- Email: [email protected]
ECHO viruses, carditis, and acute pleurodynia
P-ohm Number
82
Annotations
1
though it is not practical for active ambulation. Of the modalities evaluated, the knee high “graduated pressure” stocking* appears to be the choice to combat stasis in the hospital patient.”
Divisions
2. Ochsner, A., and DeBakey, M. E.: Therapeutic consideration of thrombophlebitis and phlebothrombosis, New Eng. J. Med. 225:207, 1941. 3. Wilkins, R. W., and Stanton, J. R.: Elastic stockings in the prevention of pulmonary embolism: II. A progress report, New Eng. J. Med. 248: 1087, 1953. 4. Husni, E. A., F,menes, J., and Hamilton, F.: Pressure bandaging of the lower extremity, Use & Abuse, J.A.M.A. 206:2715, 1968. 5. Husni, E. A., Ximenes, J., and Goyette, E.: Elastic compression of the lower limbs: A critical study, J.A.M.A. (In press.) 6. Paulsen, P. F., Creech, O., Jr., and DeBakey, M. E.: Observations on the venous circulation time in the lower extremities: Effect of elevation and compression bandages, Surg. Forum 5:137, 1954.
E. A. Husni, M.D. E. M. Goyette, M.D. Surgery and Cardiology Huron Road Hospital Cleveland, Ohio 44112
of Vascular
REFERENCES 1. Roberts, G. H.: Venous patients: A postmortem 8:11, 1963. *Jobst Institute,
thrombosis in hospital study, Scot. Med. J.
Toledo, Ohio.
ECHO viruses,
carditis,
and acute
The significant role played by enteroviruses, especially those of the Coxsackie group, in acute cardiac disease and pleurodynia at all ages is now well established and has been the subject of recent publications.‘-3 In contrast, there is limited evidence relating the ECHO virus group to these diseases, despite the fact that these viruses do not require sophisticated laboratory techniques for their isolation. Reports that certain types of ECHO virus can, like Coxsackie viruses, cause myositis in newborn mice raised the question whether these and perhaps
Table I. ECHO
virus infections
133
pleurodynia
other types might share Coxsackie-type pathogenicity for man, including causation of acute pleurodynia or acute myopericarditis. This hypothesis was tested by an analysis of the clinical diagnoses of 833 patients from whom ECHO viruses were isolated in Glasgow, Scotland.4 ECHO viruses of types 6, 11, 12, 19, and 25 were associated with pleurodynia and/or cardiac disease, and statistical analysis showed a significant excess of pleurodynia, though not of cardiac disease, in the ECHO 6 group and a strongly suggestive association of these
in cardiac disease
Virology Patient No.
Reference Type
Source
of isolate
Serology
contents
-
1
7
6
Intestinal
2 3
8 9
8 9
Feces Heart
4
10
9
Feces,
5
11
22
6
12
22
RT 8
throat
RT
periMyocardium, cardial fluid, etc. Feces
-
RT = Significantly rising antibody or not recorded.
titer to homologous
RT
&e Olr.)
Sex
Illness
?
Cardiorespiratory failure; postmortem myocarditis Acute benign pericarditis Myocarditis; acute fever, block, fibrillation; died after 7 days; postmortem myocarditis Myocarditis; paroxysmal atria1 tachycardia Acute fulminating myocarditis; congenital agammaglobulinemia Myocarditis
1 34
M 1
M M
M M
virus; Figure = titer of antibody
neutralizing
homologous
virus; - = not done
134
Amou.
