45 years old male smoker presented with cough Breathlessness wheeze having this kind of x Ray and ECG changes suggests Pulmonary Hypertension could be due to COPD as all thought . Thanks all who got involved in this case . This is very typical case of CHD Eisenmenger syndrome . X ray is very typical water jug appearance due to dilatation of MPA and branches with peripheral pruning of vessels , right Atria , right Ventricle enlightenment . X ray revealed mild calcification of MPA right Lowe lobe bronchiectasis changes. ECG is unusual inspite of severe PAH, where PAH is made out by only persistence of S wave upto V6. Sometimes ECG can be misleading . Echo revealed large Subpulmonary VSD with Bidirectional shunt & severe PAH. HB 18 g due to Erythrocytosis. Had mild clubbing and cynosis. Patient has been on Endothelin receptor antagonists Ambrisentan 5 mg of & sildanefil 20 mg bd and Small dose of diuretic torsemide 5 mg OD. I have been following him up for the past 8 years he is doing well with ambrisentan and seldanefil. Eisenmenger syndrome refers to any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, reversal of flow, and cyanosis. The previous left-to-right shunt is converted into a right-to-left shunt secondary to elevated pulmonary artery pressures and associated pulmonary vascular disease. Lesions in Eisenmenger syndrome, such as large septal defects, are characterized by high pulmonary pressure and/or a high pulmonary flow state. Development of the syndrome represents a point at which pulmonary hypertension is irreversible and is an indication that the cardiac lesion is likely inoperable Eisenmenger syndrome was initially described in 1897, when Victor Eisenmenger reported on a patient with symptoms of dyspnea and cyanosis from infancy who subsequently developed heart failure and succumbed to massive hemoptysis. An autopsy revealed a large ventricular septal defect (VSD) and an overriding aorta. This was the first description of a link between a large congenital cardiac shunt defect and the development of pulmonary hypertension. Advances in the medical treatment of patients with severe pulmonary hypertension may improve survival in patients with Eisenmenger syndrome and may potentially reverse the process in selected patients to a point at which they again become candidates for surgical repair. Pulmonary hypertension is defined as a mean pulmonary artery pressure of more than 25 mm Hg at rest or more than 30 mm Hg during exercise. Causes of Eisenmenger syndrome include the following: Large, uncorrected cardiac shunt or palliative, surgically created systemic-to-pulmonary shunt for congenital heart disease Large, nonrestrictive VSD Nonrestrictive PDA Atrioventricular septal defect, including a large ostium primum ASD without a ventricular component Aortopulmonary window Palliative, surgically created systemic-to-pulmonary anastomosis for treatment of congenital heart disease The left-to-right shunting of blood results in abnormally high blood flow and pressure directed to the right heart circulation, gradually leading to maladaptive changes that ultimately result in pulmonary hypertension. Increased right-sided blood volume and pressure causes a cascade of pathologic damage to the delicate pulmonary capillaries, causing them to be incrementally replaced with scar tissue. Scar (dead lung tissue) does not contribute to oxygen transfer, therefore decreasing the useful volume of the pulmonary vasculature. The scar tissue also provides less flexibility and compliance than normal lung tissue, causing further increases in pulmonary blood pressure, and the weakened heart must pump harder to continue supplying the lungs, leading to damage of more capillaries. It is because of this maladaptive response that at the onset of Eisenmenger's syndrome, the damage is considered irreversible, even if the underlying heart defect is corrected after the fact. Eventually, due to increased resistance and decreased compliance of the pulmonary vessels, elevated pulmonary pressures cause the myocardium of the right heart to hypertrophy (RVH). The onset of Eisenmenger's syndrome begins when right ventricular hypertrophy causes right heart pressures to exceed that of the left heart, leading to reversal of blood flow through the shunt (i.e., blood moves from the right side of the heart to the left side). As a consequence, deoxygenated blood returning from the body bypasses the lungs through the reversed shunt and proceeds directly to systemic circulation, leading to cyanosis and resultant organ damage. The defect, now a right-to-left shunt, causes reduced oxygen saturation in the arterial blood due to mixing of