February 2007 | Back to Table of Contents
2006 American College of Physicians Poster Competition Winners
Each year, the state chapters of the American College of Physicians (ACP) invite medical students, residents, and fellows to participate in a scientific poster competition. Last year in Minnesota, there were more than 148 submissions in the categories of clinical vignette and research from students, residents, and fellows from the University of Minnesota, Mayo Clinic, Abbott Northwestern Hospital, and Hennepin County Medical Center.
The abstracts were reviewed and presented in poster form at the Minnesota Chapter ACP Scientific Meeting held at the Minneapolis Convention Center on November 3 and 4, 2006. Charles Reznikoff, M.D., Kevin Larsen, M.D., and Sandra Main, administrative coordinator for the Minnesota ACP chapter, coordinated the competition. Judges included teaching faculty and community physicians. Judging was done in small groups, and posters were assessed for originality, significance, and presentation.
Winners received prizes, and the winners of the research and clinical vignette categories (see abstracts) are guaranteed entry in the national competition, which will be held in San Diego in April 2007.
Congratulations to the winners and everyone who participated in the poster competition.
Clinical Vignette Winner
Plaquenil Therapy as a Rare Cause of Restrictive Cardiomyopathy
By Vinayak A. Manohar, M.D., Kyle W. Klarich, M.D., and Kevin G. Moder, M.D., Mayo Clinic, Rochester, Minnesota
Cardiomyopathy is a rare-but-serious complication of Plaquenil therapy. It is characterized by restrictive hemodynamics on ECHO. Definitive diagnosis is made from a right ventricular endomyocardial biopsy with examination under electron microscopy revealing unique curvilinear bodies in the sarcoplasmic reticulum. These are thought to represent abnormal lysosomes replete with phospholipids and glucose.
We present the case of a 64-year-old female with a past medical history significant for systematic lupus erythematosus. Her chief complaint was 1 year of worsening dyspnea on exertion. She denied orthopnea, paroxysmal nocturnal dyspnea, chest pain, syncope, or palpitations. Her lupus was treated with prednisone and Plaquenil for the past 10 years. She had no prior cardiac history. Physical exam revealed a middle-aged woman in no distress. Vital signs were normal. Cardiac exam revealed S3 at the apex. JVP was normal. There was no lower extremity edema. Pulmonary exam was normal. Labs were unremarkable. Transthoracic ECHO revealed an ejection fraction of 46%. Systolic function was normal with generalized left ventricular hypokinesia. Left ventricular chamber size was normal, but there was concentric wall thickening of both the left and right ventricles. Grade 3/4 left ventricular diastolic dysfunction was present with severely elevated left ventricular filling pressure. Biatrial enlargement was present. The myocardium had a hyperrefractile appearance similar to amyloidosis. Fat aspiration with Congo red evaluation was negative for amyloidosis; serum protein electrophoresis did not show a monoclonal protein. Cardiac biopsy revealed sarcoplasmic clearing and vacuolization on light microscopy and myelinoid and curvilinear bodies on electron microscopy. Based on these findings, Plaquenil was discontinued. A 9-month follow-up ECHO revealed an ejection fraction of 74% with normal left ventricular systolic function and grade 2/4 diastolic dysfunction. The ventricular walls were still concentrically thickened but thinner than on the previous ECHO. The final diagnosis was restrictive cardiomyopathy secondary to chronic Plaquenil therapy.
Plaquenil cardiomyopathy is characterized by biatrial enlargement, potentially diminished systolic dysfunction, marked diastolic dysfunction, and biventricular thickening. Plaquenil induces a restrictive cardiomyopathy through the generation of generic myelinoid and unique curvilinear bodies in the sarcoplasmic reticulum leading to myocyte disarray microscopically and cardiac dysfunction macroscopically. We report a case of chronic Plaquenil therapy as an unusual cause of restrictive cardiomyopathy.