Medical Image of the Week: Wolff-Parkinson-White Syndrome

Figure 1. Presenting EKG with supraventricular tachycardia at rate of 232.

Figure 2. Post-conversion EKG demonstrating a short PR interval, slurring of the initial QRS upslope (delta wave), widened QRS, and ST-T repolarization change; characteristic of Wolff-Parkinson-White Syndrome.

A 38-year-old man developed sustained rapid heart rate while rock climbing. The patient reported that he had experienced rare bouts of self-limited palpitations in the past. Blood pressure on arrival to the emergency department was 112/ 65 mm Hg. The patient’s initial EKG demonstrated a regular, narrow complex supraventricular tachycardia, with a rate of 232 (Figure 1). Intravenous adenosine was administered with no change in his rate or rhythm. The patient then received amiodarone by intravenous bolus, with subsequent conversion to sinus rhythm (Figure 2).

Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac condition present in approximately 0.15% of the general population. WPW is characterized by the abnormal presence of conduction tissue that creates an accessory atrioventricular pathway and thus potentiates reentrant tachycardia (1). The classic resting EKG findings in WPW are: a shortened PR interval (less than 0.12 seconds), an indistinct initial upslope of the QRS complex (known as the delta wave), a widened QRS complex (0.12 seconds or greater), and ST-T repolarization changes (2). In WPW presenting as a narrow complex tachycardia without hypotension, the initial treatment is adenosine or a calcium channel blocker, followed by amiodarone if unsuccessful. If the presenting rhythm is atrial fibrillation, atrial flutter, or an undefined wide complex tachycardia without hypotension, amiodarone is used. A hemodynamically unstable rhythm warrants immediate electrical cardioversion. Definitive evaluation and treatment of WPW requires electrophysiologic mapping and subsequent ablation of the accessory pathway.

Charles Van Hook MD, Cristina Demian MD, Douglas Tangel MD, Jennifer Blair MD, and Lisa Patel MD

Avista Adventist Hospital

Louisville, Colorado USA

References

1. Katritsis DG, Camm AJ. Atrioventricular nodal reentrant tachycardia. Circulation. 2010 Aug 24;122(8):831-40. [CrossRef] [PubMed]
2. Mark DG, Brady WJ, Pines JM. Preexcitation syndromes: diagnostic consideration in the ED. Am J Emerg Med. 2009 Sep;27(7):878-88. [CrossRef] [PubMed]
3. Khairy P, Van Hare GF, Balaji S, et al. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease. Heart Rhythm. 2014 Oct;11(10):e102-65. [CrossRef] [PubMed]

Cite as: Van Hook C, Demian C, Tangel D, Blair J, Patel L. Medical image of the week: Wolff-Parkinson-White syndrome. Southwest J Pulm Crit Care. 2017;14(4):164-5. doi: https://doi.org/10.13175/swjpcc046-17 PDF 

Medical Image of the Week: DISH with OPLL and C3 Fracture

Figure 1. CT imaging showing severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable cervical spinal fracture. A and C: Sagittal images showing “flowing” anterior osteophytes (red arrow) characteristic of DISH as well as OPLL (black arrow). A: An unstable C3 fracture with posterior subluxation resulting in >50% osseous narrowing of the spinal canal is present. B: Soft tissue window and D: bone algorithm and bone window showing severe narrowing of the spinal canal. B and D are at the level of the white line seen on A.

Figure 2. Occiput to C6 posterior fusion with C1-C6 laminectomies.

A 54-year old man presented after a fall while intoxicated, during which a small frontal sinus fracture was sustained. Upon initial presentation, he was minimally responsive and eventually developed cardiopulmonary arrest. After intubation and return of circulation, he was immediately transferred from Mexico to an Arizona tertiary medical center, where his head and cervical spine CT showed severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable C3 fracture with posterior subluxation and severe canal narrowing (Figure 1).

DISH, also known as Forestier disease, is a skeletal disorder, primarily affecting middle-aged and elderly patients, in which there is a buildup of calcified osseous tissue occurring in the ligaments of the spine. DISH is associated with ossifications occurring specifically in the posterior longitudinal ligaments of the spine, referred to as DISH with OPLL, which is twice as common in men compared to women (1).

DISH with OPLL is often asymptomatic in the early stages of the disease, and thus is often diagnosed either incidentally or after the disease has progressed significantly. Patients with this disease are predisposed to increased risk of spinal fractures, even with relatively minor trauma. Additionally, as DISH with OPLL can result in decreased range of motion, difficult intubation can result, possibly resulting in altered approaches to typical intubation procedures (1).

While the patient likely fractured his spine from the initial fall, it was not determined whether the intubation procedure could have contributed to the spinal fracture subluxation and/or spinal cord injury. Regardless, the patient underwent an occiput to C6 posterior fusion with C1-C6 laminectomies (Figure 2) and will receive long term neurologic rehabilitation.

Stephanie R. Fletcher, BSHS¹ and Michael Craig Larson, MD, PhD²

¹College of Pharmacy and ²Department of Radiology

University of Arizona

Tucson, AZ USA

Reference

1. Baxi V, Gaiwal S. Diffuse idiopathic skeletal hyperostosis of cervical spine - An unusual cause of difficult flexible fiber optic intubation. Saudi J Anaesth. 2010 Jan;4(1):17-9. [CrossRef] [PubMed]

Cite as: Fletcher SR, Larson MC. Medical image of the week: DISH with OPLL and C3 fracture. Southwest J Pulm Crit Care. 2017;14(4):157-8. doi: https://doi.org/10.13175/swjpcc041-17 PDF