68-Year-Old Man with Syncope: A Case Commentary by Prof. Dr. Fawzy Megahed Khalil

1. بسم الله الرحمن الرحيم "وفي أنفسكم أفلا تبصرون" صدق الله العظيم (الذاريات 21)

2. Commentary case By Prof. Dr. Fawzy Megahed Khalil

3. Case 28-2007: A 68-Year-Old Manwith Syncope

4. A 68-year-old man was admitted to this hospital because of a syncopal episode, followed by hemiparesis and altered mental status.

5. The patient was in his usual state of health until the morning of admission, when he suddenly lost consciousness and vomited while walking with a companion.

6. He was transferred by ambulance to the emergency department of another hospital within 35 minutes after the onset of symptoms.

7. On arrival, he said he did not have chest pain or headache, but he was unable to provide other history. On examination, he was lethargic, with intermittent periods of unresponsiveness.

8. The blood pressure was 166/80 mm Hg, the pulse 74 beats per minute, and the axillary temperature 36.1°C; the respirations were 18 breaths per minute.

9. His gaze was deviated to the right, and he had a right facial droop and difficulty swallowing oral secretions. The patient’s left arm was flaccid, but he was able to move his other limbs.

10. There was no sign of head trauma; the remainder of the examination was normal. The hematocrit was 30.6%, and the remainder of the complete blood count was normal. The blood glucose level was 141 mg per deciliter (7.8 mmol per liter), and the potassium level 3.1 mmol per liter.

11. Levels of other electrolytes, renal function, and liver function were normal. Urinalysis revealed dark-yellow, turbid fluid with a pH of 7.0, a specific gravity of 1.020, and a urobilinogen level of 4.0 Erlich units per deciliter; the urine was positive for protein (2+), ketones (3+), blood (1+), and esterase (3+).

12. A radiograph of the chest showed pulmonary vascular prominence with no evidence of edema, infiltrate, or effusion. An electrocardiogram revealed sinus tachycardia with ST-segment elevation in leads V3 through V5. Tests for creatine kinase and troponin T were negative.

13. Computed tomographic (CT) scanning of the head revealed right frontal and left cerebellar infarcts that appeared old, without evidence of bleeding, edema, or midline shift.

14. CT scanning of the chest and abdomen, performed with the administration of contrast material, showed patchy perfusion of the left kidney and no perfusion of the right kidney.

15. There was variable enhancement of the small-bowel loops and a defect in the superior mesenteric artery, findings that were consistent with the presence of an embolus.

16. The patient had a history of diabetes mellitus, hypertension, and anemia. Four months before admission, a diagnosis of prostatic carcinoma had been made on transurethral prostatectomy.

17. Chemotherapy and radiation therapy were administered, and a radical prostatectomy was planned because of increasing levels of prostate-specific antigen.

18. The patient was allergic to penicillin. Medications included rosiglitazone, glipizide, metformin, erythropoietin, goserelin, ketoconazole an amlodipine and benazepril combination, and hydrocortisone. He lived with his wife and did not smoke or drink alcohol.

19. On examination, the patient was observed to be a thin man who was intubated, sedated, and lethargic, responding to noxious stimuli by partially opening his eyes,

20. He did not withdraw when pinched and did not follow commands. His blood pressure was 182/78 mm Hg, and his pulse 93 beats per minute; respirations were by mechanical ventilation.

21. There were bilateral breath sounds with a grade 2/6 holosystolic murmur radiating from the left lower sternal border to the apex; the abdomen was soft and was not distended. The patient’s pupils were midline, equal, and sluggishly reactive, with a positive doll’s-eye sign and conjugate gaze.

22. His face was symmetric; there was minimal spontaneous limb movement, and the muscles had normal tone. The remainder of the examination was normal.

23. (11.8 mmol per liter), potassium 3.4 mmol per liter, and serum creatinine 1.5 m per deciliter (132.6 μmol per liter).

24. Tests for creatine kina MB isoenzymes and troponin T were negative, as was a test for occult blood in the stool. Electrocardiography revealed ST-segment elevations in leads II, III, aVF, and V3 through V6 The blood glucose level was 212 mg per deciliter

25. Chest radiography showed endotracheal and nasogastric tubes in place and a small right pleural effusion, with left retrocardiac and midlung opacities that may have represented atelectasis, pneumonia, or effusion and moderate pulmonary edema.

26. Arterial blood gas measurements while the patient was breathing 100% oxygen revealed a partial pressure of oxygen of 205 mm Hg and a partial pressure of carbon dioxide of 35 mm Hg, with a pH of 7.39. The hematocrit was 35%, the prothrombin time 15.9 seconds (reference range, 11.1 to 13.1), and the partial-thromboplastin time greater than 150 seconds (reference range, 22.1 to 35.1).

