A patient was admitted to hospital for gradually worsening dyspnea during the last 14 days. She presented with hypoxemia, hypercapnia, respiratory acidosis not compensated metabolically and with significant spastic breathing sounds bilateral. She is severely obese (155 kg).
Her history encompasses nephrectomy for renal carcinoma, hysterectomy for adenocarcinoma and right hemicolectomy for ascending colon carcinoma.
Lab tests revealed BNP 17914 pg/ml, troponin 94 pg/ml. Inflammatory markers were not elevated. Creatinine 2.71 mg/dl.
Echocardiography was performed during the admission – the recordings are not be shown due to a bad quality resulting from the patient´s obesity. Left ventricle presented with good function and no RWMA. Signs of the pressure overload of the right heart with dilation, hypertrophy and good contractility of the right ventricle. Prediction of pulmonary hypertension based on acceleration time, good-quality recording of tricuspid regurgitation could not be acquired. Pericardial effusion was excluded. Dilation of the right atrium, the diameter of inferior vena cava exceeded the value of 25 mm. Inferior vena cava showed minimal variability over the breathing cycle. Dilation of hepatic veins. The finding was concluded as chronic cor pulmonale with acute decompensation – the cause of elevated pulmonary vascular resistance still needed to be found out. Differential diagnosis encompassed chronic thromboembolic pulmonary hypertension, obstructive sleep apnoea syndrome and primary pulmonary hypertension.
The first lung ultrasonography performed in laying patient has revealed A-profile at all BLUE points bilaterally. There was pulmonary effusion (height of 2 cm) dorsolaterally on the right side above diaphragm with compression atelectasis.
Ultrasonography of the lower limb veins and lung ultrasonography were performed due to suspicion of successive pulmonary embolism: