The possible etiology of the vibratory systolic murmur.

Between January and September 1985, 476 patients underwent two-dimensional and M-mode echocardiography. Left ventricular bands were noted in 104 of these individuals. Of these patients, 89 (85.6%) were referred for evaluation of a systolic murmur. In view of this high incidence of association between left ventricular bands and systolic murmurs, we decided to perform a prospective analysis on patients with the classical vibratory systolic murmur (Still's murmur) which is commonly found in children and young adults. The incidence of left ventricular bands would be compared with a group of individuals in whom no cardiac murmurs could be detected. It was hoped in this way to possibly determine whether there was a definite relationship between the vibratory systolic murmur and left ventricular bands. Echocardiographs were performed using an Advanced Technical Laboratories machine and gain settings were adjusted such that all artefacts and normal structures could easily be distinguished from the ventricular bands. The ventricular bands were divided into two types. Of significance, we felt, were those which crossed the left ventricular outflow tract and which could therefore have been responsible for the production of turbulence and thus a murmur reminiscent of the Still's murmur. This type of left ventricular band was noted in 76% of our patients with Still's murmurs as opposed to only 14% of the individuals without any murmur (p less than 0.001). This statistically significant difference led us to conclude that left ventricular bands might be the cause of the Still's murmur. Further investigation, particularly with Doppler studies would be required to confirm this interesting association.

True idiopathic splenomegaly--a distinct clinical entity.

10 asymptomatic young male patients with moderate splenomegaly detected at a routine examination are presented. The history and clinical examination failed to reveal the aetiology of the splenomegaly. Further investigations, including screening for blood dyscrasias, clotting abnormalities and reticuloendothelial abnormalities were likewise unrevealing. Liver biopsies, rectal biopsies for bilharzia and bone marrow aspirates for Gaucher's Disease were found to be normal. Serology for malaria and Ebstein Barr Virus infection was also negative. Positive immunofluorescent tests for IgG antibodies specific for cytomegalovirus were found in 5 patients. We consider that these patients have splenomegaly which is not of a specific nature, but may be associated with a severe antigeneic response to the previous cytomegalovirus infection. In view of the otherwise negative findings these patients should be considered to have 'True Idiopathic Splenomegaly', a term which would indicate the benign nature of the splenic enlargement. This diagnosis should be considered in the differential diagnosis of asymptomatic patients who have splenomegaly of undetermined origin.

Acute myocardial infarction with normal coronary arteries--viral myopericarditis and possible coronary vasospasm. A case report.

A young man with normal coronary arteries presented with a transmural apical myocardial infarction. This diagnosis was based on elevated serial cardiac enzyme values, ECG changes, exercise scanning with thallium-201, left ventricular angiography and selective coronary arteriography. Some of the pathophysiological mechanisms implicated in myocardial infarction in patients with normal coronary arteries are discussed and the probable diagnosis of a virus-induced myopericarditis together with coronary artery vasospasm is favoured.

Eosinophilic gastro-enteritis - a complication of schistosomiasis and peripheral eosinophilia? A case report and review of the pathogenesis.

A case of iron deficiency anaemia and eosinophilia in a 19-year-old man is presented. An eosinophilic infiltrate was found in the mucosa of the gastro-intestinal tract and schistosomiasis of the rectum and sigmoid colon was demonstrated; it is postulated that this triggered off the immunological stimulus necessary in the development of eosinophilic gastro-enteritis. The biochemical clinical features in this case are presented and the possible immunogenesis and treatment of this disorder are discussed.

Hypophosphataemia with intravascular haemolysis: A case report.

Severe hypophosphataemia in an alcoholic patient during active treatment for acute pancreatitis and diabetic keto-acidosis was associated with a transient intravascular haemolytic anaemia, thrombocytopenia and some evidence of muscular disorder. The mechanism of the clinical changes is briefly discussed, and it is stressed that such complications could easily be overlooked in a patient with other serious disorders.

A possible causal relationship between defective fibrinolysis and pulmonary hypertension.

Pulmonary hypertension may be associated with multiple thrombi in the pulmonary arteries or with diffuse microembolization from a cryptic source. A 27-year-old man without any of the recognized clinical risk factors for venous thrombo-embolic disease presented with repeated attacks of chest pain and dyspnoea. Haemodynamic studies were compatible with the diagnosis of primary pulmonary hypertension. Despite intensive study there was no evidence of peripheral venous thrombosis. A survey of the plasma fibrinolytic profile showed unequivocal evidence of low spontaneous plasma fibrinolytic activity. The plasminogen activator activity of the venous wall was also markedly reduced. From these findings it would seem that a defective fibrinolytic defence mechanism may be an important predisposing factor in the pathogenesis of 'primary' pulmonary hypertension.

Whipple's disease. A case report.

A case of Whipple's disease in which there were some unusual features, although the results of histological investigation were characteristic of the diseases, is reported. This is followed by a brief review of the literature concerning this rare condition.

The effect of oral magnesium chloride therapy on the QTc and QUc intervals of the electrocardiogram.

The effect of magnesium, given orally as enteric-coated magnesium chloride tablets, on the ECG of 25 randomly selected patients was investigated. Each patient, who served as his own control, was given 4--6 tablets, each containing 0,5 g MgCl26H2O, at night for periods varying from 6 weeks to 2 years. Findings included (i) a statistically significant decrease in OTc and QUc intervals; (ii) a progressive shortening of QTc and QUc intervals with continuing therapy; (iii) reversion to normal of ECG abnormalities, especially of ST segments and T waves.

Austin flint murmur associated with a disc mitral valve prosthesis. A case report.

A case is discussed in which the movements of a Björk-Shiley disc valve, inserted in the mitral position, were hampered by an aortic insufficiency. Probably because of the improved haemodynamics after mitral valve replacement, the aortic insufficiency became significant. The regurgitant jet prevented the disc from functioning normally, causing Austin Flint and systolic murmurs as well as a haemolytic anaemia. Echocardiography as a non-invasive examination helped correlate disc movements with opening and closure sounds.

Calcification of the left atrium.

Three cases of left atrial wall calcification complicating long-standing mitral valve disease are presented. Its possible pathogenesis and influence on further treatment are discussed.

Acute inferior wall myocardial infarction associated with complete atrioventricular block and left posterior hemiblock.

Three cases of acute inferior wall myocardial infarction associated with complete atrioventricular block and junctional escape rhythm showing left posterior hemiblock are presented. The triad appears to consitiute a distinct syndrome. It is postuated that the subsidiary pacemaker is situated either in the bundle of His or the proximal part of the anterior division of the left bundle-branch.