around 35 yrs old male pt admitted with h/o. New onset of seizures and status epilepticus.. 1. what are the clinical findings? 2 .x ray findings. 3.ecg findings. 4. CT BRAIN ..plain and contrast findings. . 5. With correlation of all these findings what will b the most suitable final diagnosis? plz share ur views. ..Thanks in advance. ..



There is cyanosis ,, muddy conjunctiva Clubbing Prominent pulmonary artery,, emphysematous changes,, patchy opacity in left upper lobe Right heart enlargement,, prominent p waves,,rt axis deviation Ring enhancing lesion in left frontoparietal cortex Looks like a brain abscess Congenital heart disease ,, looking at the age of the patient ASD with eisenmengers syndrome

Very nice approach sir. .Thanks a lot sir.

Thanx Dr.Suresh for posting a very interesting case. 1) Clinically, Their is plethoric face with congested eyes and With CENTRAL CYANOSIS Digital CLUBBING of grade 3 2)CXR s/o Cardiomegaly with RV Apex type (Acute angle), with prominent Arteries with B/L Pulmonary Oligemia (upper zones) 3)ECG findings s/o Sinus tachycardia, Extreme Right axis/Right superior axis (axis pointing above +180) P pulmonale with clock wise rotation RVH with Strain pattern overall findings s/o Right heart dominance 4)ct brain s/o ?Ring enhanced lesion with MCA Infarcted territory with peri lesional edema in Left patieto temporal region 5) It must be the case of Adult male with ASD (Septum Secundum as their was Rt ward axis) with Eisenmengerisation with PARADOXICAL EMBOLISATION PDA with Eisenmengerisation with PARADOXICAL EMBOLISATION Thanx once again for a nice case scenario.

It's NOT VSD as their is no Features s/o Bi Ventricular enlargement on ECG... Thoroughly Clinical Examination and 2D echo will help to clinch the diagnosis. Their was No h/o fever as per described by Dr.Suresh apart from, Infective Endocarditis and Brain Abscess can be ruled out.

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1.Clinical findings -central cyanosis - icterus doubtful -clubbing 2.XRay findings -Prominent pulmonary arteries ? PAH due to rt heart enlargement - emphysematous changes 3.ECG -Right axis deviation -T inversions in v1-3. 4.CT brain - ring enhanced lesion in left parieto temporal region , mostly looks like tuberculoma or brain abscess. with perilesional oedema. 5.though clubbing is common sign in lung & cardiac disorders. it is also found in GI disorders like IBD. Most of the causes of seizures are ruled out . only the CT brain is showing a lesion which looks like the possible cause for the presentation, mostly tuberculoma.TB can also give rise to clubbing. may be eisenmeenger syndrome with ASD is a possibility. with P pulmonale.

TOF is one more possibility

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35 yrs old male pt has.. cyanosis polycythemia pandigital clubbing. . RVH in x ray ecg..extreme right axis deviation. .RAE. RVH WITH strain pattern. . possiblities are.. 1. cyanotic CHD ...TOF physiology. .commonest. 2. acyanotic heart disease like ASD OR VSD...With reversal of shunt. .eisenmengers syndrome we will see our pt echo report. . TRUNCUS ARTERIOSUS TYPE 1 EISENMENGERS SYNDROME. . TRUNCUS ARTERIOSUS. .2% of congenital heart disease. . truncus arteriosus recognised in 1798. It is characterised by a single great artery with a single semi lunar valve at the base of the heart. .and give rise to coronary. .pulmonary and nd systemic circulation. .

This is case of brain abscess in case of cyanotic congenital heart dis ease likely TOF PHYDIOLOGICAL (though ECG IS NOT CLASSICAL OF TOF.there is northwest axis. Brain abscess is common complication of cyanotic heart disease due to chronic hypoxia. I had not seen such severe clubbing with eissenmenger also brain abscess not so common with eissenmenger hence I bet on cyanotic heart disease TOF PHYSIOLOGY BRAIN ABSCESS . Treatment xone metro anti epilepsy for atleast 4 6 week IV . If neurology deteriorating and pt undergo neurosurgery send pus for culture sensitivity. Prognosis poor . Let us know Echo finding . Waiting for ur reply but I feel it can be sometime like DORV

Thank you so much for ur wonderful discussion with so much of confidence sir..

very nice discussion Sir.I agree with Dr .Shrivastav-this is left MCA territory abscess -would like to keep a differential for the cause of the abscess. We generally rule out dental/ENT/Cardiac causes of brain abscess.Young male-drug abuse and HIV also need to be ruled out. Cyanotic heart disease is less likely in this age. how about endocarditis with right heart failure with drug abuse?But I would leave that to the Medicine specialists to decide.As for management of the abscess-what would you suggest?Also-what would one manage first?

Thanks a lot sir

I have posted this case..because. 1.cyanotic heart disease in adults we are seeing rarely. 2. In cyanotic heart disease in adult. .truncus arteriosus is rare.. 3..again eisenmengers syndrome in association with truncus. .first case I'm seeing. 4. cyanotic CHD. .complications we usually read in the books. .cerebral abscess. .This pt is a real case presented as status epilepticus. . Thank you so much for all the participants. . If u have any other suggestions. .adding few points. .Most welcome. .

Sclera is muddy, can't zoom the picture, there may sub conjunctival hemorrhage, grade four clubbing, chest X-ray is underexposed n shows prominent hilum, ct brain shows ring enhancing lesion with perilesional edema. Ecg lead placement is wrong for sure. U can see avr is positive. History and hemodynamic parameters of patient will be helpful to give a probable diagnosis Brain abscess- patient will be toxic with high grade fever Tuberculoma NCC

Thank you so much sir

Clinical H - Young adult presented with Status epileptic seizures Exam- Digital CLUBBING CXR- RV type apex, ?RAe EG - HR N, P pulmonale, RA deviation, Changing QRS amplitudes in rhythm strip, V1-r/s >1with t!, V2- sudden change to qs pattern, V6- No Q wave. CT Brain SOL in RT parietal lobe - hypodense with ring edema. Impression: young adult with adult CHD probably VSD eisenmenger or TOF with brain abscess and status epilepticus

Thanks a lot sir. .SOL in left side sir

Medical condition be what it may, the brain lesion is most likely to be an abscess or ??? metastasis. Fever is not necessary in brain abscesses. Young patient with features of lung and heart involvement of long duration goes more in favour of abscess than metastasis

why not it's infarct with Embolisation?

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