Clinical presentation
Blood pressure was 86/60mmHg, heart rate was 90 beats per minute at admission. Patient was sanity, tachypnea with engorgement of the neck veins. Low breath sounds in his both lungs and soft rales could be heard in the base of both lungs. Abdomen was flat and soft, there was no tenderness and rebound tenderness. Edema was found in both lower limbs. Meanwhile, there were signs of symmetrical atrophy thigh muscles, hypertrophy and stiffness gastrocnemius, and the limbs skin temperature was low. Laboratory examination results were as follows: Creatine Kinase (CK): 566IU/L, Myohemoglobin: 219.2ug/L, Urea nitrogen: 8.5mmol/L,Hemoglobin: 94g/L, Neutrophilic granulocyte percentage (NEUT):76.2%, Troponin I (TnI): <0.5ng/ml. BNP:4700pg/ml, NT-proBNP:5732 pg/ml. Electrocardiograph (ECG) results were as follows: sinus rhythm. Ventricular premature beat (Figure 1). CT scan of the lungs showed signs of inflammatory response in lung field, small effusion in bilateral pleural cavity. Echocardiography detected enlarged left ventricle (LVEDD 78mm), left atria (LADs=55 mm), right atria (RAs 54mm) and right ventricle (RVd 37mm) as well as global hyperkinesia (LVEF=20%), moderate to large mitral regurgitation and significant tricuspid regurgitation (systolic pulmonary artery pressure=72mmHg).