A systemic disease un suspected by physical examination.

A 73-year-old man was admitted to the cardiology department with unstable angina. He had a history of macroglossia with 3 years of development, attributed to hypothyroidism. On physical examination, he presented an exuberant macroglossia. The following diagnostic procedures were performed-ECG, in sinus rhythm with low voltage criteria, and transthoracic echocardiography, which revealed a left ventricle with preserved function and marked wall thickening, with low strain values in basal segments. The coronary angiography confirmed a lesion of 90% in the right coronary artery, treated with two stents. Suspecting a systemic infiltrative disease, additional tests were performed and these revealed the presence of systemic amyloid light-chain (AL) amyloidosis with cardiac involvement, associated with multiple myeloma. The patient was sent to a consult of haematology to begin chemotherapy.

Retinal artery embolization complicating Libman-Sacks endocarditis in a systemic lupus erythematosus patient.

Libman-Sacks endocarditis (LSE) is the most characteristic cardiac manifestation of systemic lupus erythematosus (SLE). It is usually clinically silent but heart failure due to valvular dysfunction, secondary infective endocarditis and embolic phenomena can complicate valvular abnormalities. We present a patient with SLE and blindness due to right central retinal artery occlusion. Echocardiographic examination revealed a verrucous vegetation on the posterior mitral valve leaflet consistent with LSE. Anticoagulation therapy was started. Echocardiographic regression of the vegetation was observed and there has been no recurrence of thromboembolic events to date.

Cardiomyopathy in Churg-Strauss syndrome.

The authors present the case of a 56-year-old man, admitted to the hospital twice in ten days for acute coronary syndrome with normal coronary angiograms. In the second hospitalization, the patient had anginal crises that did not respond to anti-ischemic therapy, associated with cough and wheezing. The echocardiogram revealed worsening left ventricular systolic dysfunction. He had no cardiovascular risk factors but there was a history of bronchial asthma, allergic rhinitis and peripheral neuropathy of the left upper limb with paresthesias. Laboratory studies showed eosinophilia, detected in previous blood tests, although more marked than before. Chest X-rays showed non-fixed pulmonary infiltrates and bronchoalveolar lavage revealed increased lymphocytes and eosinophils, suggesting Churg-Strauss syndrome with the probable cardiac manifestation of coronary vasospasm. A cardiac MRI was also performed but was inconclusive due to the patient's intolerance of the exam.