doc_clotaire
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A 42-year-old man from Vietnam, who had been a bus driver in Thailand,
presents to the emergency department after having shortness of breath
while playing soccer with his son this morning. Over the last several
months, he has been having several episodes of shortness of breath.
Several of the episodes were associated with chest pain. He denies any
significant medical history. He has a 25-pack-year use of tobacco, and
he has a sedentary lifestyle. His father had a myocardial infarction
at the age of 59. His heart rate is 72/min, blood pressure is 140/66
mm Hg, and respiratory rate is 14/min. His examination shows mild
jugulovenous distention with a collapsing carotid arterial pulse. His
cardiac examination reveals a point of maximal impulse that is
displaced laterally and inferiorly and a mild diastolic blowing murmur
at the base while he sits up. His sensory examination shows loss of
vibration sense in all extremities, and an abnormal Romberg test. EKG
shows normal sinus rhythm with left axis deviation and ST-segment
depression and T-wave inversion in leads I, aVL, V5, and V6. The chest
x-ray shows an enlarged heart with dilatation of the proximal aorta.
The CBC, chemistries, and cardiac enzymes are negative. The
echocardiogram shows an ejection fraction of 60%. What is the next
best step in the management of this patient?
(A) Treat with digitalis
(B) Exercise stress test
(C) Cardiac catheterization
(D) VDRL and lumbar puncture, followed by penicillin therapy
(E) Aortic valve replacement
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| sprint123
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Excercise stress test??!
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| Adam
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I go with C 
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| nadiabarati
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D
is it syphilis?
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| new_n_lost
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(D) VDRL and lumbar puncture, followed by penicillin therapy
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| usmile2
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Answer is E . Next best step in management would be taking care of his symptoms. it's clear that the patient has an aortic regurgitation, and he is symptomatic, sob... and has a compromised systolic function EF 60%.
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| Justice
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My answer is (E)
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| neo335
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can anyone tell me if Rx the syphillis will reverse the aortic dilatation? thnx
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| alosh_2
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I am going to go with C.
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| arlete
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The answer is E. Nothing will reverse the damage, so it needs surgical repair.
Ejection fraction of 60% is NORMAL. But there's a volume overload, so it's a matter of time for it to go down.
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| neo335
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i wud also go with a valve replacement... treating with penicillin wont help the AR.. we need to replace the valve..
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| doc_clotaire
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Answer:
(D) VDRL and lumbar puncture, followed by penicillin therapy
Explanation:
This patient has a murmur of aortic regurgitation (AR) and an abnormal neurological examination, suggesting syphilis. Therefore, this patient needs a VDRL and a lumbar puncture. Syphilis of the aorta involves theintima of the coronary arteries and may narrow the coronary ostia, leading to myocardial ischemia. There is also destruction of themedial muscle layers of the aorta, leading to aortic dilation.
Myocardial ischemia in AR happens because oxygen requirements are elevated secondary to left ventricular (LV) dilatation and elevated LV systolic wall tension. Coronary blood flow is normally during diastole when the diastolic arterial pressure is subnormal. This leads to decreased coronary perfusion pressure.
Nifedipine or ACE inhibitors are only used once the patient develops severe AR. Digoxin is of very limited use at any time. An exercise stress test is not indicated because of the baseline EKG
abnormalities. You normally detect the presence of ischemia on a stress test by looking for the development of ST-segment depression.
This patient already has baseline ST-segment depression. A thallium or sestamibi scan would be required in a case like this. If you were investigating for ischemia, surgical treatment does not restore normal LV function. Patients with AR and normal LV function are followed until surgery is indicated. This is when the patient has LV dysfunction but before the development of symptomatic congestive failure. Valve replacement is also indicated in asymptomatic patients when the ejection fraction falls to <55% or LV end-diastolic volume is >55 mL/m2. Although catheterization may be useful before surgery, it would not be done before a specific diagnosis of syphilitic aortitis has been confirmed and treatment with penicillin has been given.
Edited by new_n_lost on 04/05/07 - 11:06 AM. Reason: Just Highlighted the Imp Point.
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| arlete
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Very interesting, thanks for sharing.
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| dr19
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Syphilis--->Tertiary stage---->Neurosyphilis----->Tabes Dorsalis
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