(D) A liver biopsy revealed chronic non-suppurative destructive cholangitis was noted, indicated primary biliary cirrhosis (H&E stain). (C) The biopsy of the quadriceps femoris muscle revealed muscle cell degeneration with mild mononuclear cell infiltrates indicated inflammatory myopathy (H&E stain). (A, B) The TTE revealed diffuse mildly decreased left ventricular wall motion approximately at LVEF 52%, and no other significant abnormal findings, with wall thickness and left cavity size within the normal range. The ECG revealed no marked changes from the patient's state at the original hospital ( figure 1A).Īlthough left ventricular wall motion diffusely and mildly decreased at left ventricular ejection fraction (LVEF) 52%, transthoracic echocardiography (TTE) indicated no other significantly abnormal findings including wall thickness and valvular function ( figure 2A, B). Moreover, there were no findings indicating congestion or pleural effusion. Chest X-rays revealed no cardiac dilation, with a cardiothoracic ratio of 48%. Creatine kinase (CK) was elevated to 2188 IU/L, with muscle-type CK elevation at 90%. Blood testing revealed mildly elevated aspartate aminotransferase/alanine aminotransferase and brain natriuretic peptide at 67/58 IU/L and 118.6 pg/mL, respectively.
A manual muscle testing (MMT) 4 showed muscle weakness symmetrically on the left and right sides of the neck region, trunk and proximal muscles of the four limbs. The patient did not suffer from any muscular pain. Physical findings on hospitalisation included blood pressure of 136/92 mm Hg and heart rate of 124 bpm, which was regular with no abnormal heart or respiratory sounds. Therefore, the patient was hospitalised in December 2015 to undergo detailed testing and treatment. AFL, atrial flutter IVCD, intraventricular conduction disturbance. (B, C) Holter ECG revealed that the basic rhythm was AFL rhythm with 2:1 conduction, and the 1:1 conduction was observed mainly during exertion for a few minutes.
(B) The ECG after cardioversion revealed normal sinus rhythm, a heart rate of 60 bpm, left axis deviation and IVCD (QRS width 135 ms). (A) The ECG on admission revealed a heart rate of ∼120 bpm, a common AFL with 2:1 conduction ratio, left axis deviation and IVCD (QRS width 132 ms).