PERIPARTUM CARDIOMYOPATHY (PPCM) Mrs. Anna Smith came to the surgery complaining of worsening fatigue.

Aged 28, she had given birth to her third baby three weeks ago. Her previous pregnancies and deliveries had all been uncomplicated and she had no significant medical history of note. She is obese; her BMI was recorded as 31.2 before her pregnancy. She smoked 10 cigarettes a day; before this pregnancy she was smoking around 20 a day. Although she had expected to be tired with a newborn baby, she said the tiredness was far worse than she could ever imagine. She had also noticed she had an occasional palpitation, but otherwise felt well. At that consultation, her BP was recorded as normal. The doctor who saw her thought she might be anaemic or hypothyroid, so he arranged for her to have some blood tests. At her review appointment the following week, her FBC, U&Es and TFTs were all within normal limits. She explained that her fatigue had worsened, despite her baby being in a good night-time routine. She had noticed that she had to pass urine more frequently at night. Over the preceding few days, her ankles had become slightly swollen. She was found to have a tachycardia; her pulse was 138bpm. Auscultation of her chest revealed bibasal crackles and she was noted to have pitting oedema to her mid-calves. The patient was admitted to hospital and a diagnosis of peripartum cardiomyopathy (PPCM) was made. DILATED CARDIOMYOPATHY A 28 year old man was admitted for hemoptysis, dyspnea, fever, chills, nausea, vomiting, and jaundice. At age 12 years, he was noted to have scoliosis, and he described difficulty running. Additional clinical findings at the time of his first evaluation were enlarged calf muscles, atrophic pectoral muscles, elevated creatine phosphokinase levels, as well as an abnormal electromyogram and muscle microscopy. The patient was was not followed for his condition between the ages of 12 and 24 years. At the age of 24 years, echocardiography showed a severely dilated left ventricle with severe global hypokinesis, mild atrial enlargement, possible mural apical thrombus, and a small pericardial effusion. The patient was placed on Vasotec and Lanoxin. Repeat echocardiogram at the age of 27 years showed similar findings, and the patient was placed on Coumadin anticoagulation to prevent cardiac mural thrombi and emboli. Four months prior to his final admission, he was hospitalized briefly for pneumonia and left ventricular heart failure with pulmonary congestion. Given his deteriorating cardiac status (N.Y. Heart Association Class III/IV), the patient was subsequently placed on the cardiac transplantation list two weeks prior to admission. Past medical history revealed that his younger brother was diagnosed at age 14 years with dilated cardiomyopathy that resulted in death three weeks following the onset of severe acute congestive heart failure. Two other siblings and his parents are free of heart disease.

When admitted, the patient had hemoptysis, dyspnea, fever, chills, nausea, vomiting, and jaundice. His international normalized ratio on admission was 6.6, and his white blood cell count was 16,400/uL. A chest x-ray showed a mass-like consolidation of the right lower lobe of lung. He continued to have episodes of hemoptysis, elevated white blood cell counts and elevated international normalized ratios necessitating Vitamin K therapy. Five days after admission, the patient noted chest burning following bronchioloalveolar lavage. Shortly thereafter, he was found to be asystolic without respirations. Cardiopulmonary resuscitation failed, and the patient died. The autopsy was limited to the chest.