Dr. O’Donnell presented 2 cases of dyspnea with focus on clinical reasoning.
The first case, taken from the Journal of Hospital Medicine: Clinical Conundrums, focused on an elderly man with recent diagnosis of cryptogenic cirrhosis and subacute dyspnea on exertion. This was a good case as it stimulated discussion regarding common causes of cirrhosis (which should be assessed and ruled out) before a diagnosis of cryptogenic cirrhosis can be made. Exam was notable for absent stigmata of chronic liver disease (other than ascites) and elevated JVP.
Hepatic enzymes and tests of synthetic liver function were normal. SAAG> 1.1 with elevated total protein. ECG with low voltage. Echocardiogram revealed concentric LVH without pericardial effusion or thickening. Cardiac catheterization demonstrated equalization of diastolic pressures. A cardiac MRI was subsequently obtained which revealed a severely thickened pericardium, suggestive of constrictive pericarditis.
Cardiac MRI showing thickened pericardium
Take Home Points:
Cirrhosis due to heart failure can be distinguished from other causes of ascites based on ascitic protein concentration greater than 2.5 g/dl, relatively observed synthetic function and lack of stigmata of chronic liver disease.
A patient with cirrhosis, ascites and elevated JVP should prompt echocardiographic evaluation
Cardiac magnetic resonance is diagnostic procedure of choice for certain pericardial diseases, including constrictive pericarditis
The second case Dr. O’Donnell presented was of a middle-aged man with cough, progressive dyspnea and weight loss.
Exam notable for tachycardia and hypoxemia with diffuse rhonchi on lung auscultation. Laboratory work up notable for elevated LHD. CT chest with diffuse ground glass opacificatoins. We reviewed differential for diffuse ground glass opacifications including DAH, edema, viral illness (PJP, CMV), HSP, NSIP, and UIP (the later three are typically more chronic progresses, often with fibrotic changes).
On further interview, patient was found to have risk factors for HIV. HIV screen returned positive. Patient subsequently underwent bronchoscopy with BAL which was positive for pneumocystis stain. He was treated with TMP-SMX and prednisone and started on ART.
Take Home Points:
An elevated LDH or Beta-D-Glucan in a patient with pulmonary infiltrates should raise suspicion for PJP.
The typical radiographic features of PJP pneumonia is diffuse, bilateral ground glass infiltrates
Diagnosis is made by detecting organism in induced sputum specimen or BAL fluid.
Adjunctive glucocorticoids should be given to patients with room air PaO2 < 70 mmHg and an A-a gradient of >/= 35 mmHg or evidence of hypoxemia.
For further details, or if you wish to review Case 1 for yourself refer to:
Journal of Hospital Medicine, Clinical Care Conundrum, Vol 3, No 1, Jan/Feb 2008