The absence of fever, presence of cardiomegaly on CXR, and an elevated N-terminal pro B-natriuretic peptide level of 8800 pg/mL raised doubt about pneumonia as the sole cause of this presentation. We administered 160 mg of intravenous frusemide over 12 hours for a working diagnosis of unilateral pulmonary edema secondary to heart failure, which resulted in rapid improvement of respiratory status and oxygenation. She was able to breathe without the need for bilevel positive airway pressure after 48 hours. The blood culture and the sputum bacterial and viral cultures did not show any growth. A follow-up CXR 72 hours after admission revealed near-complete resolution of the right lung opacities, which made the diagnosis of pneumonia unlikely because pulmonary opacities secondary to pneumonia take weeks to resolve. (Figure B) The echocardiogram showed global hypokinesia, an ejection fraction of 25%, a severely dilated left atrium, and only mild mitral regurgitation. These findings supported the diagnosis of heart failure as the cause of this presentation.
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-Facundo E. Stingo, MD, Tariq Sallam, MD, Rukma Govindu, MD, Hussam Ammar, MD
