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Diagnostic Difficulties in Organ Failures

erife Sava Bozba, MDBakent University, Faculty of Medicine, Department of Pulmonary Diseaseshave no real or perceived conflicts of interest that relate to this presentationPresentation plan,

Diagnostic difficulties in:In heart failureIn renal failureIn liver failureIn bone marrow diseases

Diagnostic Difficulties in Organ Failures

Diagnostic difficulties in heart failureSimilar clinical features in lung and cardiac diseases

Lungs are usually affected in heart disease

The extent of lung involvement in heart disease is the most important factor for prognosis

Acute-chronic heart failure/COPDHeart failure-MI/PTE

Comprehensive thinking, differential diagnosis of specific disease conditions(History, risk factors, physical examination findings, laboratory results, radiographic findings and response to therapy)Mitral regurgitation (MR)Acute or chronicHistory, physical examination findings, EKG, chest X ray, Doppler echocardiograpy helpful for diagnosisDyspnea is the most common presenting symptomOn physical examination: Lateral displacement of apical impulse, pansystolic murmur, decreased S1 intensity, increased S2 intensity if pulmonary hypertension (PHT) is developed, S3 may be heard On EKG P mitrale as a result of left atrial dilation AF is frequent in severe MRDevelopment of PHT is a sign of severe MR

Chest X ray findings are non specific and include:Acute MR: interstitial and alveolar edemaCardiomegalyAsymetric pulmonary edema may be observed in 10 % of cases (depending on the regurgitant flow and anatomy of mitral valve apparatus and pulmonary veins)

Asymmetric pulmonary edema: 33 years old female, otopsy findings revealed no pneomonia but edema

ABAsymmetric pulmonary edemaThe exact mechanism of asymmetric edema not known

Possible mechanisms; Abnormality in vascular distribution and local emphysematous changesPrevious pulmonary diseases

Due to the distruption of vascular bed in emphysema the radiologic appearence of pulmonary edema may be atypical

Doppler echocardiography establishes the diagnosis in MRValvular and subvalvular structures The size and function of heart chambersDoppler evaluation of regurgitant flowPulmonary artery pressure Signs of PHT indicate severity of MRAortic regurgitation (AR)Dyspnea is the most common symptomLeft ventricular dysfunction in severe ARPhysical examination: pulse pressure is widenedCorrigan pulseVery low diastolic blood pressureLateral displacement of apical impulse,decreased S2 intensityDiastolic murmur on left sternal borderChest X ray: cardiomegaly, calcification of the aortic valve and arcus aortaDoppler echocardiography is diagnostic

Aortic stenosisClass IV dyspnea

Left heart failure

Dyspnea is the most common presenting symptomPulmonary vascular resitance increases and PHT develops in chronic heart failurePHT in independent bad prognostic factorSigns of right heart failure indicate advanced heart failureHistory and physical examination findings are important for diagnosis (angina before pulmonary edema)On physical examination: S3, S4, bilateral crepitant rales, neck vein distention, boyun venz dolgunluu, peripheral edemaPrior infarction signs on EKG

Chest X ray:CardiomegalyKerley linesPhantom tumorBilateral plural effusionInterstitial edema

proBNP is helpful in differential diagnosis

Echocardiography is diagnostic Left and right ventricular systolic and diastolic functionValvular diseasesPericardial diseasesDiastolic function should be evaluated in detail(Of heart failure cases 50% are diastolic)

62 years age, execise dyspnea, pseudotumor appearenceMRI: Left/right ventricular systolic and diastolic function Valvular diseases

Coronary angiography and heart catheterization: Ventriculography: ventricular function, pressure measurementValvular diseasesCoronary arteriesPulmonary wedge pressure, pulmonary vascylar resistance

Cardiopulmonary exercise test

Pulmonary Edema

Cardiac pulmonary edema

Systolic HFDiastolic HFValvular heart diseasecardiomyopathyDrugs (chemotherapy)Pericardial disease

Non-cardiac pulmonary edemaHead traumaSudden airway obstructionToxic drugsBlood transfusionContrast injectionAir emboliSeptic shockAspirationEpilepsy

PCWP is important for differential diagnosisPCWP18mmHg cardiacproBNP high in cardiac pulmonary edema

18Pulmonary complications of pulmonary venous hypertension

Pulmonary functional abnormalities: decreased lung volumeAirway obstruction in especially acute pulmonary edemaAir trappingDecreased lung complianceDecreased diffusion capacityHypoxemia Abnormal respirationCheyne-stokes respiration, central sleep apneaObstructive sleep apnea Disorders of peripheral and respiratory mucsles Unusual manifestationsHemoptysis, pulmonary hemorrhage, hemosiderosisOssification nodules, mediastinal lymphadenopathyHemosiderosisSmall nodules in lower lobes due to microvascular hemorrhages

