C37 CONCOMITANT PARTIAL PERICARDIAL AGENESIS, PERICARDIAL CYST AND POSTERIOR MITRAL VALVE LEAFLET HYPOPLASIA: A CASE REPORT

Background

Pericardial agenesis (1) is a congenital developmental disorder of the pleuro–pericardial membranes that is usually asymptomatic. A pericardial cyst (2) is a congenital cyst composed of mesothelial cells originating most often from the right pericardium. Hypoplasia of the posterior mitral leaflet (3) is congenital and it is very rarely diagnosed in adulthood. These alterations are usually sporadic and not associated.

Case presentation

A 53–year–old woman with obesity and bronchial asthma was referred to the emergency department for left hemiparesis and concomitant dyspnoea in new–onset atrial fibrillation. A right frontal ischemic stroke was diagnosed. During the hospitalization transthoracic echocardiography was performed showing a large prolapsed anterior mitral leaflet (AML) with an eccentric and significant regurgitation. Transesophageal echocardiography was performed. It confirmed the severity of mitral regurgitation, due to a large AML prolapse, but also showed a severely hypoplastic posterior leaflet (PML). Swinging motion was also reported in the absence of pericardial effusion. In the past the patient was surgically treated for an anterior pericardial cyst that was excised. Old CT images were reviewed and showed the absence of pericardial sheets along posterior and lateral left ventricle walls, which were not contiguous to the cyst (that was anterior). The patient was finally candidated to surgery for mitral valve replacement.

Discussion

The case report shows a unique case of association between partial pericardial agenesis, pericardial cyst, severe PML hypoplasia with AML prolapse and severe mitral regurgitation. The association of these three anomalies has never been described before. This could indicate a common pathogenetic denominator and therefore the need to look for this combination of structural abnormalities in carriers of even just one of them. Bibliography 1. Lopez D. et al, doi: 10.1016/j.pcad.2016.12.002 2. Khayata M. et al, doi: 10.1007/s11886–019–1153–5 3. Parato VM. et al, doi: 10.4103/jcecho.jcecho_73_17

P136 OCCASIONAL DIAGNOSIS OF B–CELL LYMPHOMA DURING A SCREENING EXAMINATION FOR HYPERTENSIVE CARDIOMYOPATHY: A CASE REPORT

Background

Echocardiography is fundamental in identifying early “red flags” of infiltrative cardiomyopathy in patients with monoclonal gammopathy and left ventricular hypertrophy. Nonetheless, definite diagnosis of cardiac amyloidosis requires multimodality imaging such as cardiac magnetic resonance, whole body bone scintigraphy and eventual biopsy in order to determine the disease phenotype.

Case Report

A 79 year–old male affected by Monoclonal Gammopathy of Undetermined Significance (IgM kappa) underwent a routinary echocardiography examination for arterial hypertension. The exam showed septal hypertrophy (diastolic septum width 13 mm) and right ventricular hypertrothy, E/e’>14 and valvular thickening. Based on these red flags in MGUS, in order to exclude cardiac amyloidosis, a whole body bone scintigraphy was performed: the exam was negative for myocardial uptake. Laboratory tests showed increased free kappa light chain component (61, 9 mg/L (r.v. 3.3–19.4), with lambda resulting 5,46 mg/l (r.v. 5.71–26.3), a k/l ratio of 11.34 (r.v. 0.26–1.65) and absence of Bence Jones proteinuria Subsequent cardiac MRI was performed and two restricted areas of subendocardial LGE were documented on the lateral and apical left ventricular wall without corresponding regional motion abnormalities: the findings were consistent with pathologic accumulation. In relation to the subendocardial localization of the abnormalities, obstructive coronaropathy was excluded by performing a coronary computed tomography angiography (CCTA). Abdominal Fat Biopsy was negative for amyloid protein. Osteo–medular biopsy displayed an IgM kappa lymphoplasmacytic lymphoma. Cardiological findings were, therefore, interpreted as markers of initial myocardial infiltration from a plasmacytoma. Afterwards, patient’s therapy and clinical follow up were managed by the Hematology care.

Discussion

Myocardial infiltration from plasmacytoma is very rare in comparison to Multiple myeloma and it features a more focal, less homogeneous pattern. In this case, recognizing red flags on echocardiography allowed an early diagnosis.

