Biomedical subjects
Publications and source records attributed to A G Fraser.
We report a patient whose left atrial myxoma recurred three times and review 28 other reports of recurrent myxoma. Inadequate resection and multifocal growth appear to be two separate causes for recurrence.
The echocardiographic features of left atrial ball thrombus associated with mitral stenosis are reviewed, and some previously unpublished cross-sectional echocardiographic findings presented. In one patient who had a large free-floating ball thrombus there was variation in its echocardiographic appearance; the thrombus was removed uneventfully at surgery. In another patient who had a pedunculated but immobile ball thrombus, a stalk was identified which attached it to the inter-atrial septum; this patient died suddenly before surgery could be performed, due to detachment of the thrombus and obstruction of the mitral valve orifice. Cross-sectional echocardiography is clearly superior to M-mode imaging in the detection of atrial thrombi, and variable appearances may help differentiation of thrombus from myxoma. Whether or not a ball thrombus appears mobile, emergency thrombectomy and mitral valve replacement is indicated, because of the risk of obstruction of the mitral valve.
We describe a 42-year-old man with Reiter's syndrome who developed complete heart block only 5 weeks after the onset of his illness. He was also noted to have carotid sinus hypersensitivity and evidence of sinoatrial disease. There were no clinical signs or echocardiographic findings to suggest involvement of the aortic root or aortic valve. His arrhythmias were treated successfully with a physiological pacemaker. The combination of sinoatrial and atrioventricular node disease suggests that the inflammatory process in Reiter's syndrome can produce widespread involvement of the conducting system.
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A 43-year-old Polynesian presented with fever, abnormal liver function tests, bilateral pulmonary infiltrates, and a progressive neutropenia and thrombocytopenia. Bone marrow examination showed extensive and striking hemophagocytosis which raised the diagnosis of malignant histiocytosis. Mycobacterium tuberculosis was subsequently cultured from both urine and bone marrow. Hemophagocytosis is now a recognised association of several infections and we draw attention to this finding, particularly as the confident exclusion of malignancy can be very difficult and management is obviously very different.
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The presentation, diagnosis and management of a case of phaeochromocytoma of the urinary bladder is reported and the literature briefly reviewed.
A young Polynesian man presented with severe hypertension complicated by an intracerebral hemorrhage. The hypertension was found to be secondary to hyperaldosteronism from a well differentiated adrenocortical carcinoma. Surgical removal of the tumor has resulted in a near normal blood pressure with no evidence of tumour recurrence of hyperaldosteronism after one year.
Objective changes in colour vision have not been demonstrated previously in patients on long-term amiodarone therapy, although the occurrence of blurring of vision and seeing coloured haloes around lights has been widely reported. In a masked study, colour vision was assessed in 15 patients who had been treated with amiodarone for 16-72 months. Subjects with extensive corneal microdeposits (Miller stage 3) had worse colour vision than subjects with mild or moderate corneal changes (Miller stages 1 and 2) (P = 0.02), and higher serum concentrations of the metabolite desethlyamiodarone (P = 0.008). The only subject with marked asymmetry of corneal changes had a long-standing unilateral ptosis, suggesting that exposure to light might influence the development of corneal changes.
A patient presented with tamponade and haemopericardium 16 years after experiencing sudden severe chest pain associated with enlargement of the proximal aorta. Investigations revealed a proximal aortic dissection (DeBakey type II) with extensive laminar and partially calcified thrombus within its false lumen and a large pericardial effusion, which together resulted in a cardiothoracic ratio of 100%. Long term survival after medical treatment of proximal aortic dissection, with such late progression to tamponade, has not been reported before.
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We reviewed the notes of the first 11 patients with AIDS managed by the infectious disease unit, Auckland Hospital, who all presented during 1985. All were homosexual males: none had other recognised risk factors: ten had travelled beyond New Zealand. Five were diagnosed at Auckland Hospital, six overseas. Median age was 31 (range 28-43) years. Five had Kaposi's sarcoma and three Pneumocystis carinii pneumonia. Five are alive. They have spent a median 13 (range 0-41) days in Auckland Hospital. Treatment options for the more common problems are discussed. We have tended towards conservative treatment of tumour but more aggressive treatment of opportunistic infection. Medical, nursing and ancillary hospital staff and lay people involved have rapidly adapted to caring for these patients without excessive anxiety.
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We report a patient with a malfunctioning Lillehei-Kaster aortic valve which presented only as loss of the normal valve click, 7 months after temporary interruption of anticoagulation at the time of abdominal surgery. Loss of a normal prosthetic valve click may be the only sign of prosthetic valve malfunction, and it is a surgical emergency. Patients with prosthetic heart valves, who undergo non-cardiac surgery, should not receive vitamin K1, and anticoagulation should be restarted promptly after surgery with intravenous heparin as well as warfarin.
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Three patients developed peripheral neuropathy after taking amiodarone for more than 18 months. All had high serum concentrations of amiodarone and its desethyl metabolite; in one patient concentrations in a sural nerve biopsy were 80 times higher than in serum. Peripheral neuropathy is a complication of large doses of amiodarone taken over long periods.
We compared the haemodynamic effects of a low osmolality contrast medium Hexabrix 320 (meglumine/sodium ioxaglate) with a high osmolality medium Urografin 370 (meglumine/sodium diatrizoate) in 32 patients. Each underwent left ventriculography with both media, which caused similar small and transient increases in heart rate and systolic pressure. In 15 patients with coronary artery disease, the mean left ventricular end-diastolic pressure increased by 4 mmHg after hexabrix compared with 10 mmHg after urografin (P less than 0.01); it returned to normal more quickly after hexabrix. Changes after both media did not correlate with baseline end-diastolic pressure, ejection fraction, or extent of coronary artery disease, and thus left ventriculography was unhelpful as a stress test. In 14 patients with mitral stenosis, hexabrix produced a smaller increase in left ventricular end-diastolic pressure (P less than 0.001), left atrial pressure (P less than 0.01) and mitral valve gradient (P less than 0.05) than urografin. Patients preferred the low osmolality medium (P less than 0.01). There was no difference in angiographic quality. We advocate low osmolality contrast media for patients with poor left ventricular function or severe mitral stenosis.