oxygenated blood returning from the lungs with the deoxygenated blood returning from systemic circulation. This decreased saturation is sensed by the kidneys, resulting in a compensatory increase in erythropoietin production and an increased production of red blood cells in an attempt to increase oxygen delivery. As the bone marrow increases erythropoiesis, the systemic reticulocyte count and the risk for hyperviscosity syndrome increases. Reticulocytes are less efficient at carrying oxygen as mature red cells, and they are less deformable, causing impaired transit through capillary beds. This contributes to the death of pulmonary capillary beds. A person with Eisenmenger's syndrome is paradoxically subject to the possibility of both uncontrolled bleeding due to damaged capillaries and high pressure, as well as spontaneous clots due to hyperviscosity and stasis of blood. Symptoms & signs Dyspnea upon exertion Syncope Chest pain Stroke Brain abscess Cyanosis Congestive heart failure Dysrhythmia Hyperviscosity complications Pulmonary hemorrhage/hemoptysis Endocarditis Eisenmenger syndrome is uniformly fatal; however, some patients survive into the sixth decade of life. The usual life expectancy of a patient with Eisenmenger syndrome is 20-50 years if the syndrome is diagnosed promptly and treated with vigilance. The onset of pulmonary hemorrhage is usually the hallmark of a rapid progression of the disease Diagnosis by ECG Chest X ray Echo Colour Doppler cardiac CT MRI and catheterisation studies Most patients with Eisenmenger reaction, however, are beyond the point to consider corrective therapy. Pulmonary Resistance > 10-12 wood units and Rp/Rs of greater than 0.7/1 usually indicates that corrective treatment (surgery/ catheter intervention) is associated with an increased risk for morbidity and mortality. These patients will not benefit from this approach. If however, Pulmonary resistance or Rp/Rs drops by more than 20% during exposure to oxygen and nitric oxide, medical treatment with vasoactive agents is indicated and may result in significant improvement of quality of life Treatment plan Relax the arteries to improve blood flow Keep heart beating at a regular rhythm Prevent infections (antibiotics) Prevent blood clots (blood thinners) Heart-lung transplant. This is done when the heart and lungs are failing. This is a major step that requires a sophisticated hospital and experienced surgeons. Medications are the primary treatment option for Eisenmenger syndrome. Patients to be monitored when taking medications for any changes in blood pressure, fluid volume or pulse rate. Medications for Eisenmenger syndrome include: Medications to control arrhythmias. Ironsupplements Aspirin or other blood-thinning medications. NSIAD to be avoided in ES Endothelin receptor antagonists. These medications reverse the effect of endothelin, a substance in the walls of blood vessels that causes them to narrow. Drugs Bosentan , Ambrisentan may improve energy level and symptoms by lowering the resistance in lung arteries. For bosentan, monthly liver functions has to be monitored because the drug can damage your liver. Sildenafil and tadalafil. These drugs work by opening the blood vessels in the lungs to allow blood to flow through more easily. Side effects include upset stomach, dizziness and vision problems. Antibiotics. Antibiotics are recommended only before certain dental procedures (those that cut your gum tissue or part of the teeth) and procedures involving the respiratory tract, infected skin or tissue that connects muscle to bone. Blood drawing (phlebotomy) If red blood cell count becomes too high and is causing symptoms such as headache, difficulty concentrating or visual disturbances, Phlebotomy Heart-lung transplantation Some people who have Eisenmenger syndrome may eventually need a heart and lung transplant or a lung transplant with repair of the hole in the heart if no other treatments prove effective. Birth control and pregnancy Eisenmenger syndrome patient becoming pregnant poses serious health risks — and can be fatal — for the mother and baby. It's critical that women who have Eisenmenger syndrome avoid becoming pregnant. Tubectomy is less often recommended due to the risks of having even minor surgery. Birth control pills containing estrogen aren't recommended for women who have Eisenmenger syndrome. Estrogen increases risk of developing blood clots that could potentially block an artery to your heart, brain or lungs.

A 65 years old female admitted to the ICU with Urosepsis. Past history of anemia and Interstitial Lung Disease. Please describe is there are any pathological changes in the nails ?