P393 MULTIMODALITY IMAGING IN ACROMEGALIC CARDIOMIOPATHY: A CASE REPORT

Background

Acromegaly is a disease caused by an excessive production of GH. Cardiac involvement, called acromegalic cardiomyopathy, is present in 90% of cases.

Clinical Presentation

A 56–year–old woman with acromegaly from pituitary adenoma, hypertension and obesity undewent angioCT showing thoracic aortic aneurysm (Figure 1). She was referred to a cardiological visit to evaluate the possible presence of acromegalic heart disease. The EKG showed signs of left ventricular hypertrophy (LVH) and so transthoracic echocardiogram (TTE) was prescribed: it showed slightly dilated, very hypertrophic left ventricle with ejection fraction of about 50% and signs of diastolic dysfunction. The exam also highlighted moderate to severe aortic valve regurgitation (Figure 2). In order to better characterize the cardiomyopathy a Cardiac magnetic resonance with contrast media (CMR) was performed: cine images confirmed severe left ventricular hypertrophy associated with mild dilatation, global biventricular hypertrophy and hypokinesia. After contrast media administration, a diffuse mild–enhancement pattern was found, a possible expression of diffuse interstitial fibrosis (Figure 3). In consideration of the dilatation of the ascending aorta and the contextual valve insufficiency, the patient was referred for cardiac surgery outpatient visit.

Discussion

The most frequent manifestations of acromegalic cardiomyopathy are bi–ventricular hypertrophy, the presence of diastolic and systolic dysfunction and the presence of valve regurgitation. Concentric hypertrophy is due to the increase in cardiomyocytes secondary to the GH stimulus and it is often bi–ventricular. Another characteristic finding is diffuse interstitial fibrosis with consequent systo–diastolic dysfunction and heart rhythm abnormalities. Aortic valve anomalies are linked to matrix abnormalities and myxoid degeneration.

Conclusions

this case can be considered an example of acromegalic heart disease. Multimodality imaging plays a key role in the early diagnosis of cardiac involvement and therefore it allows an early start of therapeutic strategy. Additionally, it is useful for the risk stratification of acromegalic patient.

Sonographic assessment of cartilage damage at metacarpal head in rheumatoid arthritis: qualitative versus quantitative methods

OBJECTIVE

To test the validity of the Outcome Measure in Rheumatology (OMERACT) semiquantitative score by comparing with a quantitative method in the sonographic (US) assessment of hyaline cartilage at the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and healthy subjects (HS).

METHODS

The hyaline cartilage from second to fifth MHs of both hands was scanned. Hyaline cartilage was scored semiquantitatively and quantitatively (by measuring cartilage thickness and comparing with reference values). In RA patients, radiographic joint space narrowing (JSN) was scored on the same joints using the Simple Erosion Narrowing Score (SENS).

RESULTS

Four-hundred and eight MHs in 51 RA patients and 320 MHs in 40 HS were evaluated. The OMERACT semiquantitative score was quicker to perform than the quantitative method (6.0 ± 0.5 vs 8.0 ± 1.5 min, p< 0.01). A significant correlation between the US scores (R = 0.68), and between the US scores and the JSN-SENS (R = 0.61 and R = 0.63, for semiquantitative and quantitative method, respectively) was found. The frequency of cartilage abnormalities was similar between the two US methods in RA patients (58.8% and 51.0% RA patients for semiquantitative and quantitative method, p= 0.46), while the former revealed more abnormalities in HS (27.5% and 7.5% of HS, p= 0.02).

CONCLUSION

The higher feasibility of the OMERACT semiquantitative score suggests its use as first-choice method in the evaluation of cartilage damage. However, despite its limits, the quantitative assessment of HC, providing patient-tailored information due to age- and sex-corrected cut-off values, may represent a valid supplement for optimizing the evaluation of cartilage damage in selected cases.

The crowned dens syndrome as a cause of neck pain: clinical and computed tomography study in patients with calcium pyrophosphate dihydrate deposition disease

OBJECTIVE

To investigate the association between articular chondrocalcinosis and calcification of the atlantoaxial region on a cervical computed tomography (CT) scan and to explore the relation between such calcifications and neck pain.

