Massimo Bolognesi

Complicated and delayed diagnosis of tuberculous peritonitis

Background Peritoneal tuberculosis is very rare in European countries. However, its incidence is increasing due to the continued immigration of people from endemic areas affected by tuberculosis. Case Report: The authors report a case of tuberculous peritonitis in a 46-year-old male patient from North Africa. The presenting symptoms of the disease were hiccups, dyspepsia, anorexia, and weight loss. Physical examination revealed an abdominal distension that suggested the presence of ascites. Subsequent investigations of ultrasound and computed tomography of the abdomen revealed the presence of massive ascites. A diagnostic laparoscopy went on to highlight a macro micronodular degeneration of the peritoneum. Histological examination showed the presence of epithelioid granulomas with typical Langhans cells with areas of caseous necrosis. The diagnosis of tuberculous peritonitis was then made, and the ascites quickly disappeared in response to the anti-mycobacterial therapy. The patient remained free of symptoms after 6 months of clinical follow-up. Conclusions: In this case the clinical diagnosis was complicated and delayed due to clinicians’ suboptimal knowledge of and experience with this disease. This case demonstrates why laparoscopy with peritoneal biopsy should be the gold standard in any clinical suspicion.

A prominent crista terminalis associated with atrial septal aneurysm that mimics right atrial mass leading to atrial arrhythmias: a case report

IntroductionThe crista terminalis is a variant of normal anatomical structures within the right atrium that mimics an atrial mass on a transthoracic echocardiogram. Atrial septal aneurysm is a rare but well-recognized cardiac abnormality of uncertain clinical significance. The association between crista terminalis and atrial septal aneurysm is unusual but not completely casual. Both anatomical heart structures can lead to atrial arrhythmias.Case presentationThis case report describes the accidental discovery during an echocardiographic examination of a 64-year-old Caucasian woman who had a left bundle branch block and palpitations.ConclusionThe clinical relevance of this anatomical evidence in unknown. This was an occasional finding of transthoracic echocardiography, but in this case it is possible to assume its relationship with the occurrence of atrial arrhythmias, and also that computed tomography scan and cardiovascular magnetic resonance is mandatory to define the structure and function of these incidental findings.

Silent myocardial ischemia in master marathon runners.

Background: Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. There are a number of reports of exercise-related sudden deaths and myocardial infarctions in aerobically trained athletes suffering from exercise induced silent myocardial ischemia. The most appropriate and used method to discover silent myocardial ischemia is the exercise stress testing. Case Reports: In this article the authors describe three emblematic cases of silent myocardial ischemia detected in master marathon runners during systematic prepartecipation screening. These marathon runners were asymptomatic but suffering from a severe coronary artery disease that only thanks to exercise treadmill stress test was detected and properly treated. Conclusions: Silent myocardial ischemia is not such a rare event in athletes, indeed quite the opposite. In fact, even though athletes are asymptomatic this does not exclude the possibility that they are suffering from severe coronary artery disease.

Asymptomatic Ischemic Heart Disease in a 45-year-old Male Athlete: A Case Report

Abstract Background: The primary purpose of pre-participation screening is identifying the cohort of athletes affected by unsuspected cardiovascular diseases, such as coronary artery disease (CAD) as well as preventing sudden cardiac death (SCD) during sports competitions or training, through appropriate intervention. Case Report: This case report describes the recent history of a middle-aged marathon runner suffering from asymptomatic ischemic heart disease at high risk for SCD and illustrates the clinical pathway. An exercise ECG stress testing was positive for subendocardial ischemia. Computerized tomography (CT) coronary angiogram subsequently showed critical narrowing of the left anterior descending artery. Invasive coronary angiography was performed following angioplasty procedure. One month later an exercise ECG stress testing was normal, indicative of complete myocardial revascularization. Conclusions: Silent myocardial ischemia (SMI) is not such a rare event in athletes, especially in endurance sports athletes. In fact, even though they are asymptomatic this does not exclude the presence of a severe coronary artery disease. Exercise stress testing is safe and affordable non-invasive screening for detecting asymptomatic coronary artery disease in athletes. Myocardial revascularization procedure is to re-establish the athlete’s state of fitness for competitive sports.

