P R E S E N T A T I O N O F C A S E:
A 66-year-old woman was admitted to this hospital be cause of cardiac and renal failure.
The patient had been well until approximately 6 months earlier, when dyspnea on exertion and leg edema developed. A diagnosis of congestive heart failure was made at another facility. Two months before this evaluation, dyspnea worsened. The patient was admitted to the other hospital. An electrocardiogram (ECG) showed T-wave inversions in leads I and aVL. The serum level of urea nitrogen was 38 mg per deciliter (13.6 mmol per liter), and the level of creatinine was 1.9 mg per decili-ter (168 µmol per liter); the estimated glomerular filtration rate was 27 ml per minute per 1.73 m2 of body surface area. Results of a complete blood count and of tests of coagulation were normal, as were serum levels of sodium, carbon dioxide, glucose, total bilirubin, aminotransferases, and amylase. A chest radiograph was reportedly normal; computed tomography (CT) of the chest after the administration of contrast material reportedly revealed findings that were consistent with pulmonary edema. Noninvasive testing for venous thrombosis and pulmonary emboli was negative. Urinalysis at that time reportedly revealed protein (30 to 100 mg per deciliter), and a culture grew group B streptococci. Ultrasonography of the kidneys was normal. Diuretic agents were administered, and the patient was discharged. Dyspnea on exertion persisted and gradually worsened.
Five days before admission, the patient
came to the emergency department at this hospital.
On examination, the
temperature was 36.6°C, the blood pressure 143/80 mm Hg, the pulse 60 beats per
minute, and the respiratory rate 18 breaths per minute. There was mild pitting
edema in the legs, and the remainder of the exami-nation was normal.
The
complete blood count and levels of electrolytes and glucose were normal; other
laboratory results are shown in Table 1.
An ECG showed sinus rhythm at 62 beats
per minute, with low-voltage QRS complexes, T-wave ab-normalities in precordial
leads V5
and V6,
and evidence of possible left atrial enlarge-ment. A chest radiograph was
normal. The patient was referred to the cardiac and renal clinics. During the
next 5 days, a cough productive of yellow sputum developed,
with rhinorrhea, worsening orthopnea, and dyspnea on exertion, and the patient
was able to walk only short distances before resting. She returned to the
emergency department.
The patient reported no chest pain or
pressure and no nausea, sore throat, rashes, myalgias, hemoptysis, sinusitis,
vomiting, diarrhea, abdominal pain, fevers, chills, or dysuria. She had
hypertension, hyperlipidemia, osteoarthritis, coronary artery disease, and a
history of myocardial infarction several years earlier.
She was born in Europe, had immigrated to the United States 40 years earlier, lived with her husband, and was retired. She did not smoke, drink alcohol, or use illicit drugs. Medications included furosemide, ezetimibe, atenolol, pravastatin, valsartan, and acetylsalicylic acid. Her father had had a myocardial infarction at 76 years of age, her mother had had a stroke at 86
She was born in Europe, had immigrated to the United States 40 years earlier, lived with her husband, and was retired. She did not smoke, drink alcohol, or use illicit drugs. Medications included furosemide, ezetimibe, atenolol, pravastatin, valsartan, and acetylsalicylic acid. Her father had had a myocardial infarction at 76 years of age, her mother had had a stroke at 86
An ECG showed low voltage, nonspecific
T-wave abnormalities and findings suggestive of left atrial enlargement. A
chest radiograph was normal The complete blood count and
differential count were normal, as were antistreptolysin O and anti–DNase B
titers and measurements of elec-trolytes, glucose, calcium, phosphorus,
magnesium, total protein, albumin, globulin, total and direct bilirubin,
aminotransferases, complement (C3 and C4), iron, iron-binding capacity, and
ferritin; tests for hepatitis B and C viruses were negative. Screening for
toxins and serologic testing for the human immunodeficiency virus, syphilis,
and cryoglobulins were negative; a test for antinuclear antibodies was positive
at 1:40 and 1:160 dilutions, in a speckled pattern; antibodies to
double-stranded DNA, Ro, La, Sm, RNP, Scl-70, and histone were negative.
Urinalysis showed clear, yellow urine, with a specific gravity of 1.012, pH
6.5, 2+ occult blood, 3+ albumin, 20 to 50 red cells, a few squamous cells per
high-power field, and 10 to 20 hyaline casts per low-power field. Cultures of
the sputum grew normal respiratory flora; the urine grew moderate mixed flora.
Testing for influenza A and B viruses and respiratory syncytial virus antigens
was negative. Other test results are shown in Table 1.
Furosemide and levofloxacin were
administered, and the patient was admitted to this hospital. The next day,
the temperature was normal and bibasilar pulmonary crackles persisted. CT of
the chest revealed atelectasis in the lingula, patchy groundglass opacities in
the right upper lobe, and diffuse bronchial-wall and interlobular septal
thickening, features that are consistent with pulmonary edema or atypical
pneumonia. The pulmonary artery was mildly enlarged, and multiple
subcentimeter lymph nodes in the mediastinum and diffuse osteopenia were
present. A transthoracic echocardiogram showed an ejection fraction of 56%
with biventricular hypertrophy, left atrial dilatation (55 mm in the greatest
dimension), elevated left atrial pressure, a left ventricular ejection
fraction of 56%, and an estimated right ventricular systolic pressure of 49 mm Hg.
On the third day, pulmonary-function
tests revealed a forced vital capacity of 1.77 liters (72% of the predicted
value), and the forced expiratory volume in 1 second was 1.11 liters (57% of
the predicted value). Renal ultrasonography was normal. Test results are shown
in Table 1.
A radio-graphic skeletal survey on the sixth day revealed lytic lesions within both humeri and the skull.
A radio-graphic skeletal survey on the sixth day revealed lytic lesions within both humeri and the skull.
A
diagnostic procedure was performed, and management
decisions were made.
decisions were made.
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