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Sick Sinus Syndrome Requiring Permanent Pacemaker Implantation in a Patient with Mirror-Image Dextrocardia
systems. 8 Whitehead" has suggested that inapparent infection with respiratory as well as other viruses acts as a reservoir--" for epidemic periods. Unlike other descriptions of patients with such inclusions, our subjects had no respiratory symptoms. Our findings are more in line with those of Strom," who found viral shedding in the urinary tract of apparently healthy individuals. The Tecumseh and other studies of respiratory infections 1 0 12 have demonstrated an increased incidence of infection with coronavirus, respiratory syncytial virus, and rhinovirus during the winter months; and it is, therefore, probable that the majority of our patients had asymptomatic infections with these viruses. The low postoperative respiratory complication rate noted in this series seems to indicate that the presence of viral inclusion bodies is not a precursor of respiratory disease (even under stress conditions) .
1. Dorfman HD, Monis B: Mucin containing inclusions in multinucleated giant cells and transitional epithelial cells of urine: Cytochemical observations on exfoliated cells. Acta Cytol 8:293-301, 1964 2 Melamed MR, Wolinska WH: On the signiflcance of intracytoplasmic inclusions "in the urinary sediment. Am J PathoI38:711-718, 1961 3 .Papanicolaou G N: Degenerative changes in ciliated cells exfoliating from bronchial epithelium as cytological criterion in diagnosis of diseases of lung. NY State J Med 56:2647-2650, 1956 4 Strom J: Cytology of the urine in healthy persons and cytological reactions in acute infections, especially with respect to the presence of inclusion-bearing and giant cells. Scand J Infect Dis 5:209-228, 1973 5 Chalon J, Loew DAY, Orkin LR: Tracheobronchial cytologic changes during the menstrual cycle. JAMA 218: 1928-1931, 1971 6 Chalon], Tayyab MA, Ramanathan S: Cytology of respiratory epithelium as a predictor of respiratory complications after operation. Chest 67 :32-35, 1975 7 Goldsmith JR, Berglund K: Epidemiological research to multiple factor interactions in pulmonary disease: The potential usefulness of pathologic analysis. Ann NY Acad Sci 221:361-375, 1974 8 Herrmann EC: Rates of isolation of viruses from a wide spectrum of clinical specimens. Am J Clin Path 01 57:188194, 1972 9 Whitehead EM: Viral epidemiology: The hidden universality of infection. 2:451-456, 1972 10 Monto AS, Cavallaro JJ: The Tecumseh study of respiratory illness: 2. Patterns of occurrence of infection with respiratory pathogens, 1965-1969. Am J Epidemiol 94: 280-289,19 11 Monto AS, Lim SK: The Tecumseh study of respiratory illness. 6. Frequency of and relationship between outbreaks of coronaviros infection. J Infect Dis 129:271-276,: 1974 12 McIntosh K, Kapikian AZ, Turner HC, et al: Seroepidemiologic studies of coronaviros infection in adults and children. 91:585-592, 1970
558 GOYAL ET AL
Sick Sinus Syndrome 'Requiring Permanent Pacemaker Implantation in a Patient with Mirror-Image Dextrocardia * Shiv L. Goyal, M.D.;o. Edgar Lichstein, M.D.;t Prem K. Gupta, M.D.;t Kul D. Chadda; M.D.,§ and Eouad Lafam, M.D.II
A patient with the sick sinus syndrome accompanying mirror-image dextrocardia wblch was associated with double superior veaae cavae and an absent Inferior veaa cava Is presented. A permanent traDsvenoDS demand pacemaker was iDserted because of repeated episodes of dizziness and a documented 3~-second "period of asystole. Precise knowledge of the venous system and the location of the apex of the right ventricle was necessary prior to permanent pacemaker implantation. of disorders affecting sinus-nodal function A group have recently been described which may be mani-
fested by either a slow or fast heart rate and mayor may not be associated with symptoms: of dizziness and syncope. The term, sick sinus syndrome.v- has been used and includes inadequacy of the sinoatrial node manifested by both persistent sinus bradycardia and cessation of sinus rhythm with replacement by an atrial or junctional rhythm. This report presents an adult case of sick sinus syndrome with mirror-image dextrocardia and situs inversus, double superior venae cavae, single spleen, and absent inferior vena cava with azygos continuation. The technique of permanent pacemaker insertion in dextrocardia is described.
