A man aged 62 and previously in good health was seen an hour after the abrupt onset of left iliac fossa pain and vomiting. He was afebrile, normotensive, and in sinus rhythm, and the only abnormality on examination was an area of tenderness in the lower left quadrant of the abdomen. Urine analysis, blood count, serum amylase, and tests of renal and liver function were all normal. A chest radiograph showed borderline cardiomegaly; abdominal X-ray was unremarkable. The pain improved with opioids and he was discharged home. He returned a week later, troubled by dull and unrelenting abdominal discomfort. This time he had epigastric tenderness and he was in atrial fibrillation. The electrocardiogram also showed borderline intraventricular conduction delay and nonspecific repolarization abnormalities. The previous heart tracing was examined for signs of ventricular pre-excitation but none were found.(Blood specimens taken at this time subsequently revealed above-normal C-reactive protein [119mg/L] and D-dimer [0.44μg/mL] and normal serum amylase and renal function tests.) An intra-abdominal abscess was suspected and CT imaging was arranged, but he had a sudden cardiac arrest from which he could not be resuscitated.

Necropsy revealed extensive infarction of the left kidney, the artery to which was completely occluded by an embolus. From its appearance the infarction was judged to have occurred several days before death. The heart was greatly enlarged; the left ventricle in particular was severely hypertrophied. The heart valves were normal, and no intracardiac thrombus was found. Serial myocardial slices revealed no evidence of acute or old ischaemic changes, and the coronary arteries were only mildly atherosclerotic. Despite a diligent search including other abdominal organs and the brain, there was no evidence of embolism elsewhere. The death was attributed to a lethal arrhythmia that had arisen from previously unrecognized structural heart disease.