Block 2 Case 16 Answers

1. In Los Angeles a 38 yo HIV positive man who recently traveled to Peru and originally complaining of fatigue is hospitalized with palpitations and dyspnea. He has no significant medical history and does not take any medications. He has a 20 pack year smoking history and reports occasional alcohol use, though his wife mentions that it is daily. He denies illicit drug use.

Labs:
Hemoglobin 14 g/dL
MCV 101
AST 55 U/L
ALT 45 U/L
TSH 4.5uU/mL

On Physical exam, his temp is 98.5F, BP is 120/80mmHg, and heart rate is 115/min. Jugular venous pressure is normal. The lungs are clear. Cardiac examination shows an irregularly irregular rhythm. There is trace edema at both ankles. 

Chest radiograph was as follows:

b. Based on his history and clinical presentation, what will you find on the echocardiogram that the Cardiologist ordered on your patient?

Dilated Cardiomyopathy

(For this patient,you found dilated ventricles with normal wall thickness and severely decreased systolic function--left ventricular ejection fraction, 15%)

c. What other pertinent positives in his history leads you to and exacerbates the diagnosis above? What in his labs support your etiology?

Alcoholic History

d.  Why was TSH ordered? What does this patient's TSH mean?

Severe hypothyroidism can cause myxedema heart

e. What other drugs could have cause this patient's symptoms?

Cocaine, Amiodarone, Daunorubicin, Doxorubicin


Ultimately, the patient stopped drinking alcohol to slow down the progression of his illness. The doctor, convinced that there was another related, but undiscovered etiology, sought out a cardiac biopsy ruling almost everything out.

f. What new additional diagnosis do you now have?

Chagas Disease