Annotations
diagnoses with ECHO virus type 19. These same associations of ECHO 6 infection with “muscle disease” and of ECHO 19 with “cardiac disease” emerged from an analysis of 13,400 ECHO virus infections recorded by the World Health Organization Virus Diseases Unit.4 It is interesting that type 6 ECHO virus was recently reported as being capable of causing Coxsackie B type disease in newborn mice.6 We are not aware of similar reports for type 19 ECHO virus. Surprisingly, ECHO virus 9, which has well-marked Coxsackie A type pathogenicity for newborn mice,6 did not show significant association with pleurodynia or cardiac disease in the analyses of the Scottish or international data, though it is among the types best established as etiologically important in individual cases of cardiac disease.g*10~26 Table I lists the 6 cases with the best recorded evidence of an etiological association between the virus isolated and the illness. Virus was isolated from the hearts of two patients (Patients 3 and 5) and from the intestinal contents of another (Patient 1). Rising homologous antibody titers linking the infection with the disease in time were observed in 3 other patients (Patients 2, 4, and 6). With the exception of Patient 2, all had acute myocarditis and in 3 the illness proved fatal. Five of the 6 patients were infants and, where the sex was stated, all were male. Of 513 ECHO 6 infections investigated in 1967 in The Netherlands, 4 (0.8 per cent) were classified as myocarditis or pericarditis.ra Pericarditis associated with ECHO virus 6 infection has also been described by others.r4*‘6 In one patient with pericarditis, serological evidence suggested infection with ECHO 9 virus.16 Additional evidence of the potential pathogenicity of ECHO 9 virus is provided by its recent &olatidn from the heart of a 16-year-old girl with acute mvocarditisz6 ECHO virus 19 was isolated from another patient, but serological studies showed that this was chance carriage of this agent.‘6 Two other patients, one with myocarditis and the other with severe endocarditis. vielded ECHO 11 and ECHO 19 viruses, respectively; each patient showed significant rising homologous antibody titers, but the viruses were isolated late in the illnesses and the titers suggested that the virus infections were acquired after onset of illness.3*17 Electrocardiographic (ECG) changes have also been reported by several workers in association with ECHO virus type 6,r* type 9,18-za and type 11.21 Whereas much of the proof of an etiological association in cardiac disease has of necessity depended on laboratory studies of sporadic cases, pleurodynia has frequently been reported in epidemic form and has. therefore, permitted evidence to be based on epidemiological -grounds. Thus, in an outbreak of acute pleurodynia in Aden in 1967, McCracken and Wilkiez2 isolated ECHO 1 virus from 5 of 14 patients virologically investigated. During an outbreak of aseotic meningitis associated with ECHO 6 infection, Karzon &d co-workers7 found that the frequency of pleurodynia was 38 per cent in adults and only 5 per cent in patients less than 20 years of age, an age distribution similar to that of pleurodynia due to Coxsackie B group viruses. Kapsenberg,i3 in her 1967 study of 513 infections with ECHO 6 virus,
Hcavt I. July, 1971
classified 28 (5.4 per cent) as myalgia or pleurodynia. Sporadic cases of pleurodynia studied by others have been found in association with ECHO virus type 6,3,23 type 8,24 type 9,26 and type 19.3 Interestingly, but not surprisingly, the ECHO virus types associated with pleurodynia are mainly those reported in acute cardiac disease. The ability of certain ECHO virus types to damage the cardiac or skeletal muscle of man may be linked with their ability to cause myositis in newborn mice. Others, not yet shown to infect mouselets, may be lower down the scale of human myopathogenicity and, therefore, most likely to damage the newborn or those with immunological deficiencies. Although less virulent in this respect than Coxsackie viruses, ECHO viruses are also widely prevalent and occasionally epidemic; they commonly cause viremia with opportunities to reach the heart and be filtered off by myocardial cells. It seems surprising that enteroviral damage to the heart is not more frequent! Norman
Eleanor J. Bell, B.Sc., Ph.D. B.Sc., M.B., F.R.C.P.(Edin.) F. R. C.Path. University of Glasgow Department of Infectious Diseases The Regional Virus Laboratory Ruchill Hospital Glasgow, N. W., Scotland
R. Grisf,
REFERENCES 1. 2. 3.
4. 5.
6.
7.
8.
9.
10.
