ECG of the Week

33 year old woman, prison inmate BIBA after collapsing in the shower with a briefly sustained LOC. Haemodynamically and neurologically normal during transfer. Denies prodrome of chest pain, SOB, or palpitations. PMHx IVDU (currently withdrawing from heroin addiction) and being investigated for lupus.

The key findings on this ECG are inferolateral Q waves and has the appearance of LVH (although not yet meeting criteria). With these two findings, the possibility of HOCM is raised. This patient was discharged home with a plan for an echocardiogram.

In regards to a patient with syncope, remember to also look for signs of:

• ARVC

• WPW

• Heart Block

• Long/Short QT

• Brugada

• Ischaemia/PE

 Image of the Week

Stem: 60 year old female referred from Royal Eye and Ear hospital with reduced vision in one eye and this rash. Rash appeared approx 1 month ago, right eye vision loss started 1 day ago. Afebrile, hemodynamically stable

Unfortunately, this is syphilis.

1.     Describe the features of the rash?

a.     Rash is a diffuse maculopapular rash covering the trunk and upper limbs

b.     Rash is reddish brown colour

c.      Erythematous and well circumscribed crusted macules

2.     List differential for rash with vision loss

a.     Vasculitis

b.     Autoimmune- SLE

c.      Dermatomyositis 

d.     Infectious

                                                i.     CMV retinitis

                                               ii.     HSV, VZV

                                              iii.     Syphilis

                                             iv.     HIV

                                              v.     Toxoplasmosis

3.     What would be your investigations of choice for this presentation?

a.     FBC, UEC, LFT, blood cultures

b.     LP- CSF- syphilis serology, cell count, glucose, protein, cytology, biochem

c.      ESR, CRP, IgM

d.     Skin scraping/ biopsy/ swab- viral PCR_ HSV,VZV, CMV

e.     HIV serology, hepatitis screen, toxoplasma IG, t pallidum AB, 

                                                i.     Syphilis-

1.     Non specific tests- VDLR, RPR

2.     Specific tests- EIA, TPHA, TPPA

f.       MRI brain

4.     Bonus- what are other manifestations of this condition?

a.     Pretty much anything

b.     Depends on stage

                                                i.     Primary, secondary, tertiary 

1.     Primary- painless ulcer usually genital area, +/- lymphadenopathy

2.     Secondary

a.     Cutaneous- rash 

b.     Systemic features- including neurosyphilis and ocular syphilis

3.     Tertiary symptoms

Importance- This patient was diagnosed with neurosyphilis 

This case was a 60-year-old female who lived with her husband who was her sole partner. 

She had no past medical history except for a mild rash with penicillin. She had never used IV drugs, nor did she drink.

Owned a nursery with her husband

She had seen  her LMO multiple times, and  the Eye and Ear hospital with this complaint- only diagnosed on the routine tests performed by the Lab.

Conclusion- We do have syphilis in Australia, although rare- consider it as easily treated if diagnosed early