CASE REPoRT This 48-year-old woman first came to this hospital in 1965 with the chief complaint of dizziness. Findings from the physical examination and the x-ray films of the chest and abdomen were consistent with a diagnosis of dextrocardia with situs inversus. The electrocardiogram showed a junctional rhythm with a rate of 34 beats per minute and QRS morphology typical of dextrocardia. The patient was treated with sublingual administration of isoproterenol with good results. The current admission in March 1974 was prompted by several episodes of dizziness and one episode of syncope.
Physical Examination on Admission Physical examination on admission revealed blood pressure of 110/70 mm Hg in both arms. Carotid pulses were equal and of good quality. The point of maximal impulse was ·From the Department of Medicine, Division of Cardiology, and Department of Thoracic Surgery, Mount Sinai Hospital Services, City Hospital Cente!l Elmhurst, NY, and Mount Sinai School of Medicine of the City University of New York, New York. ••Clinical Assistant. Associate Professor of Medicine. Assistant Professor of Clinical Medicine. §Assistant Professor of Medicine. IIAssistant Professor of Surgery. Reprint requests: Dr. Lichstein, City Hospital Center at Elmhurst, 79-01 Broadway, Elmhurst, New York 11373
l
CHEST, 69: 4, APRIL, 1976
FICURE 1. Standard 12-lead ECG and lead 2 rhythm strip showing wandering atrial rhythm with junctional escape beats and QRS morphology typical of dextrocardia. in the right fifth intercostal space in the midclavicular line, and there was a grade 2/6 systolic ejection murmur heard along the right sternal border between the second and fourth intercostal space. The ECG showed a slow wandering atrial rhythm with junctional escape beats and QRS changes typical of dextrocardia (Fig 1) . During a period of monitoring, the patient developed an episode of multifocal atrial tachycardia followed by spontaneous cessation of the tachycardia and then a 3l'-second period of asystole. The period of asystole was terminated by a slow, irregular junctional escape rhythm (Fig 2) . The patient was aware of palpitations during the tachycardia and noted dizziness during the episode of asystole but did not lose consciousness. Because of the evidence of the sick sinus syndrome with significant symptoms, a temporary transvenous pacemaker was inserted . Angiographic studies indicated double superior venae cavae with the left-sided vein entering the right atrium and the right-sided vein connecting with the coronary sinus (Fig 3). The inferior vena cava was
absent, and a continuation of the azygos vein was noted . A permanent endocardial bipolar demand pacemaker (Medtronic 5942) was inserted during the second week of hospitalization. The incision was made 3 em below the left clavicle and the cephalic vein was exposed in the deltopectoral grove. The electrode catheter was guided to the right ventricular cavity through the left superior vena cava. The patient was immediately placed in the lateral position, and the catheter was guided to the apex of the right ventricle using the lateral projection of the angiogram as a reference . The patient had an uneventful recovery and was discharged without symptoms one week later. DISCUSSION
This patient had evidence of the sick: sinus syndrome manifested by absence of a normal sinus-nodal stimulus, a slow atrial pacemaker, and episodes of atrial tachycardia followed by a 3*-second period of asystole. The
FIGURE 2. Continuous rhythm strip recorded with VI monitor lead showing episode of multifocal atrial tachycardia with 3lkecond period of asystole following spontaneous cessation of tachycardia. There is slow irregular junctional escape rhythm following period of asystole.
