9/12/17 Resident Morning Report – Dyspnea on Exertion, HIV/AIDs, Pulmonary Hypertension, Ischemic Liver Injury

CC: Dyspnea on exertion

ID: This is a 52 year-old male with history of HIV intermittently taking antiretrovirals that presents with 2 months of progressive dyspnea on exertion. His functional status has slowly declined and patient can barely walk a block before becoming short of breath.  Patient denies any skin rash, fevers, recent URI, cough, night sweats, recent travel, orthopnea, or extremity swelling.  On exam patient requiring 6L NC to saturate >92%, tachypneic to 26, with a lower blood pressure then is typical for him, around 100/70.  He has clear lung fields but there is notable increase in his JVP as well as cold extremities on physical exam.

Notable Labs/Studies:

ABG: pH 7.43/ PCO2 28mmHg/PO2 45 mmHg/ HCO3 12

AST/ALT: 3960/1140

Tbili/Direct Bili: 3.1/2.2

Utox positive for amphetamines and opiates

CD4 count 110

 

 

Given clear CXR, evidence of right heart hypertrophy and strain on EKG, and elevated JVP on exam TTE pursued which demonstrated significant pulmonary hypertension.  This was followed by right heart catheterization (see values below).  His severe pulmonary hypertension was thought to from HIV but drug use could not be excluded.  He was not vasoreactive on catheterization so calcium channel blockers could not be used in his management.  Liver was consulted for the transaminase elevation and after excluding other etiologies, believed this hepatocellular injury to be from ischemia due to severe right heart failure and poor cardiac output.

 

Right Heart Catheterization:

  • CVP 14
  • PAP mean 68
  • PA systolic/PA diastolic: 109/49
  • PCWP: 12
  • CO/CI: 2.85/1.6

Teaching Points:

Remember causes of hypoxia with a normal chest x-ray:

-Asthma, Pulmonary embolism, Early PNA, ILD, Early PCP, Pulmonary Hypertension, Shunts, Hypoventilation

 

Know the Criteria to diagnosing Pulmonary Arterial Hypertension:

  1. PAP mean >25
  2. Pulmonary Artery Resistance >3 woods units
  3. Wedge pressure <15

 

To Diagnose Pulmonary Hypertension secondary to HIV, it is necessary need to exclude other causes.  Important studies to pursue to work up other WHO Classifications of Pulmonary Hypertension:

  • Transthoracic Echocardiogram
  • V/Q Scan
  • PFTs
  • Polysomnography
  • Autoantibody testing
  • High resolution CT

 

 

 

 

11/4/16 Intern Morning Report – Mediastinal Mass

CC: 3 weeks of chest pain and dry cough

ID: 56 yo female with migraines and uterine cyst presents with sharp, non-exertional chest pain and dry cough for the past 3 weeks.  She was found to have a mediastinal mass on CXR and 6% peripheral blasts.  Bone marrow biopsy revealed B-lymphoblastic leukemia/lymphoma.

cxr

ct

Don’t forget:

  • To evaluate whether a mass on an upright CXR arises from the mediastinum or the lung, consider the following:
    • does the mass seem to touch the mediastinum or heart border?
    • are the borders of the mass smooth and sharp (instead of spiculated)?
    • are the angles at which the mass meets the mediastinum obtuse?
    • are the borders of the mass smooth (instead of lobulated or undulating)?

If the above answers are “yes,” it suggests that the mass is mediastinal rather than from the lung.

  • The anterior, middle, and posterior mediastinal compartments are theoretical – there are no surgical or anatomical planes that create a clear division (hence, different radiology groups define each compartment a little differently).  Therefore, a mediastinal mass can be found in more than one compartment.

mediastinal-mass

Mediastinal Masses (PDF)


Pearls from morning report:

  • Lymphomas encase, but do not compress adjacent structures.
  • Not all malignancies will result in tumor lysis syndrome (TLS).  TLS is seen most frequently in high grade lymphomas, acute leukemia, and rapidly proliferating tumors
  • Indications for HD in TLS include hyperphosphatemia-induced symptomatic hypocalcemia, persistent hyperkalemia, and severe oliguria or anuria.

Random trivia:

Wilhelm Röntgen, a German physicist and mechanical engineer, produced and detected X-rays in 1895.  X-rays are named as such to signify an unknown quantity.  They are also known as roentgenograms (röntgenograms) – named in his honor.


Want to read more?

The Tumor Lysis Syndrome (New England Journal of Medicine)


References: 

Whitten CR, Khan S, Munneke GJ, Grubnic, S. A diagnostic approach to mediastinal abnormalities. Radiographics. 2007;27(3):657-71.