Digging Deeper into Dyspnea

A 49-year-old homeless woman was admitted for worsening shortness of breath and lower extremity edema. Two weeks prior she was hospitalized for appendicitis and underwent successful laparoscopic appendectomy. Her history was notable for severe obesity, with a body mass index of 59.9 kg/m2, bipolar disorder, hypertension, impaired fasting glucose, asthma, and difficult-to-control chronic lower extremity edema for 2 years, managed with diuretics. For 2 years she complained of progressive weight gain of 40 kg and progressive dyspnea limiting her from performing daily activities. These symptoms had been attributed to her severe obesity. There was no history of tuberculosis or rheumatic disease, although she had a severe pneumonia 2.5 years prior with associated empyema. She denied recent fever, cough, or hemoptysis.

On physical examination her weight was 159 kg, temperature 36.3°C, pulse 94 beats per minute, respirations 16 breaths per minute, blood pressure 116/90 mm Hg, and oxygen saturation 98% on room air. She had a very large body habitus and no scleral icterus. Her jugular venous pressure could not be seen. Auscultation revealed clear lungs, a normal S1 and S2 with no murmurs, gallops, or rubs. The abdomen was obese soft, and nontender with healing laparoscopy incisions. The lower extremities showed 2+ pitting edema and multiple superficial skin ulcerations on the lower legs at various stages of healing.

Due to the recent appendectomy, a computed tomography (CT) scan of the abdomen was obtained, demonstrating normal postsurgical changes with marked hepatic congestion. An included portion of the lower thorax revealed a markedly thickened pericardium measurinf >6 mm in multiple locations (Figure, panel A). A transthoracic echocardiogram, although limited by suboptimal image quality, showed a subtle interventricular septal bounce, mild respiratory changes in the mitral E velocity, increased mitral medial annulus e′ velocity of 0.15 m/s (Figure, panel B), and dilated inferior vena cava with expiratory flow reversals in the hepatic veins. Subsequent tuberculin skin test and QuantiFERON-TB tests were negative, and sputum samples were negative for acid-fast bacilli.

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— Mackram F. Eleid, MD, Barry A. Borlaug, MD, Sharon Mulvagh, MD

This article originally appeared in the March 2013 issue of The American Journal of Medicine.