Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Beware the left sided pleural effusion!
- Anthony N Glaser (18 March 2004)
-
Mitral Regurgitation and Backward Failure
- Christos Venetis, Greece (19 March 2004)
-
Cleante Response
- cleante scarduelli (19 March 2004)
-
Heart failure and other possiblities
- Malvinder S. Parmar (19 March 2004)
-
A 66 year old lady with shortness of breath
- Marin Marinovic (19 March 2004)
-
CCF
- chidambaran ganapathy (20 March 2004)
-
Cardiomyopathy
- Sajeev. S Nair (21 March 2004)
-
Stat Echo
- Jussi Mikkelsson (21 March 2004)
-
CCF and Mitral Valve Disease
- Sunil Rajan (21 March 2004)
-
Pericardial effusion is to be considered
- SASI K ATTILI (21 March 2004)
-
rare presentations of common diseases is common
- lekharaju v p kumar (21 March 2004)
-
more info on examination needed?
- Ramakant sharma (21 March 2004)
-
Congestive heart failure
- Harry J. Thomas (21 March 2004)
-
Two other thoughts on Mitral Incompetance
- Stephen Head (22 March 2004)
-
Failure seems likely , what about SBE
- Des Spence (22 March 2004)
-
collateral diagnostic information
- Anil Adisesh (22 March 2004)
-
Ovarian Mass
- Muhammad Naseer Khan (22 March 2004)
-
ccf
- nishanth polapragada (22 March 2004)
-
A funny effusion
- Raffaele Rasoini, Camilla Alderighi Resident in cardiology (23 March 2004)
-
congestive heart failure(CHF)
- JUDE. I. OKOH (23 March 2004)
-
Perhaps a rare cause
- TJ Littlewood (23 March 2004)
-
Odd features for CCF
- Peter D McSorley (23 March 2004)
-
Be aware of constrictive pericarditis
- José M Porcel (23 March 2004)
-
Pleural effusions
- Cornelis K. van Sichem (24 March 2004)
-
66yr. old lady with bilateral pleural effusions.
- Olumide A Adeotoye (25 March 2004)
-
My two pence
- Chris Chung (25 March 2004)
-
Hypertensive Heart Disease
- Abdullah Mohammed (25 March 2004)
-
H Failure and Thyroid
- mansoor feroze (3 April 2004)
-
66 Year Old Woman with Breathlessness
- John B. Hearn, None (4 April 2004)
-
Re: 66 Year Old Woman with Breathlessness
- harjeet singh (1 June 2004)
-
ccf
- Prashanth Manjanabail (11 August 2004)
-
GP(General Practitioner) on his own(almost)
- Brian P Corbett (25 August 2004)
-
CHF
- Som nath (7 October 2004)
|
|
|||
|
Anthony N Glaser, Private family medicine practice Summerville, SC 29483, USA
Send response to journal:
|
1 - What is the most likely cause of Mrs Dempsey's pleural effusions and how would you treat her? - although the lack of response to a diuretic is a inconsistent with simple heart failure, common things are common, and the most likely cause is heart failure. I would initially opt for more aggressive diuresis, daily weighing, and salt/sodium restriction - but the predominance of a left rather than right pleural effusion is troubling, and suggests multiple other possible diagnoses 2 - What investigations would you suggest? - an echocardiogram - BNP (B-type natriuretic peptide) - a diagnostic thoracentesis is certainly indicated if the effusion does not resolve 3 - If these investigations are not available urgently, what alternatives are available? - a review of her medical records: has she gained weight since before her dyspnea, and does she have a history of inadequately treated hypertension. Is she taking any other medications, including OTC ones, which could cause cardiac decompensation or edema? Any history of TB exposure, asbestos exposure, prior malignancy? - a clinical breast exam and pelvic exam to assist in evaluating possible breast or pelvic malignancy 4 - What would you tell the patient at this stage? - That there are several possible causes of this problem, and tests will be needed to find out what the cause is and what the best treatment is, and that we'll keep her informed as things go along Competing interests: None declared |
|||
|
|
|||
|
Christos Venetis, Cardiologist Chief Athens 15341 A. Paraskevi, Greece
Send response to journal:
|
1. Backward heart failure (and concequently elevation of Pulmonary Artery Pressure) due to Mitral Regurgitation most probaply because of chordae tendinae rupture. 2.Echocardiography-Doppler to assess Left Ventricle and cardiac valves plus the Pulmonary Artery Pressure. 3. Echocardiography is always available 4.We would certainly be able to diminish your shortness of breath. Competing interests: None declared |
|||
|
|
|||
|
cleante scarduelli, Via Galilei 7 46100 Mantova Italy pulmonary and intensive care Unit
Send response to journal:
|
1) I think that the most probable cause of pleural effusions in CHF secondary to mitral insufficiency. 2) I'd like to have echocardiography, and thoracentesis to evaluate if it's trasudate or exudate. 3) I' ll treat her with i.v. diuretics, ACE(angiotensin converting enzyme) inibitors and than it is necessary to evaluate if there is a surgical indication. Competing interests: None declared |
|||
|
|
|||
|
Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
Send response to journal:
|
1. Various possibilities exist as the cause of this lady’s symptoms of dyspnea and ankle swelling. Congestive heart failure, of course, is on the top of the list, especially with current history and poorly controlled hypertension – secondary to hypertensive disease or cardiomyopathy. The pansystolic murmur suggests a regurgitant (mitral regurgitation) lesion with large pulse volume however it may be secondary to dilated cardiomyopathy. Poor response to lasix may be related to lack of salt and fluid restriction either because of poor compliance by the patient or due to lack of information given to the patient. Patient’s when feeling short of breath often breathe through the mouth and feel thirsty and if not given proper advice often drink more liquids than they otherwise would and use of diuretics often aggravate their thirst. The other possibilities to include in the differential diagnosis are – Pulmonary pathology (post- pneumonic, neoplastic or inflammatory pathology), Meig’s syndrome (ovarian fibroma). As her albumin level is normal, the liver (cirrhosis) or renal disease (nephrosis) is unlikely. 2. The investigations, in order, I would do are: a. Arterial blood gas – to assess the degree of hypoxemia and need for oxygen, to rule out associated acid-base disorder (that may aggravate dyspnea) and would act as baseline to monitor future response to therapy. b. Thoracocentesis – both for diagnostic and therapeutic purposes that likely would relieve her symptoms quickly than aggressive diuretics that may result in renal dysfunction (pre-renal azotemia). I would tap the left chest and remove as much fluid as possible so that on further imaging the underlying lung tissue could be assessed better. I will send the fluid for albumin, LDH, cell count, cytology and cultures and would repeat chest X-ray to view the underlying lung tissue and rule out any complications of the procedure. c. BNP, if available would be quite useful in this lady to evaluate further and to tailor further investigations. d. Echocardiogram: To assess LV function, diastolic (dys)function, and to evaluate for valvular and pericardial disease. e. CT of chest – after thoracocentesis, and if echocardiogram findings do not support a cardiac cause of her dyspnea or a post- thoracocentesis chest film shows some suspicious findings. 3. If none of the above investigations are available – then I would continue to treat her as ‘heart failure’ with diuretics but with the advise to restrict salt and fluids and would start ACE-inhibitor, initiate digoxin therapy and would assess the need for oxygen and if required supplement oxygen and then would transfer her to a center where further investigations could be performed in a timely fashion and managed effectively. 4. I would discuss various possibilities that may cause her symptoms and role of various investigations and role of continued treatment for ‘presumed heart failure’ with focus on her compliance with fluid and salt restriction. I would try to answer her questions or concerns that she may have at this time based on available information. Competing interests: None declared |
|||
|
|
|||
|
Marin Marinovic, SKMC Abu Dhabi 51900
Send response to journal:
|
1.What is the most likely cause of Mrs Dempsey's pleural effusions and how would you treat her? A/Congestive Cardiac Failure--this is less likely from the history and examination but there are enough reasons for this condition to be ruled out first. B/Malignancy-- this seems possible and I would definitely like to rule out Ca lung,Ca ovary,Lymphoma,Ca breast C/ Pulmonary pathology--Tbc,Pneumonia/unlikely from the history/ D/ Systemic diseases E/Combination or co-existance of two conditions/A and B/ 2.What investigations would you suggest? A/Arterial blood gasses on room ear B/ Serial ECG's and 24 hour Holter monitoring to rule out Paroxysmal Atrial Fibrillation despite normal initial ECG. C/ECHO-- to assess Left Ventricular function,ejection fraction,valvular function and pericardium.This will definitely help in assesing the severity of mitral incompetence and its possible cause. D/ Left Pleural Tap is almost mandatory in this scenario.It will serve as a therapeutic/at least for some time/ and hopefully diagnostic tool.I would send pleural aspirate for culture,cytology,Acid Fast bacilli and albumin.I would repeat CXR after aspiration of fluid as this may shine more light on possible diagnosis. E.Erythrocyte Sedimentation Rate F.Urine G.CT of the chest may be necessary if ECHO is normal and there is suspicion of malignancy. 3.If these investigations are not available urgently,what alternatives are available? She needs better control of Blood Pressure and I would start her on ACE inhibitor.At this stage I would not increase the dose of diuretic significantly until ECHO is done.If cardiology registrar is not around to do ECHO,pleural tap can be done relatively quickly which will provide some therapeutic releif. 4.What would you tell the patient at this stage? Dear Mrs Dempsey you need to stay in hospital for further investigations to find out why fluid is accumulating in your pleural spaces.I would mention the possible differential diagnosis and what tests are necessary to get to the correct diagnosis. Competing interests: None declared |