27. and serum creatinine 1.5 m per deciliter (132.6 μmol per liter).(11.8 mmol per liter), potassium 3.4 mmol per liter, and serum creatinine 1.5 m per deciliter (132.6 μmol per liter). Tests for creatine kina MB isoenzymes and troponin T were negative, as was a test for occult blood in the stool.

28. Electrocardiography revealed ST-segment elevations in leads II, III, aVF, and V3 through V6 The blood glucose level was 212 mg per deciliter Chest radiography showed endotracheal and nasogastric tubes in place and a small right pleural effusion, with left retrocardiac and midlung opacities that may have represented atelectasis, pneumonia, or effusion and moderate pulmonary edema.

29. Transthoracic echocardiography showed hypokinesis of the anterior, septal, and apical walls of the left ventricle. Overall left ventricular systolic function was at the lower limit of the normal range.

30. There was incomplete closure of the posterior mitral-valve leaflet and an associated jet of mild-to-moderate mitral regurgitation. The left atrium was dilated. There was a mobile echodensity in the left atrium that was attached to or associated with the atrial septum

31. Subsequent transesophageal views revealed a mass, 2.3 cm by 1.5 cm, with its base attached to the interatrial septum. The mass was highly mobile and contained multiple frondlike elements. Color Doppler imaging showed no evidence of a patent foramen ovale.

32. Magnetic resonance imaging (MRI) of the brain revealed multiple punctate and confluent new infarcts in the bilateral occipital and frontal lobes, the cerebellum, and the right temporal lobe, as well as old encephalomalacia in the left cerebellum. There was no perfusion delay.

33. Interventional angiography performed approximately 5 hours after the onset of symptoms revealed an occlusive filling defect in the distal left anterior descending coronary artery.

34. Balloon dilation improved filling, but there was a persistent occlusion in the distal apical segment of the vessel. Arterial occlusions were also found in branches of both renal arteries, resulting in obstruction of flow to the top third of the right kidney and the middle third of the left kidney.

35. The superior mesenteric artery was completely occluded proximally by what appeared to be an embolus. Multiple attempts at catheter-based embolectomy of the superrior mesenteric artery and local administration of tissue plasminogen activator (a 5-mg pulse delivered intraarterially) were unsuccessful in restoring flow. Small amounts of gelatinous material were removed and sent for pathological examination.

36. Six hours after admission, the aspartate aminotransferase level was 130 U per liter (normal range, 0 to 35), and the amylase level was 118 U per liter (normal range, 3 to 100). Measurements of cardiac enzymes revealed a creatine kinase level of 810 U per liter, a creatine kinase MB isoenzyme level of 133.4 ng per milliliter, a creatine kinase MB index of 16.5%, and a troponin T level of 4.09 ng per milliliter.

37. Differential Diagnosis

39. This patient with a history of carcinoma of the prostate and hypertension presented with abrupt syncope, multifocal neurologic deficits, a murmur of mitral regurgitation, and evidence of an acute myocardial infarction. Although the differential diagnosis for syncope in a patient with myocardial infarction includes ventricular arrhythmia, the history and physical examination indicate that arrhythmia was probably not the cause of his loss of consciousness.

40. infective endocarditis, • intracardiac thrombus, • cardiac neoplasm

43. MRI Scans of the Brain.Diffusion-weighted images of the brain show multifocalhyperintense signal abnormalities in all vasculardistributions of the anterior and posterior cerebral circulations.The abnormalities were confirmed to reflectrestriction of water diffusion on the corresponding apparent-diffusion-coefficient image (Panel A).

45. A transthoracic echocardiogram shows an apical, fourchamber view of the heart. Panel A shows the left ventricle (LV), right ventricle (RV), left atrium (LA), right atrium (RA), and interatrial septum (IAS) (see also Video 1 in the Supplementary Appendix, available with the full text of this article at www.nejm.org). A poorly circumscribed mass (arrow) appears to be adjacent to the interatrial septum.

46. A transesophageal view (Panel B) shows the left atrium, right atrium, and interatrial septum. A poorly circumscribed mass (arrow) is attached to the interatrial septum in the left atrium. The mass measures 1.5 by 1.3 cm. AV denotes aortic valve.

47. DIAGNOSIS Left atrial myxoma, with embolization to the cerebral, coronary, renal, and mesenteric vasculature.

48. Clinical Diagnosis Anterior myocardial infarction and occlusion of the renal and mesenteric arteries resulting from embolization of a left atrial myxoma.