Cardiovascular Pathology Case 4

Part 1

The patient is a 62 year old male with a history of asbestos exposure and interstitial lung disease diagnosed in 1995. He has been on steroids since then and is currently on home O2 at 12 L. He was recently treated for pneumonia and is on the lung transplant list. He presents today with severe shortness of breath and is admitted to the hospital to the pulmonary service for intubation and mechanical ventilation.

Review the Admission History and Physical from 12-18-02.

1. What are the cardiac causes of shortness of breath?

2. How does lung disease affect the heart?

3. Review the admission laboratory results how did these help rule out the possibility of a pulmonary embolus?

4. What do you see on his EKG?

5. What is your differential diagnosis?

Six months before this admission the patient underwent a work up for lung transplantation that included a heart perfusion study. This revealed no evidence of ischemia but did show right ventricular overload.

Additional workup at that time revealed marked pulmonary bullous disease on CT scan.

A Chest view composite from the CT scan also showed cardiac enlargement:

X-rays taken on this admission are shown here.

CXR of 12-20-02

CXR of 12-29-02

Compare the new films with ones from 6-11-02:

Part 2

The patient underwent broncho-alveolar lavage and pneumonia was ruled out. The patient was treated with oxygen and attempts were made to extubate the patient over the next several days. However with each attempt the patient could not maintain his O2 saturations.

Look at the patient’s O2 trends to get an idea of his lung function and how treatment with intubation helped.

Review the Cytology report for the BAL on 12-18-02.

Review the Microbiology reports to determine if there is infection.

1. How did intubation help this patient?

2. What effect does oxygenation have on the heart?

Part 3

On 12-29-02 the patient’s O2 saturations declined and the family decided not to re-intubate the patient per his wishes for non-invasive treatment only.

This is the last progress note.

Review the labs on the day of his death.

Review the Death Summary.

Part 4

The patient died on 12-30-02 and an Autopsy was requested. The Autopsy found that the patient had interstitial pneumonitis on top of his already severe interstitial lung disease; this was probably due to viral pneumonia. His heart was enlarged (590 gm) and the right atrium and ventricle were hypertrophied and dilated. There were hemosiderin laden macrophages in the lungs.

External view of the right ventricle showing enlargement:

Internal view of the right atrium and ventricle showing dilatation:

Picture of the Patent Foramen Ovale when the heart was fresh:

View of the Patent Foramen Ovale in the fixed heart:

Cut surface of the lung:

Close up of the end stage lung disease with interstitial fibrosis:

Microscopic of heart with hypertrophic fibers:

Sections of lung with end stage honey comb changes:

Sections of lung with interstitial inflammation, fibrosis and hemosiderin laden macrophages:

1. What is this type of heart disease called?

2. What is the cause of death?

3. What is the significance of the patent foramen ovale?

Part 5

Assignment for next week

Using all of the information you have gathered from the chart, prepare a presentation about this case as you would for attending rounds with a concise summary of the history, physical findings, labs and x-rays. Your presentation should be about 5 minutes long. A copy of your presentation needs to be handed in to your facilitator by the end of the lab on 12/11/03.

Incorporate the following into your report:

1. What are the effects of lung disease on the heart?

2. How is the diagnosis of Cor Pulmonale made?

3. How do you diagnosis and manage right heart failure?

4. What is a Patent Foramen Ovale, why does it occur in Cor Pulmonale and what risk does it impose on the patient?

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DATA FOR CASE

Admission H&P 12-18-02

Laboratory Reports 12-18-02

Laboratory Reports 12-29-02

Death Summary

Autopsy Report

Normal Values

Admission HP 12/18/2002

CC: worsening SOB, increased O2 requirements HPI: Pt is a 62 yo male with pulmonary interstitial disease secondary to asbestosis, requiring baseline home O2 of 10L, who originally presented on 12/11/02 complaining of SOB, cough, rhinorrhea, without fever/chills/nausea/vomiting. He was admitted and treated for community acquired pneumonia with Azithromycin/cefotaxime/Bactrim SS. While at the hospital he had a negative cardiac workup (troponin I 0.04, CK 113, CK-MB 3.1). He reports a hospital course significant for one day in the ICU and two days in telemetry prior to being discharged on 12/14/01 on Azithromycin 250mg qd, Cefuroxime 500mg bid, Bactrim 800/160 3tabs qid. Following discharge, he continued to feel poorly. He returned to the ER earlier yesterday morning where he was noted to have hypoxia on ABG. They were able to stabilize his saturation level at 88% on 10-12L and so discharged him to home. At home he continued to have difficulty maintaining his saturation levels, and felt uncomfortable lying down in bed. He then decided to come to this hospital. In the ER he was found to be in respiratory distress with a LLL infiltrate on CXR and ABG of 7.44/29.1/52.7 with saturation of 83% on 15L. ROS: chronic SOB, denies any acute changes in SOB but has recently noticed a change in his breathing pattern requiring "pursed lips" to breath over the past couple of days, denies nausea/vomiting/fever/chills, no worsening of his peripheral edema, no productive cough, denies pain or head-ache complains of constipation. PMH: 1) interstitial lung disease: Currently on lung transplant list, with interstitial lung disease secondary to asbestos/plutonium/beryllium exposure in 1962 while in the Navy. His disease was diagnosed by open lung biopsy in 1995 with complications including pulmonary hypertension, cor pulmonale, and severe exercise intolerance. He has been steroid dependent since 1995 with typical dose of 20mg prednisone qd, and he has a baseline O2 requirement of 10-12 L to keep his saturation greater than 80%. Additionally he requires 4 pillows to sleep, and he suffers from lower extremity edema for the past year. 2) steroid induced diabetes mellitus 3) gout 4) htn PSH: 1) Uvulopalatopharyngoplasty and septoplasty for OSA 2) severed tendon on right foot 3) hernia repair X 2 (age 18, 38) 4) bronchoscopy X 2 with lung biopsy SH: denies history of tobacco use occasional ETOH (one per week approx.) denies illicit drug use FH: daughter with asthma no family history of interstitial lung disease mother died of lymphoma father died at 84 years old with CAD ALLERGIES: NKDA MEDS: Furosemide 40mg po qd am NPH 30U sc qd am K 10mEq po qd am Prednisone 20mg po bid Testosterone 0.5mg po qd pm Humalog SSI Allopurinol 300mg po qd pm Calcium Carbonate 1.25gm po qd pm Lorazepam 1.0mg po qd Prilosec 20mg po qd pm Viagra 25mg po qd pm (for vasodilation and decrease cardiac work) Vancenase Aq Ds 2 sprays qd Coumadin varied dose (currently held for elevated INR)for decrease cardiac work Colchicine 0.6mg po bid Diltiazem 240mg po bid Guaifed 600mg po bid Azithromycin 250mg po qd pm Cefuroxime 500mg po bid Bactrim 800/160mg 3tabs po qid VITALS: T 36.7, HR 92, R 24, BP 115/61, 72% on 15L GEN: acute on chronically ill appearing male with cushingoid features, sitting on edge of bed in apparent respiratory distress HEENT: conjunctivae injected with blepharitis. PERRL, EOMI, proptosis, OP clear without uvula, no oral lesions visible, JVP not appreciated secondary to thick neck, no thyromegaly, no carotid bruits PULM: quick, shallow breaths without obvious accessory muscle use, has to speak in short sentences to catch breath, bilateral crackles approximately one-third of the way up bilaterally. CV: Regular rate and rhythm without M/R/G ABDOMEN: The abdomen is obese. Bowel sounds are normal without hepatosplenomegaly. EXTREMITIES: 2+ pitting edema in ankles to knees. Ecchymoses are present on the forearms bilaterally, with large hematoma on left. SKIN: multiple raised lesions on head and AK on arms/back WBC 29.64, HCT 49.3, PLT 301, 86.6%POLY Na 132, K 5.8, Cl 96, CO2 18, BUN 34, Cr 1.9, glu 99 INR 3.0 ABG 7.44/29.1/52.7/ 83% 15L CXR LLL infiltration A/P: 62 year old male with interstitial lung disease due to asbestosis/beryllium/plutonium, with steroid dependence and 12L home O2 requirements who was recently treated at the hospital for community acquired pneumonia, now presenting with continued SOB, hypoxemia, renal insufficiency. Differential includes PE but unlikely considering anticoagulation and INR of 3.0, cardiogenic but negative enzymes, likely cause of symptoms secondary to residual pneumonia in setting of severe interstitial lung disease. --will do EKG to look for baseline and to r/o ischemic changes --will hold Coumadin for elevated INR --will change antibiotic coverage to Levaquin for broad coverage --O2 non-rebreather for saturation > 90% --will transfer to the ICU with consideration for intubation in light of respiratory distress --rest of plan per ICU team patient is FULL CODE