|||
|
|
|||
|
chidambaran ganapathy, Hon.Med.Officer VHS,Adayar,Chennai,India-600020
Send response to journal:
|
Sir/Madam, I will consider an early diagnosis of CCF. For further Investigation I will go for ECCHO Doppler studies & CAT scan of Lungs for more information on this condition.If further investigations r not available means treat her for CCF[Structured therapy]. Dr.Chidambaran Competing interests: None declared |
|||
|
|
|||
|
Sajeev. S Nair, Pulmonologist S.H. Medical Centre, Kottayam, Kerala, India - 686001
Send response to journal:
|
(1) The most likely cause of bilateral pleural effusions in this lady is congestive cardiac failure secondary to cardiomyopathy - probably dilated cardiomyopathy. I will treat her with salt restriction, furosemide ( dose will be increased if salt restriction does not provide the desired relief of symptoms). After confirming the diagnosis ACE inhibitors, digoxin ,hydralazine and isosorbide dinitrate may be added. (2) Echo-cardiography, Brain Natriuretic Peptide levels in blood, Radio-nuclide ventriculography. (3) If these inestigations are not available urgently, I will repeat another X-Ray Chest, 24 - 48 hours after optimal furosemide administration and salt restriction, to see whether the effusion is less or not. (4) I will tell her about the need of further investigations to confirm the diagnosis and if the diagnosis is right we have the option of medical treatment and if the medical therapy fails a cardiac transplant may help. Competing interests: None declared |
|||
|
|
|||
|
Jussi Mikkelsson, cardiology resident Satakunta Central Hospital, Finland
Send response to journal:
|
Okay, I would most definitely need more info on the patient's murmur. Regurgitant or ejection. Is it most evident on the apex, any radiation to the axilla? Any previous data on a murmur in this patient? The onset of symptoms was quite rapid which would point to the direction of chordae rupture and MR or a small VSD. The patients ECG shows hints towards dilated myopathy. The first study would be a stat TTE. Surgey would be an immediate option in the presence of severe MR or VSD. I would not pursue any further investigations before TTE. Competing interests: None declared |
|||
|
|
|||
|
Sunil Rajan, Specialist registrar Cardiothoracic Surgery Walsgrave Hospital, Coventry
Send response to journal:
|
The most likely cause of Mrs. Dempseys bilateral pleural effusions would be congestive cardiac faialure secondary to mitral valve disease. Shortness of breath,orthopneoea, sinus tachycardia, cardiac murmur would point at this.Normal renal, liver and thyroid function tests would exclude other possible causes. An occult malignancy with secondary malignant pleural effusion should also be considered and excluded. Besides the investigations already performed, a transthoracic echocardiogram would confirm and quantify any mitral regurgitation and would provide information on ventricular function and dimensions. A coronary angiogram would provide information on associated disease. A thoracentesis would be diagnostic with regard to nature of effusion and also could be therapeutic in relieving her shortness of breath in the short term. Competing interests: None declared |
|||
|
|
|||
|
SASI K ATTILI, SHO-MEDICINE SANDWELL GENERAL HOSPITAL, WEST BROMWICH. B71 4HJ
Send response to journal:
|
What is the most likely cause of Mrs Dempsey's pleural effusions and how would you treat her? CCF is the most likely cause of a 2 month history of insidious onset breathlessness associated with Orthopnoea, Mitral regurgitation murmur, elevated JVP and pedal edema. This is the most likely etiology for her effusions. The underlying cause is most probably Ischaemic heart disease (causing Mitral regurgitation/CCF). Therefore emergency treatment would include Oxygen, Diuretics (+/- GTN infusion/ diamorphine depending on her haemodynamic state and blood gases)and thromboprophyllaxis. I would consider adding aspirin, statins ,ACE inhibitor and a B-blocker once stabilised. This would control her blood pressure as well as help her failure. Ofcourse daily weights to maintain a negetive fluid balance and salt restriction are important. HOWEVER, if there is no response to treatment I would consider alternative diagnoses. What investigations would you suggest? Though the history is pretty straightforward the hypertension, lack of ECG changes (of LVH)and absence of any other cardiac risk factors is worrying. Especially with the diuretics not giving any symtomatic relief. It is also quite unusual to develop CCF from Mitral regurgitation within a 2 month span. My investigations would include: 1. B.Glucose (to r/o diabetes) 2. ABG's. 3. Lipid profile 4. ECHO- to assess LV function/ valvular state. I would also want to r/o a percardial effusion which might be associated with pleural effusions.