Smith, W. G.: Coxsackie heart disease in adults, AMER. HEART J. 73:439, 1967. Grist, N. R., and Bell, E. J.: Coxsackie viruses and the heart, AMER. HEART J. 77:295, 1969. Bell. E. T.. and Grist. N. R.: Further studies of enterovirus infections in cardiac disease and pleurodynia, Stand. J. Infect. Dis. 2:1, 1970. Bell, E. J., and Grist, N. R.: Echoviruses, carditis and acute pleurodynia, Lancet 1:326, 1970. Vasilenko, S., and Atsev, S.: Experimental infections of mice with ECHO 6 virus, Acta Virol. (Praha) [Eng.] 9541, 1965. Sickles. G. M.. Mutterer. M.. and Placer, H.: New t;pes of Coxsackie virus; Group A-cytopathogenicity in tissue culture, Proc. Sot. Exp. Biol. Med. 102:742, 1959. Karzon, D. T., Hayner, N. S., Winkelstein, W., Jr., and Barron, A. L.: An epidemic of aseptic meningitis due to ECHO virus type 6. II. A clinical study of ECHO 6 infection, Pediatrics 29:418, 1962. Johnson, R. T., Portnoy, B., Rogers, N. G., and Buescher, E. L.: Acute benign pericarditis. Virologic study of 34 patients, Arch. Intern. Med. 108:823, 1961. Monif, G. R. G., Lee, C. W., and Hsiung, G. D.: Isolated mvocarditis with recoverv of ECHO type 9 virus from the myocardium, New Eng. J. Med. 277:1353, 1967. Cherry, J. D., Jahn, C. L., and Meyer, T. C.: Paroxysmal atria1 tachycardia associated with ECHO 9 virus infection, AMER. HEART J. 73:681, 1967.
Voltme Number
11.
12. 13.
14.
15.
16.
17.
18.
82 1
Annotations
Miller, H. M., Powers, D. F., Horowitz, R. E., and Portnoy, B.: Fatal myocarditis associated with ECHO virus type 22 infection in a child with apparent immunological deficiency, J. Pediat. 71:204, 1967. Russell, S. J. M., and Bell, E. J.: Echoviruses and carditis, Lancet 1~784, 1970. Kapsenberg, J. G.: Epidemie van infecties door ECHO virus type 6 in 1967, Versl. Meded. Volksgezondh. 20:156, 1968. Van Loon, G. R., and Masson, A. M.: Viral pericarditis: A report of five cases, Canad. Med. Ass. J. 99:163, 1968. Grist, N. R.: Viral cardiomyopathy, in Symposium, Disorders of the heart and circulation, Constable, Edinburgh, 1966, Royal College of Phvsicians of Edinburgh Publication. No. 31. Kavelman, D. A., D&an, I. B. R., and Lewis; J. A.: Acute benign pericarditis, Canad. Med. Ass. J. 85:1287, 1961. Berkovich, S., Rodriguez-Torres, R., and Lin, J-S.: Virologic studies in children with acute myocarditis, Amer. J. Dis. Child. 115:207, 1968. Kahlmeter, 0.: Clinical aspects of ECHO viruses, in Ciba Foundation study group No. 7, virus meningo-encephalitis, Boston, 1960, Little, Brown & Co., p. 24.
19.
135
von Oldershausen, H. F.: Klinische Beobachtungen iiber eine Neuartige Primare Aseptische Meningoenzephalitis (Epidemische Virusmeningoenzephalitis), Deutsch. Med. Wschr. 82:442,
i957. 20.
Lewes, D., and Rainford, D. J.: Echoviruses and carditis. Lancet 1:520. 1970. 21. Rodriguez-Torres, R.,‘Lin, J-S., and Berkovich, S.: A sensitive electrocardiographic sign in myocarditis associated with viral infection, Pediatrics 43:846, 1969. 22. McCracken, A. W., and Wilkie, K. McD.: Epidemic pleurodynia in Aden associated with infection by Echo&us type 1, Trans. Roy. Sot. Tron. Med. Hvz. 63:85. 1969. 23. McLean, D. K: Coxsackieviruses and Echoviruses, Amer. J. Med. Sci. 251:351, 1966. 24. Kantor, F. S., and Hsiung, G. D.: Pleurodynia associated with ECHO virus tvoe 8. New Enz. J. Med. 266:661, 1962. -* ’ 2.5. Solomon, P., Weinstein, L., Chang, Te-W., Artenstein, M. S., and Ambrose, C. T.: Epidemiologic, clinical and laboratory features of an eoidemic of tvoe <. 9 ECHO virus menineitis.J. P&at. 55:609, 1959. 26. Peach, B., and Cradock-Watson, J. E.: Personal communication.
