Clinical Conferences

of Case. A. S., a 28 year old nulliparous Negro housewife was admitted for the seventh time to the Medical Service of Cleveland City Hospital on March 29, 1949, with the complaint of severe, progressive dyspnea of three days' duration. She died on the third hospital day. The patient was first hospitalized at age 14 (1935) because of gonococcal urethritis and cervicitis. At this time the heart was normal. During this hospitalization the patient developed transient pain and tenderness in the right temporomandibular joint. Concurrently a small ulcer and a condyloma appeared on the left labium minus near the anus. Dark field preparations were positive for Treponema pallidumn, and the blood Wassermann reaction was negative. Healing of the lesions followed a series of 14 intravenous injections of Mapharsen and a course of bismuth. She was readmitted for five days one month following discharge, because of pain and swelling of the right knee joint. These abated after symptomatic management. The third and fourth admissions were at age 24 (1945), when she received 3,000,000 units of penicillin for recurrent gonococcal urethritis and cervicitis, as well as for positive blood and spinal fluid Wassermann reactions. In December of 1948, at age 27, she was hospitalized for the fifth time because of cough productive of mucoid sputum of six months' duration, preceded by a sore throat. There had been night sweats, exertional dyspnea and paroxysms of nocturnal dyspnea for one month. During this period the patient noted transient, nondescript precordial pain which was never anginal in character. Nine days prior to admission there developed orthopnea and ankle edema. There had been no From the Departments of Medicine and Pathology, Western Reserve University School of Medicine at City Hospital, Cleveland, Ohio. 4432 weight loss, diarrhea, nervousness or heat intolerance. This hospitalization lasted until discharge on Jan. 5, 1949. Physical Examination. The temperature was 38 C., respiratory rate 24, blood pressure 130/90, and the vital capacity 1800 cc. (56 per cent of normal). The ocular fundi were normal. Examination of the heart revealed a diffuse apical impulse without increased activity. The left border of cardiac dullness was in the sixth intercostal space 9.5 cm. from the midsternal line, and the right border 1.5 cm. from the right sternal border in the fourth intercostal space. The mechanism was sinus with a diastolic gallop rhythm. The heart sounds were of poor quality, the second pulmonic being louder than the second aortic sound. At the apex there was a moderately harsh, low pitched holosystolic murmur, transmitted well into the axilla. A softer, higher pitched systolic murmur was localized to the second right parasternal area. There were no thrills and the area of upper retromanubrial dullness was not widened. All peripheral pulses were equally and bilaterally palpable and the vessels were soft and pliable. A pulsus alternans was felt in the radial artery. The jugular veins were distended (venous pressure: 230 mm. of saline). Moist rales were present at both bases, the liver edge was palpable and tender several centimeters below the right costal margin. There was slight pitting edema over both ankles. Laboratory Findings. The hemoglobin was 12 Gm., the red blood cell count 5,100,000, the white blood cell count 13,300 with 93 per cent polymorphonuclear leukocytes. The erythrocyte sedimentation rate was 18 mm. in one hour (Wintrobe). Urinalysis was normal, except that the specific gravity of the urine was never greater than 1.024 even after 18 hours of fluid abstinence. The blood and spinal fluid Wassermann reactions were positive; there were 30 mg. of protein in the spinal fluid, with 10 mononuclear cells and a first zone gum mastic curve. Values for fasting blood sugar, blood urea nitrogen and serum proteins were normal. Cardiac fluoroscopy (following digitalization) revealed moderate generalized cardiac Circulation, Volume IX, March, 1954 by gest on Sptem er 6, 2017 http://ciajournals.org/ D ow nladed from CLINICAL CONFERENCES enlargement. The circulation times determined with ether and Decholin were 17 and 37 seconds, respectively. The admission electrocardiogram was not abnormal. Hospital Course. Congestive failure was controlled promptly with digitalis, mercurial diuretics and a salt poor diet. No growth was obtained from 13 blood cultures drawn during the first five hospital days. Hemolytic aureus and albus staphylococci were grown from two other cultures but were considered contaminants. Nevertheless, on the sixth hospital day the intramuscular administration of aqueous penicillin was begun, and continued for 21 days for a total dosage of 9,600,000 units. Two carious teeth were removed during this time. The temperature, which varied between 37 and 38.5 C., though gradually defervescing, failed to return to normal by the end of hospitalization, although the white blood cell and differential counts did so. The heart rate varied between co and 110 beats. In 12 random determinations, the blood pressure varied between 150 and 114 systolic, and 120 and 80 diastolic. Serial electrocardiograms revealed gradual and progressive inversion of T wave in leads II and III, slurring of QRS in lead III, and reduction in voltage of R in the left precordial leads. The patient was discharged to the out-clinic on the thirty-second hospital day. Two weeks later the patient was re-admitted for the sixth time because of chills, fever and dull pain in both lower hemithoraces with flank radiation of three days' duration. Escherichia coli was cultured from two catheterized specimens of urine, and one blood culture was negative. At this time there was no clinical evidence of heart failure, although a six-foot roentgenogram of the chest revealed that the heart was still slightly enlarged. The rhythm was sinus without gallop. The heart sounds were of fair quality and no murmurs were heard. The urinary tract infection responded to sulfadiazine administration, and the patient was discharged after two weeks.