(to r/o vasculitides and other misc conditions). 5. ESR would be the next inv. in my list to assist in r/o infective and vasculitic conditons. 6. I would consider an out-patient ETT/ Stress-ECHO/ MR imaging of the heart to assess her myocardial blood supply. 7. Tapping of the pleural effusion should be considered if CCF is ruled out. If these investigations are not available urgently, what alternatives are available? If none of these investigations are urgently available i would go by the clinical response to heart failure treatment. If there is no improvement and I have no investigations to help me I would fill in a IR-1 form and advice the patient to go to a private hospital. What would you tell the patient at this stage? I would tell the patient that she has undiagnosed hypertension which might have caused her heart to fail. I would explain the treatment/ investigations as above and tell her that we would keep her informed as and when the results become available. Competing interests: None declared |
|||
|
|
|||
|
lekharaju v p kumar, resident in internal medicine visakhapatnam India
Send response to journal:
|
1. This elderly lady has definite clinical signs of congestive cardiac failure. But what is the cause of ccf? 1. hypertension? 2.coronary artery disease?3.cardiomyopahty? Then why is she not responding to diuretics? This could be due to inadequate dose of diuretic, no drug for hypertension, no fluid/salt restriction in her diet. Apart from the above, the other causes of pleural effusion should be ruled out. Since she is an elderly individual malignancy should be ruled out. No history or mention was made of the appetite and wieght. Most likely it would be secondary to primary else where. Lymphomas can also present in this form connective tissue diseases should also be ruled out. 2.first investigatoion of choice would be 2D echocardiogram with doppler flow studies to know the EF, Diastolic function of the LV and also to look for pericardial effusion. Then pleurocentesis for biochemical, pathological, microbiological analysis with LDH,ADA levels. Then CT scan of chest should be done. 3.treat for hypertension with ACE inhibitors, and give diuretics, advice regarding salt restriction, and check weight daily 4. tell her that it is important to identify the cause of her symptoms and hence investigations are very essential. she will improve in due course of time. Competing interests: None declared |
|||
|
|
|||
|
Ramakant sharma, halton general hospital wa7 2da
Send response to journal:
|
sir, i agree to the management outlined by my friends already. only thing i will like to know more is detailed clinical examination. jvp is raised. how much?what waves visible? apex beat? location of the murmur and relation to respiration, effects of manouvers? whats about second heart sound, and its components? surprisingly liver is not palpable ???? this can give us more ideas towards the underlying cause. thanks Competing interests: None declared |
|||
|
|
|||
|
Harry J. Thomas, 4th year medical student Oxford University
Send response to journal:
|
1 The most likely cause of this lady’s pleural effusions is congestive heart failure. This may be due to hypertension, ischaemic heart disease, valvular heart disease or dilated cardiomyopathy. Despite 40 mg furosemide daily, her symptoms did not improve – this may be because the gut is congested, impairing drug absorption. Therefore, the furosemide may be administered intravenously. Alternatively, it may be replaced with oral bumetanide, which has a better absorption profile. In addition, ACE inhibitors should be started. 2 Echocardiography is indicated to assess heart size and function. Doppler echo will identify the site (mitral or tricuspid) and severity of the valvular regurgitation. 3 To help establish the cause of her pleural effusions, the patient should undergo diagnostic thoracocentesis. In light of the investigations already performed, a transudative effusion would strengthen the diagnosis of congestive heart failure. (The procedure should be performed before changing/increasing her diuretics, because acute diuresis in congestive heart failure may result in a pseudoexudate.) 4 I would tell the patient that there is a collection of fluid in the chest cavity, and that this is causing her breathlessness; that we are carrying out tests to find out what is causing the fluid to build up, and changing her drugs to help take off the fluid. Competing interests: None declared |
|||
|
|
|||
|
Stephen Head, General Practitioner Middleton Lodge, New Ollerton, Newark, Nottinghamshire, NG22 9SZ.