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Clinical Laboratory Report

Collected Date

Order Description

12/18/02

URINALYSIS, COMPLETE

Name	Result/Unit		Ref Interval	Status
URINE COLLECTION	NOT SPEC
URINE COLOR	YELLOW
URINE APPEARANCE	CLOUDY	A
SPECIFIC GRAVITY, URINE	1.018		1.003-1.030
pH, URINE	5.0		5.0-7.5
URINE PROTEIN	NEG		NEG
URINE GLUCOSE	NEG		NEG
URINE KETONES	NEG		NEG
URINE BILIRUBIN	NEG		NEG
URINE BLOOD	SMALL	A	NEG
URINE NITRITE	NEG		NEG
URINE WBC SCREEN	NEG		NEG
URINE RBC/HPF	2-5 /HPF		0-5/HPF
URINE UROBILINOGEN	0.2 mg/dL		0.2-1.0
UR URIC ACID CRYSTALS	MANY	A

12/18/02

Blood Gas Analysis, Arterial, Right Radial

Name	Result/Unit		Ref Interval	Status
FiO2	15 L
pH	7.439		7.35-7.45
PaCO2	29.1 mmHg	L	35-39
PaO2	52.7 mmHg	L	61-82
COHb	0.7 %		0.1-2
MethHb	0.9 %		0.1-2
tHb	16.6 gm%		13-19
O2 Content	19.4 vol%		17-24
Pb	638 mmHg
HCO3	19.4 mEq/L		19-25
BE	-2.9 mEq/L	L	-2.5-2.5
O2Hb	83.4 %	L	92-99
Temp	37 C
Allen`s Test	+
Comment	ART PUNCTURE IN ER 3

12/18/02

PT/INTERNAT. NORMALIZED RATIO

Name

Result/Unit

Ref Interval

Status

PROTHROMBIN TIME

31.0 sec

12.0-15.5

INTERNATIONAL NORMALIZED RATIO

3.0 ratio

Comments:
REFERENCE INTERVAL: International Normalized Ratio (INR)
INR values should only be used when evaluating patients on oral
anticoagulant therapy.

INR 2.0 - 3.0 : Prophylaxis of venous thromboembolism,
                treatment of venous thrombosis (following
                heparin therapy), prevention of systemic
                embolism (atrial fibrillation, valvular heart
                disease, bioprosthetic heart valves, acute
                myocardial infarction).

INR 2.5 - 3.5 : Mechanical prosthetic heart valves, recurrent
                systemic embolism.

12/18/02

BASIC METABOLIC PANEL

Name	Result/Unit		Ref Interval	Status
SODIUM	132 mmol/L	L	136-144
POTASSIUM	5.8 mmol/L	H	3.3-5.0
CHLORIDE	96 mmol/L	L	98-107
CARBON DIOXIDE	18 mmol/L	L	22-29
UREA NITROGEN	34 mg/dL	H	9-22
CREATININE, SERUM - mg/dL	1.9 mg/dL	H	0.8-1.5
GLUCOSE	99 mg/dL		64-128

ANION GAP	18 mmol/L	H	8-14
CALCIUM, SERUM OR PLASMA	8.8 mg/dL		8.4-10.2

12/18/02

CBC with PLT COUNT/AUTO DIFF

Name	Result/Unit		Ref Interval	Status
WHITE BLOOD CELL COUNT	29.64 K/uL	H	3.20-10.60
RED BLOOD CELL COUNT	5.39 M/uL		4.69-6.07
HEMOGLOBIN	16.8 g/dL		14.6-17.8
HEMATOCRIT	49.3 %		40.8-51.9
MEAN CORPUSCULAR VOLUME	91.5 fL		77.8-94.0
MEAN CORPUSCULAR HEMOGLOBIN	31.2 pg		26.5-32.6
MEAN CORPUSCULAR HGB CONC	34.1 g/dL		32.7-36.9
RED CELL DISTRIBUTION WIDTH	17.9 %	H	10.8-14.1
PLATELETS	301 K/uL		177-406

Links

Part 1

Part 2

Part 4

Part 5

Assignment for next week