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An unusual case of multiple infarcts
  1. A K O Denniston,
  2. J M Beattie

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    Answers on p 434.

    A 44 year old woman presented to the accident and emergency department with sudden onset of severe dyspnoea, right sided weakness, and loss of speech. She was a smoker, but had no other identifiable risk factors for premature atherosclerotic disease. There was no significant medical history and no history of recent trauma. She was afebrile with a regular tachycardia at 120 beats/min. She was hypoxic with inspiratory crackles up to the mid-zones bilaterally. She had an expressive dysphasia with a right sided hemiparesis. An electrocardiogram (ECG) demonstrated sinus tachycardia with extensive anterior ST elevation consistent with acute anterior myocardial infarction. A chest radiograph confirmed the clinical impression of pulmonary oedema; heart size was normal.

    The patient exhibited progressive respiratory failure requiring ventilatory support. Thrombolysis for the extensive anterior myocardial infarct was contraindicated by the apparent stroke. An emergency computed tomogram of the head showed no abnormality, but could not exclude an early cerebral infarct. Full blood count and routine biochemistry were normal; the erythrocyte sedimentation rate was 63 mm/hour. Cardiological intervention was sought with a view to primary angioplasty. Emergency coronary angiography showed normal coronary artery anatomy with no obstructive lesion or occlusion. Left ventriculography showed extensive anterior hypokinesia consistent with an acute myocardial infarction, but also disclosed a mobile filling defect limited to diastole. The ECG (fig 1), transthoracic echocardiogram (fig 2), and a biopsy taken during a subsequent procedure (fig 3) are shown.

    Figure 2

    Transthoracic echocardiogram (four chamber view).

    QUESTIONS

    1. What are the differential diagnoses before imaging?

    2. What does the echocardiogram show?

    3. What is the final diagnosis?

    4. What is the treatment?

    5. What is the prognosis?

    6. Is there any risk to her children?

    7. How could the diagnosis have been made earlier?

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