Theme: Pulmonary hypertension, right heart failure, shock
The following is a fictional case, and any resemblance to actual persons living or dead is entirely coincidental.
A 30-year-old female presents to the Emergency Department after a collapse at work. She had been feeling unwell for a few days, with a low-grade fever and increasing shortness of breath.
On further questioning she reports some dyspnoea on exertion and excessive tiredness, both of which started during a pregnancy 18 months ago. She is tachycardic, hypotensive and hypoxaemic requiring high-flow oxygen.
Blood tests demonstrate an elevated white blood count and CRP. Her ECG shows right axis deviation and a right bundle branch block. A CTPA was requested and shows left-sided lobar consolidation, no evidence of pulmonary embolism but significant right ventricular dilatation and hypertrophy, a prominent pulmonary artery trunk, and contrast reflux into the IVC and hepatic veins.
The patient is being started on antibiotics and admitted to the ICU for CPAP and vasopressors. A bedside focused echo demonstrates a dilated right ventricle with paradoxical septal motion. Left atrium was not dilated. The treating team suspects pre-existing pulmonary hypertension (PH).
