Cases in cardiology

Cases in cardiologyLIBYAN MEDICAL BOARD FIRST PART REVISIONDR.MAGDI AWAD SASI2016

LIBYAN MEDICAL BOARD 4TH PART

An elderly gentleman has a syncopal episode. He is found to have an ejection systolic murmur and an ECHO confirms Aortic Stenosis. In AS what indicates a poor prognosis?Bicuspid valve.Coexistent AR.Left ventricular hypertrophy.Left ventricular failure.Infective endocarditis.

AS become critical if area 0.7cm2 AS can present with angina ,LVF and syncopy.It is a mechanical problem that no medical treatment has been approved to be beneficial.If the patient is symptomatic ,AVR is the correct choice.Pressure gradient >50mmHg indicate severity.LVF carry a poor prognosis

You review a 35-year-old woman who is overweight with a body mass index (BMI) of 31. She presents with increasing lethargy and shortness of breath over the past few weeks. There is a past history of deep vein thrombosis three years ago.Electrocardiogram (ECG) reveals evidence of right ventricular hypertrophy. Saturations are 91% on air and fall on only minor exercise. D-Dimers are raised.

Which of the following stems represent optimal management of this patient? Low-molecular weight heparin followed by 6 months of warfarin Insertion of inferior vena cava filter Low-molecular weight heparin followed by permanent warfarin therapy Tissue plasminogen activator (TPA) therapy Streptokinase therapy

C. Low-molecular weight heparin followed by permanent warfarin therapyThere is no clear cause for DVT and the patient developed recurrent PE with RVH and haemodynamically stable.If there is no cause for DVT ,permanent warfarin is the best choice

Indication of thrombolysis Duration of warfarin When to use IVF

What are the indications for thrombolytic therapy in a patient presenting with ischemic chest pain?

2mm ST depression in all chest leads.T wave inversion in chest leads.1 mm ST elevation in 2 limb leads. Q wave in any 2 leads.1 mm ST depression in 2 limb leads

What is definition of MI?When to use thrombolysis?C/I to thrombolysis

74 old man admitted to ER with chest pain of one hour. He is now pain free following morphine in the ambulance. He had H/O haemorrhagic stroke 3 years back with residual left arm weakness .ECG-ST up I AVL V 1-6 The next step in the managemnt is:A. Thrombolytic therapyB. Echocardiography C. Indomethacin D. Primary PCIE. ACE I ,BB ,aspirin ,prasaguel tab or plavix

When to do PCI?

You are the admitting doctor on the acute medical team and are referred a patient by the GP with a creatinine of 547 mol/l, which has risen from a baseline of 85 mol/l 2 months previously. The patient describes feeling generally unwell with whole-body myalgia and arthralgia. On examination he has a soft ejection systolic murmur over the aortic area, bibasal crepitations on auscultation, and a soft and non-tender abdomen with no suprapubic bladder palpable. Urine is concentrated and dark, with dipstick showing the presence of protein + and blood + + +.The patient has a past history of ischaemic heart disease which has required three coronary artery stents following a myocardial infarction 2 years previously. He has recently been found to be in atrial fibrillation, for which he taking amiodarone 200 mg once daily, in addition to his aspirin 75 mg once daily, ramipril 5 mg once daily, isosorbide mononitrate modified release 120 mg once daily, furosemide 40 mg once daily and simvastatin 40 mg at night.

Which ONE of the following is the most appropriate? A Echocardiogram B Renal ultrasound C Prednisolone D Renal biopsy E Intravenous fluids

IV fluidsThis is the scenario of rambdomyolysis due to atorvastatin There is no benefit of ECHO in ESM with out clue for palpable thrill and LV failure symptoms.

Which of the following is the best treatment of GH-secreting pituitary adenoma?OctreotideCabergolinePigvisomantTrans-sphenoidal adenomectomyPituitary radiation

Management of functioning pituitary tumoursTumorTreatment of choiceProlactinomasMedical(usually microadenoma)GH-secreting(acromegaly)Surgical(usually macroadenoma)Corticotropin-secreting adenoma(Cushing disease)Surgical(usually microadenoma)

Which of the following is not feature of MEN 1?Acromegaly.Parathyroid adenoma.Pheochromocytoma.Insulinoma.Gastrinoma.