Mitral regurgitation and atrial fibrillation

Mitral regurgitation22

Heart failure mimicking COPD

74 years old male, diffuse asymmetric infiltrateHeart failure: infiltrate resolved with heart failure therapy

66 years old female, infiltrate resolved with heart failure therapy

64 years old patient, right hilar infiltrate due to left heart failure

67 years old male, diuretic therapy resolved insterstitial edema(7kg weight loss)Cardiovocal syndrome (Ortner Syndrome):Causes: Mitral stenosis, aortic aneurysm, ASD, PDA and endocardial PM implantationHoarsenessLeft recurrent laryngeal nerve paralysis

Case;75 years old patient having hypertension Dyspnea (Class 2), weight loss, cough, hoarseness ENT examination: left vocal cord paralysis

Aysel grel

HYPERTENSION TYPE 1 RESPIRATORY FAILURE HYPERTROPHIC CARDIOMYOPATHY

(Heart failure with preserved ejection fraction)(Diastolic heart failure)Diagnostic Difficulties in Renal FailurePulmonary complications are common in the course of renal diseases

Extracellular volume increase, long lasting hypertension, heart failure symptoms and signs

Pulmonary edema is the most feared complication hypervolemiaPulmonary edema;HypervolemiaAcute renal failure due to SIRS: increased capillary permeability, hypoalbuminemia incresaes myocardial infarction risk

Pulmonary edema may develop before renal function deteriorates in Glomerular diseasesTreatment: Renal replacement therapy (Hemodialysis and ultrafiltration)

After hemodialysis treatmentHypervolemia, hypoalbuminemia Pleural fluidUsually bilateral/massive

Pleuretic painFriction rub and pleural effusionSerous/hemorrhagic fluidTransudate/Exudate Spontaneous/regression with HD Fibrothorax

Diagnosis: Exclusion of other conditionsFibrinz plrit(%20-40)Asthma crisis due to acetate in dialysate during HD

Metastatik calcifications (upper lobes usually)

Unexplained dyspnea, Chest X ray may be normal, HRCT can show calcifications

Differential diagnosis in severe calcifications: Bronchopulmonary infectionsPulmonary edema

Figure 1: 47 year-old man with metastatic pulmonarycalcification due to chronic renal failure. PA chest X-ray image shows bilateral multiple, ill defined, opacities. The opacities are predominant in the upper and mid lung zone.Calcification is not apparent.Figure 4: 47 year-old man with metastatic pulmonary calcification due to chronic renal failure. High-resolution CT image in mediastinal window at the level of the carina shows multiple, ill-defined, calcified nodules (arrows). There are also calcifications in the bronchial and tracheal walls.37Hypoxemia induced by HDDecrease in PaO2 during HD (%90)Severity of hypoxia; Dialysis membrane type Chemical nature of dialysate

MechanismsIncrease in pH during HD, shift in oxyhemoglobin dissociation curveDepression of central respiratory output due to alkalosisOxygen diffusion abnormality Leukocyte stasis in large pulmonary vessels, V/Q missmatchHypoventilation due to removal of CO2 with dialysateAtelectasis, pneumonia and pleural effusion due to peritoneal dialysis (PD)Accumulation of pleural fluid may start in several hours during PD and may result in respiratory insufficiency Differential diagnosis; hyperglycemia, methylene blue, scintigraphy

Risk of DVT and PTE increase in patients with nephrotic syndrome and diagnostic value of D-dimer decreasesThe clinical presentation of acute renal failure (ARF) and respiratory failure;

Pulmonary edema due to ARF + HypervolemiaPulmonary edema, HF/cardiogenic shockSevere pneomonia (Legionella!)Pulmonary emboli due to vena cava inferior ve renal vein thrombosis

* Clinical and radiologic impovement in pulmonary edema with dialysis is diagnostic Complications of central catheter (DVT)

Notice to the risk associated with use of thorax CT and CT angiography in diagnosis of PTE, pneumonia, hypervolemia in patients with ARF

D-dimer may be elevated in renal failure Diagnostic difficulties in liver failureThorax and abdomen are neighbours via diaphragmaHepatopulmonary syndrome;Advanced liver disease Increased P(A-a)O2 gradient Intrapulmonary vascular dilations HypoxemiaEchocardiography: Intrapulmonary shuntOrthodeoxia and platypneaPleural fluid (25%)Transudative, similar features with ascites and more on right side Transdiaphragmatic passagePleurodesis, repair of diaphragmatic tears, TIPS

Increased ascites lead to a decrease in lung volumes and result in restrictive pattern in pulmonary function test

