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Critical Care |

Rapidly Rising Pressure to Make a Diagnosis

Rachel Le, MD; Sherry-Ann Brown, MD; Omar Abou-Ezzedine, MD; Darlene Nelson, MD
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Mayo Clinic, Rochester, MN


Chest. 2014;146(4_MeetingAbstracts):349A. doi:10.1378/chest.1993721
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Abstract

SESSION TITLE: Miscellaneous Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary hypertension (PH) is the final common pathway for a number of small vessel pulmonary vascular disorders. Defining the underlying mechanism is essential to guide therapies.

CASE PRESENTATION: A 43 year old woman with a past medical history of recurrent left breast carcinoma was noted to have an insidious cough, hypoxemia and rapid progression of dyspnea on exertion prompting emergency evaluation. Initial vital signs were significant for tachycardia (HR 117 bpm) and tachypnea (RR 28). Cardiac examination was remarkable for an accentuated pulmonary component to the second heart sound, pulmonary auscultation was normal. Contrast enhanced CT chest showed no acute pulmonary emboli. There were scattered bilateral ground-glass opacities and nodules. Transthoracic echocardiogram demonstrated right ventricular (RV) systolic pressure estimated at 79 mmHg with severe RV enlargement and mild decrease in function. Left ventricular function was preserved. Ventilation perfusion scan showed heterogeneous perfusion throughout both lungs concerning for chronic thromboembolic disease, pulmonary vascular disease, or possible microangiopathy. Right heart catheterization (RHC) was performed with concomitant pulmonary capillary wedge (PCW) fluid cytology. Mean PA pressure 49 mmHg; pulmonary vascular resistance index 18 WU. Concurrent bronchoscopy with trans-bronchial biopsy was obtained. Biopsy results confirmed pulmonary lymphangitic carcinomatosis (PLC) on transbronchial biopsy and wedge blood cytology. Our patient rapidly declined with increased work of breathing over the next several days. Given the results and poor prognosis associated with this she requested comfort measures only and passed away 24 hours after diagnosis.

DISCUSSION: The mechanism for PH should be evaluated in all patients to guide prognosis and therapies. PLC is an uncommon cause of PH requiring a tissue diagnosis typically obtained via lung biopsy or post-mortem examination. This case illustrates the utility of PCW cytology to aid in the diagnosis of PLC. PCW cytology was first described in 1985 but remains infrequently used. Diagnostic yield has not been extensively studied. It may be particularly useful in patients deemed too high risk for transbronchial biopsy.

CONCLUSIONS: PLC should be considered as a cause of PH in patients with metastatic disease.

Reference #1: Pulmonary microvascular cytology. Chest 1985:88(6)908-914.

DISCLOSURE: The following authors have nothing to disclose: Rachel Le, Sherry-Ann Brown, Omar Abou-Ezzedine, Darlene Nelson

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