MEN 1-----Wermers Syndrome11q 11-131. Parathyroid hyperplasia or adenoma2. Islet cell hyperplasia, adenoma, or carcinoma3. Pituitary hyperplasia or adenoma

Rarely Cortical InvolvementOther less common manifestations: foregut carcinoid, , subcutaneous or visceral lipomas, dermal angiofibromas or collagenomas

Pancreatic islet cell tumors are diagnosed by identification of a characteristic clinical syndrome, hormonal assays with or without provocative stimuli, or radiographic techniques. One approach involves annual screening of people at risk with measurement of basal and meal-stimulated levels of pancreatic polypeptide to identify the tumors as early as possible; the rationale of this screening strategy is the concept that surgical removal of islet cell tumors at an early stage will be curative. Other approaches to screening include measurement of serum gastrin and pancreatic polypeptide levels every 2 to 3 years, with the rationale that pancreatic neoplasms will be detected at a later stage but can be managed medically, if possible, or by surgery. High-resolution, early-phase computed tomography (CT) scanning provides the best noninvasive technique for identification of these tumors, but intraoperative ultrasonography is the most sensitive method for detection of small tumors.

ZESis caused by excessive gastrin production and occurs in more than half of MEN 1 patients with pancreatic islet cell tumors. Clinical features include increased gastric acid production, recurrent peptic ulcers, diarrhea, and esophagitis. The ulcer diathesis is refractory to conservative therapy such as antacids. The diagnosis is made by finding increased gastric acid secretion, elevated basal gastrin levels in serum [generally >115 pmol/L (200 pg/mL)], and an exaggerated response of serum gastrin to either secretin or calcium. Other causes of elevated serum gastrin levels, such as achlorhydria, treatment with H2 receptor antagonists or omeprazole, retained gastric antrum, small-bowel resection, gastric outlet obstruction, and hypercalcemia, should be excluded. Gastrin-producing carcinoid-like tumors are frequently present in the duodenal wall.

Insulinoma causes hypoglycemia in about one-third of MEN 1 patients with pancreatic islet cell tumors. The tumors may be benign or malignant (25%). The diagnosis can be established by documenting hypoglycemia during a short fast with simultaneous inappropriate elevation of serum insulin and C-peptide levels. More commonly, it is necessary to subject the patient to a supervised 72-h fast to provoke hypoglycemia. Large insulinomas may be identified by CT scanning; small tumors not detected by radiographic techniques may be localized by selective arteriographic injection of calcium into each of the arteries that supply the pancreas and sampling the hepatic vein for insulin to determine the anatomic region containing the tumor. Intraoperative ultrasonography can also be used to localize these tumors, but preoperative calcium injection data are helpful in guiding the subtotal pancreatectomy if multiple or no abnormalities are detected by intraoperative ultrasonography.

GlucagonomaMEN 1 patients causes a syndrome of hyperglycemia, Skin rash (necrolytic migratory erythema) Anorexia, glossitis, anemia, depression, diarrhea Venous thrombosis."4 D's": Diabetes, Dermatitis (rash), Deep vein thrombosis (e.g., blood clot in the legs), and Depression In about half of these patients the plasma glucagon level is high, leading to its designation as the glucagonoma syndrome, although elevation of plasma glucagon level in MEN 1 patients is not necessarily associated with these symptoms. The glucagonoma syndrome may represent a complex interaction between glucagon overproduction and the nutritional status of the patient.

The Verner-Morrison or watery diarrhea syndrome consists of watery diarrhea, hypokalemia, hypochlorhydria, and metabolic acidosis. The diarrhea can be voluminous and is almost always found in association with an islet cell tumor, prompting use of the term pancreatic cholera. However, the syndrome is not restricted to pancreatic islet tumors and has been observed with carcinoids or other tumors. This syndrome is believed to be due to overproduction of VIP, although plasma VIP levels may not be elevated. Hypercalcemia may be induced by the effects of VIP on bone as well as by hyperparathyroidism.

MEN 2ASipples SyndromeRETParathyroid hyperplasia or adenomaMedullary Thyroid CarcinomaPheochromocytomaCutaneous lichen amyloidosisHirschsprung diseaseFamilial Medullary Thyroid Carcinoma

MEN 2BMTCPheochromocytomaMucosal and gastrointestinal neuromasMarfanoid features

A 30-year-old fitness instructor comes to the General Medical Clinic with a 3-month history of malaise, lethargy and weight loss. On further questioning he reports intermittent colicky abdominal pain with diarrhoea, mucus and blood per rectum. On examination he is a tall thin man; cardiovascular, respiratory and abdominal examination are unremarkable and rectal examination reveals a few anal skin tags. Examination of the mouth reveals some aphthous ulcers.