Acute coronary syndrome vs. myopericarditis - not always a straightforward diagnosis.

Patient: Male, 58 Final Diagnosis: Myopericarditis Symptoms: Retrosternal thoracic pain Medication: — Clinical Procedure: MRI Specialty: Cardiology Objective: Challenging differential diagnosis Background: Patients with acute cardiac symptoms, elevated cardiac troponin, and culprit-free angiograms are a consistent proportion of patients admitted with presumed acute coronary syndromes (ACS). Current literature on this population of patients justifies the diagnostic importance of cardiovascular magnetic resonance (CMR) imaging. Case Report: This report describes the case of a 58-year-old cyclist in which CMR allowed us to perform a diagnosis of myopericarditis mimicking acute STEMI against other evidence. There are several such reports in literature because the clinical presentation of myocarditis is quite variable. Conclusions: This case report emphasizes the importance of cardiovascular magnetic resonance imaging in the differential diagnosis of the etiology of acute coronary syndromes. This is especially important because the signs and symptoms presented are ambiguous and equivalent to those of other diseases, such as myopericarditis, which affects mainly young athletes but also middle-aged athletes.

A classical presentation of Hodgkin's disease in a 27-year- old healthy female

Herein, we report a case of classical Hodgkin’s lymphoma (HL) in an otherwise healthy 27- year-old female who came to the office of her general practitioner with flu-like illness and left supraclavicular swelling of uncertain nature, without other symptoms. An ultrasound of the neck detected many enlarged lymph nodes in the left supraclavicular region, and a chest X-ray showed left mediastinal enlargement. Subsequent Computed Tomography scan of the chest and abdomen confirmed the presence of many enlarged lymph nodes in the neck, mediastinum and liver, and a FDG-PET/CT scan showed multiple scattered consolidation lesions involving also the bones. The diagnosis of classical Hodgkin’s lymphoma, nodular sclerosis subtype, was made on a subsequent cervical lymph node biopsy.

Right Ventricular Overload Due to Severe Pulmonary Valve Regurgitation in 44-Year-Old GUCH

Notoriously, the valvular disease of the right heart have always received less attention than the left heart valvular disease both by echocardiographers and by researchers, probably due to the long period of latent asymptomatic and for the intrinsic difficulties of examination. However, it is increasingly recognized that right-sided valve disease is not a benign lesion and has a significant and independent impact on morbidity and mortality. Pulmonary regurgitation (PR) is common after surgical or percutaneous relief of pulmonary stenosis and following repair of tetralogy of Fallot. This case report describes the natural history of an adult patient with grown-up congenital heart (GUCH) who became competitive athlete and who showed signs of extreme morphological and functional adaptation of the right heart resulting in the outcome of a previous run surgical valvotomy at the age of 5 years for a congenital pulmonary stenosis. These anatomic changes of the right ventricle and pulmonary circulation have requested the replacement of the pulmonary valve for the symptomatic pulmonary hypertension, with subsequent gradual return to sports activity.

A teenager with tetralogy of fallot becomes a soccer player

Patient: Male, 0 Final Diagnosis: Tetralogy of Fallot Symptoms: — Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Unusual or unexpected effect of treatment Background: Tetralogy of Fallot (ToF) is the most common form of cyanotic congenital defect. Adult subjects with results of repair of tetralogy of Fallot may present post-surgical consequences that limit their physical capacity and thus their ability to compete in sports. Conversely, adults with excellent repair of congenital heart disease may have a chance to participate in competitive sports. Case Report: This case report illustrates the clinical course of a teenager with an outcome of surgical repair for TOF and demonstrates the boy’s excellent physical capacity that ensures his ability to play soccer. Conclusions: This case report raises the question of the possible revision of the criteria of the Italian COCIS protocol in terms of corrected congenital heart disease.