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A man in his 40s presents to the cardiology department for an ECG. He had a prior kidney transplant for an unknown reason and a history of dyspnoea and long-term neurological pain in the limbs triggered by stress and extremes of temperature (heat or cold). Physical examination revealed small reddish-purple skin lesions in the hip, periumbilical region and lips ( figure 1A). The 12-lead ECG revealed a short PR interval, voltage criteria for left ventricular hypertrophy (LVH), prolonged QRS duration and repolarisation changes with diffuse and deep T-wave inversions (figure 1B). A transthoracic echocardiogram revealed concentric LVH with septal and posterior wall thickness of 14 mm and grade 2 diastolic dysfunction.