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Diagnostic Difficulties in Organ Failures Şerife Savaş Bozbaş, MD Başkent University, Faculty of Medicine, Department of Pulmonary Diseases.

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Presentation on theme: "Diagnostic Difficulties in Organ Failures Şerife Savaş Bozbaş, MD Başkent University, Faculty of Medicine, Department of Pulmonary Diseases."— Presentation transcript:

1 Diagnostic Difficulties in Organ Failures Şerife Savaş Bozbaş, MD Başkent University, Faculty of Medicine, Department of Pulmonary Diseases

2 HAVE NO REAL OR PERCEIVED CONFLICTS OF INTEREST THAT RELATE TO THIS PRESENTATION

3 Presentation plan, Diagnostic difficulties in: In heart failure In renal failure In liver failure In bone marrow diseases Diagnostic Difficulties in Organ Failures Diagnostic Difficulties in Organ Failures

4 Diagnostic in heart failure Diagnostic difficulties in heart failure Similar 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

5 Acute-chronic heart failure/COPD Heart 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)

6 Mitral regurgitation (MR) Acute or chronic History, physical examination findings, EKG, chest X ray, Doppler echocardiograpy helpful for diagnosis Dyspnea is the most common presenting symptom On 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 MR

7 Development of PHT is a sign of severe MR Chest X ray findings are non specific and include: ◦ Acute MR: interstitial and alveolar edema ◦ Cardiomegaly ◦ Asymetric pulmonary edema may be observed in 10 % of cases (depending on the regurgitant flow and anatomy of mitral valve apparatus and pulmonary veins)

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

9 AB Asymmetric pulmonary edema

10 The exact mechanism of asymmetric edema not known Possible mechanisms; ◦ Abnormality in vascular distribution and local emphysematous changes ◦ Previous pulmonary diseases Due to the distruption of vascular bed in emphysema the radiologic appearence of pulmonary edema may be atypical

11 Doppler echocardiography establishes the diagnosis in MR ◦ Valvular and subvalvular structures ◦ The size and function of heart chambers ◦ Doppler evaluation of regurgitant flow ◦ Pulmonary artery pressure ◦ Signs of PHT indicate severity of MR

12 Aortic regurgitation (AR) Dyspnea is the most common symptom Left ventricular dysfunction in severe AR Physical examination: pulse pressure is widened ◦ “Corrigan pulse” ◦ Very low diastolic blood pressure ◦ Lateral displacement of apical impulse, ◦ decreased S2 intensity ◦ Diastolic murmur on left sternal border Chest X ray: cardiomegaly, calcification of the aortic valve and arcus aorta Doppler echocardiography is diagnostic

13 Aortic stenosis Class IV dyspnea

14 Left heart failure Dyspnea is the most common presenting symptom Pulmonary vascular resitance increases and PHT develops in chronic heart failure PHT in independent bad prognostic factor Signs of right heart failure indicate advanced heart failure History and physical examination findings are important for diagnosis (angina before pulmonary edema) On physical examination: S3, S4, bilateral crepitant rales, neck vein distention, boyun venöz dolgunlu ğ u, peripheral edema Prior infarction signs on EKG

15 Chest X ray: – Cardiomegaly – Kerley lines – Phantom tumor – Bilateral plural effusion – Interstitial edema proBNP is helpful in differential diagnosis Echocardiography is diagnostic – Left and right ventricular systolic and diastolic function – Valvular diseases – Pericardial diseases – Diastolic function should be evaluated in detail (Of heart failure cases 50% are diastolic)

16 62 years age, execise dyspnea, pseudotumor appearence

17 MRI: Left/right ventricular systolic and diastolic function Valvular diseases Coronary angiography and heart catheterization: ◦ Ventriculography: ventricular function, pressure measurement ◦ Valvular diseases ◦ Coronary arteries ◦ Pulmonary wedge pressure, pulmonary vascylar resistance Cardiopulmonary exercise test

18 Pulmonary Edema Cardiac pulmonary edema Systolic HF Diastolic HF Valvular heart disease cardiomyopathy Drugs (chemotherapy) Pericardial disease Non-cardiac pulmonary edema Head trauma Sudden airway obstruction Toxic drugs Blood transfusion Contrast injection Air emboli Septic shock Aspiration Epilepsy PCWP is important for differential diagnosis PCWP<18mmHg noncardiac PCWP>18mmHg cardiac proBNP high in cardiac pulmonary edema

19 Pulmonary complications of pulmonary venous hypertension Pulmonary functional abnormalities: decreased lung volume – Airway obstruction in especially acute pulmonary edema – Air trapping – Decreased lung compliance – Decreased diffusion capacity – Hypoxemia Abnormal respiration –Cheyne-stokes respiration, central sleep apnea –Obstructive sleep apnea Disorders of peripheral and respiratory mucsles Unusual manifestations –Hemoptysis, pulmonary hemorrhage, hemosiderosis –Ossification nodules, mediastinal lymphadenopathy

20 Hemosiderosis Small nodules in lower lobes due to microvascular hemorrhages

21 Mitral regurgitation and atrial fibrillation

22 Mitral regurgitation

23 Heart failure mimicking COPD

24 74 years old male, diffuse asymmetric infiltrate Heart failure: infiltrate resolved with heart failure therapy

25 66 years old female, infiltrate resolved with heart failure therapy

26 64 years old patğient, right hilar infiltrate due to left heart failure

27 67 years old male, diuretic therapy resolved insterstitial edema (7kg weight loss)

28 Cardiovocal syndrome (Ortner Syndrome): ◦ Causes: Mitral stenosis, aortic aneurysm, ASD, PDA and endocardial PM implantation ◦ Hoarseness ◦ Left recurrent laryngeal nerve paralysis Case; 75 years old patient having hypertension Dyspnea (Class 2), weight loss, cough, hoarseness ENT examination: left vocal cord paralysis

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30 Aysel gürel HYPERTENSION TYPE 1 RESPIRATORY FAILURE HYPERTROPHIC CARDIOMYOPATHY (Heart failure with preserved ejection fraction) (Diastolic heart failure)

31 Diagnostic Difficulties in Renal Failure Pulmonary 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 hypervolemia

32 Pulmonary edema; ◦ Hypervolemia ◦ Acute renal failure due to SIRS: increased capillary permeability, hypoalbuminemia incresaes myocardial infarction risk Pulmonary edema may develop before renal function deteriorates in Glomerular diseases Treatment: Renal replacement therapy (Hemodialysis and ultrafiltration)

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34 After hemodialysis treatment

35 Hypervolemia, hypoalbuminemia Pleural fluid ◦ Usually bilateral/massive Pleuretic pain Friction rub and pleural effusion Serous/hemorrhagic fluid Transudate/Exudate Spontaneous/regression with HD Fibrothorax Diagnosis: Exclusion of other conditions Fibrinöz plörit (%20-40)

36 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 infections ◦ Pulmonary edema

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38 Hypoxemia induced by HD ◦ Decrease in PaO2 during HD (%90) ◦ Severity of hypoxia; Dialysis membrane type Chemical nature of dialysate Mechanisms ◦ Increase in pH during HD, shift in oxyhemoglobin dissociation curve ◦ Depression of central respiratory output due to alkalosis ◦ Oxygen diffusion abnormality ◦ Leukocyte stasis in large pulmonary vessels, V/Q missmatch ◦ Hypoventilation due to removal of CO2 with dialysate

39 Atelectasis, 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 decreases

40 The clinical presentation of acute renal failure (ARF) and respiratory failure; ◦ Pulmonary edema due to ARF + Hypervolemia ◦ Pulmonary edema, HF/cardiogenic shock ◦ Severe pneomonia (Legionella!) ◦ Pulmonary emboli due to vena cava inferior ve renal vein thrombosis * Clinical and radiologic impovement in pulmonary edema with dialysis is diagnostic

41 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

42 Diagnostic difficulties in liver failure Thorax and abdomen are neighbours via diaphragma Hepatopulmonary syndrome; ◦ Advanced liver disease ◦ Increased P(A-a)O 2 gradient ◦ Intrapulmonary vascular dilations Hypoxemia Echocardiography: Intrapulmonary shunt Orthodeoxia and platypnea

43 Pleural fluid (25%) ◦ Transudative, similar features with ascites and more on right side ◦ Transdiaphragmatic passage ◦ Pleurodesis, repair of diaphragmatic tears, TIPS Increased ascites lead to a decrease in lung volumes and result in restrictive pattern in pulmonary function test

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45 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)

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

47 ARDS in a patient with fulminant hepatitis

48 Dyspnea Exercise induced syncope Hemoptysis Chest pain Echocardiography should be considered on controls Portopulmonary hipertansiyon

49 Diagnostic difficulties in hematologic diseases Disorders of Erythrocytes Erythrocytosis (Polycythemia) Anemia Disorders characterized by high erythropoetin levels ◦ Hematopoetik kök hücre seviyesinde bozukluk Aplastic anemia  Anemi  Leukopenia (increased infection risk)  Thrombocytopenia (increased bleeding risk) Disorders characterized by low erythropoetin levels ◦ Chronic disease anemia ◦ Anemia in patients with chronic renal failure Hemoglobinopathies

50 Diagnostic difficulties in hematologic diseases Sickle cell anemia (HbS) ◦ In Beta globulin chain glutamic acid valine ◦ Sickling under severe hypoxia ◦ Increased pulmonary emboli risk ◦ Most common cause of death are pulmonary complications ◦ Acute attacks; pneumonia and acute chest syndrome ◦ Chest X-ray may be normal ◦ Acute chest syndrome: infiltration in lung graphy ± pleural fluid, fever, leukocytosis, hypoxia, chest pain

51 Infarction and air emboli due to microvascular occlusion Vaso-occlusive infarction ; –Linear scars –Interlobular septal thickening (mainly on bases) –Parenchymal bands, pleural retraction –Traction bronchiectasis, structural distortions –Mosaic pattern because of PHT HRCT: ground glass appearence Treatment; Oxygen, analgesics, hydration and exchance

52 Bilateral diffuse alveolar and interstitial infiltrates Control after 10 days following erytrocytopheresis

53 Radiology 2002; 225:639–653 Small-Vessel Diseases of the Lung: CT-Pathologic Correlates

54 Leukemias ◦ WBC> 50.000/mm 3 leukostasis risk ◦ Vaso-occlusion of alveolar capillaries and small vessels with blast cells ◦ Fever, pulmonary infiltrations, hypoxemia ◦ Leukostasis may mimic PTE ◦ Thorax CT-Angiography, V/Q scintigraphy

55 85 years of male patient addmitted with dyspnea Leucocyte 247000/UL

56 Spread of primary disease in lungs and lymph nodes Toxic effects of radiotherapy and chemotherapy Leukemic infiltration Hemorrhage Infections Malignant pleural effusion Upper airway obstrution due to CLL Alveolar proteinosis Pulmonary embolism

57 Thrombocyte disorders ◦ Hemoptysis ◦ Alveolar hemorrhage ◦ DIC(microvascular trombosis, dissemination coagulopathy) characterized by thrombin formation in systemic circulation  Most common cause sepsis  PTE ve infarction may lead to death

58 Transplantation and the lungs Solid organ/hematopoetic stem cell transplantation ◦ Infectious complications ◦ Neoplastic diseases (PLPH) ◦ Metastatic calcifications ◦ Toxic effects of the drugs to the lungs ◦ Pulmonary allograft rejection ◦ Idiopathic pneumonia syndrome (HKHT) (3weeks-3 months) ◦ Diffuse alveolar hemorrhage ◦ Engraftment Syndrome ◦ Bronchiolitis obliterans ◦ Pulmonary venoocclusive disease

59 THANKS…

60 Türk Toraks Derneği Bağışıklığı Baskılanmış Erişkinlerde Gelişen Pnömoni Tanı ve Tedavi Uzlaşı Raporu-2009

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