CHEST, 69: 4, APRIL, 1976
SICK SINUS SYNDROME REQUIRING PACEMAKER 559
FIGURE 3. Venous angiogram in the posteroanterior (left) and lateral (right) projections following injection of radiopaque contrast medium into superior venous system. Double superior venae cavae are noted . Temporary pacing catheter is seen, and its course identifies hemiazygos continuation which empties into right superior vena cava and then into huge coronary sinus. RV, right ventricle; and RA, right atrium.
patient also had mirror-image dextrocardia, double superior venae cavae, an absent inferior vena cava with an azygos continuation, and situs inversus. Sinus-nodal dysfunction may be due to an ischemic, sclerotic, rheumatic, or inflammatory condition. It also occurs with pericarditis or cardiomyopathy, acute or chronic coronary occlusion, Friedreich's ataxia, progressive muscular dystrophy, collagen disease, surgical injury to tissue, metastatic disease, infiltration of atria in amyloidosis and hemochromatosis, and local fibrosis of the sinus node." Diphtheria has been incriminated in some cases but the link has not been proven ." Familial sinus-nodal disease has been reported." In our patient, none of these causes appeared to be responsible for sinusnodal dysfunction. The characteristic electrocardiographic findings in mirror-image dextrocardia include negative P waves with inverted QRS complex and T wave in lead 1 and the interchanging of lead aVL for aVR, of lead 2 for lead 3, and of right precordial leads for the corresponding left precordial leads . The absence of a negative P wave in lead 1 as in our case, is unusual with mirror-image dextrocardia and should lead to suspicion of associated abnormalities. In their study of cardiac rhythms in dextrocardia, Momma and Linde" found that an upright Pwave in lead 1 was frequently associated with either bilateral superior venae cavae or absent inferior vena cava . With bilateral superior venae cavae the P-wave vector was thought to arise from a left atrial rhythm, while with absent inferior vena cava, there was thought to be a coronary sinus rhythm. Mirowski et al" described eight patients with mirror-image dextrocardia with intermittent or permanent abnormality in the direction of the P wave in lead 1. These patients had complex congenital cardiac lesions which included bilateral superior
560 GOYAL ET AL
venae cavae in three and an absent inferior vena cava in two. Mirowski et al' noted that these patients had a tendency to develop spontaneous or induced arrhythmias which were, in most instances, episodes of supraventricular or atrial tachycardia, and in one instance, syncope was noted. Mirror-image dextrocardia with situs inversus is compatible with a normal life span. The development of all forms of cardiovascular disease, including arteriosclerotic heart disease, would be anticipated" and may occur with similar frequency and manifestations as in the general population." Although arteriosclerotic heart disease is a common cause of the sick sinus syndrome, we could find no evidence of this entity in our patient. Treatment Symptomatic sinoatrial rhythmic disturbances have been effectively treated with permanent pacemakers.10 , l1 We are not aware of any previous experiences with the insertion of a permanent pacemaker in patients with mirror-image dextrocardia. We found the information gained from the venous angiograms to be essential and feel that angiographic studies should be done in all similar cases. Since there is a high prevalence of venous abnormalities when mirror-image dextrocardia is seen without a negative P wave in lead 1, the angiogram is helpful in determining the route of the endocardial catheter. . ACKNOWLEDGMENT: We thank Ulrich Vieux, M.D., Department of Radiology, City Hospital Center, Elmhurst, NY, for performing the venous angiogram and Mrs. Edith Erick and Mrs. Frances Schlesinger for their secretarial assistance. REFERENCES
1 Ferrer MI: The sick sinus syndrome in atrial disease. JAMA 206:645, 1968 2 Schulman CL, Rubenstein H, Yurchak PM, et al: The
CHEST, 69: 4, APRIL, 1976
3 4 5 6 7
8 9 10
11
"sick sinus" syndrome: Clinical spectrum. CirCuIation 17(suppI3) :42,1970 Ferrer MI: The sick sinus syndrome. Circulation 47:635, 1973 Rasmussen K: Chronic sinoatrial heart block. Am Heart J 81 :38, 1971 . Spellberg RD : Familial sinus node disease. Chest 60:246251, 1971 Momma K, Linde LM : Cardiac rhythms in dextrocardia. Am J Cardiol25:420, 1970 Mirowslci M, Neil CA, Taussig HG: Left atrial ectopic rhythm in mirror image dextrocardia and in normally placed malformed hearts : Report of 12 case~· with "dome and dart" P waves. Circulation 27:864, 1963 Maleki M, Tristani PE: Coronary arteriography in situs inversus dextrocardia. Chest 65:220-222, 1974 Hynes KM, Gau GT, Titus JL : Coronary heart disease in situs inversus totalis. Am J Cardiol3i :666, 1973 Conde CA, Leppo J, Lipski J, et al : Effectiveness of pacemaker treatment in the bradycardia-tachycardia syndrome. Am J CardioI32:209, 1973 Chokshi DS, Mascarenhas E, Samet P, et al: Treatment of sinoatrial rhythm disturbances with permanent card iac pacing. Am J Cardiol 32 :215, 1973 FIGURE 1. Cavitating lesion located in superior segment of right lower lobe.