The SlQ3 (McGinn-White) pattern in acute car pulmonale: A form of transient left posterior hemiblock?
In 1935 McGinn and Whiter described an electrocardiographic pattern occurring in acute car pulmonale consisting of an SrQa configuration (as well as certain ST-T changes). This pattern is usually transient but when present is highly suggestive of pulmonary embolism. I have never been entirely satisfied with the electrophysiologic attempts to explain this SlQ3 pattern. The usual explanation offered is that there is clockwise rotation of the heart around its long axis related to right ventricular dilatation. The septum is supposedly oriented in such a way that the initial left to right forces are projected as a Q wave on Lead III. The terminal forces are directed rightwardly and result in S waves in Lead I (and also in Lead V,). It has been emphasized subsequently that Q waves may occur in Lead avF as well as in Lead III but only infrequently in Lead II, as contrasted to their occurrence in all three inferior leads in acute
inferior myocardial infarction. This is supposedly related to a less superiorly directed initial force in acute car pulmonale.e Although not a common finding in acute car pulmonale, the McGinn-White pattern (SrQa) when present is highly significant and usually associated with a massive pulmonary embolism. Rosenbaum*-r has recently introduced the concept of left ventricular hemiblock. A block in the anterior division of the left bundle is referred to as left anterior hemiblock (LAH) and results in left axis deviation in the frontal plane. A block in the posterior division of the left bundle is referred to as left posterior hemiblock (LPH) and results in right axis deviation (RAD) in the frontal mane with an SrQs pattern and large R waves in the&inferior leads. This concept is now well founded both experimentally and clinically and has gained wide acceptance, although Watt and Pruitt* have advised caution in its electrocardiographic diagnosis. Castellanos
82
Annotations
1
though it is not practical for active ambulation. Of the modalities evaluated, the knee high “graduated pressure” stocking* appears to be the choice to combat stasis in the hospital patient.”
Divisions
2. Ochsner, A., and DeBakey, M. E.: Therapeutic consideration of thrombophlebitis and phlebothrombosis, New Eng. J. Med. 225:207, 1941. 3. Wilkins, R. W., and Stanton, J. R.: Elastic stockings in the prevention of pulmonary embolism: II. A progress report, New Eng. J. Med. 248: 1087, 1953. 4. Husni, E. A., F,menes, J., and Hamilton, F.: Pressure bandaging of the lower extremity, Use & Abuse, J.A.M.A. 206:2715, 1968. 5. Husni, E. A., Ximenes, J., and Goyette, E.: Elastic compression of the lower limbs: A critical study, J.A.M.A. (In press.) 6. Paulsen, P. F., Creech, O., Jr., and DeBakey, M. E.: Observations on the venous circulation time in the lower extremities: Effect of elevation and compression bandages, Surg. Forum 5:137, 1954.
E. A. Husni, M.D. E. M. Goyette, M.D. Surgery and Cardiology Huron Road Hospital Cleveland, Ohio 44112
of Vascular
REFERENCES 1. Roberts, G. H.: Venous patients: A postmortem 8:11, 1963. *Jobst Institute,
thrombosis in hospital study, Scot. Med. J.
Toledo, Ohio.
