Kotaro Oe

Pericardial Involvement in IgG4-related Disease

We herein report the case of a 65-year-old man with pericardial involvement associated with autoimmune pancreatitis. Chest CT imaging showed pericardial thickening. The patient responded to corticosteroid therapy, and the pericardial thickening resolved. Multiple organs are involved in immunoglobulin G4 (IgG4)-related disease (IgG4-RD); however, only a few cases of IgG4-related chronic constrictive pericarditis have been reported. To our knowledge, this is the first reported case of IgG4-RD with pericardial involvement at an early stage. This case indicates that recognizing pericardial complications in autoimmune pancreatitis is important and that CT imaging may be useful for obtaining the diagnosis and providing follow-up of pericardial lesions in cases of IgG4-RD.

Polymorphic ventricular tachycardia in a patient with hypertrophic cardiomyopathy and digitalis intoxication

We report the case of a 74-year-old woman who presented with recurrent episodes of polymorphic ventricular tachycardia (PVT) with a normal QT interval due to digitalis intoxication (serum digoxin concentration, 5.0 ng/mL) and severe hyperkalemia (serum potassium level, 8.3 mEq/L). In addition, laboratory data showed elevated levels of blood urea nitrogen (54 mg/dL) and serum creatinine (1.57 mg/dL), suggesting dehydration. She had been treated with a combination of digoxin and eplerenone for atrial fibrillation and heart failure. The PVT resolved after treatment for hyperkalemia. Cardiac magnetic resonance imaging and left ventriculography showed left ventricular hypertrophy predominantly in the apex, suggesting apical hypertrophic cardiomyopathy (HCM). We presume that the presence of HCM was related to the occurrence of PVT in this patient with digitalis intoxication and hyperkalemia. <Learning objective: PVT with a normal QT interval caused by digitalis intoxication with hyperkalemia was observed in a patient with HCM treated with digoxin and eplerenone for atrial fibrillation and heart failure. The presence of HCM may be related to the occurrence of PVT. Combination therapy with digoxin and aldosterone receptor antagonist may predispose severe hyperkalemia, and monitoring of serum digitalis concentration and potassium level should be done strictly.>.

Rapid progression of coronary artery disease in a patient with retroperitoneal fibrosis

A 76-year-old woman with a history of hypertension and dyslipidemia was admitted to our hospital because of chest pain. On the basis of an electrocardiogram showing ST elevation in V1-3 leads, the patient was diagnosed with acute anterior myocardial infarction. Coronary angiography (CAG) revealed occlusions of the mid portion of the left anterior descending artery (LAD) and distal portion of the left circumflex artery (LCX). A paclitaxel-eluting stent was implanted in the LAD. Two weeks later, the patient complained of abdominal pain. A computed tomography (CT) scan showed a perivascular cuff around the abdominal aorta and F18-fluorodeoxyglucose positron-emission tomography with CT (FDG-PET/CT) scan showed increased tracer uptake around the abdominal aorta and aortic arch, suggestive of retroperitoneal fibrosis. The second CAG, performed on day 46, revealed occlusion of the posterolateral branch of the LCX and rapidly progressing stenosis of the proximal portion of the LCX. The patient was suspected of coronary arteritis and received oral corticosteroid therapy. The third CAG, performed on day 77, revealed occlusion of the posterior descending branch of the right coronary artery. The corticosteroid therapy was gradually tapered after discharge. The fourth CAG, performed 5 months later, did not show progression of the coronary lesions.

Fatal cytomegalovirus infection with CD4+ T-lymphocytopenia during corticosteroid therapy for bronchial asthma

An 80-year-old woman was admitted with dyspnea. She had been treated with oral prednisolone for bronchial asthma. She was intravenously treated with dexamethasone. On the 9th day, she presented oliguria and thrombocytopenia. She was diagnosed as dehydration and disseminated intravascular coagulation, and was treated with hydration and heparin infusion. On the 12th day, she presented macroscopic hematuria and melena. Cystoscopy revealed hemorrhagic cystitis. Bone marrow aspiration showed hemophagocytosis. Serum antigen of cytomegalovirus (CMV) was positive. CD4+ T cell count was very low (40/μL). She was diagnosed as disseminated CMV infection, and was treated with gancyclovir and immunoglobulin infusion. On the 14th day, she died of pneumonia. This is the first report of fatal CMV infection during corticosteroid therapy for bronchial asthma.