Aspergilloma within a Malignant Pulmonary Cavity* I. O. Torpoco, M.D.;oO Mohammed Yousufluddin, M.D.;oO and lames W. Pate, M.D., F.C.C.P.t
The simultaneous appearance of both bronchogenic carcinoma and aspergiUoma with the typical radiographic appearance of a mycetoma emphasizes the importance of consistent suspicion for malignancy in any pulmonary lesion. This is apparently the first reported case in which allergic phenomena (asthm.Uke symptoms and eosinophilia) are associated with an aspergWoma occurring within a cavitary bronchogenic carcinoma.
CASE REPORT
A 68-year-old black man was referred because of an abnormal chest x-ray Blm. Three months prior to admission, the patient had "flu-like" symptoms which he treated with home remed ies while the symptoms became worse. He complained of dyspnea on exertion and tightness and discomfort in the chest. The patient had felt "feverish," lost about 4.5 kg (10 lb ) of weight, and had one episode of a small hemoptysis . The patient had smoked one pack of cigarettes per day for over 30 years but had stopped smoking for no obvious reason about a year prior to this illness; he had a past history of hypertensive cardiovascular disease and peptic ulcer .
Mycetomas due to aspergillosis characteristically occur in pulmonary cavities which have resulted from infectious processes, frequently superimposed upon emphysematous or metabolic pulmonary diseases. There have been a few cases in which aspergillosis was believed to have been invasive, evolving from a pneumonic process to the classic fungal ball.r-e The purpose of this paper is to report the second case in the English literature of aspergilloma occurring in a malignant pulmonary cavity and the first such case to be associated with asthmatic "attacks." Since cavitating bronchogenic carcinomas are not rare, the possible association of aspergilloma with malignant cavities deserves emphasis. °From the Department of Surgery, College of Medicine, University of Tennessee, Memphis. ° °Resident inThoracic Surgery. tProfessor of Surgery.
CHEST, 69: 4, APRIL, 1976
FIGURE
cavity.
2. Bronchogram demonstrating patent bronchus into
ASPERGILLOMA WITHIN MALIGNANT PULMONARY CAVITY 561
1. Dorfman HD, Monis B: Mucin containing inclusions in multinucleated giant cells and transitional epithelial cells of urine: Cytochemical observations on exfoliated cells. Acta Cytol 8:293-301, 1964 2 Melamed MR, Wolinska WH: On the signiflcance of intracytoplasmic inclusions "in the urinary sediment. Am J PathoI38:711-718, 1961 3 .Papanicolaou G N: Degenerative changes in ciliated cells exfoliating from bronchial epithelium as cytological criterion in diagnosis of diseases of lung. NY State J Med 56:2647-2650, 1956 4 Strom J: Cytology of the urine in healthy persons and cytological reactions in acute infections, especially with respect to the presence of inclusion-bearing and giant cells. Scand J Infect Dis 5:209-228, 1973 5 Chalon J, Loew DAY, Orkin LR: Tracheobronchial cytologic changes during the menstrual cycle. JAMA 218: 1928-1931, 1971 6 Chalon], Tayyab MA, Ramanathan S: Cytology of respiratory epithelium as a predictor of respiratory complications after operation. Chest 67 :32-35, 1975 7 Goldsmith JR, Berglund K: Epidemiological research to multiple factor interactions in pulmonary disease: The potential usefulness of pathologic analysis. Ann NY Acad Sci 221:361-375, 1974 8 Herrmann EC: Rates of isolation of viruses from a wide spectrum of clinical specimens. Am J Clin Path 01 57:188194, 1972 9 Whitehead EM: Viral epidemiology: The hidden universality of infection. 2:451-456, 1972 10 Monto AS, Cavallaro JJ: The Tecumseh study of respiratory illness: 2. Patterns of occurrence of infection with respiratory pathogens, 1965-1969. Am J Epidemiol 94: 280-289,19 11 Monto AS, Lim SK: The Tecumseh study of respiratory illness. 6. Frequency of and relationship between outbreaks of coronaviros infection. J Infect Dis 129:271-276,: 1974 12 McIntosh K, Kapikian AZ, Turner HC, et al: Seroepidemiologic studies of coronaviros infection in adults and children. 91:585-592, 1970
558 GOYAL ET AL
Sick Sinus Syndrome 'Requiring Permanent Pacemaker Implantation in a Patient with Mirror-Image Dextrocardia * Shiv L. Goyal, M.D.;o. Edgar Lichstein, M.D.;t Prem K. Gupta, M.D.;t Kul D. Chadda; M.D.,§ and Eouad Lafam, M.D.II
A patient with the sick sinus syndrome accompanying mirror-image dextrocardia wblch was associated with double superior veaae cavae and an absent Inferior veaa cava Is presented. A permanent traDsvenoDS demand pacemaker was iDserted because of repeated episodes of dizziness and a documented 3~-second "period of asystole. Precise knowledge of the venous system and the location of the apex of the right ventricle was necessary prior to permanent pacemaker implantation. of disorders affecting sinus-nodal function A group have recently been described which may be mani-
