Postmenopausal Estrogen Levels May Predict Heart Disease

Postmenopausal Estrogen Levels May Predict Heart Disease

By Rob Goodier

NEW YORK (Reuters Health) Jun 21 – In older women, higher levels of endogenous estrogen at baseline predicted a lower risk of heart disease in the Women’s Health Initiative trials, a new analysis shows.

“Regardless of treatment, your hormone levels predicted your chance of heart disease,” Dr. Douglas Bauer, who led the new research at the University of California in San Francisco, told Reuters Health. Dr. Bauer and his team presented their findings Sunday at the 93rd annual meeting of the Endocrine Society in Boston.

The WHI trials studied two treatments: estrogen, and estrogen plus progestin. The estrogen-alone trial randomized 10,739 women to take either conjugated equine estrogens, or a placebo, and tracked them for about seven years.

The estrogen-plus-progestin trial randomized 16,608 women to take either estrogen plus medroxyprogesterone acetate, or a placebo, and tracked them for more than five years.

Overall, 748 women had heart disease events (e.g., myocardial infarction, silent MI, or cardiac death) during follow-up, including 416 subjects in the estrogen-alone trial and 332 in the estrogen-plus-progestin trial.

When Dr. Bauer and his colleagues analyzed baseline quartiles of serum estradiol (E2) levels, they found that heart disease risk decreased with higher E2 levels (p for trend, <0.05).

Furthermore, “baseline levels of total E2 did not modify the relationship between treatment and coronary heart disease risk” in either trial, the researchers said in their abstract for their meeting.

In the estrogen-plus-progestin trial, women in the highest quartile of E2 levels had a 70% lower risk of heart disease compared to those in the lowest quartile (hazard ratio: 0.3). In the estrogen-alone trial, women with the highest E2 levels were 50% less likely to suffer a cardiac event compared to those with the lowest E2 levels (HR: 0.5).

“This is more likely to be useful in women trying to predict their risk of heart disease than in trying to determine the best treatment,” Dr. Bauer said. “In the future, you could, perhaps, measure estrogen to tell the likelihood of heart disease.”

Reuters Health Information © 2011

Giant Intracranial Aneurysm

A 56-year-old woman with hypertension underwent an evaluation for recurrent syncope. On physical examination, the blood pressure and heart rate were normal, with no observed bradycardia or pauses on telemetry, and the respiratory rate and oxygen saturation were normal. The funduscopic examination was normal, with no signs of papilledema. Computed tomographic (CT) angiography of the head showed a partially thrombosed giant paraclinoid aneurysm of the left internal carotid artery, measuring 5 cm in diameter (Panels A and B, arrows). Six years earlier, an aneurysm of the left internal carotid artery (2.2 cm by 1.3 cm) had been diagnosed, but the patient was subsequently lost to follow-up. During the year before the current presentation, increasing forgetfulness, subjective gait instability, headaches, and urinary incontinence had developed. Despite the patient’s reports of occasional dizziness, motor, sensory, cerebellar, gait, and cranial-nerve examinations were normal. The aneurysm was compressing the third and lateral ventricles, resulting in hydrocephalus and ventricular dilatation (Panel C, arrow). The patient underwent placement of a ventriculopleural shunt, with marked improvement in headaches, cognition, and subjective gait stability. On repeat CT, there was complete resolution of the hydrocephalus and decreased ventricular size. The patient is being followed at the aneurysm clinic, where she is being evaluated for endovascular repair of the intracranial aneurysm.

Vishesh Kumar, M.D.
North Shore Medical Center, Salem, MA
vkumar3@partners.org

Christopher S. Ogilvy, M.D.
Massachusetts General Hospital, Boston, MA

Melanonychia Striata

An otherwise healthy 23-year-old black man was concerned about a dark line, 1 mm in width, arising from the nail bed of his right thumb (Panels A and B). The finding had been present for approximately 2 years and had not changed. The line originated in the lunula and stretched to the distal end of the nail in the axis of normal nail growth, an appearance consistent with the descriptive term melanonychia striata. The line did not extend into the cuticle, and the patient had noted no recent change in its width or color. There was no overlying nail dystrophy, no history of trauma, no family history of melanoma, and no involvement of other nails. Subungual melanoma is difficult to rule out on clinical grounds alone and remained an important diagnostic consideration, despite several reassuring features. However, the patient was concerned about the possibility of dystrophic scarring and declined a biopsy of the nail bed. After 2 years, the dark line remains unchanged, and the patient reports no new medical problems.