Traumatic Esophageal Injury Detected By Transthoracic Echocardiography

A 65-year-old man was admitted to our hospital after being injured in a motor vehicle accident. Fractures of the sternum and right tibia were diagnosed and surgical bone repair was planned. Preoperative transthoracic echocardiography (TTE) revealed an unusual round-shaped mass with a central high echoic lesion, measuring 2-3 cm in diameter, behind the left atrium (Picture 1). Contrast-enhanced CT revealed a marked dilatation of the lower esophagus; a thickened and partially disrupted wall and surrounding fluid collection (Picture 2). Thus, traumatic esophageal injury with mediastinitis was diagnosed and conservatively treated. The patient successfully recovered without any complications. Esophageal injury is a rare, but serious complication after a traffic accident, and an early diagnosis and treatment are required (1). This is the first reported case of traumatic esophageal injury which was diagnosed by preoperative TTE (2). If a dilatation of the esophagus is detected by TTE in patients after a traffic accident, then contrast-enhanced CT is necessary in order to make a definite diagnosis of esophageal injury.

Pericarditis-complicated takotsubo cardiomyopathy in a patient with rheumatoid arthritis

A 64-year-old woman with medication-controlled rheumatoid arthritis (RA) was admitted to our hospital complaining of chest pains. An electrocardiogram showed elevated ST-segments in the inferior leads, and inverted T-waves in the left precordial leads. Left ventriculography demonstrated apical ballooning, and cardiac magnetic resonance imaging demonstrated apical ballooning of the left ventricle, and moderate pericardial effusion. The patient was diagnosed with takotsubo cardiomyopathy (TTC), complicated by pericarditis. In the literature, autoimmune disorders have been associated with TTC. We suggest that this patients pericardial effusion was caused by TTC, and that her coexisting RA might have played a role in the etiology of the significant pericardial fluid accumulation.

Coronary arteriovenous fistulas complicated by complete atrioventricular block: A case report

We report the case of a patient with bilateral coronary arteriovenous fistulas (CAVFs) connecting the right coronary artery and left circumflex coronary artery with the right atrium who had progression of first-degree atrioventricular (AV) block to complete AV block during a 4-year period. The His bundle electrogram revealed that the complete AV block was the result of a block at the level of the AV node. Dipyridamole stress thallium-201 myocardial imaging showed decreased perfusion in the inferoapical wall. Coronary angiography and computed tomography showed fistulas that arose from the AV nodal branch of the right coronary artery and from the distal portion of the circumflex coronary artery and drained into the right atrium. Because the fistulas were small, they were not repaired surgically, and a permanent pacemaker was implanted to treat the complete AV block. We presumed that the complication by complete AV block was due to abnormalities of the arteries feeding the AV node and chronic ischemia resulting from a coronary steal associated with the fistulas. To the best of our knowledge, this is the first report of CAVF complicated by complete AV block.

A case of left ventricular diverticulum: Change of characteristics after myocardial infarction and usefulness of cardiac computed tomography

A 72-year-old man with an old myocardial infarction was admitted to our hospital for cardiac reexamination. He had suffered from an inferior myocardial infarction when he was 60-year-old. The left ventriculogram had then shown a small contractile diverticulum at the apical portion of the left ventricle. Anterior myocardial infarction had recurred when he was 63-year-old. The left ventriculogram performed after the anterior myocardial infarction revealed that the diverticulum had become dilated and non-contractile. On admission, electrocardiography and chest X-ray showed no remarkable changes from the previous studies. Cardiac computed tomography (CT) demonstrated an apical left ventricular diverticulum with narrow communication to the main chamber and myocardial discontinuity of the wall at the site of the diverticulum. Tc-99m tetrofosmin myocardial images showed a perfusion defect in the apex. We presumed that a muscular left ventricular diverticulum had changed to the fibrous type after the anterior myocardial infarction. Cardiac CT imaging provides accurate evaluation of the left ventricular diverticulum and is useful for the differentiation between a left ventricular diverticulum and an aneurysm.

Prolonged Atrioventricular Block and Ventricular Standstill Following Adenosine Triphosphate Injection in a Patient Taking Dipyridamole and Antiarrhythmic Agents: A Case Report

An 83‐year‐old woman was admitted to our hospital because of palpitation. She had hypertension and paroxysmal atrial fibrillation, treated with digoxin and cibenzoline, and took dipyridamole for microalbuminuria. Before admission, she had taken pilsicainide pills in addition. On admission, electrocardiogram showed regular tachycardia with mildly prolonged QRS width. For the purpose of terminating tachycardia, 10 mg of adenosine triphosphate (ATP) was rapidly injected. About 20 sec later, atrioventricular block and ventricular standstill occurred. She presented loss of consciousness and convulsion, and chest compression was performed. About 30 sec later, the QRS complex reappeared, and she became alert. Serum concentration of digoxin, cibenzoline and pilsicainide was within therapeutic level, respectively. We should be cautious in using ATP for a patient taking dipyridamole and antiarrhythmic agents.

Scintigraphic evaluation of regression of abnormal Q waves in myocardial infarction

We report regression of the abnormal Q waves of an inferior old myocardial infarction after an additional anterior acute myocardial infarction, and demonstrate the scintigraphic correlation and chronological course of this phenomenon. Scintigraphic findings in the present case here may contribute to an interpretation of regression of abnormal Q waves in myocardial infarction.