fested by either a slow or fast heart rate and mayor may not be associated with symptoms: of dizziness and syncope. The term, sick sinus syndrome.v- has been used and includes inadequacy of the sinoatrial node manifested by both persistent sinus bradycardia and cessation of sinus rhythm with replacement by an atrial or junctional rhythm. This report presents an adult case of sick sinus syndrome with mirror-image dextrocardia and situs inversus, double superior venae cavae, single spleen, and absent inferior vena cava with azygos continuation. The technique of permanent pacemaker insertion in dextrocardia is described.
CASE REPoRT This 48-year-old woman first came to this hospital in 1965 with the chief complaint of dizziness. Findings from the physical examination and the x-ray films of the chest and abdomen were consistent with a diagnosis of dextrocardia with situs inversus. The electrocardiogram showed a junctional rhythm with a rate of 34 beats per minute and QRS morphology typical of dextrocardia. The patient was treated with sublingual administration of isoproterenol with good results. The current admission in March 1974 was prompted by several episodes of dizziness and one episode of syncope.
Physical Examination on Admission Physical examination on admission revealed blood pressure of 110/70 mm Hg in both arms. Carotid pulses were equal and of good quality. The point of maximal impulse was ·From the Department of Medicine, Division of Cardiology, and Department of Thoracic Surgery, Mount Sinai Hospital Services, City Hospital Cente!l Elmhurst, NY, and Mount Sinai School of Medicine of the City University of New York, New York. ••Clinical Assistant. Associate Professor of Medicine. Assistant Professor of Clinical Medicine. §Assistant Professor of Medicine. IIAssistant Professor of Surgery. Reprint requests: Dr. Lichstein, City Hospital Center at Elmhurst, 79-01 Broadway, Elmhurst, New York 11373
l
CHEST, 69: 4, APRIL, 1976
FICURE 1. Standard 12-lead ECG and lead 2 rhythm strip showing wandering atrial rhythm with junctional escape beats and QRS morphology typical of dextrocardia. in the right fifth intercostal space in the midclavicular line, and there was a grade 2/6 systolic ejection murmur heard along the right sternal border between the second and fourth intercostal space. The ECG showed a slow wandering atrial rhythm with junctional escape beats and QRS changes typical of dextrocardia (Fig 1) . During a period of monitoring, the patient developed an episode of multifocal atrial tachycardia followed by spontaneous cessation of the tachycardia and then a 3l'-second period of asystole. The period of asystole was terminated by a slow, irregular junctional escape rhythm (Fig 2) . The patient was aware of palpitations during the tachycardia and noted dizziness during the episode of asystole but did not lose consciousness. Because of the evidence of the sick sinus syndrome with significant symptoms, a temporary transvenous pacemaker was inserted . Angiographic studies indicated double superior venae cavae with the left-sided vein entering the right atrium and the right-sided vein connecting with the coronary sinus (Fig 3). The inferior vena cava was
absent, and a continuation of the azygos vein was noted . A permanent endocardial bipolar demand pacemaker (Medtronic 5942) was inserted during the second week of hospitalization. The incision was made 3 em below the left clavicle and the cephalic vein was exposed in the deltopectoral grove. The electrode catheter was guided to the right ventricular cavity through the left superior vena cava. The patient was immediately placed in the lateral position, and the catheter was guided to the apex of the right ventricle using the lateral projection of the angiogram as a reference . The patient had an uneventful recovery and was discharged without symptoms one week later. DISCUSSION
This patient had evidence of the sick: sinus syndrome manifested by absence of a normal sinus-nodal stimulus, a slow atrial pacemaker, and episodes of atrial tachycardia followed by a 3*-second period of asystole. The
FIGURE 2. Continuous rhythm strip recorded with VI monitor lead showing episode of multifocal atrial tachycardia with 3lkecond period of asystole following spontaneous cessation of tachycardia. There is slow irregular junctional escape rhythm following period of asystole.
