24957905 Visualization

A 56 Age - year Age - old Age African Personal_background American Personal_background man Sex who initially presented Clinical_event with diarrhea Sign_symptom , weight Sign_symptom loss Sign_symptom and painless Detailed_description jaundice Sign_symptom , was subsequently found to have adenocarcinoma Disease_disorder of the head Biological_structure of Biological_structure pancreas Biological_structure .
An initial Diagnostic_procedure workup Diagnostic_procedure revealed localized Detailed_description cancer Disease_disorder with no evidence of distant Detailed_description metastases Disease_disorder .
He then underwent pancreaticoduodenectomy Therapeutic_procedure with complete Detailed_description surgical Therapeutic_procedure resection Therapeutic_procedure of a 5cm Distance moderately Detailed_description differentiated Detailed_description pancreatic Biological_structure adenocarcinoma Disease_disorder .
Although our patient underwent complete Detailed_description surgical Therapeutic_procedure resection Therapeutic_procedure , a pathological Diagnostic_procedure examination Diagnostic_procedure revealed a neoplastic Sign_symptom invasion Sign_symptom of the resected adjacent Biological_structure organs Biological_structure , and one Quantitative_concept out Quantitative_concept of Quantitative_concept the Quantitative_concept seven Quantitative_concept resected lymph Biological_structure nodes Biological_structure contained cancer Sign_symptom ( T3N1M0 Lab_value ).
At that point, the oncology Nonbiological_location department Nonbiological_location recommended Clinical_event to proceed with adjuvant Detailed_description chemotherapy Medication with gemcitabine Medication ( 1000mg/m2 Dosage IV Administration on days Frequency 1, Frequency 8, Frequency 15 Frequency on Frequency a Frequency 28 Frequency - day Frequency cycle Frequency for Frequency six Frequency cycles Frequency ) to try to reduce the likelihood of recurrence Sign_symptom .
However, after completing two Quantitative_concept cycles Quantitative_concept (a total of six Quantitative_concept doses Quantitative_concept ) of chemotherapy Medication , he presented Clinical_event to the emergency Nonbiological_location department Nonbiological_location with worsening exertional Detailed_description dyspnea Sign_symptom , three Detailed_description - pillow Detailed_description orthopnea Sign_symptom , paroxysmal Detailed_description nocturnal Detailed_description dyspnea Sign_symptom and fatigue Sign_symptom .
His physical Diagnostic_procedure examination Diagnostic_procedure revealed an elevated Lab_value jugular Diagnostic_procedure venous Diagnostic_procedure pressure Diagnostic_procedure ( JVP Diagnostic_procedure ) ( 10cm Lab_value above Lab_value the Lab_value sternal Lab_value angle Lab_value ), bibasilar Detailed_description rales Sign_symptom and +2 Lab_value pitting Detailed_description edema Sign_symptom of both Biological_structure lower Biological_structure extremities Biological_structure .
Cardiac Biological_structure auscultation Diagnostic_procedure revealed a gallop Sign_symptom rhythm Sign_symptom with an S3 Detailed_description and a grade Lab_value 3 Lab_value holosystolic Detailed_description murmur Sign_symptom over precordium Biological_structure .
A chest Biological_structure X Diagnostic_procedure - ray Diagnostic_procedure showed cardiomegaly Sign_symptom with mild Severity to moderate Severity - sized Severity right Detailed_description - sided Detailed_description pleural Disease_disorder effusion Disease_disorder .
It was thought that his presentation was consistent with fluid Sign_symptom overload Sign_symptom secondary to congestive Disease_disorder heart Disease_disorder failure Disease_disorder ( CHF Disease_disorder ) and he was started on intravenous Administration ( IV Administration ) furosemide Medication with partial improvement in his symptoms Sign_symptom .
The next Date day Date , a two Diagnostic_procedure - dimensional Diagnostic_procedure echocardiography Diagnostic_procedure ( 2D Diagnostic_procedure Echo Diagnostic_procedure ) was performed, which showed left Diagnostic_procedure ventricular Diagnostic_procedure ejection Diagnostic_procedure fraction Diagnostic_procedure ( LVEF Diagnostic_procedure ) of 15 Lab_value to Lab_value 20 Lab_value percent Lab_value with global Detailed_description hypokinesia Sign_symptom along with moderate Severity mitral Sign_symptom regurgitation Sign_symptom .
