Now You See It, Now You Don’t?

Abstract

Foreword Information about a real patient is presented in stages (boldface type) to an expert (Dr Omid Salehian) who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows.A 52-year-old woman is referred by her family physician to a general internist's clinic for assessment of a 3-month history of exertional dyspnea. She also reports a nonproductive nocturnal cough, night sweats, and an 18-lb weight loss over the preceding 3 months. The patient denies any history of chest pain, palpitations, presyncope, or syncope.The patient has a history of chronic obstructive pulmonary disease for which she was admitted to hospital 3 times in the last several months. Each time, she received a course of antibiotics and oral glucocorticoids, with no relief of her dyspnea. She reports no prior cardiac history, history of malignancies, or venous thromboembolic disease. Her home medications include salbutamol and tiotropium. She is a current smoker, with a 40-pack-year history, and denies alcohol intake or recreational drug use.Dr Salehian: Exertional dyspnea is a common complaint in patients presenting to emergency departments, general practitioners, internists, respirologists, and cardiologists. It has a very broad differential and could be attributable to a problem with the cardiovascular, respiratory, central nervous, or endocrine system. Furthermore, many patients with neoplastic or autoimmune disorders can present with dyspnea. The presence of constitutional symptoms and weight loss in a middleaged smoker is definitely concerning. Malignancy involving the lung, breast, or gastrointestinal system should be at the top of the differential diagnosis. One must also consider the possibility of hematologic malignancies such as lymphoma. Chronic systemic infections such as subacute bacterial endocarditis should be considered in the differential diagnosis. Collagen vascular disorders such as systemic lupus erythematosus or vasculitides could also have a similar presentation. Patient presentation (continued):On physical examination, she appears cachectic, weighing 51 kg at a height of 148 cm. Her blood pressure is 142/80 mm Hg and heart rate is 104 bpm; she has a regular respiratory rate of 24 breaths per minute and oxygen saturation of 93% on room air. Her temperature is 37.8°C. She is in mild respiratory distress, speaking in short sentences. Jugular venous pressure is 7 cm above the sternal angle with a positive abdominojugular reflux. Her carotid pulse is of normal volume and contour with no audible bruits. The apical impulse is normal in location and size. Auscultation reveals a normal S1 and S2 with a soft diastolic murmur heard best at the apex. No extra heart sounds are audible. There are coarse inspiratory crackles bilaterally at the lung bases. There is no pedal edema, and peripheral pulses are all palpable. There are no rashes, swollen joints, or palpable lymph nodes.On laboratory investigations, her total white blood cell count is 13 500 with 90% neutrophils, ...

Letter by Barik Regarding Article, “Now You See It, Now You Don’t?”

“…by Haroun et al 1 The authors have shared a real-time documentation wherein a part of left atrial myxoma had embolized into the brain, lower limbs, and possibly in the coronary arteries. Tumor embolization is one of the malignant presentations of cardiac myxoma which is a benign tumor.…”