Marcos de Almeida Santos, M.D.
Tiago Osternack Malucelli, M.D.
Hospital de Clinicas da Universidade, Federal do Parana – Internal Medicine, Curitiba, Brazil
marcos.sjr@gmail.com

Pyogenic Liver Abscess

A 44-year-old man with diabetes mellitus presented to our hospital after 4 days of fever and abdominal pain. The initial evaluation revealed tachycardia (heart rate, 137 beats per minute), hypotension (blood pressure, 81/44 mm Hg), and abdominal discomfort in the right upper quadrant. There was no rebound tenderness. A lesion with heterogeneous radiodensity was noted in the right upper abdomen on chest radiography (Panel A, arrowheads). Computed tomographic imaging revealed an intrahepatic lesion containing gas and fluid (Panel B, arrowheads). A pyogenic liver abscess was suspected. Blood cultures ultimately grew Klebsiella pneumoniae, which can be gas-producing. Diabetes is an important risk factor for this condition. Despite fluid resuscitation and treatment with inotropic agents and antibiotics, the patient’s clinical condition deteriorated, and he died within 48 hours after admission.

Chin-Wei Yu, M.D.
Ching-Hsing Lee, M.D.
Chang Gung Memorial Hospital, Taoyuan, Taiwan

Podoconiosis

A 36-year-old man presented to an Ethiopian clinic with a 20-year history of skin nodules, pain, and edema involving his legs and feet. He was otherwise healthy and worked as a farmer. Circulating filarial antigen tests for the presence of Wuchereria bancrofti were negative; he was not tested for other types of filaria. This clinical presentation prompted a diagnosis of probable podoconiosis (also known as nonfilarial elephantiasis or mossy foot). This locally endemic, noninfectious condition is caused by the long-term exposure of susceptible persons to irritant volcanic soil. Colloid particles are thought to be absorbed through the skin and taken up by macrophages, leading to lymphatic fibrosis and elephantiasis. Affected persons are typically barefoot agricultural workers in the highland tropics. Social stigma associated with this condition is widespread; patients are banned from schools, churches, and marriage. Economic productivity is often impaired. Podoconiosis is preventable with fastidious shoe wearing and foot hygiene. Treatment is limited to compression bandaging and elevation. The patient was instructed to wear shoes, but additional nodules continued to develop on uncovered areas of his sandaled feet.

Whitney Lapolla, M.D.
Stephen K. Tyring, M.D., Ph.D.
Center for Clinical Studies, Webster, TX
whitneylapolla@gmail.com

Coral-Red Fluorescence

A 66-year-old man presented to a dermatologist with a pruritic, erythematous, scaly, and mildly hyperpigmented rash of 2 weeks’ duration that involved the scrotum and both inguinal creases (Panel A). Under examination with ultraviolet A light from a Wood’s lamp, the rash exhibited coral-red fluorescence (Panel B), a finding pathognomonic for erythrasma. This common disorder results from overgrowth of Corynebacterium minutissimum in the superficial stratum corneum of moist intertriginous and interdigital regions. The coral-red fluorescence is a result of the production of coproporphyrin III by C. minutissimum, and it helps to distinguish this disorder from dermatophytoses, candidal intertrigo, and psoriasis. Skin scrapings show gram-positive filamentous rods, which may be helpful in assessing for concurrent dermatophytic and candidal infection. After a short course of oral erythromycin, this patient’s rash and pruritus resolved completely.

Ivana Binic, M.D., Ph.D.
Aleksandar Jankovic, M.D., Ph.D.
Clinical Center Nis, Nis, Serbia

Giant Syphilitic Aortic Aneurysm

A 76-year-old man presented with progressive dyspnea and leg swelling. He had a remote history of syphilis, which had gone untreated until quite recently. Auscultation of the precordium was notable for the diastolic blowing murmur of aortic regurgitation, and there was electrocardiographic evidence of left ventricular hypertrophy. A chest radiograph showed a mediastinal mass with tracheal deviation (Panel A, arrowhead). Contrast-enhanced computed tomography of the chest revealed an aortic aneurysm measuring 11.4 by 11.5 by 18.0 cm (Panel B, axial image, asterisk, and Panel C, sagittal reconstruction image, asterisk), its caliber markedly different from that of the normal descending aorta (Panels B and C, daggers). The patient underwent replacement of the aortic valve and repair of the aneurysm. Findings on pathological examination of the excised tissue were consistent with syphilitic aortitis, a condition in which spirochetal invasion of the aortic adventitia causes an obliterative endarteritis of the vasa vasorum. Blood supply to the aortic wall is impaired, which results in weakening of the tunica media and formation of the aneurysm.

