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CE SE POATE ASCUNDE IN SPATELE UNEI INSUFICIENTE CARDIACE ?

CE SE POATE ASCUNDE IN SPATELE UNEI INSUFICIENTE CARDIACE ?. ALEXANDRA KOSEVOI TICHIE MEDIC REZIDENT, AN II, REUMATOLOGIE SPITALUL CLINIC SFANTA MARIA, BUCURESTI. Scoala de Vara a Tinerilor Internisti, Sibiu, 2014. Istoricul bolii : ♀, 51 ani , fara APP semnificative

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CE SE POATE ASCUNDE IN SPATELE UNEI INSUFICIENTE CARDIACE ?

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  1. CE SE POATE ASCUNDE IN SPATELE UNEI INSUFICIENTE CARDIACE ? ALEXANDRA KOSEVOI TICHIE MEDIC REZIDENT, AN II, REUMATOLOGIE SPITALUL CLINIC SFANTA MARIA, BUCURESTI Scoala de Vara a Tinerilor Internisti, Sibiu, 2014

  2. Istoriculbolii: • ♀, 51 ani, fara APP semnificative • 2005: artralgii cu caracterinflamator la nivelularticulatiilormici ale mainilor remise dupatratamentambulator cu AINS • 2008: tuseseaca, dispneeinspiratorie, asteniefizicamarcata, fen Raynaud •  HTP severa(90mmHg estimataprin eco cord) • se indrumacatre o clinica de pneumologieundedupaefectuareaunuicateterism cardiac se deceleaza PAPs 117mmHg • se instituietratament cu inhibitor al fosfodiesterazei 5(sildenafil) si antagonist al receptorului de endotelina (bosentan) (studiu clinic)

  3. 2009: Clinicareumatologie • Clinic: • Artralgii difuze • Microstomie • Pliuri orale radiale • Telangiectazii faciale • Slabiciune musculara proximala simetrica • Fen Raynaud • Biologic: • HLG N • VSH N, CRP 22 mg/l (0-5mg/l) • Complement seric N • Factor reumatoid - • CK 457 U/L (0-145 u/l)

  4. Profilautoimun: • Ac anti SCL-70 – • Ac anti Centromer– • Ac anti U1RNP – • Ac anti JO-1 + Se punediagnosticul de Polimiozitaidiopatica a adultului

  5. Apr 2013: • Hipotensiunearteriala • Sincoperepetate • Acumulare de lichid de ascita •  Se intrerupedublaterapievasodilatatoare • Aug 2013: • Se decide introducereapacientei in studiu clinic cu dublaterapie (agonist de prostaciclinasi inhibitor al fosfodiesterazei 5)

  6. Ian 2014: asteniefizicamarcata, dispnee de repaus, edemegambiere, ameteli, cefaleeoccipitala • Ex clinic: • Microstomie, pliurioraleradiale, telangiectaziifaciale • Edemegambiere moderate albe, moi • Pulmonar: raluricrepitantesisubcrepitantebazal bilateral • CV: zgomote cardiac ritmice, suflusistolic in focareletricuspidiansipulmonar, jugulareturgide, TA 110/80mmHg, Av 75bpm

  7. Ex paraclinic: • EKG: RS, AV 65 bpm, ax QRS 0, aspect S I Q III, subdenivelare ST in DII, aVF, unde T negative V3-V6, faramodificari acute de fazaterminala • Eco cord: cord stang de dimensiuni N, VD 51 mm, AD 60/65mm, regurgitaretricuspidianasevera – velocitate 5m/s, gradient VD-AD 100mHg, PAPs-115mmHg, VCI 28mm. Pericard liber. • Biologic: • CRP20,4 (0-5mg/dl) • Na134 (136-146mmol/l), creatinina1,02 (0,5-0,95mg/dl), acid uric 10,45 (2,3-6,1mg/dl) • GGT323 (7-32 U/l)

  8. Aug 2014: cefalee intense, greata, inapetenta, ameteli, dispnee la eforturi minime • Clinic: facies de icoana bizantina, microstomie, telangiectazii , cianoza periorala, • Pulmonar: frecatura pleurala bilaterala, SpO2 74% • CV: zgomote cardiace echidistante, echipotente, suflu sistolic in focarele tricuspidian si mitral, TA=100/60mmHg, AV 60bpm, jugulare turgide

  9. Paraclinic • EKG: RS, AV 60 bpm, ax QRS 0, aspect S I Q III, subdenivelare ST in DII, aVF, unde T negative V3-V6, faramodificari acute de fazaterminala

  10. Scopiepulmonara: cardiomegalie, hilurimarite vascular, opacitatinodulare cu caracter alveolar localizateperihilar bilateral • Biologic: • GGT322 (9-36 UI/l), BT2,1 (0,2-1,2mg/dl), BD0,8 (0-0,2mg/dl), FA196 (25-125 /U/L)

  11. Tratament: • Sildenafil - 60 mg • Perindopril 2,5mg • Amiodarona 100mg • Spironolactona/Furosemid 50/20 • Digoxin 0,25mg • Medrol 4mg • Acenocumarol 2mg • Omeprazol 20mg

  12. Diagnostice: • Polimiozitaidiopatica a adultului cu afectarepulmonara (fibrozapulmonarainterstitiala) • Hipertensiunearterialapulmonarasevera • ICC clasa IV NYHA • Insuficientatricuspidianasevera • Boala de reflux gastro-esofagian

  13. Discutii:Pece ne bazampentrudiagnosticul de boala de tesutvasculo-conjunctiv? clinic sauparaclinic? Polimiozitasausclerodermie? • Asemanari: • Artralgii cu caracter inflamator • Fenomen Raynaud • Tulburari de deglutitie • Tulburari de ritm sau de conducere • Dispnee • Sd inflamator • Cresterea CK • Deosebiri: • Slabiciune musculara proximala simetrica (P) vs generalizata (SSc) • Facies caracteristic SSc (microstomie, pliuri radiale orale, telangiectazii) • Ac anti Jo 1+

  14. Concluzii: • desiaspectul clinic a fostsugestivpentruSScdiagnosticul a fostcel de Polimiozita • Poate fi luata in considerareposibilitateaunui overlap Ssc-P • debutulbolii a fostprinartralgiidiag + a fost pus in momentulaparitieiprimelorcomplicatii

  15. VA MULTUMESC

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