SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: The diaphragm is the primary muscle of inspiration. Each side of the diaphragm is innervated by the ipsilateral phrenic nerves, which derive from cervical nerve roots three, four, and five. Interruption or injury to either of the phrenic nerves can result in unilateral diaphragmatic paralysis. Well recognized causes of unilateral paralysis include phrenic nerve injury during cardiothoracic surgery, viral infections such as herpes zoster or poliomyelitis, cervical pathologies like spondylosis, cervical compressive tumors, or neck trauma. We present a unique case of unilateral diaphragm paralysis secondary to pulmonary embolism (PE)
CASE PRESENTATION: A 59 year old male with a past medical history of HTN, DM, psoriasis, GERD, and anemia was admitted for sepsis secondary to scrotal abscess. While the patient was being taken to the operating room for incision and drainage, he developed acute shortness of breath and hypoxemia. A stat CT pulmonary angiography revealed extensive bilateral pulmonary emboli and anticoagulation was initiated. A chest X- ray done on the following day showed an elevated right hemi diaphragm. A Sniff Test was performed that demonstrated paradoxical elevation of the right hemidiaphragm with inspiration compared with the rapid descent of the left hemidiaphragm. The patient’s primary care physician was contacted who confirmed that the patient did not have a history of elevated hemi diaphragm and his last chest X- ray showed no diaphragmatic abnormalities.
DISCUSSION: Based on an extensive literature search, we found only one relevant case which reported reversible unilateral diaphragmatic paralysis in a patient with a PE. Our case confirms that this is in fact a reproducible phenomenon.The reported case documented resolution of their patient's unilateral diaphragm elevation after two months of treatment with anticoagulants. We will continue to follow our patient to confirm if resolution occurs during the course of his treatment.
CONCLUSIONS: Our case brings attention to the fact that PE should be kept in mind as a differential diagnosis when we encounter a patient with an elevated hemi diaphragm. The diagnosis of unilateral diaphragm paralysis is usually made by the upright chest radiograph which is sensitive, but not specific. However, the diagnosis can be easily confirmed with a fluoroscopic sniff test in which diaphragmatic movement is observed fluoroscopically while the patient sniffs forcefully. Whether this is a transient paralysis or permanent after treatment of the PE warrants further investigation.
Reference #1: Pils, Katharina, and Raimund Mark. "Reversible Unilateral Diaphragmatic Paralysis in Pulmonary Embolism." CHEST 116.2 (1999): 587-88.
DISCLOSURE: The following authors have nothing to disclose: Umbreen Arshad, Arundeep Kahlon, Ansar Vance, Amit Dhamoon
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