1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Scott Sasovetz Affiliation: Naval Medical Center San Diego

2. MedPix No: 13122 - History Pt Demographics: Age = 26 y.o. Gender = man 26 y.o. athletic man with one week history of cough, congestion, and shortness of breath post open-ocean swim. Downloaded by (-1)

3. MedPix No: 13122 - EXAM & LABS Rhonchi throughout lung fields. No fevers, chills, chest pain or hemoptysis. EKG, CBC and electrolytes normal.

4. Chest X-ray Central haziness with slight alveolar filling and Kerley B lines consistent with swimming- induced pulmonary edema (SIPE) Downloaded by (-1)

5. Chest X-ray Central haziness with slight alveolar filling and Kerley B lines consistent with swimming- induced pulmonary edema (SIPE) Downloaded by (-1)

6. Chest X-ray Increased bronchial wall visibility (thickening), central peri-hilar haziness, slight alveolar filling, and Kerley B lines (red arrows) consistent with mild pulmonary edema. In this patient, swimming-induced pulmonary edema (SIPE). Also labeled: carina (white arrow) liver and spleen opacity in upper abdomen. Downloaded by (-1)

7. Lateral X-ray Central haziness with slight alveolar filling and Kerley B lines consistent with swimming- induced pulmonary edema Downloaded by (-1)

8. Lateral X-ray Another patient with similar symptoms but greater patchy airspace opacities along with increased interstial markings Downloaded by (-1)

9. Lateral X-ray Another patient with similar symptoms but greater patchy airspace opacities along with increased interstial markings Downloaded by (-1)

10. FINDINGS Central haziness with slight alveolar filling; and, Kerley B lines consistent with pulmonary interstitial lung disease.

11. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Cardiogenic - Congestive heart failure - Acute left ventricular failure - Cardiomyopathy - Myocardial infarction - - Noncardiogenic - SIPE - Pneumonia (aspiration and community acquired) - Allergic/drug reaction - Near drowning - ARDS - Fluid overload - High-altitude pulmonary edema

12. Diagnosis: Swimming-Induced Pulmonary Edema (SIPE) Dx Confirmed by: Radiographic findings, History, exclusion of other factors

13. DISCUSSION SIPE is a well known entity that affects limited members of the community. It typically is found in those that spend time in cold water exercise such as military training with heavy swimming and surface swimming. It tends to occur with prolonged fin use and overhydration prior to the activity. It is theorized that a weakness or failure in the pulmonary capillaries is the cause of the pulmonary edema. - - Overhydration prior to the exercise increases the load on the capillaries and can weaken the blood-gas barrier causing them to leak into the lungs. The cold temperature of the water contributes by vasoconstricting the peripheral vessels and increasing core blood volume. This also increases pulmonary pressures as well as preload and afterload. Stress furthers this effect with vasoconstriction due to sympathetic activity. - - The net effect is increased volume and pressures in the lungs that can leak RBCs and protein-containing edematous fluid into the interstitium. The resulting pulmonary edema can cause dyspnea, tachypnea, cough and reduced oxygen saturation. - - References: Ludwig BB, Mahon RT, Schwartzman EL. Cardiopulmonary function after recovery from swimming-induced pulmonary edema. Clin J Sport Med. 2006; 16: 348-351. - - Lund KL, Mahon RT, Tanen DA, et al. Swimming-induced pulmonary edema. Ann Emerg Med. 2003; 41: 251-256. - - Adir Y, Shupak A, Gil A, et al. Swimming-induced pulmonary edema: clinical presentation and serial lung function. Chest. 2004; 126: 394-399. - - Yoder JA, Viera AJ. Management of swimming-induced pulmonary edema. Am Fam Physician. 2004; 69: 1048-1049.