Case 1

History: A 56-year-old woman presents with:
• 12 years of chronic nocturnal cough
• Progressive dysphagia (first liquids then solids)
• New episodes of presyncope during exertion over last 3 months
• One episode of ‘almost fainting’ while climbing stairs with palpitations
• No weight loss yet
• No fever, chest pain, or regurgitation of undigested food

Past History: Childhood illness at age 11 after sleeping in mud-walled house in rural Mexico: High fever, Periorbital swelling - treated symptomatically; diagnosis never made

Examination:
HR 52/min, regular | BP 110/70 | SpO₂ 97%
Mild bilateral basal crackles
No JVP elevation | No edema

Correct Path: Serological panel for endemic vector-borne disease from rural Latin America returns positive on two different antigen platforms.

Presumptive Diagnosis confirms chronic infection
Given the triad of: Dysphagia, Cough and Presyncope.

Wrong Path: No structural abnormalities visualized on transesophageal echocardiography

Three weeks later, she collapses briefly at home (near syncope).
HR on arrival: 36 bpm
ECG: 2nd-degree AV block (Mobitz II)

Correct: HREM

Manometry Findings:
• 90% ineffective swallows
• 10% failed swallows
• Integrated Relaxation Pressure borderline elevated
• Mild panesophageal pressurization
• Pattern = Pre-achalasia

You confirm GI involvement.

Wrong Path: Delay

No ECG changes associated with cough syncope.
You delay motility workup. She develops acute choking on liquids and new episode of syncope.

Correct: Cardiac Screening

ECG: RBBB + LAFB, Intermittent Type II AV block, Frequent PVCs

ECHO: EF 45%, Apical aneurysm, Trace MR

24-Hour Holter: NSVT (6-beat run at 160 bpm), Frequent PVCs, Sinus pauses up to 2.8 sec

Wrong Path: Diagnostic Drift

Dysphagia persists. She develops aspiration pneumonia (hospitalized for 4 days). Now she has multiple palpitations and syncope episodes.

Correct: Initiate Arrhythmia Management

Management:
• Benznidazole not useful in chronic infection
• Admit due to high-risk arrhythmias
• Start HF therapy (Amiodarone + ACEI/ARB + β-blocker)
• GI: Evaluate for dilation or Heller myotomy if progressing achalasia

Which complication is NOT managed?

Wrong: Undertreatment

Two days later she had syncopal episode.
ECG: sustained VT at 180/min, spontaneously terminates.

Aspirations, Stroke, Heart failure & Cardiac arrest prevented

Next best management?

Correct: Cardiac MRI

CMR Findings:
• Patchy mid-wall and epicardial late gadolinium enhancement
• Confirmed apical aneurysm with mural thrombus
• EF now 42%
• No pericardial effusion

Next best management?

Wrong: Misfire

You fail to risk-stratify. She returns with syncope + head injury.

Correct: Advanced Care

You initiated:
• ICD implantation for VT + syncope
• Warfarin for apical thrombus
• GDMT for Heart failure
• GI follow-up (repeat HREM at 6–12 months)

She stabilizes. Dysphagia improves slightly, cough improves markedly. No further arrhythmias.

Appropriate GI follow-up?

Correct GI Long-term Management

• Annual HREM
• Report on recurrent vomiting/aspiration cough/severe constipation
• Annual CXR
• Possible dilation if progression toward achalasia
• Continue cardiac surveillance (ECG, echo, holter and CMR)

She remains stable for 4 years.

Most important lifestyle measure to prevent complications?