A case of progressive bilateral pitting oedema

A 68 year old man presented with a two month history of progressive shortness of breath. He had previously been able to swim three times a week, but was now becoming short of breath on climbing stairs. His associated symptoms included orthopnoea, swollen ankles, weight gain, and anorexia. He was being treated with simvastatin for hypercholesterolaemia and diltiazem for hypertension and had never smoked.

On examination, he was plethoric, his pulse was regular at 84 beats/min, and his blood pressure was 138/72 mm Hg. Heart sounds were normal and his jugular venous pressure was not raised, although he had pitting oedema to the mid thighs. Findings on respiratory examination included a respiratory rate of 20 breaths/min, with dullness to percussion and associated reduced breath sounds over the right lung base. His abdominal examination was unremarkable.

Laboratory tests showed haemoglobin 129 g/L (reference range 130-170), mean cell volume 79.4 fL (80-100), and creatinine 127 μmol/L (80-115). All other blood test results, and an electrocardiogram, were unremarkable. Chest radiography showed mild cardiomegaly and echocardiography showed well preserved left ventricular size and function. As a result, computed tomography with contrast of his chest, abdomen, and pelvis was performed (figure⇓).