Dear Dr. Chung,

As you may recall from a few months prior, I posted a message in
regards to an unknown, prolonged illness of two years duration.

My main symptoms were "TIA" like attacks, with a sudden and severe
onset of shortness of breath. At that time, you suggested that the
etiology may be due to a combination of a hypercoagulable state in
combination with a PFO, leading to recurring PE and other embolic
events.

Your recommendation was undergoing TEE w/bubble study, and workup for
a hypercoagulable state. The TEE was normal, with no evidence of PFO
or ASD (performed with and without Valsalva). Chiari Network was
present in the right atrium, however. I am told that this holds no
significance. This supposed "Chiari Network" was also present on a
recent TTE taken back in Nov of 2006. A TTE taken in Dec of 2004 did
not reveal the Chiari Network.

In essence, the hypercoagulable state workup was normal. The only
positive finding was a gene variant for MTHFR A1298C, which I'm told
is a common finding among the population.

Despite the lack of clinical findings, my condition continues to
decline. A recent TTE taken in March shows an LVEDD of 63 mm, and a
LVESD of 46 mm. Two years ago, the same measures were 56 and 39,
respectively.

The ECG continues to change as well, showing complete right bundle
branch block with a QRS of 0.122 seconds, and an rSR complex in V1.
The "T" waves in the inferior leads are "flat".

Stress testing revealed a moderate sized area of mid-to-distal
inferoapical ischemia (reversible on rest), however, the cardiac cath
showed no blockages.

D-Dimer was negative, and a spiral CT of the lungs with contrast
revealed no PE. Despite this, I continue to have oxygen desaturations
into the low 80's with cyanosis of the fingernails.

Looking at recent lab results, the only abnormality I see is with the
CBC. The Lymphocyte count is 14 (21-51 normal), and the Neutrophil
count is 85 (36-72 normal). Past abnormalities included a positive
ANA, elevated Cortisol, and elevated Bilirubin.

Current signs and symptoms:

- SOB, varies in intensity, improved by laying on left side
- Sleep apnea type syndrome
- Heart rate varies grossly from 38 bpm to 150 bpm with no exertion
- BP spikes to 230/130, with average BP of 160/100 (despite two
medicines)
- Sudden onset of faintness, dizziness
- Complete vision loss left eye
- Joint pain, chest/shoulder/musculoskeletal
- Splinter hemorrhages in fingernails - frequent
- Petechial lesions on both forearms
- Chest pain radiating to left side of neck on exertion
- Frequent PVC's, felt in left side of neck
- Variable Bells Palsy, left side of face
- Numbness of the extremities
- 40 lbs weight loss (unintentional)
- Low body temp (96.9 F)
- Unequal dilation of pupils during an "event"

Height = 6'3", Weight = 178 lbs, Age 24

The local doctors (and independent cardiologist) are perplexed by my
condition. No explaination for the positive stress test, positive
echo, evolving ECG changes, etc can be appreciated. I have tried
dozens of antihypertensives (beta blockers, ACE, ARB's, Methyldopa)
without success. The average pressure remains 160/100 regardless.
Benzodiazepines (Klonopin, Valium) were also tried with no benefit.

Workup's for PE, Pheochromocytoma, Aldosteronism, Cushings, Renal
Artery Stenosis, Coarctation of Aorta, Neurological, and Lupus are all
normal.

Do you have any further suggestions at this point that could
potentially identify the culprit for this illness? Autoimmune perhaps?
Infectious process?

At any rate, I want to thank you for your past contributions. I
continue to search for the answer (although I'm just about out of
options at this point).

Sincerely,

Bill