1. AN INTERESTING CASE OF CARDIOMYOPATHY Vth MEDIACAL UNIT DR.J.SANGU MANI M.D, D.diab. DR.MURUGESAN M.D DR.R.SUNDARAM M.D

2. HISTORY SYMPTOMS  Male, 57 years old, Farmer, 2 children Breathlessness since 20 days NYHA class IV Orthopnea + Easy fatigability + Excessive sweating + Snoring / sleep disturbance / sleep apnea / excessive daytime sleepiness

3. Hard of hearing Blurring of vision Polyuria / polydipsia Low back ache Increased tongue size with change of voice

4. Past & personal History - Known type 2 diabetics on insulin therapy since 5 years - Known systemic hypertensive more than 20 years - Amputation of right great toe 2 years back Non smoker Not an alcoholic

5. GENERAL EXAMINATION Conscious, alert with dysmorphic features of Frontal bossing Protruded jaw Mandibular enlargement Large fleshy nose macroglossia Prominent chest bones Kyphosis Big hands with wide finger tips Big feet with wide heel pad Oily skin / hyperhidrosis

7. Protruded jaw Mandibular enlargement Large fleshy nose

8. Frontal bossing

9. Prominent chest bones Kyphosis

10. Big hands with wide finger tips

12. No pallor No icterus No clubbing No cyanosis No lymphadenopathy B/L pitting pedal edema + Right side amputated great toe +

13. VITALS  HEIGHT – 175 cms  WEIGHT – 96 kgs  BMI – 31.3 kgs / m 2 (Obese class-I )  BP – 150/100 mmHg  PULSE – 110 / mt, regular  RESPIRATION – 26/ mt

14. SYSTEM EXAMINATION  CVS – S1 S2 +, no murmur  RS – NVBS +, B/L crepts + P/A – soft, no hepatosplenomegaly CNS – NFND

15. INVESTIGATIONS Hb - 10.6 gms % TC -6000 cells / cu.mm Polymorphs - 58% Leucocytes – 20% Platelets - 2.6laks ESR -24 mm / hr

16. FASTING BLOOD SUGAR 154 mgs% POST PRANDIAL BLOOD SUGAR 258 mgs %

17. Blood urea 25 mgs% Sr. creatinine 1.0 mgs %

18. LIPID PROFILE Sr. total cholesterol – 150 mgs % Sr. TGL – 100 mgs % Sr. HDL – 20 mgs % Sr. VLDL – 20 mgs % Sr. LDL – 110 mgs %

19. CHEST XRAY cardiomegaly with loculated right side pleural effusion USG ABDOMEN LIVER measures 16 cms with normal echoes IVC & hepatic veins appear prominent SPLEEN measures 12.5 cms with normal echoes right kidney - 11×6 cms left kidney – 12.3×7 cms B/L kidneys CMD maintained, cortical echoes normal

20. ECG  HR -150 / mts, normal sinus rhythm, Left axis deviation +  PR – 160 ms,QRS – 80 ms  Persistent S wave in V1 to V6  I, aVl T wave inversion + LVEF – 26% Left atrium, left ventricle dilated global hypokinesia of left ventricle mild MR Imp : DCM with severe LV systolic dysfunction Mild pericardial effusion ECHO

21. ENDOCRINOLOGIST SUGGEST Sr.T4, TSH,LH, FSH, prolactin,total testosterone, measurement Growth hormone level (Overnight fasting & 60 minutes after 75 gram of glucose ingestion) Contrast enhanced MRI Sella Ophthalmologist opinion

22. total testosterone – 196 ng/dl (normal 270-1070 ng/dl) sr. Growth hormone - 35.30 ng/ml (normal < 3 ng/ml ) Sr.T4 - 80 ng/ml (normal 55-135 ng/ml) TSH - 4 miu /ml (normal 0.17-4.05 miu/ml) LH - 3 IU/L (normal 1.8- 8.6 IU/L) FSH - 4.6 IU/L (normal 1.42-15.4 IU/L) Prolactin – 8mcg/l (normal 3-15 mcg/L)

23. OPTHALMOLOGIST OPINION RIGHT EYE VISUAL ACQUITY 3/60 FIELD OF VISION - NORMAL FUNDUS – MODERATE NPDR LEFT EYE VISUAL ACQUITY 2/60 FIELD OF VISION - NORMAL FUNDUS - SEVERE NPDR WITH MACULAR EDEMA BOTH EYE GRADE III HYPERTENSIVE RETINOPATHY

24. X RAY SKUL -Thickened cranial vault -Enlarged frontal sinuses -prominent maxilla -Elongation and projection of mandible

25. X RAY HANDS - Widening of MCP joint spaces -Soft tissue thickening

26. X RAY FOOT - Soft tissue enlargement -increased heel pad thickness ≈ 25mm

27. Contrast enhanced MRI BRAIN & Pituitary fossa The pituitary gland and optic chiasma are normal.

28. Contrast enhanced MRI BRAIN & Pituitary fossa