Send response to journal:
|
I agree congestive cardiac failure due to Mitral Valve disease is the likliest cause of the pleural effusions, but suggest Rheumatic Heart Disease should be considered along with myxomas as possible causes of her pansystolic murmur. Mrs Dempsey might well have had unrecognised rheumatic fever as a child, presenting now either with late decompensation or due to infective endocarditis (the absence of inflamatory markers does not exclude this). The patient needs serial blood cultures and a four-hourly temperature chart, besides echocardiography and pleurocentesis as most contributors suggest. The patient's history needs carefully reviewing with her, and perhaps any visiting siblings and her husband. Is there anything to suggest rheumatic fever as a child, for example did she have any close family members sent away to "the Fever Hospital"? Competing interests: None declared |
|||
|
|
|||
|
Des Spence, GP Glasgow G20 9DR
Send response to journal:
|
1.Heart failure seems the most likely cause and obvoiusly there are range of different causes for this to explore. One comment would that you would suspect a Pansystolic mumur to have presented at a younger age either incidentally or with failure. I would conclude that this is new. Clinically this may be secondary to a iscaheamic event or perhaps SBE. SBE can present with type of picture even with normal inflammatory markers etc. 2.ECHO, BNP(negative predictive value), Blood Culture, Dipstic Urine, Possible serology re atypical cause SBE. 3.As above. 4.Be postive but share uncertainty.It seem likely that any cause would be treatable.Keep the family informed. PS Have people noticed that this has come from a Heamatologist! Competing interests: None declared |
|||
|
|
|||
|
Anil Adisesh, Consultant Occupational Medicine Trafford General Hospital M41 5SL
Send response to journal:
|
Pointing out the case origin is helpful. Perhaps in a search for further collateral diagnostic aids the indexing under Cancer "Other" should lead us more in the direction of atrial myxoma. A knowledge of the epidemiology of the condition is also useful - in my experience it is 10 times more prevalent in case presentations than in clinical practice. Unfortunately real medicine doesn't work like this so perhaps the eBMJ should index and credit contributors after the case is worked through? Competing interests: None declared |
|||
|
|
|||
|
Muhammad Naseer Khan, Clinical Attachee James Cook University Hospital, Middlesbrough,TS4 3BW
Send response to journal:
|
At this age this is not an uncommon pathology. Ovarian mass or tumor can compress the iliac vessels and so can cause the leg oedema. For pleural effusion,to explain,there is an association of ovarian tumor with the pleural effusion called Meigs Syndrome. Although most commonly in Meigs Syndrome there is Right sided pleural effusion but this can be a rare presentation. We should do tumor markers,ultrasound of pelvis,and laproscopy if possible. We should also do the diagnostic as well as therapeutic pleural tap. If this diagnosis is confirmed then treatment is mostly surgical excision of tumor and pleural effusion is mostly self remitting in that case. Competing interests: None declared |
|||
|
|
|||
|
nishanth polapragada, post graduate k.g.h,vishakapatnam
Send response to journal:
|
sir, the cases shows features of congestive heart failure but the question is what is the cause of congestive heart failure?.some of the data if provided in full maybe suggestive,especially as regards to jvpand the pan systolic murmur.but my impression from the data given is congestive heart failure due to longt standing hypertension resulting in dilated cardiomyopathy.investigations i would suggest are 1.2-d echo.2.coronary angiogram.3.pulmonary angiogram to rule out multiple pulmonary emboli,which can cause chf and can also led to effusion Competing interests: None declared |
|||
|
|
|||
|
Raffaele Rasoini, resident in cardiology Florence 50100, Camilla Alderighi Resident in cardiology
Send response to journal:
|
Heart failure (CHF) is the first cause of pleural effusion in the western world. Mrs Dempsey’s pre-test probability of CHF calculated with the Boston criteria is very high. Coronary heart disease is the first cause of CHF in the western world and, despite the absence of ECG findings or chest pain, should not be excluded. The presence of a holosystolic murmur could suggest a mitral rigurgitation or an interventricular septal defect due to a silent ischemic injury, even though the absence of a third heart sound seems unlikely in this clinical presentation. An infective endocarditis is unlikely, because of the normal WBC and the absence of renal failure, spleen enlargment or systemic findings. It is not known, however, if the patient had fever. The rupture of a tendinae chordae would be also possible, but the insidious onset of breathlessness argues against this possibility. A dilatative cardiomyopathy, either primitive, ischemic, valvular or due to hypertension cannot be excluded and the worsening of the mitral regurgitation could have led to this clinical presentation. The predominance of the effusion on the left lung is strange, because more tipically, when the effusion due to CHF is in both lungs, it is of the same size or bigger on the right side. Constrictive pericarditis (as restrictive cardiomyopathy) could be an interesting hypothesis due to the presence of a raised central venous pressure, a tricuspid murmur and dispnoea on exertion. It’s not known if she had a history of TBC exposure, even though there’s not anemia, lymphocytosis, cough, weight loss or systemic illness. A neoplastic constrictive pericarditis in another interesting option and pleural effusion could be a consequence of this as well as a concomitant process. The primitive and secondary lung cancer rarely cause such a cardiac failure unless there are cardiac metastases or