55yo man presented with worsening SOB over 4/7. Overnight he had an acute exaccerbation and spent the night sitting up in bed. Nil CP/ cough/ sputum/ fever.
AF - ablated 7/7 ago
TTE at the time: grade 1 ventricle
R pleural effusion (treated as per a parapneumonic effusion 5/12 ago)
OE sats 91% on air post exercise, increasing to 99% on air at rest
HR 52 SR
chest: R basal crackles, nil wheeze
1. recent ablation: ?pericardial effusion
2. ?atypical pneumonia
3. ?recurrence of pleural effusion
4. pulmonary oedema: but very unlikely given grade one ventricle on recent TTE
ED echo excluded #1 and showed a normal LV and a mildly dilated LA
Lung US was more interesting
L axilla lung US shows multiple B lines. Mutiple B lines were seen throughout the L lung.
R anterior chest showing normal lung
R lower/ middle lobe seen from axilla shows an increase in B lines.
R lower lobe seen posteriorly has thickened pleural line, sub pleural consolidation/ infarction and multiple B lines
FAST view of RUQ showing a R pleural effusion and collapsed/consolidated lung floating in the effusion
So in total we have
1. wet looking L lung and R mid to lower lung
2. R pleural effusion
3. R basal consolidation/ collapse
? early infective changes
? pulmonary oedema/ pulmonary embolus
Pt was treated with antibiotics and lasix given these findings.
CXR didn't add much more
So CTPA was organised to define the pathology
CTPA showed R basal consolidation, R pleural effusion and diffuse bilateral basal ground glass appearance consistent with pulmonary oedema.
While waiting for a bed in the private hospital under his private cardiologist, pt felt much better and self discharged. Sent home with oral AB and frusemide, with early FU. Especially for close followup re recurrent pleural effusion ?underlying malignancy.