Primary biliary cirrhosis (PBC); granolumatous disease characterized by chronic intrahepatic chlestasis

In lungs of affected patients: gronulamas and elevation in ACE levels were noted (resembling to Sarcoidosis)

Drugs used in the treatment of liver disease should be monitorized for side effects

ARDS in a patient with fulminant hepatitis DyspneaExercise induced syncopeHemoptysisChest pain

Echocardiography should be considered on controlsPortopulmonary hipertansiyonDiagnostic difficulties in hematologic diseasesDisorders of ErythrocytesErythrocytosis (Polycythemia)AnemiaDisorders characterized by high erythropoetin levelsHematopoetik kk hcre seviyesinde bozuklukAplastic anemiaAnemiLeukopenia (increased infection risk)Thrombocytopenia (increased bleeding risk)Disorders characterized by low erythropoetin levelsChronic disease anemiaAnemia in patients with chronic renal failureHemoglobinopathies

Diagnostic difficulties in hematologic diseasesSickle cell anemia (HbS)In Beta globulin chain glutamic acid valineSickling under severe hypoxia Increased pulmonary emboli risk Most common cause of death are pulmonary complicationsAcute attacks; pneumonia and acute chest syndromeChest X-ray may be normalAcute chest syndrome: infiltration in lung graphy pleural fluid, fever, leukocytosis, hypoxia, chest pain

Akut ataklar pnmoni ve akut gs sendromuna (AGS) bal

50 Infarction and air emboli due to microvascular occlusion

Vaso-occlusive infarction;Linear scarsInterlobular septal thickening (mainly on bases)Parenchymal bands, pleural retractionTraction bronchiectasis, structural distortionsMosaic pattern because of PHT

HRCT: ground glass appearence

Treatment; Oxygen, analgesics, hydration and exchance

Bilateral diffuse alveolar and interstitial infiltrates

Control after 10 days following erytrocytopheresis

Figure 1: Chest X-ray on admission to the intensive care unit. It shows diffuse bilateral alveolar and interstitial infiltrates with decreased air entry. Figure 2: Chest X-ray obtained 10 day after erythrocytapheresis shows significant improvement.

52Radiology 2002; 225:639653Small-Vessel Diseases of the Lung: CT-Pathologic Correlates

53Leukemias WBC> 50.000/mm3 leukostasis riskVaso-occlusion of alveolar capillaries and small vessels with blast cellsFever, pulmonary infiltrations, hypoxemiaLeukostasis may mimic PTEThorax CT-Angiography, V/Q scintigraphy

85 years of male patient addmitted with dyspneaLeucocyte 247000/UL

regurgitation jet 3,7m/sn and pulmonary artery pressure was calculated as 65mmHgpH of 7.42, an arterial carbon dioxide tension (PaCO2) of 46mmHg, an arterial oxygen tension (PaO2) of 36mmHg, and oxygen saturation was 70%.leukocyte was 247000/UL, More than 1000/mm3 leucocyts were counted on pleural fluid smear. Biochemical analysis of the pleural fluid showed pH:7.0, glucose:112mg/dl (serum:138 mg/dl), albumin:1,4g/dl(serum 3,9g/dl), total protein1,9g/dl (serum:5g/dl), LDH:80 U/L(serum 321U/L), leucocyt: 1770 /UL, ADA: 20 U/L. ARB was negative in pleural fluid and no bacteria was identified on culture. Pleural fluid cytology showed rare mesothelial cells and widespread small lymphocytes. Urgent leukapheresis was planned due to the hyperleucocytosis.

55Spread of primary disease in lungs and lymph nodesToxic effects of radiotherapy and chemotherapyLeukemic infiltrationHemorrhageInfections Malignant pleural effusionUpper airway obstrution due to CLLAlveolar proteinosisPulmonary embolism

Thrombocyte disordersHemoptysisAlveolar hemorrhageDIC(microvascular trombosis, dissemination coagulopathy) characterized by thrombin formation in systemic circulationMost common cause sepsisPTE ve infarction may lead to deathTransplantation and the lungsSolid organ/hematopoetic stem cell transplantationInfectious complicationsNeoplastic diseases (PLPH)Metastatic calcificationsToxic effects of the drugs to the lungsPulmonary allograft rejectionIdiopathic pneumonia syndrome (HKHT) (3weeks-3 months)Diffuse alveolar hemorrhageEngraftment SyndromeBronchiolitis obliteransPulmonary venoocclusive disease

THANKS

Trk Toraks Dernei Bakl Basklanm Erikinlerde Gelien Pnmoni Tan ve Tedavi Uzla Raporu-2009

Trk Toraks Dernei Bakl Basklanm Erikinlerde Gelien Pnmoni Tan ve Tedavi Uzla Raporu-2009