A Patient with Third-Space Fluid Loss.

Abstract

A 64-year-old woman with underlying hypertension treated with oral perindopril presented with a history of worsening abdominal distension, bilateral leg swelling, and exertional dyspnea over 4 months. In addition, she also complained of intermittent palpitations, weight loss, and anorexia. Her blood pressure was 125/68 mmHg, and she was tachycardic (114 beats per minute) with a low-grade fever of 37.5°C (99.5°F) and good oxygen saturation on room air. Physical examination suggested the presence of third-space fluid loss, evidenced by ascites, right-sided pleural effusion, and bilateral lower limb edema. There was no cardiac murmur or evidence of chest infection on examination. Initial laboratory investigations revealed pancytopenia, a decreased serum folate concentration, and severe hypoalbuminemia with an albumin to globulin (A:G) ratio of 0.13 (reference interval 1–2). The rest of the initial investigations showed normocalcemia, no renal impairment, and no electrolyte imbalance (Table 1). A chest X-ray showed a right-sided pleural effusion, which confirmed the need for a work-up for third-space fluid loss. An echocardiogram revealed an ejection fraction of 59% (reference interval 54–74%), and grade 1 left ventricular hypertrophy with diastolic dysfunction.