POCUS reveals Hickam’s Dictum
A 19 year old man presented to the urgent care clinic complaining of 2 months of increasing lethargy. He had been seen by his doctor the previous month with a cough and shortness of breath, thought to have been caused by a viral respiratory tract infection. In the past two weeks he had noticed swelling of his ankles and lower legs. On enquiry he admitted to ongoing shortness of breath on exertion and for the past few days he had been sleeping propped up on the couch.
He had no significant past history. There was a family history of renal failure secondary to glomerulonephritis
t-37.3 hr 120 bp 180/100 O2sat 97%. There was pitting oedema of his legs and sacral oedema. Auscultation revealed a few bi-basal crepetations.
Urine dipstick – protein +++
Disposition
Nephrotic syndrome was suspected based on the history of lethargy, oedema, hypertension, proteinuria and a family history of glomerulonephritis.
However, the point of care ultrasound images also reveal a dilated cardiomyopathy with severely reduced LV systolic function. (The apical 4 chamber view is unfortunately under gained in the near field)
On admission to hospital Cr = 298 eGFR = 25, and a subsequent renal biopsy confirmed glomerulonephritis.
A formal ECHO demonstrated a severely dilated LV with globally impaired function and EF of 27%.
Discussion
Patients with nephrotic syndrome can present with dyspnoea, usually secondary to pleural effusions. Non-cardiogenic pulmonary oedema in such patients is extremely rare, although cases have been reported. (1)
In this case, the dyspnoea and orthopnoea were cardiogenic, secondary to dilated cardiomyopathy with severely reduced LVSF.
This appears to be an example of type 3 cardio-renal (acute reno-cardiac) syndrome, where volume overload and other metabolic derangements from acutely worsening renal function leads to heart injury and/or dysfunction. (2)
Hickam’s Dictum reminds us to consider that there may be more behind a history than what we first assume, and that multiple pathologies may be present and contributing to the symptom complex.
References
(1) Zhang BS et al. A rare cause of non-cariogenic pulmonary oedema. The George Washington University. [Link]
(2) Ronco C, McCullough P, Anker SD. Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative. European heart journal. 2010; 31(6):703-11. [pubmed]
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