CHEST, 69: 4, APRIL, 1976
SICK SINUS SYNDROME REQUIRING PACEMAKER 559
FIGURE 3. Venous angiogram in the posteroanterior (left) and lateral (right) projections following injection of radiopaque contrast medium into superior venous system. Double superior venae cavae are noted . Temporary pacing catheter is seen, and its course identifies hemiazygos continuation which empties into right superior vena cava and then into huge coronary sinus. RV, right ventricle; and RA, right atrium.
patient also had mirror-image dextrocardia, double superior venae cavae, an absent inferior vena cava with an azygos continuation, and situs inversus. Sinus-nodal dysfunction may be due to an ischemic, sclerotic, rheumatic, or inflammatory condition. It also occurs with pericarditis or cardiomyopathy, acute or chronic coronary occlusion, Friedreich's ataxia, progressive muscular dystrophy, collagen disease, surgical injury to tissue, metastatic disease, infiltration of atria in amyloidosis and hemochromatosis, and local fibrosis of the sinus node." Diphtheria has been incriminated in some cases but the link has not been proven ." Familial sinus-nodal disease has been reported." In our patient, none of these causes appeared to be responsible for sinusnodal dysfunction. The characteristic electrocardiographic findings in mirror-image dextrocardia include negative P waves with inverted QRS complex and T wave in lead 1 and the interchanging of lead aVL for aVR, of lead 2 for lead 3, and of right precordial leads for the corresponding left precordial leads . The absence of a negative P wave in lead 1 as in our case, is unusual with mirror-image dextrocardia and should lead to suspicion of associated abnormalities. In their study of cardiac rhythms in dextrocardia, Momma and Linde" found that an upright Pwave in lead 1 was frequently associated with either bilateral superior venae cavae or absent inferior vena cava . With bilateral superior venae cavae the P-wave vector was thought to arise from a left atrial rhythm, while with absent inferior vena cava, there was thought to be a coronary sinus rhythm. Mirowski et al" described eight patients with mirror-image dextrocardia with intermittent or permanent abnormality in the direction of the P wave in lead 1. These patients had complex congenital cardiac lesions which included bilateral superior
560 GOYAL ET AL
venae cavae in three and an absent inferior vena cava in two. Mirowski et al' noted that these patients had a tendency to develop spontaneous or induced arrhythmias which were, in most instances, episodes of supraventricular or atrial tachycardia, and in one instance, syncope was noted. Mirror-image dextrocardia with situs inversus is compatible with a normal life span. The development of all forms of cardiovascular disease, including arteriosclerotic heart disease, would be anticipated" and may occur with similar frequency and manifestations as in the general population." Although arteriosclerotic heart disease is a common cause of the sick sinus syndrome, we could find no evidence of this entity in our patient. Treatment Symptomatic sinoatrial rhythmic disturbances have been effectively treated with permanent pacemakers.10 , l1 We are not aware of any previous experiences with the insertion of a permanent pacemaker in patients with mirror-image dextrocardia. We found the information gained from the venous angiograms to be essential and feel that angiographic studies should be done in all similar cases. Since there is a high prevalence of venous abnormalities when mirror-image dextrocardia is seen without a negative P wave in lead 1, the angiogram is helpful in determining the route of the endocardial catheter. . ACKNOWLEDGMENT: We thank Ulrich Vieux, M.D., Department of Radiology, City Hospital Center, Elmhurst, NY, for performing the venous angiogram and Mrs. Edith Erick and Mrs. Frances Schlesinger for their secretarial assistance. REFERENCES
