ABC | Volume 110, Nº6, June 2018

Anatomopathological Correlation Arduine & Aiello Female patient with chagas disease, heart failure and cachexia Arq Bras Cardiol. 2018; 110(6):588-596 Figure 3 – Chest X-ray (posterior-anterior view): increase and cephalization of the pulmonary vasculature. Her physical examination revealed an emaciated patient (53 kg), on regular general condition, tachypneic, with heart rate of 72 bpm, arterial blood pressure of 95/60 mm Hg, and O 2 saturation of 92%. Her auscultation revealed rales over the pulmonary bases, rhythmic heart sounds, and systolic heart murmur over the mitral area (++++/6+). Her abdomen was flaccid, with a tender liver, palpated 2 cm from the costal margin. There was lower limb edema (+++/4+). The patient was using amiodarone (200 mg), enalapril (5 mg), hydrochlorothiazide (25 mg), levothyroxine (25 µg), metoprolol (100 mg), simvastatin (20 mg), warfarin (5 mg). Her ECG (September 22) showed: sinus rhythm; heart rate, 63 bpm; indirect signs of right atrial overload (Peñaloza- Tranchesi); low-voltage QRS complexes on the frontal plane; probable electrically inactive lateral area; left anterior-superior hemiblock (Figure 4). After a few days, the new ECG revealed an operational pacemaker with atrial stimulus propagating to the ventricle (AAI) (Figure 5). Her chest X-ray (September 22, 2016) evidenced the presence of an ICD/pacemaker with electrodes in the left atrium and ventricle, pulmonary congestion, opacity area suggestive of pneumonia in the right pulmonary lower field (air bronchogram), elevation of the left main bronchus (suggestive of enlarged left atrium), and global enlargement of the heart area, attributed mainly to the right ventricle (Figure 6). Her laboratory tests (September 22) revealed: hemoglobin, 8.2 g/dL; hematocrit, 26%; leukocytes, 17500/mm³ (neutrophils 79%, eosinophils 0%, lymphocytes 15% and monocytes 6%); platelets, 344000/mm³; urea, 33mg/dL; creatinine, 0.71mg/dL; AST, 148 IU/L; ALT, 136 IU/L; gamma GT, 36 IU/L; alkaline phosphatase, 75 mg/dL; total proteins, 6.9 g/dL; albumin, 3.1 g/dL; C-reactive protein, 124.39 mg/L; sodium, 140 mEq/L; potassium, 3.6 mEq/L. Arterial blood gas analysis: pH, 7.54; pCO 2 , 31.1 mm Hg; pO 2 , 62.3 mmHg; O 2 saturation, 93%; bicarbonate, 26.2 mmol/L; base excess, 3.9 mmol/L. Because of the diagnostic suspicion of pneumonia, ceftriaxone and clarithromycin were initiated. The dyspnea and edema improved, arterial hypotension episodes occurred, and the dry cough and mild hyperthermia (37.6°C) persisted. Assessment of the ICD/pacemaker revealed 14 episodes of ventricular tachycardia in July 2016: 12 abolished by burst (high-frequency stimuli) and 2 abolished with 31-J shocks. Her echocardiogram (September 26, 2016) showed: aorta, 26 mm; left atrium, 60 mm; basal and mid right ventricle, 43 mm and 33 mm, respectively; ventricular septal thickness, 10 mm; posterior wall, 7 mm; left ventricle (diast/syst), 73/60 mm; LVEF, 40%. The atria were severely enlarged, the left ventricle was dilated with dyskinesia of the lateral wall (basal segment), akinesia of the inferior wall (basal segment), and apical aneurysm. The right ventricular function was normal. The mitral and tricuspid valves showed severe regurgitation due to inadequate leaflet coaptation. Systolic pulmonary artery pressure was estimated at 47 mmHg. No pericardial change was observed. On the days following admission, her laboratory tests continued to show leukocytosis (around 19000), anemia, hypoalbuminemia (1.9 g/dL) and elevated C-reactive protein (above 150 mg/L). A new chest X-ray detected an opaque nodule in the right base (Figure 7). Chest tomography (September 28, 2016) evidenced: pacemaker with endocavitary electrodes in the right chambers; dilation of the pulmonary trunk (41 mm); permeable trachea and main bronchi of normal caliber; diffuse thickening of the bronchial walls; enlarged pulmonary hila; and hilar calcifications that could be lymph node sequelae. There was an irregular nodule measuring 2.3 x 2.5 x 1.9 cm in the transition between the medial and lateral segments of the middle lobe, in 590