Calcified plaque of the aorta at the entrance of a patent ductus arteriosus: A point in diagnosis
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CALCIFIED PLAQUE OF THE AORTA AT THE ENTRANCE OF A PATENT DUCTUX ARTER~IOXUS: A POINT IN DIAGNOSIS” EDIVARD Wmss, M.D PHILADELPHIA, PA. CASE REPORT E. M., a colored woman, aged 33 years, was admitted to the Jefferson Hospital, May 20, 1931. She eomplained of pain in the right chest and shortness of breath. The family history was negative. Past history.-Pelvie inflammatory disease in 1925 and again in 1930; operated upon in 1925 and 1926. The patient had five living children and two mis- easriages. The present illness began about five weeks before admission with fever and general malaise followed by slight cough, then severe chills and high fever. Pain in the right side1 and increasing shortness of breath occurred just before admission. Physical examination showed a poorly nourished young colored woman with some dyspnea, no clubbing of the fingers and no evidence of petechiae. The pulse rate was 120 and regular. The pupils reacted to light and in accommodation. The heart; apex beat was forceful in the 6th interspace at the anterior axillary line; left ventricle dulness apparently extended into the mid-axilla. The first sound had poor tone and there was a slight systolic murmur at the apex, also a rough systolic murmur over the pulmonary area. No thrill was felt.. The right ventricle apparently was not extended. The lungs were resonant with the exception of the right base posteriorly and lower right axilla, where there was slight im- pairment of the percussion note but no &es. The abdomen was held rather rigidly. No organs or masses were made out. There was no edema of the legs. The knee jerks were active. About 5 cc. of slightly turbid fluid were withdrawn from the base of the right chest posteriorly. No more could be ob- tained, No organisms were obtained from the fluid. The blood count on admis- sion was hemoglobin 52 per cent, R.B.C.-2,940,000, W.B.C.-15,200 with 81 per cent polynuclears. On May 29 the W.B.C. were 27,000, on June 2, 31,000. The blood Wassermann was 4 plus. The blood culture was negative. The sputum was negative for tubercle bacilli. The urine contained a trace of albumin and an excessive number of white blood cells. The eye-ground examination was negative. Spinal fluid examination was negative. Electrocardiogram.-Rate 110; rhythm regular; spreading of the base of the R-spike suggested delay of conduction along a branch of the bundle; a-v con- duction time was normal; there was no disturbance of the muscle balance. Evidence of myocardial degeneration, probably advanced, was present. X-ray of the chest showed no special pulmonary findings but an interesting ob- servation was made regarding the heart and aorta, as follows: “There is an atheromatous plaque in the aortic knob’ and a slight fullness in the region of the left auricle. The heart is enlarged, particularly to the left. Its transverse diameter is 15 cm.; while that of the chest is 27 cm." The patient was very ill and stuporous almost from the’ beginning. Near the end of the illness pulmonary findings became a, little more marked, that is, dulness increased at the right base posteriorly, breath sounds were harsh, and numerous rbles were heard. The temperature averaged about 103” with sharp peaks; the pulse and respirations accordingly were raised. Death occurred on June 7. Autopsy was delayed until the following day. Int.erest centered chiefly about the heart which weighed 350, gm. The perienrdial sac contained a little excess of cloudy fluid and there was some evidence of acute inflammation. The muscle of the 8From the Department of Medicine, Service of Dr. Thomas McCrae, Jefferson Med- ical College Hospital, Philndelphia, Pa. 114
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Transcript of Calcified plaque of the aorta at the entrance of a patent ductus arteriosus: A point in diagnosis
CALCIFIED PLAQUE OF THE AORTA AT THE ENTRANCE OF A PATENT DUCTUX ARTER~IOXUS: A POINT IN DIAGNOSIS”
EDIVARD Wmss, M.D PHILADELPHIA, PA.
CASE REPORT
E. M., a colored woman, aged 33 years, was admitted to the Jefferson Hospital, May 20, 1931. She eomplained of pain in the right chest and shortness of breath.
The family history was negative. Past history.-Pelvie inflammatory disease in 1925 and again in 1930; operated
upon in 1925 and 1926. The patient had five living children and two mis- easriages.
The present illness began about five weeks before admission with fever and general malaise followed by slight cough, then severe chills and high fever. Pain in the right side1 and increasing shortness of breath occurred just before admission.