Taufiek Konrad Rajab, M.D., B. Chir.
Robert P. Gallegos, M.D., Ph.D.
Brigham and Women’s Hospital, Boston, MA

Acute Mesenteric Infarction Associated with Atrial Fibrillation

A 75-year-old woman with chronic atrial fibrillation presented to the hospital with a 2-day history of colicky abdominal pain. The physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness. Laboratory tests showed a white-cell count of 19,400 per cubic millimeter with 92% neutrophils, a blood urea nitrogen level of 42 mg per deciliter (15 mmol per liter), and a serum creatinine level of 3.0 mg per deciliter (267 μmol per liter). Abdominal computed tomography with contrast material showed occlusion of the main trunk of the superior mesenteric artery with mesenteric venous gas (Panel A, reconstructed coronal image, arrow) and pneumatosis intestinalis (arrowhead). Laparotomy revealed ischemic changes with congestion and transluminal necrosis of the small bowel (Panel B) and ascending colon. The superior mesenteric artery is susceptible to embolic occlusion because of its large caliber and narrow take-off angle from the aorta. Although surgical resection of the necrotic bowel is the treatment of choice, the patient and her family opted for conservative treatment. The patient died 3 days later.

Jia-Ming Wang, M.D.
Shih-Chieh Chang, M.D.
National Yang-Ming University Hospital, Yilan City, Taiwan
dtsurga9@yahoo.com.tw

Amalgam Tattoo

A 64-year-old man was referred for evaluation of an asymptomatic pigmented lesion on the buccal mucosa (Panels A and B). After 15 pack-years of smoking, he had quit smoking more than 30 years earlier and had no other risk factors for oral cancer. A biopsy of the lesion revealed interstitial accumulation of brown and black particles within the submucosa, a finding that was compatible with a diagnosis of amalgam tattoo. Amalgam dental fillings contain mercury, silver, and other metals that may inadvertently be implanted into adjacent gingival, buccal, palatal, or lingual mucosa at the time of tooth restoration. This produces black, blue, or gray macules that are asymptomatic and change little over time. Although amalgam tattoos are common and benign, they may mimic pigmented oral lesions with more worrisome causes, such as melanoma or Kaposi’s sarcoma. Only a minority of amalgam tattoos are radioopaque on plain radiography. A biopsy can be performed without difficulty and is effective in ruling out cancer, although it is usually unnecessary when the lesion is typical and has been evaluated by an experienced practitioner.

Patrick Dubach, M.D.
Marco Caversaccio, M.D.
Department of Otorhinolaryngology, Head and Neck Surgery, University of Bern Inselspital, Bern, Switzerland
patrickdubach@insel.ch

Keloidal Morphea

A 44-year-old woman presented with a 2-year history of multiple enlarging, painful nodules. Physical examination revealed several irregularly shaped, firm nodules with hyperpigmentation and induration on the trunk and upper arms (Panel A). She reported no other concerns about her health, and physical examination showed no other abnormal findings. Neither she nor her family had a history of keloidal scars or systemic sclerosis. The results of laboratory investigations, including assays for antinuclear and anti-dsDNA antibodies and screening for extractable nuclear antigens (including anti-Jo-1, anti-SSA, anti-SSB, anti-Scl-70, anti-Sm, and anti-RNP antibodies) were unremarkable. Findings on examination of a specimen from a skin biopsy were consistent with a diagnosis of keloid formation, except for the presence of perieccrine lymphocytic infiltration. On the basis of these clinical and pathological features, the nodules were diagnosed as keloidal morphea, a rare form of localized cutaneous scleroderma. Despite multiple treatments, the lesions enlarged over a 10-year period (Panel B).

Hsien-Yi Chiu, M.D.
Tsen-Fang Tsai, M.D.
National Taiwan University Hospital, Taipei, Taiwan
tftsai@yahoo.com