ABC OF : NAIL DISORDERS. ( I ). MAY BE USEFUL. *** ANONYCHIA is the absence of nails, an anomaly, which may be the result of a congenital ectodermal defect, ichthyosis, severe infection, severe allergic contact dermatitis, self-inflicted trauma, Raynaud phenomenon, lichen planus, epidermolysis bullosa, or severe exfoliative diseases....... *** PSORIASIS can also affect the fingernails and toenails, leading to thick fingernails with pitting, ridges in the nails, nail lifting away from the nail bed, and irregular contour of the nail....... *** LICHEN PLANUS of the nails can cause brittle or split nails, and the affected nails may have ridges running lengthwise....... *** FUNGAL nail infections are common infections of the fingernails or toenails that can cause the nail to become discolored, thick, and more likely to crack and break. Infections are more common in toenails than fingernails.....by some dermatophytes, Candida (Monilia) species, etc....... The technical name for a fungal nail infection is “ONYCHOMYCOSIS.”....... *** SPOON-SHAPED or spooning fingernails refers to a concavity in the fingernail itself, resulting in a depression in the nail that gives an appearance of a spoon shape to the entire nail. This growth disturbance in the nail is known as KOILONYCHIA....... In particular, koilonychias is associated with IRON DEFICIENCY. *** Fingernails are made by living skin cells....... So a skin condition such as eczema may lead to fingernail ridges. Skin dryness can also cause these ridges. If the body is low in protein, calcium, zinc.......or vitamin A, a deficiency can sometimes be revealed by ridges in the fingernails. ** HORIZONTAL RIDGES run from side to side on nails and are often referred to as BEAU'S LINES may be a sign of previous injury, underlying health conditions, or in rare cases, arsenic poisoning....... Horizontal ridges can be caused by trauma to the nail and may be deep or discolored. The can also indicate malnutrition, psoriasis or a thyroid problem....... ** VERTICAL RIDGES are usually harmless and a consequence of ageing.......nail injury, or trauma, or underlying medical conditions....... *** The ECTODERMAL DYSPLASIAS (EDs) are genetic disorders affecting the development or function of the teeth, hair, nails and sweat glands....... ** ED is not a single disorder, but a group of closely related conditions of which more than 150 different syndromes have been identified....... *** Nail CLUBBING, also known as digital clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs. ... Hippocrates was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called "Hippocratic fingers"..... ** Lung cancer is the most common cause of clubbing. Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. ... Heart defects that are present at birth (congenital) Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis, or lung abscess....... *** While the NAIL BITING and picking seems to be such a common problem, the psychological and medical research does not agree on the exact motivation for the action. However, it suggests that nail biting can be the result of STRESS, VARIOUS MEDICAL DISORDERS, LEARNED BEHAVIORS, OR JUST PLAIN HABIT....... *** SPLINTER HEMORRHAGES : They run in the direction of nail growth. They are named splinter hemorrhages because they look like a splinter under the fingernail. The hemorrhages may be caused by tiny clots that damage the small capillaries under the nails. Splinter hemorrhages can occur with infection of the heart valves (endocarditis)....... *** YELLOW TOENAILS in an infection by a fungus that attacks the nails..... or, in some cases, they may be a sign of skin cancer. The fungal infection is caused most often by dermatophytes, which eat keratin to grow....... One of the MOST COMMON CAUSES of YELLOW NAILS is a FUNGAL INFECTION. As the infection worsens, the nail bed may retract, and nails may thicken and crumble. In rare cases, yellow nails can indicate a more serious condition such as SEVERE THYROID DISEASE, LUNG DISEASE, DIABETES or PSORIASIS....... *** WHILE NAILS ( LEUKONYCHIA ) : CAUSES : Iron deficiency anemia. Cirrhosis of liver. Kidney disease. Heart failure. Diabetes. Problems with the digestion of proteins. An excessive loss of proteins in the intestines. zinc deficiency........etc....... *** RED NAILS :- CAUSES : LUPUS patients get quirky, angular blood vessels in their nail folds. PSORIASIS starts in the nails up to 10 percent of the time and CAUSES SPLITTING and PITTING of the nail bed. HEART DISEASE can turn the nail beds red....... ** If the NAIL BED is RED, it could be caused by a high content of fatty acids and cholesterol, due to an excess of dairy products, sugar and salt in the diet. This can lead to an underactive liver and blocked arteries....... To keep the system healthy by replacing refined foods with wholegrain rice and bread, and flush out the system with plenty of fresh vegetables and at least five glasses of water a day....... *** HALF PINK and HALF WHITE nails can be a sign of kidney disease....... *** BRITTLE NAILS :- CAUSES : AGING. CHEMICAL/TOXIN EXPOSURE. LONG-TERM USE OF NAIL POLISH AND POLISH REMOVE. LOW HUMIDITY ENVIRONMENT. MALNUTRITION. NAIL-PATELLA SYNDROME. PROLONGED EXPOSURE TO WATER. TRAUMA. ** B complex vitamins (especially biotin), calcium, and zinc have all been implicated. There are other medical conditions which can cause brittle nails such as ANEMIA (low blood count), THYROID DISORDERS, and skin disorders such as LICHEN PLANUS and PSORIASIS. ** ONYCHOSCHIZIA includes splitting, brittle, soft or thin nails. Onychoschizia is MORE COMMON IN WOMEN. Only VERY RARELY are INTERNAL DISEASE or VITAMIN DEFICIENCIES the reason (IRON DEFICIENCY is the MOST COMMON).......

