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A 46 year old woman with a history of dilated cardiomyopathy, an ejection fraction of 10% and a left ventricular thrombus, HIV, hypertension, and a history of hepatitis B, was admitted with increasing shortness of breath, paroxysmal nocturnal dyspnoea (PND), orthopnoea, and pedal oedema over a three week period. On admission, the patient was in respiratory distress and hypertensive. Her cardiovascular examination showed tachycardia and an S3, and her respiratory examination revealed crackles throughout; she also had pedal oedema. The patient was admitted and treated for pulmonary oedema with aggressive diuresis. On the second day after admission the patient had a cardiac arrest and was resuscitated, requiring endotracheal intubation. Subsequent to this episode the patient became hypotensive; she also had fevers and a chest x ray showed a left lower lobe infiltrate. She was treated for sepsis and started on fluids and noradrenaline (norepinephrine). A two dimensional echocardiogram showed a dilated left and right ventricle with an ejection fraction of 10%, and two thrombi—one measuring 4.1 × 3.2 cm and the other 1.2 × 1.6 cm (panel). Both thrombi were freely mobile, with the large one almost obliterating the left ventricular cavity; there was also a hint of a right ventricular thrombus. The patient was started on dobutamine and weaned off noradrenaline. Her blood pressure stabilised over the next few days and her fluid boluses were stopped; she was also placed on anticoagulation with enoxaparin. However, on day 5 after admission, the patient had an embolic stroke in the right gangliocapsular region. A repeat echocardiogram no longer revealed any thrombus. The patient was eventually discharged with minimal signs of the stroke. She was clinically stable at six months follow up.
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