Given the findings of 2D Diagnostic_procedure Echo Diagnostic_procedure and the absence of significant risk Sign_symptom factors Sign_symptom for Sign_symptom coronary Disease_disorder artery Disease_disorder disease Disease_disorder ( CAD Disease_disorder ) and ischemic Detailed_description cardiomyopathy Disease_disorder ( CMP Disease_disorder ), it was concluded that our patient’s CMP Disease_disorder was related to the recent use of gemcitabine Medication .
Our patient was then started on carvedilol Medication and an angiotensin Medication - converting Medication enzyme Medication inhibitor Medication in addition to diuretics Medication and he was discharged Clinical_event from the hospital Nonbiological_location two Date days Date later Date in a euvolemic Sign_symptom state.
At that point, the cardiology Nonbiological_location department Nonbiological_location recommended Clinical_event stopping further chemotherapy Medication with gemcitabine Medication .
The oncology Nonbiological_location department Nonbiological_location advised Clinical_event further testing Diagnostic_procedure to rule out ischemia Sign_symptom as a cause of CMP Disease_disorder as, in their opinion, chemotherapy Medication with gemcitabine Medication was the only option to reduce the risk of recurrence Sign_symptom in this patient.
Two Date weeks Date later Date , our patient underwent myocardial Diagnostic_procedure perfusion Diagnostic_procedure imaging Diagnostic_procedure ( MPI Diagnostic_procedure ), which showed a fixed Detailed_description small- to Severity moderate Severity - sized Severity inferior Biological_structure wall Biological_structure defect Sign_symptom without any evidence of active ischemia Sign_symptom .
The ejection Diagnostic_procedure fraction Diagnostic_procedure ( EF Diagnostic_procedure ) on MPI Diagnostic_procedure was calculated to be around 17 Lab_value to Lab_value 20 Lab_value percent Lab_value with severe Severity global Detailed_description hypokinesia Sign_symptom .
Our patient was continued on standard heart Therapeutic_procedure failure Therapeutic_procedure therapy Therapeutic_procedure with one more admission Clinical_event to the hospital Nonbiological_location for CHF Disease_disorder exacerbation Detailed_description about two Date months Date later Date .
He responded well to IV Administration furosemide Medication and adjustment Detailed_description of heart Therapeutic_procedure failure Therapeutic_procedure therapy Therapeutic_procedure .
A 2D Diagnostic_procedure Echo Diagnostic_procedure was repeated a Date few Date months Date later Date and it showed improvement Lab_value in systolic Diagnostic_procedure function Diagnostic_procedure with an LVEF Diagnostic_procedure of 40 Lab_value percent Lab_value .
Due to his poor Lab_value functional Diagnostic_procedure status Diagnostic_procedure and underlying CMP Disease_disorder , further gemcitabine Medication chemotherapy Medication was stopped.
Later, our patient developed a recurrence Sign_symptom of his pancreatic Disease_disorder cancer Disease_disorder ; he refused further chemotherapy Medication and decided to proceed with palliative Therapeutic_procedure care Therapeutic_procedure .
Although the exact etiology of our patient’s dilated Detailed_description cardiomyopathy Disease_disorder remains unclear, gemcitabine Medication remains the most likely culprit.
The temporal relationship of his symptoms to the initiation of gemcitabine Medication chemotherapy Medication ; the lack of risk Sign_symptom factors Sign_symptom for Sign_symptom ischemic Sign_symptom CMP Sign_symptom and prior history History of History CAD Disease_disorder , finding of global Detailed_description hypokinesia Sign_symptom on 2D Diagnostic_procedure Echo Diagnostic_procedure , absence of ischemia Sign_symptom on MPI Diagnostic_procedure ; and improvement Lab_value in his systolic Diagnostic_procedure function Diagnostic_procedure after discontinuation of gemcitabine Medication were all consistent with gemcitabine Medication -induced cardiomyopathy Disease_disorder .