ECHO viruses,
carditis,
and acute
The significant role played by enteroviruses, especially those of the Coxsackie group, in acute cardiac disease and pleurodynia at all ages is now well established and has been the subject of recent publications.‘-3 In contrast, there is limited evidence relating the ECHO virus group to these diseases, despite the fact that these viruses do not require sophisticated laboratory techniques for their isolation. Reports that certain types of ECHO virus can, like Coxsackie viruses, cause myositis in newborn mice raised the question whether these and perhaps
Table I. ECHO
virus infections
133
pleurodynia
other types might share Coxsackie-type pathogenicity for man, including causation of acute pleurodynia or acute myopericarditis. This hypothesis was tested by an analysis of the clinical diagnoses of 833 patients from whom ECHO viruses were isolated in Glasgow, Scotland.4 ECHO viruses of types 6, 11, 12, 19, and 25 were associated with pleurodynia and/or cardiac disease, and statistical analysis showed a significant excess of pleurodynia, though not of cardiac disease, in the ECHO 6 group and a strongly suggestive association of these
in cardiac disease
Virology Patient No.
Reference Type
Source
of isolate
Serology
contents
-
1
7
6
Intestinal
2 3
8 9
8 9
Feces Heart
4
10
9
Feces,
5
11
22
6
12
22
RT 8
throat
RT
periMyocardium, cardial fluid, etc. Feces
-
RT = Significantly rising antibody or not recorded.
titer to homologous
RT
&e Olr.)
Sex
Illness
?
Cardiorespiratory failure; postmortem myocarditis Acute benign pericarditis Myocarditis; acute fever, block, fibrillation; died after 7 days; postmortem myocarditis Myocarditis; paroxysmal atria1 tachycardia Acute fulminating myocarditis; congenital agammaglobulinemia Myocarditis
1 34
M 1
M M
M M
virus; Figure = titer of antibody
neutralizing
homologous
virus; - = not done
134
Amou.
Annotations
diagnoses with ECHO virus type 19. These same associations of ECHO 6 infection with “muscle disease” and of ECHO 19 with “cardiac disease” emerged from an analysis of 13,400 ECHO virus infections recorded by the World Health Organization Virus Diseases Unit.4 It is interesting that type 6 ECHO virus was recently reported as being capable of causing Coxsackie B type disease in newborn mice.6 We are not aware of similar reports for type 19 ECHO virus. Surprisingly, ECHO virus 9, which has well-marked Coxsackie A type pathogenicity for newborn mice,6 did not show significant association with pleurodynia or cardiac disease in the analyses of the Scottish or international data, though it is among the types best established as etiologically important in individual cases of cardiac disease.g*10~26 Table I lists the 6 cases with the best recorded evidence of an etiological association between the virus isolated and the illness. Virus was isolated from the hearts of two patients (Patients 3 and 5) and from the intestinal contents of another (Patient 1). Rising homologous antibody titers linking the infection with the disease in time were observed in 3 other patients (Patients 2, 4, and 6). With the exception of Patient 2, all had acute myocarditis and in 3 the illness proved fatal. Five of the 6 patients were infants and, where the sex was stated, all were male. Of 513 ECHO 6 infections investigated in 1967 in The Netherlands, 4 (0.8 per cent) were classified as myocarditis or pericarditis.ra Pericarditis associated with ECHO virus 6 infection has also been described by others.r4*‘6 In one patient with pericarditis, serological evidence suggested infection with ECHO 9 virus.16 Additional evidence of the potential pathogenicity of ECHO 9 virus is provided by its recent &olatidn from the heart of a 16-year-old girl with acute mvocarditisz6 ECHO virus 19 was isolated from another patient, but serological studies showed that this was chance carriage of this agent.