We had a really interesting case this past week, please let me share.
A 47 yo male with a meth addiction comes into the ED complaining of lower extremity cellulitis that was making him really sick and uncomfortable. In the ED he was afebrile but tachycardic with an elevated WBC, lactate and ESR meeting sepsis criteria. So ED doctors started him on 3 different antibiotics thinking that the cellulitis was causing bacteremia, drew blood cultures and admitted him to the med-surg floor.
Upon examining this guy in the ED, it became clear to my team (IM) that the cellulitis appeared chronic in nature. What was more concerning was his complaint of mid-epigastric pain that with further questioning he reported was present after eating for the past week. He also complained of shortness of breath, ongoing for the past year but worse in the past week, post-prandial nausea, and anorexia. He had a couple episodes of diarrhea while in the ED and was feeling very uncomfortable over all. He denied fever but had chills intermittently.
On exam, he is a young-appearing guy with multiple tattoos and piercings laying uncomfortably on his right side. Heart and Lung sounds were normal. Abdominal exam revealed a distended abdomen with hypoactive bowel sounds and tympanic on percussion with tenderness to palpation in the mid-epigastrium and RUQ. Lower extremity exam showed dusky colored feet and ankles with poor capillary refill, edematous ankles b/l, color changes consistent with chronic venous stasis with scaling and a 1 x 3 cm superficial ulcer on the right anterior tibia. Similar to below, but with more ankle and foot edema.
We then got the following Imaging and Labs with these results:
- CT Angiogram: negative for PE and PNA
- noted: right ventricular hypertrophy
- Pulmonary artery transverse diameter: 3.9 cm (upper limit of normal: 3.3 cm)
- Venous Doppler: negative for DVTs
- Ankle Brachial Index: normal, no evidence for peripheral arterial disease
- RUQ Ultrasound:
- Gall Bladder wall thickening of 8 mm (normal: 3-4 mm)
- no evidence of gall stones
- Hepatic venous congestion
- EKG: normal sinus rhythm @ 96 bpm, no ST elevation or depression
- Troponins: < 0.024
- BNP: 307
- Alk phosphatase: 188
With the Ultrasound findings & labs we were certain we had a diagnosis: Acalculous Cholecystitis. A HIDA Scan was promptly ordered, but he was unable to complete the study due to abdominal pain. His elevated BNP levels were concerning for heart failure, in a 47 year old., so an ECHO was then ordered.
- Left Ventricular systolic function normal with LVEF of 55-60%
- Mild Aortic Valve Stenosis
- Severe Tricuspid Valve Regurgitation
- Severe Pulmonary Hypertension
- Pulmonary Artery systolic pressure of 79 mm Hg (normal is 15-30 mm Hg)
Meanwhile, the patient’s labs began to return to baseline: no leukocytosis, normal ESR and downtrending Lactate, but the patient did not look better at all. Clinically, he looked more uncomfortable, more distended, and then started complaining of worsening discomfort with breathing.
A CXR was done and revealed a pleural effusion leading to a thoracentesis. Pleural fluid labs compared with serum labs:
- Pleural Fluid LD/ Serum LD Ratio = 0.55
- Pleural Fluid Protein/ Serum Protein Ratio = 377
- According to Light’s Criteria, this is a Exudative Effusion
Now we have the following working diagnoses:
- Acalculous Cholecystitis
- Right-sided Heart Failure secondary to Pulmonary Arterial Hypertension
- Pleural Effusion with an Exudative process
- Sepsis, improving
There were many trails to follow with this fellow, but I’ll summarize now.
Essentially we have a meth addict, smoking meth 1-2x/day for 15 years who is found to have Pulmonary Arterial Hypertension from meth use that caused a right-sided heart failure leading to Tricuspid Valve regurg, and chronic stasis dermatitis. His complaints of dyspnea, abdominal pain, and lower extremity edema were consistent with right heart failure as fluid congestion in the Hepatic Vein, Portal venous system and IVC were increased. His sepsis was likely related to his exudative pleural effusion and maybe with an element of cholecystitis contributing.
The picture was very clinically confused and we chased every lab and imaging available. This was such an interesting case to me because there was a lot of clinical judgement that came into play. Each day, we had to step back and re-think what the patient’s presentation combined with imaging and lab results were indicating to us. It was not straight-forward and, though we threw a ton of imaging at him and daily labs (we even worked him up for Lupus and Rheumatoid disease and Scleroderma!) a team of 4 plus me the med student, were stumped until the end. That is to say, not all that wheezes is asthma, keep digging and keep the bigger picture in mind.