Friends today I am discussing about Nail Abnormalities. What are nail abnormalities? Healthy nails appear smooth and have consistent coloring. As you age, you may develop vertical ridges, or your nails may be a bit more brittle. This is harmless. Spots due to injury should grow out with the nail. Abnormalities — such as spots, discoloration, and nail separation — can result from injuries to the fingers and hands, viral warts (periungual warts), infections (onychomycosis), and some medications, such as those used for chemotherapy. Certain medical conditions can also change the appearance of your fingernails. However, these changes can be difficult to interpret. Your fingernails’ appearance alone isn’t enough to diagnose a specific illness. A doctor will use this information, along with your other symptoms and a physical exam, to make a diagnosis. Abnormalities of the fingernail Some changes in your nails are due to medical conditions that need attention. See your doctor if you have any of these symptoms: discoloration (dark streaks, white streaks, or changes in nail color) changes in nail shape (curling or clubbing) changes in nail thickness (thickening or thinning) nails that become brittle nails that are pitted bleeding around nails swelling or redness around nails pain around nails a nail separating from the skin These nail changes can be caused by a variety of different conditions, including ones we describe below. Beau’s lines Depressions that run across your fingernail are called Beau’s lines. These can be a sign of malnourishment. Other conditions that cause Beau’s lines are: diseases that cause a high fever such as measles, mumps, and scarlet fever peripheral vascular disease pneumonia uncontrolled diabetes zinc deficiency Clubbing Clubbing is when your nails thicken and curve around your fingertips, a process that generally takes years. This can be the result of low oxygen in the blood and is associated with: cardiovascular diseases inflammatory bowel disease liver diseases pulmonary diseases AIDS Koilonychia (spooning) Koilonychia is when your fingernails have raised ridges and scoop outward, like spoons. It’s also called “spooning.” Sometimes the nail is curved enough to hold a drop of liquid. Spooning can be a sign that you have: iron deficiency anemia heart disease hemochromatosis, a liver disorder that causes too much iron to be absorbed from food lupus erythematosus, an autoimmune disorder that causes inflammation hypothyroidism Raynaud’s disease, a condition that limits your blood circulation Leukonychia (white spots) Nonuniform white spots or lines on the nail are called leukonychia. They’re usually the result of a minor trauma and are harmless in healthy individuals. Sometimes leukonychia is associated with poor health or nutritional deficiencies. Factors can include infectious, metabolic, or systemic diseases as well as certain drugs. Mees’ lines Mees’ lines are transverse white lines. This can be a sign of arsenic poisoning. If you have this symptom, your doctor will take hair or tissue samples to check for arsenic in your body. Onycholysis When the nail plate separates from the nail bed, it causes a white discoloration. This is called onycholysis. This can be due to infection, trauma, or products used on the nails. Other causes for onycholysis include: psoriasis thyroid disease Pitting Pitting refers to small depressions, or little pits, in the nail. It’s common in people who have psoriasis, a skin condition that causes the skin to be dry, red, and irritated. Some systemic diseases can also cause pitting. Terry’s nails When the tip of each nail has a dark band, it’s called Terry’s nails. This is often due to aging, but it can also be caused by: congestive heart failure