‘6 Two other patients, one with myocarditis and the other with severe endocarditis. vielded ECHO 11 and ECHO 19 viruses, respectively; each patient showed significant rising homologous antibody titers, but the viruses were isolated late in the illnesses and the titers suggested that the virus infections were acquired after onset of illness.3*17 Electrocardiographic (ECG) changes have also been reported by several workers in association with ECHO virus type 6,r* type 9,18-za and type 11.21 Whereas much of the proof of an etiological association in cardiac disease has of necessity depended on laboratory studies of sporadic cases, pleurodynia has frequently been reported in epidemic form and has. therefore, permitted evidence to be based on epidemiological -grounds. Thus, in an outbreak of acute pleurodynia in Aden in 1967, McCracken and Wilkiez2 isolated ECHO 1 virus from 5 of 14 patients virologically investigated. During an outbreak of aseotic meningitis associated with ECHO 6 infection, Karzon &d co-workers7 found that the frequency of pleurodynia was 38 per cent in adults and only 5 per cent in patients less than 20 years of age, an age distribution similar to that of pleurodynia due to Coxsackie B group viruses. Kapsenberg,i3 in her 1967 study of 513 infections with ECHO 6 virus,
Hcavt I. July, 1971
classified 28 (5.4 per cent) as myalgia or pleurodynia. Sporadic cases of pleurodynia studied by others have been found in association with ECHO virus type 6,3,23 type 8,24 type 9,26 and type 19.3 Interestingly, but not surprisingly, the ECHO virus types associated with pleurodynia are mainly those reported in acute cardiac disease. The ability of certain ECHO virus types to damage the cardiac or skeletal muscle of man may be linked with their ability to cause myositis in newborn mice. Others, not yet shown to infect mouselets, may be lower down the scale of human myopathogenicity and, therefore, most likely to damage the newborn or those with immunological deficiencies. Although less virulent in this respect than Coxsackie viruses, ECHO viruses are also widely prevalent and occasionally epidemic; they commonly cause viremia with opportunities to reach the heart and be filtered off by myocardial cells. It seems surprising that enteroviral damage to the heart is not more frequent! Norman
Eleanor J. Bell, B.Sc., Ph.D. B.Sc., M.B., F.R.C.P.(Edin.) F. R. C.Path. University of Glasgow Department of Infectious Diseases The Regional Virus Laboratory Ruchill Hospital Glasgow, N. W., Scotland
R. Grisf,
REFERENCES 1. 2. 3.
4. 5.
6.
7.
8.
9.
10.
Smith, W. G.: Coxsackie heart disease in adults, AMER. HEART J. 73:439, 1967. Grist, N. R., and Bell, E. J.: Coxsackie viruses and the heart, AMER. HEART J. 77:295, 1969. Bell. E. T.. and Grist. N. R.: Further studies of enterovirus infections in cardiac disease and pleurodynia, Stand. J. Infect. Dis. 2:1, 1970. Bell, E. J., and Grist, N. R.: Echoviruses, carditis and acute pleurodynia, Lancet 1:326, 1970. Vasilenko, S., and Atsev, S.: Experimental infections of mice with ECHO 6 virus, Acta Virol. (Praha) [Eng.] 9541, 1965. Sickles. G. M.. Mutterer. M.. and Placer, H.: New t;pes of Coxsackie virus; Group A-cytopathogenicity in tissue culture, Proc. Sot. Exp. Biol. Med. 102:742, 1959. Karzon, D. T., Hayner, N. S., Winkelstein, W., Jr., and Barron, A. L.: An epidemic of aseptic meningitis due to ECHO virus type 6. II. A clinical study of ECHO 6 infection, Pediatrics 29:418, 1962. Johnson, R. T., Portnoy, B., Rogers, N. G., and Buescher, E. L.: Acute benign pericarditis. Virologic study of 34 patients, Arch. Intern. Med. 108:823, 1961. Monif, G. R. G., Lee, C. W., and Hsiung, G. D.: Isolated mvocarditis with recoverv of ECHO type 9 virus from the myocardium, New Eng. J. Med. 277:1353, 1967. Cherry, J. D., Jahn, C. L., and Meyer, T. C.: Paroxysmal atria1 tachycardia associated with ECHO 9 virus infection, AMER. HEART J. 73:681, 1967.
Voltme Number
11.
12. 13.
14.
15.
16.
17.
18.
