Author contributions: Matteo Pernigo and Marco Triggiani drafted the manuscript; Emanuele Gavazzi, Simona Fisogni, Ester Costantino and Gian Franco Pasini took part to clinical management of the case and data collection; Ilaria Papa, Alberto Vaccari, Simona Fisogni and Emanuele Gavazzi revised the manuscript.
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FIGURE CAPTIONS
Figure 1: A. Electrocardiogram on admission. Sinus tachycardia with left axis deviation, slight diffuse ST depression more prominent in inferior-lateral lead.
B. Chest X-ray. Interstitial edema limited to left superior and lateral regions, and no pleural effusion.
C. Image from high resolution computed tomography scan of the lungs. Ground glass-like hyper density opacities in the peripheral portions of inferior lobes bilaterally (arrows)
Figure 2: Echocardiogram performed on day 10th
a: Parasternal long-axis view, showing moderate concentric LV hypertrophy with echo-bright appearance of myocardium. LV: left ventricle; S: septum; LA: left atrium.
b-e: 2D-speckle tracking longitudinal strain evaluation; b: bull’s eye with global results. Global longitudinal strain: -12% (18 segments). Diffuse hypokinesia is evidenced, more pronounced in basal anterior and septal segments (arrows), and relative apical sparing. c, d, e: longitudinal strain evaluated in apical 4-chamber, 2-chamber, and 3-chamber views respectively, with strain curves for each segment.
Figure 3: Cardiac magnetic resonance imaging. Short tau inversion recovery (STIR) sequences in 2-chamber (A) and short-axis view (B) showed mild myocardial signal hyperintensity in left ventricle anterior wall and anterior septum in medium and apical segments (arrows), consistent with interstitial edema, confirmed and best depicted in corresponding T2-Mapping sequences (C and D, arrows).Phase sensitive inversion recovery (PSIR) sequences in short-axis (E) and 4-chamber view (F) showed diffuse intramural late gadolinium enhancement.
Figure 4: Renal biopsy specimens, PAS (Periodic Acid Schiff) stain. A: Capsular thickening and wrinkling of glomerular basement membrane (arrow). Circumferential arteriolar hyaline sclerosis (asterisk). B: Diffuse acute tubular injury with brush border loss, tubular dilatation, epithelial thinning or swollen, focal vacuolization (red arrows); partial desquamation of tubular epithelial cells (star); focal regeneration features (prominent nucleoli and mitosis – yellow arrows); modest interstitial chronic inflammation with minimal tubulitis.
Supplementary files, Figure 1: image from cranial CT scan. Several ischemic lacunar foci of the basal ganglia bilaterally (arrows), and white matter hypodensity are visible.
Supplementary files, Figure 2: Coronary angiography. Upper panels: left coronary artery. A 50% stenosis of mid left anterior descending (LAD) artery and a 50% stenosis of the first marginal branch of left circumflex (LCX) artery are visible. The lesions resulted non emodynamically significant (as documented by iFR – not showed). Lower panels: right coronary artery (RCA), no significant stenosis in the main vessel – posterior descending artey (PDA). Significant stenosis of a small posterior-lateral branch (PL).