A 60-year-old Black patient presented to the emergency department with a 2-month history of chest pain and shortness of breath with exertion, 3 months of toe numbness, and unintended weight loss of 8 kg over 6 months. The patient also had a history of lumbar spinal stenosis. On presentation, blood pressure was 104/73 mm Hg; heart rate, 91/min; respiratory rate, 16/min; and oxygen saturation, 96% on room air. Physical examination revealed edema to the mid-calf bilaterally, hypoesthesia below the knees, and ankle plantar flexion strength of 3 of 5 based on the Medical Research Council Scale for muscle strength. Laboratory testing revealed a high-sensitivity troponin level of 52 ng/L (reference, <34 ng/L); brain-type natriuretic peptide, 112 pmol/L (reference, <30 pmol/L); aspartate aminotransferase, 51 U/L (0.85 μkat/L) (reference, 0-35 U/L [0-0.58 μkat/L]); and alanine aminotransferase, 76 U/L (1.27 μkat/L) (reference, 0-45 U/L [0-0.75 μkat/L]). A chest radiograph showed cardiomegaly without pulmonary vascular redistribution or pulmonary edema.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Henk-Jan Boiten, MD, PhD, Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Vlietlandplein 2, 3118 JH Schiedam, the Netherlands (email@example.com).
Published Online: June 22, 2023. doi:10.1001/jama.2023.8977
Conflict of Interest Disclosures: None reported.
Additional Information: We thank the patient for providing permission to share his information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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