A 32-year-old woman comes to the office because of fatigue, progressively worsening shortness of breath, and swelling of her feet. The patient has had these symptoms for the last 4 or 5 days. She denies chest pain. The patient has no other medical conditions except for a cold 2 weeks ago. She takes no medications. Temperature is 36.7 C (98 F), blood pressure is 110/65 mm Hg, pulse is 90/min, and respirations are 20/min. Physical examination shows bilateral basilar crackles, elevated jugular venous pressure, and 2+ bilateral pitting edema extending above the ankles. Complete blood count reveals no abnormalities. Which of the following will most likely be shown on echocardiography?

Question

A 32-year-old woman comes to the office because of fatigue, progressively worsening shortness of breath, and swelling of her feet.  The patient has had these symptoms for the last 4 or 5 days.  She denies chest pain.  The patient has no other medical conditions except for a cold 2 weeks ago.  She takes no medications.  Temperature is 36.7 C (98 F), blood pressure is 110/65 mm Hg, pulse is 90/min, and respirations are 20/min.  Physical examination shows bilateral basilar crackles, elevated jugular venous pressure, and 2+ bilateral pitting edema extending above the ankles.  Complete blood count reveals no abnormalities.  Which of the following will most likely be shown on echocardiography?

Quizplus · Accepted Answer

11ec25c8_d34a_6e91_bc81_7d906a973d8f_MD0003_00 This patient has evidence of decompensated heart failure (DHF) that is most likely due to viral myocarditis. This condition most commonly affects relatively young adults and is often preceded by a viral prodrome (eg, upper respiratory symptoms, enteritis). Most cases of viral myocarditis likely remain clinically undetectable, but some individuals may have a genetic predisposition that allows viral infection (eg, coxsackievirus, adenovirus, parvovirus B19) to persist within cardiomyocytes, causing disruption of myocardial contractility. With progressive biventricular contractile failure, there is compensatory eccentric hypertrophy and the eventual development of dilated cardiomyopathy (DCM). On echocardiography, DCM is recognized by dilated ventricular chambers and diffuse hypokinesis of the ventricular walls. compensatory Treatment of DCM due to viral myocarditis is mostly supportive and involves medical management of heart failure with reduced ejection fraction (eg, diuretics, beta blocker, ACE inhibitor), with some patients experiencing eventual recovery of cardiac function. (Choice A) Bacterial endocarditis of the aortic valve can cause aortic regurgitation leading to DHF; however, fever and leukocytosis are expected. (Choice B) Asymmetric septal hypertrophy characterizes hypertrophic cardiomyopathy (HCM), which is unlikely to present with DHF. HCM often presents with sudden cardiac death in patients without prior symptoms. (Choice C) Concentric left ventricular hypertrophy results from chronic pressure overload, as can occur with systemic hypertension or severe aortic stenosis. (Choice E) Mitral stenosis is typically recognized by a middiastolic murmur and opening snap. Patients can develop DHF, but mitral stenosis is unlikely in this patient with no known history of rheumatic fever. (Choice F) Segmental inferior wall hypokinesis is typical of inferior wall myocardial infarction (MI), which is unlikely in the absence of chest pain. In addition, inferior wall MI often predominantly affects the right ventricle and would not cause pulmonary edema. (Choice G) A thickened pericardium with a loculated pericardial effusion can occur with bacterial pericarditis, often as a complication of untreated bacterial pneumonia. Affected patients typically are acutely ill with high fever, tachycardia, and chest pain. Educational objective: Viral myocarditis is a potential cause of dilated cardiomyopathy in relatively young adults (eg, age <55). Patients usually present with decompensated heart failure that is often preceded by a viral prodrome. Echocardiography typically shows biventricular enlargement with diffuse ventricular wall hypokinesis. References: Diagnosis and treatment of viral myocarditis. (http://www.ncbi.nlm.nih.gov/pubmed/19880690)

A 32-Year-Old Woman Comes to the Office Because of Fatigue