Intern Emerg Med (2014) 9:891–892 DOI 10.1007/s11739-014-1134-z
CE - PHYSICAL EXAMINATION
An unusual diagnosis of increasing respiratory failure after lung resection Cristiano Carbonelli • Giorgio Vezzani • Teresa Grimaldi • Filippo Lococo • Cristian Rapicetta Luigi Zucchi
•
Received: 22 July 2014 / Accepted: 16 September 2014 / Published online: 7 October 2014 Ó SIMI 2014
Keywords Postoperative respiratory failure Thoracic surgical oncology Pulmonary circulation physiopathology Dyspnea Interventional cardiology Cardiovascular disease
Case presentation A 77-year-old non-smoker female with an unremarkable medical history was admitted to the Thoracic Surgery Unit for a solitary pulmonary nodule (SPN) of the right lower
C. Carbonelli (&) G. Vezzani L. Zucchi Pulmonology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Viale Risorgimento 80, 42123 Reggio Emilia, Italy e-mail: [email protected] G. Vezzani e-mail: [email protected] L. Zucchi e-mail: [email protected] T. Grimaldi Cardiology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy e-mail: [email protected] F. Lococo C. Rapicetta Thoracic Surgery Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico Reggio Emilia, Reggio Emilia, Italy e-mail: [email protected] C. Rapicetta e-mail: [email protected]
lobe. At diagnostic workup, a brain CT scan showed multiple ischemic chronic lesions. Despite these findings, which could be suggestive of an asymptomatic chronic paradoxical embolism scenario, a transthoracic echocardiography (TTE) did not reveal cardiac defects or shunts. After clinical staging, the patient underwent sublobar resection for diagnostic purposes for suspicion of primary lung cancer. The frozen section analysis was indicative of a bronchial carcinoid tumor, and, accordingly, a right lower lobectomy was performed during the same surgical attempt. The postoperative course was uneventful, and the patient was discharged on the 7th post-op day. The final diagnosis was indicative of an atypical bronchial carcinoid. Two weeks later, the patient returned to the Emergency Department due to the occurrence of increasing dyspnoea; a hypoxic and hypocapnic respiratory failure was detected at blood gas analysis. Due to the clinical suspicion of a pulmonary thromboembolic event, a CT scan was performed, followed by lung scintigraphy: neither confirmed the diagnosis. At clinical examination, we noted that both the dyspnoea and the gas exchanges worsened (decreased to 20 % of the baseline SaO2 values,) when changing from the supine to the standing position. This condition, generally called platypnea orthodeoxia syndrome, was deemed to be related to a cardiopulmonary right-to-left shunt (RLS) [1]. A retrospective re-evaluation of the lung scintigraphy, showed a tracer uptake in both kidneys and in the brain [2], and a transcranial color-coded duplex sonography (TCCS) with saline contrast medium injection showed multiple high-intensity transient signals (HITS) even during normal breathing [3], confirming the clinical presence of a RLS. A transesophageal contrast echocardiography (TEE,) showed a severe tricuspid insufficiency and fibrotic endocardial plaques (Fig. 1), suggesting long-standing rightsided carcinoid heart disease [4, 5]. Moreover, a patent
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Fig. 1 a Severe tricuspidal regurgitation and endocardium lesions (arrows) and b the large patent foramen ovale (PFO), common findings in carcinoid syndrome
Fig. 2 a Transcatheter clamshell occlusion of patent foramen ovale and b the Amplatzer device no. 35, positioned for relief of severe arterial desaturation and dyspnea due to intracardiac shunts
foramen ovale (PFO) associated with an atrial septal aneurysm was observed at this time, determining an inverse right-to-left cardiac shunt. The mean right atrial pressure was 12 mmHg, higher than in the left atrium. Therefore, a percutaneous closure procedure was indicated [6]; an Amplatzer device was placed (Fig. 2) and a remarkable improvement in the gas exchanges in both supine and standing position was finally obtained in few days. A 68gadotatoc PET scan requested for the persistence of abnormal circulating markers of the neuroendocrine malignant disease, despite radical surgery, showed no residual disease. Chromogranin level was 450 ng/ml and decreased to 175 ng/ml [nv 20–100] following percutaneous closure procedure. The patient was discharged 6 days after the procedure with no need for long-term oxygen therapy.
Acknowledgment
Ms. Jacqueline Costa for writing assistance.
Conflict of interest The author(s) declare(s) that he/she/they have no competing interests.
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Informed consent Written informed consent was obtained from the patient for publication of this Case Report and any and all accompanying images. A copy of the written consent is available for review by the Series Editor of this journal.
