Question of the Week!

[Hani]

An 84 year old lady presented with a 6 week history of feeling episodically dizzy and 2 episodes of near collapse (pre-syncope). She also admitted to mild dyspnoea on exertion which she had noticed over the same 6 week period. She had no previous cardiac history and was only on medications for constipation.

Let’s cut to the chase as I'm interested in cardiology and hence I’ll tell you that the cause of her dizziness, pre-syncope & dyspnoea is (we think!) cardiac. What do you think of her ECG?

ecg1.png

Confused? If in doubt repeat the trace; what about this one?

ecg2.png

The rhythm is irregularly irregular and at first we wondered whether her symptoms could be due to paroxysmal AF (this led us to wonder whether she was having posterior circulation TIAs and dizziness secondary to this) but then we looked at the rhythm strip with more care and we see this

strip1.png

1. What is the diagnosis?
2. What is the best management for such a case?

[Hani]

Answer:

This is a wandering pacemaker. with a possibility of a cerebral vessels injury (?emboli=?TIA)

The best thing we do for this pt is to implant a pace maker. and for sure refer her to a neurologist

Thanks

[Wail]

dear friend can u explain to me how did u link her cardiac problem to a cerebral event ? is it just the symptoms of near syncope and dizziness??
thanx for such an interesting case.

[memorand]

Salam

do you mean WANDERING!!! not wondering...or what

why you opted for such Rx !!! I meant what evidence you have apart from this ECG
can you elaborate abit how diagnostic workout has been done so far tor reach conclusive diagnosis as such

Regrads

[mohamedhakem]

Hypophosphatasia, especially the severe infantile form, is usually associated with mild to moderate hypercalcemia (see Chapter 694 ). Serum levels of phosphorus are
normal, and those of alkaline phosphatase are subnormal. The bones exhibit rachitic-like lesions on radiographs. Urinary levels of phosphoethanolamine, inorganic
pyrophosphate, and pyridoxal 5'-phosphate are elevated; each is a natural substrate to a tissue-nonspecific (liver, bone, kidney) alkaline phosphatase enzyme.
Missense mutations of the tissue-nonspecific alkaline phosphatase enzyme gene result in an inactive enzyme in this autosomal recessive disorder.

FROM NELSON 17ed