Which ONE of the following findings would not occur in patients with the above disease? A Rose-thorn ulceration on sigmoidoscopyB Transmural granulomatous inflammationC Colovesical fistula formationD Toxic dilatationE Osteomalacia

Which of the following features best distinguishes Crohn's disease from ulcerative colitis?

A. Oral ulcers B. Rectal bleeding C. Continuous colonic involvement on endoscopy D. Noncaseating granulomas E. Crypt abscesses

Oral ulcerations can occur both in Crohn's disease and ulcerative colitis. Rectal bleeding and continuous involvement of the colon may be also seen in both Crohn's disease and ulcerative colitis. The presence of crypt abscesses does not distinguish ulcerative colitis from Crohn's disease; however, noncaseating granulomas, when present, are pathognomonic of Crohn's disease.

A 15-year-old boy comes to the office because of occasional shortness of breath every few weeks. Currently he feels well. He uses no medications and denies any other medical problems. Physical examination reveals a pulse of 70 and a respiratory rate of 12 per minute. Chest examination is normal. Which of the following is the single most accurate diagnostic test at this time? Peak expiratory flow Increase in FEV1 with albuterol Diffusion capacity of carbon monoxide >20% decrease in FEV1 with use of methacholine Flow-volume loop on spirometry

Answer: DWhen a patient is currently asymptomatic, it is less likely to find an increase in FEV1 with the use of short-acting bronchodilators like albuterol. This test, when the patient is asymptomatic, may be falsely negative. When the patient is asymptomatic, the most accurate test of reactive airway disease is a 20% decrease in FEVl with the use of methacholine or histamine. Chest CT, like an x-ray, shows either nothing or hyperinflation. The ABG and PEF are useful during an acute exacerbation. Flow-volume loops are best for fixed obstructions such as tracheal lesions or COPD.

Pulmonary function tests (PFTs) in asthma show: Decreased FEVl and decreased FVC with a decreased ratio of FEVl/FVC Increase in FEVl of more than 12% and 200 mL with the use of albuterol Decrease in FEVl of more than 20% with the use of methacholine or histamine Increase in the diffusion capacity of the lung for carbon monoxide (DLCO)

A 30 year old man presented with bloody diarrhoea. This started 2 days ago. He returned from a business trip to Egypt recently 1 week ago. What is the most likely causative organism? A. Cholera B. E coliC. GiardiasisD. ShigellaE. Crytosporidiosis

The presence of large numbers of leukocytes in stool is diagnostic of colonic mucosal inflammation and should suggest infection with enteroinvasive organisms such as: 1. Shigella 2. E. histolytica 3. Salmonella 4. Campylobacter 5. invasive Escherichia coli 6. Y. enterocolitica. Those organisms that cause diarrhea by a noninvasive mechanism (Giardia lamblia, enterotoxigenic E. coli, Vibrio cholerae) are not associated with leukocytes in the stool

A 23-year-old woman experienced watery diarrhea, nausea, vomiting, and abdominal cramps 6 hours after eating a salad and a hamburger in a local restaurant. The most likely organism causing her disease is

A. Vibrio vulnificus B. Listeria monocytogenes C. Yersinia enterocolitica D. Clostridium welchii E. Staphylococcus aureus

Staphylococcal food poisoning is manifested 2 to 6 hours after eating food (salad, potato salads) contaminated by a preformed enterotoxin. Yersinia is most commonly associated with the ingestion of improperly cooked meat, but symptoms generally begin more than 1 day after ingestion of the contaminated food. Symptoms resulting from L. monocytogenes also occur more than 24 hours after the ingestion of contaminated foods (milk, ice cream, and poultry). V. vulnificus-associated food poisoning presents usually 24 to 48 hours after the ingestion of contaminated seafood (usually oysters). C. welchii is not associated with food poisoning. The two clostridia associated with food poisoning are C. perfringens and C. botulinum.

1. A 35 year old woman is admitted to the intensive care department with difficulty breathing initially thought to be acute bronchial asthma. Following which she developed nasal regurgitation and choking on food and drink. On examination she is noted to have bilateral fatigable ptosis, multidirectional gaze diplopia, proximal limb weakness and normal deep and superficial reflexes. There are no sensory symptoms or signs.If she can only count with the breath held up to 3 only ,the following is true except :A-Cardiac involvement is a common presentationB-Measure arterial blood gasesC-Measure vital capacityD- Chest x ray and Ct scan chest are mandatory.E- Start oral steroids.

