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Old 03-11-2011
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Eye Abnormal fundal examination of the eye

A 30 year old lady was admitted with a six-month history of lethargy, palpitation and shortness of breath. On admission, she was afebrile. On auscultation of the precordium, there was a murmur at left lower sternal edge. Examination of chest, abdomen and CNS was normal. This is her fundus.

Abnormal fundal examination of the eye-eye-fundus.jpg
click image to enlarge

What is the most likely diagbosis?

A) Infective endocarditis
B) SLE
C) Polyarteritis nodosa
D) Leukemia
E) Anaemia
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Image shows Roth's spots as well as retinal hemorrhage. I am completely confused. Roth's spot can be seen in Infective endocarditis, leukemia, anemia (given options). Retinal hemorrhage can be seen in leukemia, not sure if it is seen in other options. But history more likely suggest infective endocarditis. I'll go with option A - Infective endocarditis.
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infective endocarditid ---- roth spots and murmer along the left sternal border
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I'll go with A, roth spots, retinal hemorrhage and mumur.
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I think, it's E) Anemia
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Quote:
Originally Posted by prasaddesai View Post
Image shows Roth's spots as well as retinal hemorrhage. I am completely confused. Roth's spot can be seen in Infective endocarditis, leukemia, anemia (given options). Retinal hemorrhage can be seen in leukemia, not sure if it is seen in other options. But history more likely suggest infective endocarditis. I'll go with option A - Infective endocarditis.
I'm confused, too - mostly by the fundoscopic image being the centerpiece of the question. As prasaddesai says, Roth spots and other hemorrhaging can be indicative of any of the answers, really. The fundus does look amemic, but you'd have to be both very anemic and thrombocytopenic. I don't think we can rule out any of the answer choices based on the fundoscopic exam, which leaves us with the six-month history of non-specific cardiac symptoms and the murmur. So... A, B, and E would be my top choices. How can we choose which one of those three is the best?
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Thanks Guys for your effort!

Yes. You all are right-Roth's spot!

All listed are its differential diagnoses. Actually pale fundi suggests anaemia. This is a case of severe anaemia in a lady with menorrhoea. Cardiac murmur is a manifestation of severe anaemia. Lack of fever is against the diagnosis of IE.

This senario is meant to give us the fact that Roth's spot is not specific finding of IE.
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Quote:
Originally Posted by 1TA2B View Post
Thanks Guys for your effort!

Yes. You all are right-Roth's spot!

All listed are its differential diagnoses. Actually pale fundi suggests anaemia. This is a case of severe anaemia in a lady with menorrhoea. Cardiac murmur is a manifestation of severe anaemia. Lack of fever is against the diagnosis of IE.

This senario is meant to give us the fact that Roth's spot is not specific finding of IE.
agree lack of fever goes against IE so we can rule it out. the patient can have anemia or poyarteritis nodosa based on the symptom lethargy.
i am confused how to distinguish anemia from poyarteritis nodosa in this case??
my diagnoses is slightly towards polyarteritis nodosa coz there is involvement of heart as well as in the picture the arteries look swollen.
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i'd go with a-infective endocarditis.
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Thank you 1TA2B for a challenging question and wonderful explanation.

I have one doubt. What is the reason for left lower sternal murmur (tricuspid)? I think that anemia would most likely present with a left sided heart murmur. Correct me if I am wrong. Actually that is why I ruled out anemia from my answer choice and started thinking on the lines of subacute bacterial endocarditis - Longer duration symptoms, along with infective endocarditis signs. I was not happy with my reasoning and also I didn't notice pale fundus. I was only concentrating on roth's spot and retinal hemorrhage, so forgot to consider an important finding.

Thanks again.
Take care
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Quote:
Originally Posted by prasaddesai View Post
...I have one doubt. What is the reason for left lower sternal murmur (tricuspid)? I think that anemia would most likely present with a left sided heart murmur...
I could see it, I think. Wouldn't the murmur in a case of severe anemia be one of relative insufficiency and thus a systolic regurgitation murmur? You're probably right though that mitral insufficiency is more probable than tricuspid, since LV pressure is so much greater than RV pressure...

gratuitous figure:
Attached Thumbnails
Abnormal fundal examination of the eye-picture-15.png  
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Murmur in anaemia is a functional murmurs and I don't think it's site-specific like pathological murmurs. Agree wtih prasaddesai that LPS murmur generally generated by tricuspid valve lesion.

Thanks Guys!
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Thanks Mondoshawan for useful diagram
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