SHM Converge Scientific Abstract ePoster Gallery-Focus-Ing Towards a New Diagnosis in a Case of Congestive Heart Failure

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A 73-year-old man presented with 2 months of progressive dyspnea, orthopnea, bilateral leg edema, weight loss, night sweats, anorexia, and new hypoxia. Because his symptoms and exam suggested congestive heart failure, he was initially evaluated for CHF exacerbation. However, key findings argued against volume overload: BNP was low, there was no JVD or wheezing, the IVC was small and fully collapsible on point-of-care ultrasound (POCUS), and cardiac ultrasound showed normal ventricular size and function with preserved LVEF. Lung ultrasound instead demonstrated bilateral large pleural effusions with A-line pattern in the apices, supporting an alternative diagnosis.<br /><br />Chest x-ray showed small bilateral pleural effusions and emphysematous changes. Lab work showed hyponatremia, thrombocytosis, mild anemia, and hypoalbuminemia. Formal echocardiography confirmed preserved systolic function.<br /><br />Bilateral thoracenteses provided immediate symptomatic relief. Pleural fluid analysis revealed a chylous effusion on the left and an exudative effusion on the right. Subsequent CT imaging of the chest, abdomen, and pelvis showed diffuse necrotic lymphadenopathy and a retroperitoneal mass encasing the aorta and right renal artery, causing severe renal artery stenosis. Biopsy of a retroperitoneal lymph node confirmed metastatic carcinoma of renal origin.<br /><br />This case highlights that elderly patients with dyspnea and edema are often presumed to have heart failure, but clinical exam can mislead. POCUS was crucial in rapidly excluding CHF, identifying pleural effusions, and prompting further workup that led to the diagnosis of metastatic renal cell carcinoma presenting with chylous pleural effusion.

Asset Subtitle

Tiffany J. Galush

Meta Tag

Author List John Bundrick, Tiffany J. Galush

Category Clinical Vignettes

Distinguished Non-Finalist

Presenter Organization Mayo Clinic

Presenting Author Tiffany J. Galush

Track Adult

Keywords

dyspnea

orthopnea

pleural effusion

chylous effusion

point-of-care ultrasound

congestive heart failure

renal cell carcinoma

metastatic carcinoma

lymphadenopathy

thoracentesis