Physical examination showed a poorly nourished young colored woman with some dyspnea, no clubbing of the fingers and no evidence of petechiae. The pulse rate was 120 and regular. The pupils reacted to light and in accommodation. The heart; apex beat was forceful in the 6th interspace at the anterior axillary line; left ventricle dulness apparently extended into the mid-axilla. The first sound had poor tone and there was a slight systolic murmur at the apex, also a rough systolic murmur over the pulmonary area. No thrill was felt.. The right ventricle apparently was not extended. The lungs were resonant with the exception of the right base posteriorly and lower right axilla, where there was slight im- pairment of the percussion note but no &es. The abdomen was held rather rigidly. No organs or masses were made out. There was no edema of the legs. The knee jerks were active. About 5 cc. of slightly turbid fluid were withdrawn from the base of the right chest posteriorly. No more could be ob- tained, No organisms were obtained from the fluid. The blood count on admis- sion was hemoglobin 52 per cent, R.B.C.-2,940,000, W.B.C.-15,200 with 81 per cent polynuclears. On May 29 the W.B.C. were 27,000, on June 2, 31,000. The blood Wassermann was 4 plus. The blood culture was negative. The sputum was negative for tubercle bacilli. The urine contained a trace of albumin and an excessive number of white blood cells. The eye-ground examination was negative. Spinal fluid examination was negative.
Electrocardiogram.-Rate 110; rhythm regular; spreading of the base of the R-spike suggested delay of conduction along a branch of the bundle; a-v con- duction time was normal; there was no disturbance of the muscle balance. Evidence of myocardial degeneration, probably advanced, was present.
X-ray of the chest showed no special pulmonary findings but an interesting ob- servation was made regarding the heart and aorta, as follows: “There is an atheromatous plaque in the aortic knob’ and a slight fullness in the region of the left auricle. The heart is enlarged, particularly to the left. Its transverse diameter is 15 cm.; while that of the chest is 27 cm."
The patient was very il l and stuporous almost from the’ beginning. Near the end of the illness pulmonary findings became a, little more marked, that is, dulness increased at the right base posteriorly, breath sounds were harsh, and numerous rbles were heard. The temperature averaged about 103” with sharp peaks; the pulse and respirations accordingly were raised. Death occurred on June 7.
Autopsy was delayed until the following day. Int.erest centered chiefly about the heart which weighed 350, gm. The perienrdial sac contained a little excess of cloudy fluid and there was some evidence of acute inflammation. The muscle of the
8From the Department of Medicine, Service of Dr. Thomas McCrae, Jefferson Med- ical College Hospital, Philndelphia, Pa.
114
WEISS : CALCIFIED PLAQUE OF THE AORTA 115
left ventricle was soft and pale. A ductus arteriosus was present and was filled with recent thrombus material which stopped abruptly at the, sortie opening of the ductus but continued on the pulmonic side so that a large soft thrombotic mass 1.5 cm. in diameter was attached to the wall of the pulmonary artery and pro- jected into the lumen of the vesse;i. At the point of attachment of the ductus to the aorta there was a hollowed-out depression measuring 1 em. in diameter. At this point was a large calcified plaque. It was flat and disk-like with very small nodular projections.
The right lung contained a number of suppurative areas varying in size from a few millimeters to several centimeters. The uterus, tubes and ovaries were matted together by dense adhesions. The tubes were dilated and the lumen of the left was closed off at its point of entrance into the uterus and several places in its course. In other places it was filled with bloody exudate. The left ovary and part of the tube were necrotic and there was considerable fibrous tissue reaction about them.
The post-mortem diagnoses were: (1) Bacterial endoearditis of the ductus arteriosus .and adjacent pulmonary artery, (2) Calcified plaque of the aorta at the point of entrance of the duetus arteriosus, (3) Acute fibrinous pericarditis, (4) Multiple pulmonary abscesses, right lung, (5) Chronic suppurative left oophoritis and salpingitis.
COMMENT
The diagnosis of p&tent ductus arteriosus frequently can be made by the presence of a ‘imachinery” murm~n and intense thrill in the pulmonary area and evidence of an exaggerated pulmonary arc under the fluoroscope or on the x-ray plate. The absence of cyanosis and clubbing are negative points of importance in differentiating from congenital lesions of the pulmonary orifice. In the present case evi- dences of sepsis dominated the clinical picture and the murmur in the pulmonary area was considered to be of hemic origin. The calci- fied plaque of the aorta had a significance in this young wornan which was not appreciated at the time.
A communication from Dr. M. E. Abbott, whose contributions to congenital heart disease are authoritative, informs me that in her series of 90 cases of patent ductus. arteriosus calcifie deposits at tile
aortic end of the ductas were observed in two oases, as follow. Murray1 noted calcification of the wall of the aortic side of a patent and infected ductus in a patient aged 36 years, and White2 recorded marked sclerosis and calcification at the aortic opening of a patent ductus arteriosus in a patient who attained the age of 66 years. How- evler in White’s case there was marked calcification of the remainder of the aorta. Abbott observes that the finding is probably more com- mon than her series indicates. It’is suggested therefore that in cases of suspected duetus arteriosus in young persons, in whom the presence of calcification from ordinary arteriosclerosis would be unlikely, roentgen-ray evidence of calcification in the arch of the aorta may be looked upon as a confirmatory sign:
REFERENCES 1. Murray, H. W.: Trans. Path. Soe. London 39: 67, 1888. 2. White, P. D.: J. A. M. A. 91: 1107, 1928.
