CASE HISTORY

The patient was a typical case of acromegaly of four years duration. On the day of admission she suddenly passed into coma. On admission she was deeply comatose but with no definite nervous sign other than a bilateral extensor plantar response. Heart enlarged. B.P. 230/140. Vessels thickened. Eyes showed bilateral papilloedema with thick vessels and retinal haemorrhage. Patient died with 24 hours of admission.

PATHOLOGY

Female, born 1923. 1947 Diagnosed atrial fibrillation (AF) and cardiomegaly. 1954 Successful pregnancy followed by "white leg". Paroxysmal dyspnoea during pregnancy. 1957 cerebral ebolism: left hemiplegia. Dyspnoea on exertion steadily increased until 1957, then restricted mainly by hemiplegia. Haemoptysis. Bronchitis. Some dysuria. March 1959 Saddle embolism of aorta: complete occlusion of right popliteal and distal arteries shown on arteriogram. June 1959 Transferred to Hammersmith hospital. On examination: Thin woman. Controlled AF. Small pulse. RV ++, LV +, JVP O. Full length diastolic thrill and murmur at apex. Early opening snap. Loud M1. P2++. Grade 1 apical SM. Lungs clear. Liver not enlarged. No oedema. BP 125/85 Femoral pulses absent. Right below knee amputation. No pulses in left leg. Left leg cool and pale - impaired reactive hyperaemia. CNS: weakness left arm. Plantar responses flexor. Reflexes normal. Cranial nerves normal. Investigations: Hb. 96%, WBC 11,000, electrolytes normal. Urea 35 mg% Chest X-ray: RA and LA ++. RV + marked pulmonary hypertension. Aortogram: complete iliac artery bifurcation block. Right femoral artery not outlined. ECG: RV++ grade 2. Digitalis. AF. Diagnosis: tight mitral stenosis; multiple emboli. Treated with digitalis and phenindione (after aortogram) to prevent further embolism from left atrium. Decuded on mitral valvotomy under anticoagulant cover and later reconstructive surgery for iliac block. Prothrombin time on 29.6.59 was 20 sec. (25-30%) and on 30.6.59 15 sec (35-40% 2.7.59: sudden spigastric pain and continuous vomiting BOR. No abdominal tenderness. Bowel sounds initially present then disappeared. Distension of abdomen. Diagnosis: mesenteric embolism. Laparotomy: right retro-peritoneal haematoma. Presumed leak from aortic puncture. Anti-coagulants stopped. 3.7.59: prothrombin time 17 sec (30-37% (7th day after aortogram). 22.7.59: Mitral valvotomy. Mitral valve tightly stenosed(1cm); calcified ++. No incompetence. Split to 3 cm. Atrium full of soft and mobile thrombus. 23.7.59 left femoral pulse felt. Unable to pass urine. Catheter - 450ml. clear urine. 24.7.59 JVP +6cm. Short MDM only. Catheter - 450ml blood stained urine. 25.7.59 Tender both loins, renal infarction, renal infection.

26.7.59 incontinent. Urine less blood stained. Burning pain on micturition. CSU Strp.faecalis and pus cells. Blood urea 195mg/ml. Chloramphenical and nitrofurantoin 5 days. Intake 2 litres/day. No diurectics. 31.7.59 Blood urea 175mg. Na 130, K 5.5, Cl 85, CO2 26. Hb 83%. 1.8.59 soft systolic murmur at apex. JVP +2cm BP 160/90. Urinary output 1-1.5 1./day. 10.8.59 Steady deterioration. Anticoagulants restarted. 11.8.59 Small vein lower abdomen wall draining.