Intended for healthcare professionals

Endgames Case Report

A young man becomes short of breath and yellow

BMJ 2011; 342 doi: (Published 18 May 2011) Cite this as: BMJ 2011;342:d2637
  1. K Sambasivan, foundation doctor,
  2. E Osman, consultant in acute medicine
  1. 1Basildon and Thurrock University Hospital, Essex SS16 5NL, UK
  1. Correspondence to: K Sambasivan, 107 Brim Hill, London N2 0EZ, UK k.sambasivan{at}

A previously well 48 year old man presented with a two week history of worsening shortness of breath, leg swelling, and “yellowing of his skin.” His medical history included excessive alcohol intake (65 units/week) and carpal tunnel syndrome, and he was taking no regular medication. On inspection he was tachypnoeic (respiratory rate 30 breaths/min), tachycardic (heart rate 102 beats/min), and jaundiced. His blood pressure was 98/60 mm Hg. Cardiovascular examination showed a raised jugular venous pressure (visible at the earlobe), a pansystolic murmur at the left sternal edge, and bilateral pedal oedema. Both respiratory and abdominal examinations were unremarkable, and resting electrocardiography showed a sinus tachycardia.

Blood tests on admission showed deranged liver function (alanine aminotransferase 332 U/L, aspartate aminotransferase 80 U/L, bilirubin 37 µmol/L, international normalised ratio 1.6) and a red cell macrocytosis (mean cell volume 98 fL). Chest radiography showed an enlarged heart shadow with a globular outline. An ultrasound of the abdomen showed the liver to be normal in size, shape, and echo texture. The common bile duct was not dilated.

Blood tests three days later showed a rapid deterioration in liver function (alanine aminotransferase 938 U/L, aspartate aminotransferase 846 U/L, bilirubin 53 µmol/L, and international normalised ratio 1.9). Hepatitis serology, tissue autoantibodies, ferritin, and caeruloplasmin were normal. Abdominal ultrasound was repeated and showed 18 cm hepatomegaly (with normal texture and reflectivity of the liver), with distension of the inferior vena cava and hepatic veins.


  • 1 What is the diagnosis?

  • 2 What is the most likely underlying cause?

  • 3 What further investigations would you consider?

  • 4 How would you manage this patient?


1 What is the diagnosis?

Short answer

Congestive cardiac failure.

Long answer

This …

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