek, then the test is positive

Treatment

  • Most cases respond to appropriate systemic antibiotic therapy
    • Culture expressed purulence to aid in antibiotic selection
    • Acute (7-10 days of therapy)
      • Mild cases – Clindamycin
      • Severe – Vancomycin + 3rd generation cephalosporin
  • For infants:
    • External digital massage of the lacrimal sac is first line
      • Increases the hydrostatic pressure to force open the obstructed membrane
  • Nasolacrimal probing is indicated in acute cases and cases persisting for > 6 months
    • Some cases require balloon dilation, silicone stent placement, or inferior turbinate fracture
  • For adults:
    • Chronic topical antibiotic drops can help keep patent, but this is only symptomatic relief
      • Fluoroquinolones – moxifloxacin, ciprofloxacin, ofloxacin
      • Aminoglycoside – tobramycin, gentamicin
    • Dacryocystorhinostomy is required to prevent recurrence
      • Permanent fistula formed between lacrimal sac and the nose

The Cottage Physician (1893)

References

  1. Duncan JL, Parikh NB, Seitzman GD, Riordan-Eva P. Disorders of the Lids & Lacrimal Apparatus. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. New York, NY: McGraw-Hill
  2. Orbit. In: Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, 2e New York, NY: McGraw-Hill;
  3. Vagefi M. Lids & Lacrimal Apparatus. In: Riordan-Eva P, Augsburger JJ. eds. Vaughan & Asbury’s General Ophthalmology, 19e New York, NY: McGraw-Hill
  4. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill
  5. Hoffmann J, Lipsett S. Acute Dacryocystitis. The New England journal of medicine. 2018; 379(5):474. [pubmed]
  6. Campolattaro BN, Lueder GT, Tychsen L. Spectrum of pediatric dacryocystitis: medical and surgical management of 54 cases. Journal of pediatric ophthalmology and strabismus. ; 34(3):143-53; quiz 186-7. [pubmed]
  7. Qian Y, Traboulsi EI. Lacrimal sac compression, not massage. Journal of pediatric ophthalmology and strabismus. ; 46(4):252. [pubmed]
  8. Örge FH, Boente CS. The lacrimal system. Pediatric clinics of North America. 2014; 61(3):529-39. [pubmed]