References 1. Krowka MJ, Cortese DA (1994) Hepatopulmonary syndrome— current concepts in diagnostic and therapeutic considerations. Chest 105:1528–1537 2. Dogan SA, Rezai K, Kichner PT et al (1993) A scintigraphic sign for detection of right-to-left shunts. J Nucl Med 34:1607–1611 3. Martı´nez-Sa´nchez P, Medina-Ba´ez J, Lara-Lara M et al (2012) Low sensitivity of the echocardiograph compared with contrast transcranial doppler in right-to-left shunt. Neurologia 27(2):61–67 4. Mansencal N, Mitry E, Forissier JF et al (2006) Assessment of patent foramen ovale in carcinoid heart disease. Am Heart J 151:1129.e1–1129.e6 5. Gustafsson BI, Hauso O, Drozdov I et al (2008) Carcinoid heart disease. Int J Cardiol 129:318–324 6. Mansecal N, Mitry E, Pilliere R et al (2008) Prevalence of patent foramen ovale and usefullness of percutaneous closure device in carcinoid heart disease. Am J Cardiol 101:1035–1038
CE - PHYSICAL EXAMINATION
An unusual diagnosis of increasing respiratory failure after lung resection Cristiano Carbonelli • Giorgio Vezzani • Teresa Grimaldi • Filippo Lococo • Cristian Rapicetta Luigi Zucchi
•
Received: 22 July 2014 / Accepted: 16 September 2014 / Published online: 7 October 2014 Ó SIMI 2014
Keywords Postoperative respiratory failure Thoracic surgical oncology Pulmonary circulation physiopathology Dyspnea Interventional cardiology Cardiovascular disease
Case presentation A 77-year-old non-smoker female with an unremarkable medical history was admitted to the Thoracic Surgery Unit for a solitary pulmonary nodule (SPN) of the right lower
C. Carbonelli (&) G. Vezzani L. Zucchi Pulmonology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Viale Risorgimento 80, 42123 Reggio Emilia, Italy e-mail: [email protected] G. Vezzani e-mail: [email protected] L. Zucchi e-mail: [email protected] T. Grimaldi Cardiology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy e-mail: [email protected] F. Lococo C. Rapicetta Thoracic Surgery Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico Reggio Emilia, Reggio Emilia, Italy e-mail: [email protected] C. Rapicetta e-mail: [email protected]
lobe. At diagnostic workup, a brain CT scan showed multiple ischemic chronic lesions. Despite these findings, which could be suggestive of an asymptomatic chronic paradoxical embolism scenario, a transthoracic echocardiography (TTE) did not reveal cardiac defects or shunts. After clinical staging, the patient underwent sublobar resection for diagnostic purposes for suspicion of primary lung cancer. The frozen section analysis was indicative of a bronchial carcinoid tumor, and, accordingly, a right lower lobectomy was performed during the same surgical attempt. The postoperative course was uneventful, and the patient was discharged on the 7th post-op day. The final diagnosis was indicative of an atypical bronchial carcinoid. Two weeks later, the patient returned to the Emergency Department due to the occurrence of increasing dyspnoea; a hypoxic and hypocapnic respiratory failure was detected at blood gas analysis. Due to the clinical suspicion of a pulmonary thromboembolic event, a CT scan was performed, followed by lung scintigraphy: neither confirmed the diagnosis. At clinical examination, we noted that both the dyspnoea and the gas exchanges worsened (decreased to 20 % of the baseline SaO2 values,) when changing from the supine to the standing position. This condition, generally called platypnea orthodeoxia syndrome, was deemed to be related to a cardiopulmonary right-to-left shunt (RLS) [1]. A retrospective re-evaluation of the lung scintigraphy, showed a tracer uptake in both kidneys and in the brain [2], and a transcranial color-coded duplex sonography (TCCS) with saline contrast medium injection showed multiple high-intensity transient signals (HITS) even during normal breathing [3], confirming the clinical presence of a RLS. A transesophageal contrast echocardiography (TEE,) showed a severe tricuspid insufficiency and fibrotic endocardial plaques (Fig. 1), suggesting long-standing rightsided carcinoid heart disease [4, 5]. Moreover, a patent
123
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Intern Emerg Med (2014) 9:891–892
Fig. 1 a Severe tricuspidal regurgitation and endocardium lesions (arrows) and b the large patent foramen ovale (PFO), common findings in carcinoid syndrome
Fig. 2 a Transcatheter clamshell occlusion of patent foramen ovale and b the Amplatzer device no. 35, positioned for relief of severe arterial desaturation and dyspnea due to intracardiac shunts
foramen ovale (PFO) associated with an atrial septal aneurysm was observed at this time, determining an inverse right-to-left cardiac shunt. The mean right atrial pressure was 12 mmHg, higher than in the left atrium. Therefore, a percutaneous closure procedure was indicated [6]; an Amplatzer device was placed (Fig. 2) and a remarkable improvement in the gas exchanges in both supine and standing position was finally obtained in few days. A 68gadotatoc PET scan requested for the persistence of abnormal circulating markers of the neuroendocrine malignant disease, despite radical surgery, showed no residual disease. Chromogranin level was 450 ng/ml and decreased to 175 ng/ml [nv 20–100] following percutaneous closure procedure. The patient was discharged 6 days after the procedure with no need for long-term oxygen therapy.
Acknowledgment
Ms. Jacqueline Costa for writing assistance.
Conflict of interest The author(s) declare(s) that he/she/they have no competing interests.
123
Informed consent Written informed consent was obtained from the patient for publication of this Case Report and any and all accompanying images. A copy of the written consent is available for review by the Series Editor of this journal.
References 1. Krowka MJ, Cortese DA (1994) Hepatopulmonary syndrome— current concepts in diagnostic and therapeutic considerations. Chest 105:1528–1537 2. Dogan SA, Rezai K, Kichner PT et al (1993) A scintigraphic sign for detection of right-to-left shunts. J Nucl Med 34:1607–1611 3. Martı´nez-Sa´nchez P, Medina-Ba´ez J, Lara-Lara M et al (2012) Low sensitivity of the echocardiograph compared with contrast transcranial doppler in right-to-left shunt. Neurologia 27(2):61–67 4. Mansencal N, Mitry E, Forissier JF et al (2006) Assessment of patent foramen ovale in carcinoid heart disease. Am Heart J 151:1129.e1–1129.e6 5. Gustafsson BI, Hauso O, Drozdov I et al (2008) Carcinoid heart disease. Int J Cardiol 129:318–324 6. Mansecal N, Mitry E, Pilliere R et al (2008) Prevalence of patent foramen ovale and usefullness of percutaneous closure device in carcinoid heart disease. Am J Cardiol 101:1035–1038
