CHRONIC LUNG DISEASE AND ITS PROGRESSION TO PULMONARY HYPERTENSION: THE NEED FOR EARLY SCREENING

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Despite the evolution of group 3 pulmonary hypertension (PH) management and treatment, reports suggest that over half of patients are diagnosed with PH at an advanced stage (1). Factors such as the presence of nonspecific symptoms, over-reliance on echocardiography, and decreased use of right-heart-catheterization (RHC) contribute to delayed diagnosis (2). We present this case to highlight the importance of early diagnosis of PH due to chronic lung disease. CASE PRESENTATION: A 60-year-old African-American female with a past-medical-history of chronic obstructive pulmonary disease on 3L home oxygen (GOLD stage 4), secondary erythrocytosis, and obstructive sleep apnea presented with bilateral leg pain and subjective fevers. Vitals were significant for hypotension (BP 96/51) and tachycardia (HR 106). Physical exam revealed an obese female in moderate distress with 2+bilateral lower extremity edema with diffuse, erythematous, and purulent rashes in the same areas. Labs were significant for elevations in lactic acid (2.7), bicarbonate (39), and hemoglobin/hematocrit (15.3/51.7). Chest x-ray (CXR) showed cardiomegaly. EKG showed normal sinus rhythm without any ischemic findings. The patient was started on broad spectrum antibiotics and IV fluid resuscitation for sepsis secondary to cellulitis. On hospital day 4, the patient developed acute respiratory distress with desaturation to 85%. Arterial blood gases showed pH 7.26, pO2, 69, pCO2 68, consistent with hypercarbic respiratory failure. Repeat CXR revealed interval development of a large right pleural effusion. Emergent thoracentesis was performed with 600cc of fluid with labs consistent for transudative effusion (serum/pleural: LDH 227/59, protein 5.5/2). Echocardiograph revealed normal ejection fraction and left ventricular function, but an elevated right ventricular systolic pressure (50-60mmhg) and a flattened septum. RHC was performed and revealed fixed severe pulmonary hypertension with negative vasoreactivity (PA:59mmhg, RA:33mmhg, PAVR:7) The patient was started on non-invasive ventilatory support in addition to aggressive diuresis given negative vasoreactivity on RHC. However, her respiratory status continued to deteriorate despite sepsis resolution. After further discussion with the patient, she decided to transition to comfort measures with subsequent transfer to a hospice facility DISCUSSION: PH associated with chronic lung diseases confers poor prognosis. Despite a high prevalence (62.4%) of PH in COPD patients (3), there are no PH screening guidelines in this high-risk patient population. CONCLUSIONS: The establishment of early screening methods prior to the progression of pulmonary vascular dysfunction to PH will ultimately decrease the disease progression, reduce mortality, and improve quality of life in this high-risk population. Reference #1: Ginoux M, Turquier S, Chebib N, et al. Impact of comorbidities and delay in diagnosis in elderly patients with pulmonary hypertension. ERJ Open Res. 2018;4(4):00100-2018. Published 2018 Nov 28. https://doi.org/10.1183/23120541.00100-2018 Reference #2: Maron BA, Galiè N. Diagnosis, Treatment, and Clinical Management of Pulmonary Arterial Hypertension in the Contemporary Era: A Review. JAMA Cardiol. 2016;1(9):1056–1065. https://doi.org/10.1001/jamacardio.2016.4471 Reference #3: Gupta KK, Roy B, Chaudhary SC, et al. Prevalence of pulmonary artery hypertension in patients of chronic obstructive pulmonary disease and its correlation with stages of chronic obstructive pulmonary disease, exercising capacity, and quality of life. J Family Med Prim Care. 2018;7(1):53-57. DISCLOSURES: No relevant relationships by Temidayo Abe, source=Web Response No relevant relationships by Philip Bene, source=Web Response No relevant relationships by Eric Chang, source=Web Response No relevant relationships by Gabrielle De Allie, source=Web Response No relevant relationships by Parris Tanksley, source=Web Response