Clinical Review Interactive case report

A 66 year old woman with breathlessness: case progression

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7442.758 (Published 25 March 2004) Cite this as: BMJ 2004;328:758
  1. Douglas Lowdon, specialist registrar in medicine for the elderly (douglas.lowdon{at}tpct.scot.nhs.uk)1,
  2. Marion McMurdo, professor of ageing and health2
  1. 1Royal Victoria Hospital, Dundee DD2 1SP
  2. 2Ageing and Health, Division of Medicine and Therapeutics, Ninewells Hospital, University of Dundee, Dundee DD1 9SY
  1. Correspondence to: douglas

    Last week (20 March, p 698) we described the case of Mrs Dempsey, who was investigated for a two month history of breathlessness and swollen ankles. Despite the paucity of cardiovascular risk factors and normal electrocardiographic appearances, we made a presumptive diagnosis of cardiac failure because of her bilateral pleural effusions. She was prescribed an angiotensin converting enzyme inhibitor and her diuretic dose was doubled. Outpatient echocardiography was organised to define the pathology and quantify her cardiac dysfunction.

    She was advised her breathlessness was probably a consequence of heart dysfunction. The cause of the potential cardiac failure, though, was not clear. She did not seem concerned by this; she was convinced she did not have heart problems because she had never had chest pain and was excited at the prospect of having “the fluid on her lungs” treated.

    We reviewed Mrs Dempsey three weeks later, after her echocardiography results were available. Her condition had not changed despite treatment. We asked her about adherence, but this did not seem an issue and, indeed, she complained about “rushing to the toilet all the time.” The echocardiogram showed good systolic function and normal diastolic size. She had no left ventricular hypertrophy and only mild mitral regurgitation. She had mild pulmonary artery hypertension (pulmonary artery systolic pressure 32 mm Hg). Repeat chest radiography confirmed similarly sized effusions. The normal echocardiographic results made a diagnosis of heart failure questionable, and we sought another cause for the pleural effusions.

    Questions

    1. What are the possible causes of the pleural effusions?

    2. What investigations would you do next?

    3. What information should the hospital pass back to the general practitioner at this stage?

    4. What action might be appropriate for the family doctor?

    A diagnostic pleural tap of the left effusion was not blood stained and the fluid had a protein count of 39 g/l, in keeping with an exudative process. Microscopy of the fluid showed no malignant cells but many mature lymphoid cells together with macrophages and a few mesothelial cells. Culture gave negative results.

    We investigated Mrs Dempsey's history again. As well as her previously elicited symptoms, she described non-specific lethargy, weight loss of half a stone in the last six months, and a feeling of abdominal fullness. She denied pleuritic chest pain. A further physical examination showed no obvious masses, lymphadenopathy, enlarged organs, or any clinical evidence of deep vein thrombosis.

    She was told that her breathlessness was now unlikely to be due to heart failure because her echocardiogram appeared normal and analysis of the pleural fluid was not consistent with the diagnosis. The cause of the effusions was not clear.

    This is the second of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. In four weeks' time we will report the outcome and summarise the responses

    Acknowledgments

    We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers. Full details of criteria are available at: bmj.com/cgi/content/full/326/7389/564/DC1

    Footnotes

    • Competing interests None declared

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