A-Cardiac involvement is a common presentation

2. Which is INCORRECT regarding myasthenia gravis? a. Onset in females usually 2nd and 3rd decades, males 7th and 8th decades. b. The thymus is abnormal in 75% and removal will improve symptoms in the majority. c. Acute crises in these patients can be due to myasthenia crisis or cholinergic crisis secondary to the medication. d. Muscle weakness is more marked peripherally. e. Diagnosis with Ach receptor antibody testing is possible but false negatives occur in 15%.

3. A 17 year old Libyan girl was admitted with difficulty walking for 2 days prior to that she had had tingling and paraesthesiae over her limbs. On examination she had a right LMN 7th nerve palsy , a left convergent squint and a reduced gag reflex with salivation and choking. The pupils were normal. She had reduced tone of her four limbs with weakness grade 4/5 of the upper limbs and 2-3/5 of the lower limbs, she had diffuse loss of reflexes. The planter response was flexor bilaterally. The weakness of the limbs was more obvious proximally. In her past history she had been well and had received all the state vaccinations at the correct age.The immediate next step should be which one of the following?A-Admission to intensive or high care and assessment and management of airway and ventilationB-Lumbar punctureC-MR Imaging of the spineD-Nerve conduction studiesE-Tensilon (edrophonium) test

4. Which is incorrect regarding Guillain Barre Syndrome?

a. 80% of patients will have antecedent infection with Campylobacter jejuni. b. CSF will show low protein, high glucose and often a pleocytosis up to 100. c. High dose immune globulin and plasmapheresis have been shown to be equally efficacious in reducing length of illness. d. Severe cases will not only involve demyelination but also axonal degeneration. e. 85% will recover to their previous normal functioning in one year.

5. A 34-year-old woman presents with facial pain, discolored nasal discharge, bad taste in her mouth, and fever. On physical examination she has facial tenderness. Which of the following is the most accurate diagnostic test? Sinus biopsy or aspirate CT scan X-ray d. Culture of the discharge Transillumination

6. An HIV-positive man comes in with progressive dysphagia and odynophagia. He has 75 CD4 cells but no history of opportunistic infections.

What is the next best step in management? Fluconazole Amphotericin Barium swallow Endoscopy Antiretroviral therapy

Odynophagia is pain on swallowing. Dysphagia is simply difficulty swallowing (i.e., food getting "stuck" in the esophagus).

When odynophagia occurs in an HIV-positive patient, particularly when there are < 100 CD4 cells, the diagnosis is most likely esophageal candidiasis, and giving empiric fluconazole is both therapeutic as well as diagnostic.

Amphotericin is not necessary

7. A 50-year-old patient presents with muscle weakness of the girdle with an increased CPK and aldolase. Her anti-Jo-1 antibody is positive. Which of the following is most likely to happen to her? Stroke Myocardial infarction Septic arthritis DVT Interstitial lung disease

8. A 50-year-old white man is transferred to your hospital with a presumptive diagnosis of tuberculosis. His chest radiograph shows nodular cavitary lesions in both lung fields. His urinalysis shows 50 RBCs per high power field and 3+ proteinuria. He is scheduled for bronchoscopy with transbronchial lung biopsy in the morning. That evening he has a sudden deterioration consisting of massive hemoptysis and progressive renal failure. The most appropriate therapeutic intervention at this point would be supportive management and

A. IV corticosteroids B. Antituberculous medications C. IV cyclophosphamide 4 mg/kg D. Oral cyclophosphamide 2 mg/kg E. IV corticosteroids and IV cyclophosphamide 4 mg/kg

9. A 32-year-old woman presents with left inguinal and groin pain of 1 week duration that is worse with weightbearing and ambulation. Physical examination reveals full range of motion of the left hip. She walks with a limp. She had previously been treated with mechlorethamine, vincristine, procarbazine, and prednisone therapy for Hodgkin's disease. An anteroposterior film of the pelvis demonstrates no osseous abnormality. Which of the following tests would be most useful in making the diagnosis?