there’s an involvment of pulmonary arteries. I would consider in particular lymphoma, lung cancer (even though there’s not smoking history), breast, ovarian, renal cancer and melanoma. Nonetheless weight loss, anorexia or other systemic symptoms are not known and the plasma viscosity and WBC are normal. However, a cardio-pulmonary neoplastic syndrome should not be excluded and the greatest effusion on the left could also suggest a retraction of the lung induced by cancer. The association between hypertension and constrictive pericarditis has been moreover described. Some connective tissue disorders as some vasculitis can present with a pleuro-pericardial involvment, but the apparent lack of systemic finding, the normal WBC and plasma viscosity make this diagnoses unlikely. Furthermore these elements, as the absence of the cough, argue against a parapneumonic effusion. Pulmonary embolism looks like an attractive hypothesis, mainly multiple micro-embolization altough there are any risk factor known for deep venous thrombosis. The bilateral ankle oedema could suggest thrombosis of the inferior vena cava. Systemic hypertension and orthopnoea lower the probability of pulmonary embolism as well as the absence of chest pain or cough, but do not rule out it. In conclusion, CHF remains the leading hypothesis and the cause of this syndrome needs to be rapidly discovered. Even constrictive pericarditis, particulary neoplastic, and pulmonary embolism should be carefully considered. With regard to the concomitant hypertension, I would keep in mind other less probable etiologies, such as renal artery stenosis, a carcinoid syndrome or an atrial septal defect. I would continue the diuretic therapy, increasing the dose (intravenous) and monitoring the patient for two-three days. I think that we still don’t need to make a thoracentesis, unless the patient develops rest dispnoea. I would not give her an ACE inhibitor before a renal artery stenosis has been excluded. I would make thoracentesis if there has been any improvement after two days. I would ask echocardiography at this instant and the next steps are largely dependent on his results. I would dose glicemia, lipids, amilase, lipase, DE-dimers, serum globulins level and ask for an abdominal-pelvic ecography. I would ask more about her past history and make an accurate objective examination. If these investigations would not be available, the dosage of BNP could be an idea, but the pre-test probability of CHF is very high and only a very low level of BNP could significantly lower this value. I would esplain to Mrs Dempsey that her dispnoea is due to an overload of fluids in her lungs an that this condition can be due to many causes, most of which are resolvable. I would also tell her that in the next days it could be necessary to make a thoracentesis in order to discover the cause of her illness and give her relief. Competing interests: None declared |
|||
|
|
|||
|
JUDE. I. OKOH, medical officer(general practice) michelin group nigeria
Send response to journal:
|
likely cause of her bilateral pleural effusion is from a CHF as baseline either from a dilated cardiomyopathy,or incompetent valves from a rheumatic heart dx. must have been an insidious condition which must have been compensating for long only to start decompensating at the onset of her symptoms. one must also rule out neoplasia either of pulmonic origin or as secondaries. There is also a possibility of an infectious base to explain the effusions e.g T.b. in terms of treatment, the dose of frusemide should be increased in additional to using an ACE inhibitor to control the B.P in stepwise fashion pending outcome of other investigations.if the effusions are still refractory,a drainage option may be considered investigations- These investigations are available. I will tell mrs dempsey that there are a number of likely causes of her condition and that it is pre-emptive to jump to conclusion at this stage but will be able to get to the root as soon as the investigations are completed but meanwhile we will need her to be on admission both for close monitoring and for investigations. Competing interests: None declared |
|||
|
|
|||
|
TJ Littlewood, Consultant haematologist Kohn Radcliffe Hospital, OX£ 9DU
Send response to journal:
|
Heart failure, pulmonary emboli, malignancy, constrictive pericarditis/pericardial effusion are all possibilities. The raised JVP and ankle swelling make me wonder whether the pansystolic murmur might be tricuspid rather than mitral. An echocardiogram and pleural tap would be very helpful but we also need more detail about the physical signs which have been detected. Pulmonary emboli need to be specifically excluded, if possible. The present findings should be explained. She can be reassured that although we do not know the cause of her breathlessness at the moment we should do so very soon and we will let her know the results of further tests as they happen. Like another correspondent the role of the haematologist is noted. I have recently seen someone with primary amyloid present just like this; so that's an outside thought. Competing interests: None declared |
|||
|
|
|||
|
Peter D McSorley, Consultant FDRI FK15QE
Send response to journal:
|
1. LV systolic dysfunction is very unusual in the presence of a virtually normal ECG. The features might suggest a restrictive disorder like amyloid perhaps associated with myeloma - it must be of some relevance that the patient was under a haematologist. Multiple PE is also possible but pericardial effusion is unlikely as the ECG shows normal sized complexes. Treatment with loop diuretic and spironolactone might be helpful. 2. Echocardiogram, plasma proteins, urinary peptides, blood cultures 3. Pleural aspirate culture, cytology and LDH would be a reassurance that neoplasia had not been missed. CT of chest and abdo also. 4. That fluid is present in the chest and that more tests are needed to say what the case might be Competing interests: None declared |
