[An unexpected cause of dyspnea and degradation of performance]. / Dyspnoe und Leistungsminderung mit unerwartetem Ausgang.

HISTORY AND ADMISSION FINDINGS: A 55-year old man suffers from progressive, distinctive dyspnoea and physical weakness since 5 days. Due to ST-segment changes in the ECG and a positive troponin-test, the primary care physician initiates an hospitalization. INVESTIGATIONS: After admission, the laboratory tests confirm the elevated troponin-values, and show additionally elevated pro-brain-natriuric-peptide-values. The coronary angiography presents a highly reduced left ventricular function, an aortic insufficiency III° and a coronary heart disease. DIAGNOSIS, TREATMENT AND COURSE: After clinical deterioration and fever up to 42°C with consecutive tachycardia, the patient is taken over to the intensive care unit. Blood cultures are taken and an empirical antibiotic treatment is started. The patient dies within a few hours in catecholamine refractory circulatory failure. In the autopsy we find signs of an acute recurrent bacterial aortic valve endocarditis with a paravalvular abscess in the myocardium and a septic abscess in the left kidney. The patient died on acute left ventricular failure. DISCUSSION: The manifestation of an endocarditis can be presented very variable and can thus be a challenge in clinical practice. For one thing, the disease presents as an acute, rapidly progressive infection, on the other hand it acts as subacute or chronic disease with just little fever and nonspecific symptoms. To initiate an adequate therapy without loss of time, endocarditis should be included in the differential diagnosis where the risk profile is evident. There are risk factors (poor dental status, intravenous drug use, artificial valve or cardiological devices) for endocarditis. These risk factors with additional symptoms should always be given to a further diagnostics to detect an endocarditis. In addition to a multiple cultivation and laboratory analysis additional diagnostics such as ECG, echocardiography (transthoracic, transthoracic) and chest X-ray should be performed. Further stratification of patients is then performed using the modified Duke criteria. The anti-infective therapy is carried out using the new ESC Guidelines (2015). If a surgical procedure is indicated, this should be done in close consultation with the colleagues of Thoracic and Cardiovascular Surgery.

[Hematologic chest pain]. / Hämatologischer Thoraxschmerz - Fall 3 / 2016.

HISTORY AND ADMISSION FINDINGS: We report the case of a 59-year-old male who was admitted to hospital with acute chest pain. Coronary heart disease was known from the medical history. The patient reported recurrent ostealgia and susceptibility for infection during the last months before admission. INVESTIGATIONS: A 75% stenosis of the circumflex branch was treated with a drug eluting stent. Platelet aggregation was inhibited with acetylsalicylic acid and clopidogrel. Due to persisting ostealgia and inflammatory state, spondylodiscitis was excluded in MRI. However, platelets remained low after successful treatment of the infection. DIAGNOSIS, TREATMENT AND COURSE: Bone marrow biopsy revealed an acute lymphoblastic leukemia with positive detection of the Philadelphia chromosome. After chemotherapy and allogenic hematopoietic cell transplantation the patient remains in remission of his acute lymphoblastic leukemia. CONCLUSIONS: Especially in patients with documented history of coronary heart disease, the differential diagnosis of chest pain can be challenging. In this case, the chest pain was based on a subacute coronary ischemia as well as on proliferation of the acute lymphoblastic leukemia. The management of dual oral anticoagulation was performed with higher transfusion limits for thrombocytes and continuous application of thrombocyte aggregation inhibitors.

[42-year-old patient with portal hypertension - case 6/2012]. / 42-jährige Patientin mit portaler Hypertension - Fall 6/2012.

HISTORY AND ADMISSION FINDINGS: A 42-year-old woman was referred with a bleeding in the upper gastrointestinal tract, varices in the fundus of the stomach and portal hypertension of unknown primary. INVESTIGATIONS: Ultrasound examinations showed splenomegaly as well as portal hypertension. Blood examinations revealed low levels of haemoglobin. CT imaging showed multiple arteriovenous malformations with arterioportal shunts within the liver which led to a volume-induced portal hypertension. The genetic analysis revealed no mutations in the activin receptor-like kinase (ALK) 1 or endoglin genes. DIAGNOSIS, TREATMENT AND COURSE: The patient was clinically diagnosed with hereditary hemorrhagic teleangiectasia, also known as Osler-Weber-Rendu disease. Because of the multiple arterioportal shunts within the liver and the resulting portal hypertension with live-threatening gastrointestinal bleeding, the only therapeutic option for the patient is liver transplantation. Therefore, an application for a standard exception was made at Eurotransplant and the patient is going to be liver transplantated within the next months. CONCLUSIONS: Osler-Weber-Rendu disease is an autosomal dominant hereditary disease which leads to arteriovenous malformations and which can affect different organ systems. The course of the disease can be rather benign, but it can also lead to live-threatening complications requiring fast interventions.