A. Serum rheumatoid factor B. Erythrocyte sedimentation rate C. Magnetic resonance imaging (MRI) of the left hip D. Arthrogram of the left hip E. Blood alcohol level

Osteonecrosis is one of the most common causes of hip pain and incapacity in patients with a variety of diseases who have been treated with corticosteroids. A major problem in diagnosing osteonecrosis relates to the lag between the onset of symptoms (pain and limp) and defined radiographic changes.

MRI has been shown to be extremely valuable in evaluating high-risk patients who are symptomatic but radiographically normal.

A 51-year-old white man was recently diagnosed with a solitary 2.7-cm papillary cancer of the thyroid with no invasion of the capsule, no lymphadenopathy, and no distant metastases. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Which of the following measures is most appropriate for his management?

A. Partial thyroidectomy followed by radioactive iodine (RAI) B. Treatment C. Near-total thyroidectomy followed by RAI treatment Thyroid hormone treatment D. A and C E. B and C

Thyroid cancer remains a significant medical problem in the United States; 12,000 new cases are diagnosed and 1000 deaths are reported each year. Differentiated thyroid cancer is classified into follicular and papillary (derived from the follicular cells) and medullary thyroid carcinoma (derived from the C cells). Rarely, the thyroid is the site of involvement by lymphoma. Anaplastic cancer arises from the papillary and follicular cancers. The most common type of thyroid cancer is papillary cancer, which accounts for approximately 70% of all thyroid cancers. It is two to three times more common in females and peaks in the third and fourth decades of life. Papillary cancer is usually nonencapsulated and sometimes multifocal and tends to spread by the lymphatic route. Follicular cancer is the second most common form of thyroid cancer, accounting for 15% of all thyroid cancers. It affects a slightly older age group and is more commonly diagnosed in females than in males. Follicular cancer tends to be encapsulated, is usually unifocal, and tends to spread via the hematogenous route; early metastases are seen with small lesions. Thyroid cancer is now diagnosed at an early stage, and its slow rate of growth makes for a favorable outcome in a majority of cases. Sometimes, however, thyroid tumors are encountered that display aggressive features leading to early death despite aggressive treatment. Moreover, the treatment modalities themselves can sometimes be attended by significant complications, making the optimum treatment of thyroid cancer a highly controversial issue.

Therefore, an understanding of the factors that affect prognosis should guide selection of treatment modalities. In papillary cancer, prognosis is affected by tumor size, presence or absence of metastases, patient age, and degree of differentiation. Generally, the smaller tumors (2.5 cm) tend to carry a poorer prognosis. Patient age greater than 40 years at diagnosis tends to carry a poor prognosis in part because of poor concentration of iodine by most tumors. Poorly differentiated tumors tend to run a more aggressive course. The first line of treatment of thyroid cancer consists of surgical resection. Although the optimum procedure is not known, the more aggressive tumors should be managed with more extensive procedures (near-total or total thyroidectomy with or without lymph node dissection). RAI ablation should be considered when residual or metastatic disease is present. Finally, thyroid hormone treatment should be used with a goal of keeping the TSH level as low as possible without causing overt hyperthyroidism. RAI ablation and thyroid hormone suppression have been shown to reduce recurrence of thyroid cancer. In this patient, age and tumor size predict a poor outcome. Treatment should, therefore, consist of near-total thyroidectomy, RAI ablation, and thyroid hormone treatment

10. Which ONE of the following is associated with pernicious anaemia?

A Ileal resection

B Thyroid antibodies in serum

C Systemic lupus erythematosus

D Malabsorption of B12-intrinsic factor complex

11. A patient presents with headache, morning vomiting and double vision for three weeks. On examination nystagmus is present when the eyes are turned to either side. The most likely diagnosis is

A. acoustic neuroma

B. craniopharyngioma

C. frontal glioma

D. pituitary adenoma

E. posterior fossa tumour

Early morning vomiting = raised ICP Double and blurred vision, nystagmus = infratentorial lesion Problems with equilibrium, gait, and coordination = infratentorial lesion Focal problems (eg motor or sensory deficit, speech change, seizures) = supratentorial lesion Strong hand preference = supratentorial lesion Neuroendocrine problems (DI, hypothyroidism) = suprasellar lesion Change in visual acuity, visual field defect, Marcus Gunn pupil (afferent papillary defect), nystagmus = visual pathway lesion Long nerve tract motor and/or sensory deficits, bowel and bladder deficits, and back or radicular pain = spinal cord lesion

12. A 19-year-old college student is noted to seem confused by her flat mate. She has been complaining of a diffuse headache and general malaise for the past 24 hours.