82 1
Annotations
Miller, H. M., Powers, D. F., Horowitz, R. E., and Portnoy, B.: Fatal myocarditis associated with ECHO virus type 22 infection in a child with apparent immunological deficiency, J. Pediat. 71:204, 1967. Russell, S. J. M., and Bell, E. J.: Echoviruses and carditis, Lancet 1~784, 1970. Kapsenberg, J. G.: Epidemie van infecties door ECHO virus type 6 in 1967, Versl. Meded. Volksgezondh. 20:156, 1968. Van Loon, G. R., and Masson, A. M.: Viral pericarditis: A report of five cases, Canad. Med. Ass. J. 99:163, 1968. Grist, N. R.: Viral cardiomyopathy, in Symposium, Disorders of the heart and circulation, Constable, Edinburgh, 1966, Royal College of Phvsicians of Edinburgh Publication. No. 31. Kavelman, D. A., D&an, I. B. R., and Lewis; J. A.: Acute benign pericarditis, Canad. Med. Ass. J. 85:1287, 1961. Berkovich, S., Rodriguez-Torres, R., and Lin, J-S.: Virologic studies in children with acute myocarditis, Amer. J. Dis. Child. 115:207, 1968. Kahlmeter, 0.: Clinical aspects of ECHO viruses, in Ciba Foundation study group No. 7, virus meningo-encephalitis, Boston, 1960, Little, Brown & Co., p. 24.
19.
135
von Oldershausen, H. F.: Klinische Beobachtungen iiber eine Neuartige Primare Aseptische Meningoenzephalitis (Epidemische Virusmeningoenzephalitis), Deutsch. Med. Wschr. 82:442,
i957. 20.
Lewes, D., and Rainford, D. J.: Echoviruses and carditis. Lancet 1:520. 1970. 21. Rodriguez-Torres, R.,‘Lin, J-S., and Berkovich, S.: A sensitive electrocardiographic sign in myocarditis associated with viral infection, Pediatrics 43:846, 1969. 22. McCracken, A. W., and Wilkie, K. McD.: Epidemic pleurodynia in Aden associated with infection by Echo&us type 1, Trans. Roy. Sot. Tron. Med. Hvz. 63:85. 1969. 23. McLean, D. K: Coxsackieviruses and Echoviruses, Amer. J. Med. Sci. 251:351, 1966. 24. Kantor, F. S., and Hsiung, G. D.: Pleurodynia associated with ECHO virus tvoe 8. New Enz. J. Med. 266:661, 1962. -* ’ 2.5. Solomon, P., Weinstein, L., Chang, Te-W., Artenstein, M. S., and Ambrose, C. T.: Epidemiologic, clinical and laboratory features of an eoidemic of tvoe <. 9 ECHO virus menineitis.J. P&at. 55:609, 1959. 26. Peach, B., and Cradock-Watson, J. E.: Personal communication.
The SlQ3 (McGinn-White) pattern in acute car pulmonale: A form of transient left posterior hemiblock?
In 1935 McGinn and Whiter described an electrocardiographic pattern occurring in acute car pulmonale consisting of an SrQa configuration (as well as certain ST-T changes). This pattern is usually transient but when present is highly suggestive of pulmonary embolism. I have never been entirely satisfied with the electrophysiologic attempts to explain this SlQ3 pattern. The usual explanation offered is that there is clockwise rotation of the heart around its long axis related to right ventricular dilatation. The septum is supposedly oriented in such a way that the initial left to right forces are projected as a Q wave on Lead III. The terminal forces are directed rightwardly and result in S waves in Lead I (and also in Lead V,). It has been emphasized subsequently that Q waves may occur in Lead avF as well as in Lead III but only infrequently in Lead II, as contrasted to their occurrence in all three inferior leads in acute
inferior myocardial infarction. This is supposedly related to a less superiorly directed initial force in acute car pulmonale.e Although not a common finding in acute car pulmonale, the McGinn-White pattern (SrQa) when present is highly significant and usually associated with a massive pulmonary embolism. Rosenbaum*-r has recently introduced the concept of left ventricular hemiblock. A block in the anterior division of the left bundle is referred to as left anterior hemiblock (LAH) and results in left axis deviation in the frontal plane. A block in the posterior division of the left bundle is referred to as left posterior hemiblock (LPH) and results in right axis deviation (RAD) in the frontal mane with an SrQs pattern and large R waves in the&inferior leads. This concept is now well founded both experimentally and clinically and has gained wide acceptance, although Watt and Pruitt* have advised caution in its electrocardiographic diagnosis. Castellanos