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The significant acute hepatocelluar damage can only be explained by ischaemic heptic injury as drugs/toxins were unlikely culprits. The low cardiac output has triggered acute renal failure and hepatic ischaemic injury. The heart shadow size was nearly normal on admission, but has increased considerably within two days. Further tests performed:
BNP 1500 pg/mL (< 68), only for those who like BNP!
Serial TnI were elevated up to 2.6 ug/L
ECG showed atrial fibrillation and non specific ST elevation in some leads.
Echocardiography showed pericardial effusion and moderate
580 mL of straw coloured pericardial fluid was drained and biochemistry showed:
Glucose 1.1 mmol/L
Fluid LDH 2280 IU/L
Protein 55 g/L
Albumin 26 g/L
This was therefore was presumed to be a case of perimyocarditis? Cause. It could be primary due to infectious or non-infectious cause or secondary to a multisystemic disorder such as collagen disease or malignancy. The clinical scenario was atypical of an infectious cause, so we should look for a rare atypical cause.
Further comments are welcome.
A 70-year-old man presented with shortness of breath, he gave 4 weeks history of being SOB and was treated by his GP with antibiotics for presumed respiratory tract infection. Chest X-ray showed slightly increased basal shadowing and heart size was within normal. He was admitted to a medical ward and the admission biochemical profile showed:
Sodium 139
Potassium 4.5
Sodium 139
Urea + 9.1
Potassium 4.5
Creatinine 114
Urea + 9.1
CRP + 138
Creatinine 114
eGFR 61
Urea:Creat + 80
R. Glucose 6.3
GGT + 123
ALT 38
ALP 89
Bilirubin 5
Albumin 36
Two days later, he was still having SOB and had developed hypotension, anuria
and atrial fibrillation and was therefore transferred to ICU, his GCS was 15 and a biochemical profile showed:
Sodium - 130
Albumin 36
Potassium + 6.1
TropI + 0.21
Urea + 24.9
Creatinine + 320
CRP + 344
Chol 3.30
eGFR 16
GGT + 153
ALT + 1453
ALP 122
Bilirubin 16
Arterial blood sample on blood gas machine showed:
pH - 7.178
pCO2 + 5.51
pO2 + 14.8
Base XS - -12.3
Act Bicarb - 14.7
O2 SAT 96.1
Lactate 9.10
IFO2 40
A chest X-ray showed cardiomegaly and blood cultures were negative.
He was haemodialysed and his LFTs showed further deterioration:
Sodium 137
Potassium 4.9
Urea + 17.6
GGT + 94
Creatinine + 269
ALT + 4260
CRP + 217
ALP 86
Calcium 2.32
Bilirubin + 22
Albumin - 24
Adj.Calc. + 2.64
CK + 337
Phosphate + 2.84
eGFR 20
His coagulation was abnormal:
P.T. 29.7
INR 3.0
APTT 35
APTT ratio 1.4
Can you, at this stage, suggest a provisional diagnosis/diagnoses and further testing to prove it?
kind regards
Mohammad