Pulmonary valve papillary fibroelastoma diagnosed by echocardiography: a case report.

Papillary fibroelastomas (PFEs) are rare cardiac valve tumours with reported incidence of <0.03% according to autopsy studies. Among them, pulmonary valve PFEs are extremely rare. With wider use of echocardiography, they are being increasingly recognized premortem. We describe a case of a 32-year-old Caucasian woman with PFE of pulmonic valve diagnosed by echocardiography. The patient underwent surgery due to high mobility of the tumour and high risk of embolic complications. The surgery was done with complete tumour resection and total preservation of valve function. This case report discusses diagnostics of PFEs, their characteristic echocardiographic and histological features, and possible complications and suggests treatment options in this rare cardiac tumour.

[Varicella zoster myopericarditis in an immunocompetent adult]. / Mioperikarditis izazvan virusom varicella-zoster u imunokompetentnog odraslog bolesnika.

More than 20 viruses have been reported to cause myopericarditis, a rare but potentially dangerous complication. To our best knowledge only a few dozen cases of myopericarditis caused by varicella zoster virus have been reported, most frequently in children, seldom in immunocompetent adults. We report on a case of a myopericarditis caused by varicella zoster virus in a previously healthy young man, with a typical development and a fast and complete recovery. A 27-years-old male was admitted to our hospital with chest pain and signs of acute cardiac injury. He had no medical history of serious previous illnesses. Four weeks earlier, the patient was in contact with a child having chickenpox. Two days prior to admission patient became suddenly febrile up to 40 degrees C along with dry cough, and the following day intense chest pain set in. At the admission we found in the patient diffuse vesiculous exanthema on the whole body and capillitium. Heart beat was rhythmical with no audible murmurs or pericardial friction rub, 100 beats per minute, blood pressure RR 130/90 mm Hg, body temperature 37.4 degrees C, and ST segment elevation in lateral leads along with elevated cardiac markers were found. All parameters of complete blood count were within normal range. Chest X-ray showed somewhat enlarged heart with incipient signs of cardiac decompensation. Echocardiogram was normal, apart from a mild dyskinesis of the apical third of intraventricular septum, with ejection fraction slightly reduced to 50% and no valvular defect. Clinical diagnosis of acute infection with varicella zoster virus was confirmed serologically by a positive ELISA test. Patient received conservative therapy (isosorbide mononitrate, low molecular weight heparin, acetylsalicylic acid and bisoprolol), while he remained hemodinamically, and apart from one non sustained ventricular tachycardia immediately after admission, also rhythmically stable. During his stay in hospital we observed the typical evolution and regression of rash while the levels of cardiac markers normalised, with patient becoming afebrile the third day. Before dismission a control echocardiograph showed improvement of contractile function, ejection fraction improved to 65%, but also signs of mild pericarditis were recorded. Since the patient had no discomfort and was in a very good shape, he was dismissed from hospital with ibuprofen 400 mg twice a day as therapy. Two months later, the patient was readmitted for control. In the mean time he had no discomfort, all laboratory and the physical examination findings were normal, as well as the ECG. Echocardiogram showed normal contractility, systolic and diastolic function. Cardiac stress testing and coronary angiography both ruled out a coronary heart disease. Diagnosis of myocarditis in this case was made based on echocardiogram, anamnestic data and on the typical clinical presentation of an acute varicella zoster virus infection, and was serologically confirmed by ELISA test. Therapy with NSAID was started immediately and because of favorable development of the disease we did not perform myocardial biopsy. During second hospitalization an eventual coronary heart disease was ruled out by coronary angiography. Due to its rarity there are no guidelines regarding therapy of varicella myocarditis, but there is a consensus that these patients should receive intensive care unit. The basis of the therapy are certainly the NSAIDs, but also a combination of acyclovir and hyperimmunoglobulins has been reported which in this mild case was not necessary. With this report we want to point out that varicella zoster virus can cause myopericarditis in immunocompetent adults, which must be taken into consideration in differential diagnosis, and that an early diagnosis and adequate therapy can help achieve a fast and complete recovery.

[Cholesterol crystal embolism and renal insufficiency: case report and literature review]. / Kolesterolska embolizacija i bubrezna insuficijencija: prikaz bolesnika i pregled literature.

Cholesterol crystal embolism with renal impairment is increasingly recognised as an iatrogenic complication of invasive vascular procedures. We present a 58-year-old patient in whom the presence of a classic triad of precipitating event (coronary angiography), subacute presentation of renal failure and cutaneous lesions (livedo reticularis and Blue Toe syndrome) suggested this entity. The confirmatory diagnosis was made by means of renal biopsy which revealed cholesterol crystals lodged in arteries. In our patient severe renal insufficiency requiering hemodialysis ensued. Glucocorticoid and statin therapy failed to recover the renal function. The patient died from acute myocardial infarction. Invasive cardiac procedures are increasing in number especially in the elderly population so higher incidence of cholesterol crystal embolism coud be expected in the future. Increased awareness of this syndrome is necessary for early recognition, which is crucial for treatment, and defining the high-risk patient in whom other modalities of coronary diagnostics coud be considered.

[Vasculitis in rheumatoid arthritis--case report]. / Prikaz bolesnice s vaskulitisom tijekom reumatoidnog artritisa.

The presence of positive rheumatoid factor (RF) titer in a patient with rheumatoid arthritis (RA) is of clinical value because its presence tends to correlate with the development of extraarticular manifestations. There is a loose correlation with severity of disease and titer. Extraarticular manifestations includes vasculitis, pericarditis, subcutaneous nodules, pulmonary nodules or interstitial fibrosis, episcleritis and mononeuritis multiplex. The vasculitis is most frequently evidenced as skin infarctions/ulcerations and mononeuritis multiplex. We report a case of rheumatoid vasculitis in a 48 years old women with long history of RA, who developed vasculitis of distal arteries with gangrene of digits of upper and lower extremities.

A familial cluster of idiopathic dilatation of the right atrium-A two-case report.

We report two cases of idiopathic atrial dilatation in two adult siblings, a brother and a sister. The first patient was a 36-year-old man who was referred to our institution for evaluation of atrial fibrillation and syncopes. Transthoracic echocardiography revealed an enlarged right atrium accompanied by a severe tricuspid regurgitation associated with annular dilatation. The diagnosis of idiopathic atrial enlargement was made after all other lesions known to produce it have been excluded. The patient did not consent to the proposed cardiothoracic surgical treatment so he remained on conservative therapy. On electrocardiography, atrial standstill was noted, resulting in the implantation of a VVI cardiac pacemaker one year later. After an asymptomatic period, the patient suffered sudden death at the age of 40 years. His 45-year-old sister suffering from the same symptoms was also referred for examination, also to be diagnosed with idiopathic atrial dilatation and severe tricuspid regurgitation. Idiopathic dilatation of the right atrium, although a rare disorder, should not be forgotten as differential diagnosis for enlarged right atrium. Transthoracic echocardiography is the most commonly used technique and in our cases it was sufficient for establishing the diagnosis.