He had been treated with oral immunosuppressive agents, including prednisolone (10 mg daily), tacrolimus (4 mg, bid) and mizoribine (50 mg, qd). Vital signs on arrival included a blood pressure of 162/98 mmHg and a VX-765 cell line regular pulse rate of 73 bpm, and body temperature of 36.5℃. The initial electrocardiogram showed LVH with a strain pattern, ST-T changes in leads II, III, aVF, V3-V6 and short PR interval (Fig. 1). Chest radiography demonstrated cardiomegaly (cardiothoracic Inhibitors,research,lifescience,medical ratio = 70%) and blunting of both costophrenic angle (Fig. 2). Laboratory studies revealed that hemoglobin was 6.2 g/dL, BUN 64.2 mg/dL, creatinine 6

mg/dL, sodium 134 mEq/L, potassium 6.1 mEq/L, and serum N-terminal pro-B type natriuretic peptide level 126043 pg/mL. On hospital day two, two-dimensional transthoracic echocardiography revealed Inhibitors,research,lifescience,medical concentric LVH (interventricular septal dimension 23 mm, LV posterior

wall dimension 22.8 mm), mimicking non-obstructive HCM (Fig. 3). The interventricular septal dimension and posterior wall dimension was thicker than 3 years ago (interventricular septal dimension 17 mm, LV posterior wall dimension 17 mm). And left atrial enlargement was seen (4.5 cm). Left ventricular systolic function was preserved (ejection fraction = 59%), but diastolic dysfunction was present. Pulsed-wave Doppler recording of mitral inflow revealed Inhibitors,research,lifescience,medical a phase resembling an abnormal relaxation diastolic filling pattern, with an ratio between early (E) and late (A) mitral inflow velocity (E/A) of 0.82 (Fig. 4A). The mitral annulus early diastolic tissue Doppler velocity (E’) and the E/E’ index were 2.64 cm/s and 26.4, respectively, indicating

increased LV filling pressure and a pseudonormal pattern (Fig. 4B). Inhibitors,research,lifescience,medical The patient was prescribed diuretics for dyspnea and epokine for anemia. And the patient’s condition improved. The patient’s history of early onset ESRD and echocardiographic findings were suggestive of Fabry cardiomyopathy as well as idiopathic HCM. Alpha-galactosidase Inhibitors,research,lifescience,medical activity assay was performed. The assay was performed by fluorescence assay with 4-methylumbelliferyl and sequencing. The patient was confirmed FD by demonstration of a low plasma α-Gal A activity of 3.8 nmoles/hr/mg (normal mean, 7.5-12.5 nmol/hr/mg). Sequent analysis of genomic DNA showed c.639 + 5G > A [IVS4 (+5)G > A] mutation in the α-Gal A gene leading to a low plasma α-Gal A activity. Family screening was Rolziracetam done, and his brother was also confirmed FD by α-Gal A enzyme activity test and renal biopsy. Enzyme replacement therapy with recombinant α-Gal A was started on an out-patient basis. Fig. 1 The initial electrocardiogram showed left ventricular hypertrophy with a strain pattern, ST-T changes in leads II, III, aVF, V3-V6. Fig. 2 Chest radiography. Chest radiography demonstrated cardiomegaly (cardiothoracic ratio = 70%) and blunting of both costophrenic angle. Fig. 3 Two dimensional echocardiography.