MATERIALS AND METHODS

CT slices of the cervico-occipital junction were performed routinely in 49 consecutive patients (male/female ratio 28/21; mean age 70.4 yrs), diagnosed with calcium pyrophosphate dihydrate crystal deposition disease (CPPD). Of these, 35 met criteria for definite CPPD and 14 met the criteria for probable. The cervical CT scans were analyzed for the presence of periodontoid calcifications by 2 independent musculoskeletal radiologists. Both assessors were blinded to the disease status of the patients. Furthermore, conventional radiographs of the upper cervical spine were performed. An ad hoc designed protocol was used to register information at diagnosis, including age, sex, location of pain and stiffness, fever, presence of synovitis and its location.

RESULTS

CT scan of the cervico-occipital junction showed periodontoid calcified deposits in 25 out of 49 patients (51%) with CPPD. In 10 of the 25 cases (40%) with periodontoid calcified deposits, CT scanning showed osseous abnormalities of the odontoid process, such as subchondral cysts or erosions. Conventional radiographs showed calcification behind the odontoid process in 17 patients (34.7%). Nine of CPPD cases (18.4%) presented with neck symptoms. In three patients, articular chondrocalcinosis was revealed only by an acute attack of neck pain with segmentary stiffness, fever, and an increased erythrocyte sedimentation rate; in one of them initial clinical examination found cervical stiffness with Kernig's and/or Brudzinski's sign. For the other two patients, impairment of general condition, occipito-temporal and mandible pain and weakness with inflammatory pain of the shoulder girdle was suggestive of giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR). In the six additional patients, questioning elicited a history of previous subacute or chronic neck pain, from one week to one year before their admission to our ambulatory or hospital.

CONCLUSIONS

These results suggest that CPPD deposition disease frequently involves the cervical spine. Although such calcification often remains asymptomatic, it may be associated with attacks of acute neck pain with segmentary stiffness, fever, and an increased erythrocyte sedimentation rate, sometimes mimicking PMR and/or GCA or neurological symptoms.

[Echo Doppler in the characterization of thyroid nodular disease]

This study was aimed at investigating role and efficacy of color-Doppler US in the characterization of thyroid nodules. Eight-three consecutive patients with only one solid thyroid nodule, not smaller than 0.8 cm, were examined. They were submitted to scintigraphy and laboratory tests first and then to color-Doppler US, to fine-needle biopsy and/or to histologic examinations. Color-Doppler US examinations were performed with a 7.5 MHZ linear probe, 5-MHz Doppler frequency, PRF = 0.8 KHz, 40-50 degrees insonation angle, wall filters at the lowest level, 2-5 mm sample volume, color and Doppler gains set at 30-50% and asynchronous data collection. The final diagnosis, made at cytology and/or histology, showed 43 follicular hyperplasias, 19 follicular adenomas and 21 carcinomas. The following US variables were considered: nodule size, site, margins and the possible presence of the "halo sign" pattern, with a special attention paid to micro-/macrocalcifications, signs of invasion of surrounding anatomic structures and possible adenopathies. With color-Doppler US, we studied presence and distribution of nodular vascularization, peak (Vp) and middle (Vm) velocity, resistive index (RI) and Doppler spectrum morphology. In agreement with the current literature, 3 patterns of nodular vascularization were considered: not apparent, or type I (3/83), which was found only in follicular hyperplasia; peripheral, or type II (46/83) and finally, peri- and intranodular, or type III (31/83). Hyperplasias exhibited a type I pattern rarely and exclusively and, if vascularized, they always exhibited Vp < 50 cm/s, Vm < or = 40 cm/s and mostly (39/40 RI < or = 0.75; adenomas were always vascularized, with Vp > 50 cm/s and mostly (18/19) RI < or = 0.75; primary or secondary tumors were always vascularized, with an extremely variable distribution, and if Vp < 50 cm/s, their RI > 0.75, while if Vp < 50 cm/s, their RI was independent of the threshold value of 0.75. These preliminary conclusions seem to confirm that vascular patterns alone are not particularly helpful, compared with B-mode US results, in distinguishing among thyroid nodules. Nevertheless, Vp and RI may be of great usefulness in the characterization of solid nodules and in the selection of the patients to submit to fine-needle biopsy.