A 73-year-old woman had an episode a week ago in which she became disoriented, had difficulty speaking, and had persisting weakness on the right side of her body. On physical examination, she is now afebrile with pulse of 68/min, respirations of 15/min, and blood pressure of 130/85 mm Hg. On auscultation, the lungs are clear, the heart rate is irregular, and there is a midsystolic click. A chest CT scan shows a focus of bright attenuation within the heart. An echocardiogram shows that one valvular leaflet appears to balloon upward. The ejection fraction is estimated to be 55%. Laboratory findings show serum creatine kinase (CK), 100 U/L; glucose, 77 mg/dL; creatinine, 0.8 mg/dL; calcium, 8.1 mg/dL; and phosphorus, 3.5 mg/dL. Which of the following is the most likely diagnosis? Carcinoid heart disease
Correct Answer: Rheumatic heart disease
Description: Mitral annular calcification is often an incidental finding on chest radiograph, echocardiography, or at autopsy. Larger accumulations of calcium in the mitral ring can impinge on the conduction system, however, causing arrhythmias or disrupting the endocardium to provide a focus for infective endocarditis and thrombus formation (which can embolize and cause a stroke, as in this patient). Some cases are associated with mitral valve prolapse. Carcinoid heart disease leads to endocardial and valvular collagenous thickening. Hyperparathyroidism can cause metastatic calcification, which usually does not involve the heart, and deposits would not be so focal; this patient does not have hypercalcemia. Infective endocarditis is a destructive process, and healing may lead to fibrosis, but not to nodular calcium deposition. The most common infiltrative cardiomyopathies are hemochromatosis and amyloidosis. Rheumatic heart disease can lead to scarring with some calcium deposition, but the valve leaflets undergo extensive scarring, with shortening and thickening of the chordae tendineae that preclude upward prolapse. Senile calcific stenosis involves the aortic valve; in this case, there is no evidence of stenosis.
Category:
Pathology
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