|||
|
|
|||
|
José M Porcel, Internist Arnau de Vilanova University Hospital, 25198 Lleida, Spain
Send response to journal:
|
The most likely cause of pleural effusion in this 66-year old woman with breathlessness is constrictive pericarditis. There are a number of data suggesting this diagnosis: fatigue, excercise intolerance, and signs of systemic venous congestion (e.g. elevatad jugular venous pressure, peripheral edema). As in this case, chest radiograph usually shows a normal cardiac silhoutte, bilateral (less frequently unilateral) pleural effusion and abscense of pulmonary venous congestion. The clinical pìcture is often misdiagnosed as heart failure. Thoracentesis should be performed. In most patients, analysis of pleural fluid demonstrates a transudate. Echocardiography is a primary tool for the diagnosis of constrictive pericarditis, but usually not conclusive. Computed tomography and magnetic resonance imaging can readly detect the presence of pericardial thickening. However, confirmatory diagnosis requires documentation of abnormal hemodinamic values by means of catheterization. Patient should be informed that pericardiectomy is the treatment of choice, but that clinical improvement after this surgical procedure may be delayed for months. Competing interests: None declared |
|||
|
|
|||
|
Cornelis K. van Sichem, GP 2071 DH Santpoort-Noord Netherlands
Send response to journal:
|
Given the results this seem to be a case of right (jugular venous pressure and periferal edema) and left ventricular failure. Causes are many, e.g. silent myocardial infarction (the ECG shows poor R- progression), which could explain the likely mitral valve insufficiency, pleuritis/pericarditis carcinomatosis, pulmonary emboli, collagen diseases as rheunatoid arthritis and many more.As my trainer used to say, "Common things occur commonly", a trial of loop diuretics would be the initial treatment. This should give quick relief. If there is no response further investigations are mandatory to reveal the cause of the effusions. In general practice this would probably mean referral, although a pleural tap is quite easy to perform. As the lab results are normal, a pleural tap is probably the best option as it will probably, at least partially, resolve the breathlessness. Yours sincerely
Competing interests: None declared |
|||
|
|
|||
|
Olumide A Adeotoye, Consultant Physician & Geriatrician St. George's Hospital, Suttons Lane, Hornchurch, RM12 6RS
Send response to journal:
|
The most likely cause of Mrs Dempsey's pleural effusion is biventricular heart failure secondary to a pericardial effusion. I would suggest an echocardiogram, pleural fluid aspiration for biochemical and cytological analysis, and a CT scan of the thorax. Alternatively a lateral chest radiograph could be done. I would tell the patient that there was evidence of congestion of both lungs with fluid collections covering both lungs due to heart disease. I would also explain the need for further tests to clarify things. Competing interests: None declared |
|||
|
|
|||
|
Chris Chung, SHO Orthopaedics Great Western Hospital, Swindon
Send response to journal:
|
My answers would be: 1)Lung malignancy - the lung oedema is more marked on the right, a powerful loop diuretic frusemide has been tried and it has not benefited this lady, mild ankle oedema suggests that CCF is less likely, and the ECG doesn't show any ischaemic signs or any cardiac hypertrophy. 2)Needle aspiration of the pleural effusion for microscopy, culture and sensitivity, for acid fast bacilli, for gram staining, for protein analysis,for microscopy and histology. Further investigations depending on the results of this initial battery of tests. 3)Oxygen therapy tailored to the degree of dyspnoea helped with physiotherapy until investigations are available. 4)We need to do further tests. Competing interests: None declared |
|||
|
|
|||
|
Abdullah Mohammed, Clinical Research Registrar The Cardiothoracic Unit, Northern General Hospital Herris Rd,Sheffield S4 ,UK
Send response to journal:
|
This lady presented with symptoms and signs consistent with biventricular failure and probable functional mitral regurgitation.The history gives no clues as to the cause of her obvious heart failure apart from hypertension.This is likely to be long standing in view of the presence of LVH criteria on the ECG(deepest S wave and highest R wave in chest leads totalling more than 35 mm).Although ischaemic heart disease remains the commonest cause of heart failure ,this seems unlikely in the abscence of other risk factors apart from hypertension,especially in the abcsence of ischaemiac changes on the ECG in particular those which indicate previous myocardial infarctions.The only other possibility is a primary mitral valve pathology with hypertension being a second diagnosis which may have exaerbated the problem.The clinical findings makes no mention of specific mitral pathology such as mitral valve prolpase signs apart from the pansystolic murmur.Rheumatic heard disease is possible even in the abcsence of history of rheumatic fever as many patients have no definitive childhood diagnosis of rheumatic fever.Rheumatic mitral regurgitation is often associatede with features of mitral stenosis not mentioned in the in the clinical findings, unless those are missed in the prodominace of mitral regurgitation signs. As the lady clearly has siginfican fluid overlaod and odema she is less likely to respond to oral diuretics in view of the associated gut oedema which reduce absorption .Therefore inravenous twice daily boluses of frusemide at 80 mg is likely to produce good diuresis.Daily weight , fluid balance monitoring, fluid restriction to a maximum of 1.5 L/24 hours and daily Urea and electrolytes is mandatory to guide changes to her treatment.An ACE inhibitor would