On examination she has a temperature of 38 C. She is restless and mildly dysphasic. The remainder of the general and neurological examination is normal. CT brain scan shows hypodensity in both temporal lobes.Cerebrospinal fluid (CSF) examination showswhite cell count of 16/mm3 (lymphocytes)slightly raised protein concentration of 0.75 g/lnormal CSF/blood glucose ratio.

Which of the following is likely to be the most effective early treatment? Intravenous fluids, broad-spectrum antibiotics and prophylactic anticonvulsants pending further CSF analysis Intravenous fluids and iv aciclovir Intravenous fluids, aciclovir and corticosteroids Intravenous fluids, aciclovir and prophylactic anticonvulsants Intravenous fluids, aciclovir and broad-spectrum antibiotics

The short history and presence of dysphasia are both characteristic of herpes simplex encephalitis (HSE), which is caused by herpes simplex virus (HSV). The presence of temporal lobe changes (focal oedema) on neuroimaging is typical of HSV (though note that CT may be normal in the early stages MRI is much more sensitive).

IV aciclovir treatment should always be given in adequate doses for any possible case, and continued for a full course of at least 10 days unless an alternative diagnosis is found. Steroids may be given. Anticonvulsants are used to treat symptomatic focal and generalised seizures, though are not routinely given prophylactically

13. Diabetics with cardiac denervation due to autonomic neuropathy develop:

A. Supine hypertension

B. Orthostatic hypotension

C. Resting tachycardia

D. Painful myocardial ischaemia

E. All of the above

Hypertension Painless MI Orthostatic hypotension Lack of heart rate variability with breathing (normal heart rate variability during voluntary deep breathing is > 10 beats/min) Resting tachycardia Early satiety (due to delayed gastric emptying) Neurogenic bladder Lack of sweating and impotence. Impaired thermoregulation (intraoperative hypothermia) Sudden death syndrome Gastroparesis Bladder atony Asymptomatic hypoglycaemia

14. A 42-year-old man who is known HIV positive presents with difficulty with short term memory, confusion ,dysarthria ,generalised weakness and gait disturbance. He also has headaches and blurred vision for last 2months.O/E he has 3/5 weakness of the left arm and 4/5 power weakness of the right leg.Investigations show:Hb 11.5 g/dl WCC 6.7 x109/l CD4count 82 cells/mm3 PLT 184 x109/lNa+ 137 mmol/l K+ 4.5 mmol/l Creatinine 134 mol/l CSF Elevated proteinMRI brain shows multiple hypodense white matter lesions seen on the T2 weighted scan PV, predominantly in the frontal and parieto-occipital regions-nonenhanced Which of the following is the most likely diagnosis? Progressive multifocal leukoencephalopathy (PML) Toxoplasmosis CNS lymphoma Herpes simplex encephalitis CMV encephalitis

CMV encephalitis : Periventricular and meningeal with cognitive abnormlities , neuropathic syndromesdemyelinating nerve root diseaseMay cause ulceration anywhere in the GIT and occasional retinal disease.Owel,s eyes inclusion bodies are seen in the biopsy material. DX--- use CSF CMV PCRTr Ganciclovir or valganciclovirCNS lymphoma :Involves the periventicular region ?One mass lesionNon white matter mass lesion

TOXOPLASMOSIS :Comes with the blood with the perforator ---mass lesions enhance at the grey-white matter region (( thalamus , pons ))

PMLE :PML occurs in HIV positive patients with reduced CD4 count.Infects oligodendrocytes, the cells responsible for maintaining the myelin sheath.Histology reveals multifocal demyelination, hyperchromatic enlarged oligodendrocytic nuclei and enlarged astrocytes.Cause ----Polyomavirus JC Progressive demyelinating disorderManifests as focal neurologic findings ,seizures and lesions in the white matter.Treatment :Withdraw the immunosuppresion as in renal transplant ,solid organ transplantation ,MS HIV--- TO reconstitute the immune systemRegression of the condition has been described in association with HAART, but ultimately the condition is progressive in fatal

Vasovagal syncope should not occur with activity, but more commonly with Valsalva (such as during a bowel movement), during urinary (micturation syncope), or during other times with elevated vagal tone. Atrial fibrillation rarely causes syncope and there is no evidence of such on her ECG. There are no ischemic ECG changes to be concerned for myocardial infarction .