Julianne Nichols

Subacute Right Ventricle Perforation by Pacemaker Lead Presenting with Left Hemothorax and Shock

Cardiac perforation by pacemaker is a rare but potentially fatal complication. Acute perforations occurring within twenty-four hours of insertion of pacemaker can lead to hemopericardium, cardiac tamponade, and death. Hemothorax occurring as an acute complication of pacemaker insertion is reported but extremely rare. Previously, hemothorax and shock as a subacute complication following pacemaker insertion have not been reported. We report the case of an 85-year-old patient who presented with shock from hemothorax caused by pacemaker perforation, two weeks after insertion. Device interrogation showed normal function. Chest X-ray and echocardiogram missed lead dislocation and the diagnosis was made on computed tomogram (CT) of the chest. Following surgical repair, a new ventricular pacemaker was placed transvenously in the right ventricular septum. This case illustrates that CT scan of the chest should be performed in all patients in whom cardiac perforation by pacemaker is suspected but not diagnosed on chest X-ray and echocardiogram. Normal functioning of pacemaker on device interrogation does not exclude perforation.

Idiopathic pulmonary haemosiderosis with celiac disease (Lane–Hamilton syndrome) in an adult – a case report

Idiopathic pulmonary haemosiderosis (IPH) is a rare disorder of unknown cause characterised by haemoptysis, diffuse alveolar infiltrates and iron‐deficiency anaemia. IPH predominantly affects children; it is rare in adults, in whom it usually manifests before 30 years. In adults, course is protracted with a better prognosis, in contrast to children. Even rarer is the Lane–Hamilton syndrome, a condition in which IPH is associated with celiac disease. Only 15 cases of Lane–Hamilton syndrome affecting adults are reported in literature. Treatment of IPH is based on anecdotal case reports and case series because of its rare occurrence. High‐dose steroids reportedly reduce morbidity and mortality and delays or stops disease progression; more effectively in adults than children. In Lane–Hamilton syndrome, a gluten‐free diet for the celiac disease in addition to steroids for IPH, is the mainstay of therapy. The optimal treatment duration of steroid therapy is not known but anecdotally a more prolonged course results in improved outcome. We report a case of a young woman who presented with exertional dyspnoea, intermittent haemoptysis, severe anaemia and lung infiltrates but no gastrointestinal complaints. After extensive work‐up, she was diagnosed with Lane–Hamilton syndrome based on a diagnosis of IPH made from lung biopsy and concomitant celiac disease because of positive anti‐gliadin antibody and endomyosial antibody and jejunal biopsy. She was treated with sustained low‐dose steroid therapy for a year and a gluten‐free diet with resolution of her symptoms, anaemia and lung infiltrates. At 4 years of follow‐up, she remains stable, without recurrence.

A 26-year-old man with a slowly growing heterogeneous intrathoracic mass.

A 26-year-old man presented with complaints of leftsided chest pain and shortness of breath with moderate exertion, of 6 month duration. The patient had a history of asthma but reported that the exertional shortness of breath was not like his typical asthma symptoms and was not associated with wheezing. The left-sided chest pain was a dull and constant ache, without any aggravating or relieving factors. The patient denied fever, chills, night sweats, cough, or weight loss. Past medical history was signifi cant for asthma since childhood, which was well controlled on budesonide inhaler. He had received a gunshot wound 11⁄2 years earlier and had abdominal surgery at that time “to stop the bleeding,” but records of the procedure were not accessible. Examination revealed a young man who appeared well and in no distress. Vital signs were as follows: temperature, 36.6°C ; heart rate, 80/min, regular; BP, 120/76 mm Hg; respiratory rate, 15/min; and oxygen saturation, 98% on room air. There was no pallor, icterus, or cyanosis. No jugular venous distension, thyromegaly, or cervical lymphadenopathy was discerned. Lung examination revealed diminished breath sounds at the left base with decreased vocal resonance and increased dullness to percussion. Cardiac examination revealed normal heart sounds without any murmur. No organomegaly or localized tenderness was noted on A 26-Year-Old Man With a Slowly Growing Heterogeneous Intrathoracic Mass