be beneficial to treat both hypertension as well as the evident cardiac failure , provided confidence of the abscence of mitral stenosis can be ascertained clinically. An Echocardiogram or other mode of imaqging to the heart eg MRI would be most useful to clarify both left and right ventricular function as well as to identify and quantify the nature of the pansystolic murmur and assess other valves and chambers dimensions and rule out rare and unexpected pathologies. If the echocardigram is not availble some suggested BNP ,although useful in the context of dyspnoea of mixed cardiac and respiratory nature for example in COPD patients,BNP in this lady is likely to be high as there is no doubt to the diagnosis of heart failure.Bilateral pneumoniae and associated pleural effusion is discounted by the lack of raised inflammatory markers and abscence of features of chest infection, smoking history travel, or chronic lung disease. Patients councelling is essentail based on available data.Hence one would allow the patient to ask the questions, she wishes answers for.The clinical diagnosis of reduced heart function and fluid overload is evident.The emphasis on further investigations including the possibility Sending pleural fluid samples for histology if the most likely diagnosis(heart failure)is not confirmed. Competing interests: None declared |
|||
|
|
|||
|
mansoor feroze, senior registrar, ASH, Karachi 74700
Send response to journal:
|
Mrs. Dempsey has presented with symptoms that are typical of chronic heart failure, but there are findings that point towards another possibility: Bilateral pleural effusion, borderline cardiomegaly with normal ECG are unlikely to represent chronic heart failure of this severity, and rapid progression. But it suggests that this lady had pre- existing ischaemic heart disease (and hypertension) which become unusually progressive due to some other associated disorder, most probably hypothyroidism in this case. This is further suggested by a low voltage, and QTc (in upper limits of normal) in her ECG. So, the pleural effusion here is secondary to chronic heart failure. At this stage, I would be reluctant to go for thoracentesis, as it is unlikely to help in establishing (or refute) the diagnosis. Echocardiogram will be helpful to quantify LV function, and to exclude any structural mitral valve disease, if any. Thyroid function tests have already been checked and found to be normal. However, in heart failure it is often difficult to interpret thyroid function tests. Free T4, and detection of thyroid antibodies will help. On the management side, I would intensify therapy for heart failure: intravenous furosemide, angiotensin converting enzyme inhibitor. Thyroxin therapy upon confirmation of diagnosis. I will reassure the lady that her symptoms would resolve, but she needs hospitalisation for the treatment, and for further evaluation of her symptoms. Competing interests: None declared |
|||
|
|
|||
|
John B. Hearn, Retired Radiologist Siant Joseph Hospital Medical Centre Towson Md 21136 USA, None
Send response to journal:
|
I would advise a CT scan of the abdomen with IV contrast. She may have an obstruction to her inferior vena cava from a thrombosis possibly from a malignancy that is causing tumour thrombosis spreading into the cava and impeding the normal venous drainage of the lower exremities in addition to the pleura, if the thrombosis has spread high enough. A possible site could be an undetected hypernephroma. I note, from the history that she has lost weight for 6 months and has fullness in the abdomen. I feel reasonably certain that the cause lies in the abdomen Competing interests: None declared |
|||
|
|
|||
|
harjeet singh, sho cv34 5 yr
Send response to journal:
|
i think most probable cause is heart failure .my second thought also goes to carcinoma (metastasis)particularly ovarian (meigs syndrome).so for further investigaions i would recommend analysis of pleural fluid for proteins and carcinomatic cells,tumor markers ,and abdomen scan, echocardiography to rule out cardiac pathology,. patient sholud be informed about all the possibilities and need for further investigations. Competing interests: None declared |
|||
|
|
|||
|
Prashanth Manjanabail, Doctor DN25AB
Send response to journal:
|
My diagnosis at this stage 1)biventricular failure 2)pulmonary hypertension to be ruled out i would like to get a echo in first instance.If echo is not suggestive a full pulmonary function test .I would also like to get the pleural fluid analysed I would tell the patient that at the moment i am still investigating her and i have not arrived at a conclusive diagnosis Competing interests: None declared |
|||
|
|
|||
|
Brian P Corbett, GP The Village Medical Centre, Linthorpe, Middlesbrough.
Send response to journal:
|
1)Mitral incompetance from ruptured Chordae tendina was my first thought with insufficiently tried diuresis. The addition of ACE (Angiotensin Converting Enzyme) inhibtors, starting with low dose and at night, while monitoring renal function at each change of dose. 2) We can call on our local heart failure clinic which has a couple of GPs in its staff to do an echocardiogram. 3) A lateral CXR(Chest X Ray) might allow better assessment of the true cardiac enlargment. 4) That she was not having a heart attack and that her prognosis is good due to her general well being and fitness, although I would mention my uncertainty without transmitting a sense of catastrophy. Competing interests: None declared |
|||
|
|
|||
|
Som nath, Sr.Consultant Medicinr & CriticalCare Hyderabad-500073
Send response to journal:
|
1.It seems a case of Diastolic Heart Failure becuse of Undiagnosed long standing Hypertansion. 2.I will go for 2D Echocardiography. 3.First control the High B.P. as well as optimize the Diuretics. 4.Do not stress till the treatment is optimized. Dr. Somnath
Competing interests: None declared |
|||