PMC8566889_01
Large ulcer (arrows) observed at the tongue base of Cat-1 at day 0.
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F1
A large ulcer was also found at the tongue base (Figure 1).
Two-dimensional (2D) right parasternal short-axis view (A), M-mode echocardiogram (B), and color-flow Doppler mode (C) from Cat-1 at presentation (day 0). (A) This 2D right parasternal short-axis view taken at end-diastole at the level of the aortic valve shows marked dilation of the left atrium (LA) and the left auricle (Aur) with an increased LA:aorta ratio (LA:Ao = 2.09), spontaneous echo contrast (white arrow heads), associated with pleural effusion (Ple), and a pulmonary consolidation near the left auricle (blue arrows). (B) This M-mode image obtained from the 2D right parasternal short-axis view taken at the level of the aortic valve confirms a markedly decreased LA fractional shortening (LAFS% = 8.4%). (C) This 2D left apical 5-chamber view taken at end-systole shows left ventricular hypertrophy (yellow arrow heads) and a pulmonary consolidation near the left ventricle (blue arrows) surrounded by Ple. RA, right atrium.
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F2
The focused point-of-care ultrasound examination revealed numerous B-lines suggestive of pulmonary alveolar disease (e.g., pulmonary edema), mild pleural effusion, and severe left atrial dilation as confirmed by high values of end-diastolic left atrium-to-aorta ratio [LA:Ao = 2.09; reference range <= 1.2; Figure 2A], maximum LA diameter on right parasternal 4-chamber view [Max LAD = 22.0 mm; reference range <16.0 mm ], and end-systolic LA volume (LAVs) assessed by the modified Simpson method of discs from the right parasternal 4-chamber view [6.10 mL; reference range <1.96 mL/cat ]. The LA fractional shortening (LAFS%) was dramatically decreased [8.4%; reference range >17.5%; Figure 2B] confirming marked alteration of LA function associated with blood stasis as shown by decreased LA appendage velocities [maximal velocity = 0.2 m/s; reference range 0.24-1.00 ], and spontaneous echo-contrast within the LA and the left auricle. LA and the left ventricle (LV; Figure 2C). Lastly, important amount of fat was found within both pericardial and pleural spaces.
Thoracic radiographs from Cat-1 at presentation (A,B) and after 1 month (C,D). An ill-defined unstructured interstitial lung pattern (blue arrows) and thin interlobar fissures (white arrows) consistent with mild pleural effusion are present at presentation. Mild cardiomegaly and subjectively enlarged pulmonary vessels are also noted (blue stars). After 1 month, the pulmonary pattern and interlobar fissures have resolved, and the cardiac silhouette and pulmonary vessels have decreased in size. On (A,C), a large amount of fat is visible around the apex of the cardiac silhouette (white stars).
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F3
A large quantity of sternal and/or pericardial fat was also present, in agreement with the ultrasound examination (Figures 3A,B).
Two-dimensional (2D) right parasternal short-axis view (A) and M-mode echocardiograms (B,C) from Cat-1 1 month after initial presentation. (A) As compared with day 0 (see Figure 2A), this 2D right parasternal short-axis view taken at end-diastole at the level of the aortic valve shows a markedly decreased left atrial size (left atrium:aorta ratio (LA:Ao) = 1.26 vs. 2.09) associated with disappearance of spontaneous echo contrast, pleural effusion, and pulmonary consolidation. (B) This M-mode image obtained from the 2D right parasternal short-axis view taken at the level of the aortic valve confirms normalization of the LA fractional shortening (LAFS% = 40.7 vs. 8.4%). (C) This M-mode echocardiogram obtained from the right parasternal transventricular short-axis view confirms marked asymmetric left ventricular hypertrophy, more pronounced for the left ventricular free wall (LVFW) than the interventricular septum (IVS), i.e., end-diastolic thicknesses of 9.7 and 7.6 mm, respectively [normal values <6 mm ]. Note also posteriorly the important amount of pericardial fat (maximal thickness of 6 mm). LV, left ventricle.
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F4
A dramatic decrease in LA size (LA:Ao = 1.26; max LAD = 12.2 mm; LAVs = 1.50 mL), associated with both normalization of LA function (LAFS% = 40.7%) and Doppler LA appendage maximal velocities (0.73 m/s), was found (Figures 4A,B). An HCM phenotype was confirmed (Figure 4C), associated with impaired LV relaxation, as shown by an inverted maximal early:late diastolic mitral flow velocities ratio [E:A ratio = 0.67; reference range >1 ] and decreased mitral annular (E') velocity [4 cm/s; reference range >6 cm/s ], respectively assessed by pulsed-wave Doppler mode and pulsed-wave tissue Doppler imaging, with an E:E' ratio within upper ranges [11.6; reference range <12 ].