1 Ferrer MI: The sick sinus syndrome in atrial disease. JAMA 206:645, 1968 2 Schulman CL, Rubenstein H, Yurchak PM, et al: The
CHEST, 69: 4, APRIL, 1976
3 4 5 6 7
8 9 10
11
"sick sinus" syndrome: Clinical spectrum. CirCuIation 17(suppI3) :42,1970 Ferrer MI: The sick sinus syndrome. Circulation 47:635, 1973 Rasmussen K: Chronic sinoatrial heart block. Am Heart J 81 :38, 1971 . Spellberg RD : Familial sinus node disease. Chest 60:246251, 1971 Momma K, Linde LM : Cardiac rhythms in dextrocardia. Am J Cardiol25:420, 1970 Mirowslci M, Neil CA, Taussig HG: Left atrial ectopic rhythm in mirror image dextrocardia and in normally placed malformed hearts : Report of 12 case~· with "dome and dart" P waves. Circulation 27:864, 1963 Maleki M, Tristani PE: Coronary arteriography in situs inversus dextrocardia. Chest 65:220-222, 1974 Hynes KM, Gau GT, Titus JL : Coronary heart disease in situs inversus totalis. Am J Cardiol3i :666, 1973 Conde CA, Leppo J, Lipski J, et al : Effectiveness of pacemaker treatment in the bradycardia-tachycardia syndrome. Am J CardioI32:209, 1973 Chokshi DS, Mascarenhas E, Samet P, et al: Treatment of sinoatrial rhythm disturbances with permanent card iac pacing. Am J Cardiol 32 :215, 1973 FIGURE 1. Cavitating lesion located in superior segment of right lower lobe.
Aspergilloma within a Malignant Pulmonary Cavity* I. O. Torpoco, M.D.;oO Mohammed Yousufluddin, M.D.;oO and lames W. Pate, M.D., F.C.C.P.t
The simultaneous appearance of both bronchogenic carcinoma and aspergiUoma with the typical radiographic appearance of a mycetoma emphasizes the importance of consistent suspicion for malignancy in any pulmonary lesion. This is apparently the first reported case in which allergic phenomena (asthm.Uke symptoms and eosinophilia) are associated with an aspergWoma occurring within a cavitary bronchogenic carcinoma.
CASE REPORT
A 68-year-old black man was referred because of an abnormal chest x-ray Blm. Three months prior to admission, the patient had "flu-like" symptoms which he treated with home remed ies while the symptoms became worse. He complained of dyspnea on exertion and tightness and discomfort in the chest. The patient had felt "feverish," lost about 4.5 kg (10 lb ) of weight, and had one episode of a small hemoptysis . The patient had smoked one pack of cigarettes per day for over 30 years but had stopped smoking for no obvious reason about a year prior to this illness; he had a past history of hypertensive cardiovascular disease and peptic ulcer .
Mycetomas due to aspergillosis characteristically occur in pulmonary cavities which have resulted from infectious processes, frequently superimposed upon emphysematous or metabolic pulmonary diseases. There have been a few cases in which aspergillosis was believed to have been invasive, evolving from a pneumonic process to the classic fungal ball.r-e The purpose of this paper is to report the second case in the English literature of aspergilloma occurring in a malignant pulmonary cavity and the first such case to be associated with asthmatic "attacks." Since cavitating bronchogenic carcinomas are not rare, the possible association of aspergilloma with malignant cavities deserves emphasis. °From the Department of Surgery, College of Medicine, University of Tennessee, Memphis. ° °Resident inThoracic Surgery. tProfessor of Surgery.
CHEST, 69: 4, APRIL, 1976
FIGURE
cavity.
2. Bronchogram demonstrating patent bronchus into
ASPERGILLOMA WITHIN MALIGNANT PULMONARY CAVITY 561