diabetes liver disease Yellow nail syndrome Yellow nail syndrome is when the nails get thicker and don’t grow as fast as normal. Sometimes the nail lacks a cuticle and may even pull away from the nail bed. This can be the result of: internal malignancies lymphedema, swelling of the hands pleural effusions, fluid buildup between the lungs and chest cavity respiratory illnesses such as chronic bronchitis or sinusitis rheumatoid arthritis These are just some of the signs of abnormal fingernails. Having any of these signs isn’t proof of any medical condition. You’ll need to visit your doctor to determine if your condition is serious. In many cases, proper care of your nails is enough to correct their appearance. How to care for your nails You can prevent many nail abnormalities by taking good care of your nails. Follow these general guidelines to keep your nails healthy: Tips Don’t bite or tear at your nails, or pull on hangnails. Always use nails clippers and trim them after you bathe, when nails are still soft. Keep your nails dry and clean. Using sharp manicure scissors, trim your nails straight across, rounding the tips gently. If you have a problem with brittle or weak nails, keep them short to avoid breakage. Use lotion on your nails and cuticles to keep the nail and nail beds moisturized. Homoeopathic medicines for nail abnormalities Medicines according to Cause1 Cause Medicines From a hurt Ledum pal. Prick with a needle under the nail Allium cepa, Bovista, Sulphur; Hard work Rhus tox, Sepia; Prick near the nail Iodum; Splinters Baryta carb., Hepar sulph., Iodum, Lachesis, Nitricum acidum, Petroleum, Silicea, Sulphur; Splits of the skin adhering to the nails Allium cepa, Natrum mur. TABLE 2 Medicines according to the Sensation Sensations Medicines Irritable feeling under finger nails, relieved by biting them Ammonium brom. Itching-about roof of Upas tiente Pains-Burning under Sarsarparilla Pains, gnawing, beneath finger nails Alumina; Sarsaparilla.; Sepia Pains, neuralgic, beneath finger nails Berberis vulgaris Pains, neuralgic Alumina; Allium cepa; Colchicum Pains, smarting at roots Sulphur Pains, splinter-like, beneath toe nails Fluoric acidum Pains, ulcerative, beneath toe nails Antimonium crudum; Graphites; Teucrium Medicines according to Location1 Fig. Medicines according to location pastedGraphic.png TABLE 3 Medicines according to Pathology Pathology Medicines Atrophy Silicea Blueness Digitalis; Oxalicum Acidum Deformed-brittle, thickened (onchogryposis) Alumina; Anatherium; Antimonium crudum; Arsenicum album; Causticum; Dioscorea; Fluoricum acidum; Graphites; Merc. Sol.; Natrum muriaticum; Sabadilla; Secal cor..; Senecio aureus; Sepia; Silicea; Thuja.; X-ray. Falling off Brassica napus; Butyric acid; Helleborus faetidus; Helleborus Hangnails Lycopodium; Natrum muriaticum; Sulphur; Upas tiente Hypertrophy (onychauxis) Graphites Inflammation of pulp (onychia) Arnica; Calendula; Fluoricum acidum.; Graphites; Phosphorus; Psorinum; Sarsaparilla; Silicea; Upas tiente Inflammation, under toe nails Sabadilla Ingrowing toe nails Causticum; Magnetis polus austral.; Nitricum acidum; Silicea; Staphysagria; Teucrium; Tetrodymite Softening Plumbum met; Thuja Spots, white on Alumina; Nitricum acidum Trophic changes Radium brom Ulceration Alumina; Garphites; Merc. Sol.; Phosphorus; Sanguinaria; Sarsaparilla; Silicea; Teucrium; Tetrodymite Yellow color Conium maculatum

7 yr pt came with c/o SOB after slight exertion or running, symptoms from early childhood, that's why not going even to school, on auscultation systolic murmur heard with thrill in all areas, belong to low socioeconomic class and used to consult quacks or pharmacist only, discuss possible dx considering ECG, CXR etc attached below..