March 2013 Pulmonary Case of the Month: Don’t Rein Me In

Robert W. Viggiano, MD

Michael B. Gotway, MD

Departments of Pulmonary Medicine and Radiology

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 70 year old man was referred for a pleural effusion. The patient had pitting edema of the lower extremities noted in March, 2013. At that time a myocardial perfusion study and an echocardiogram were interpreted as being normal with an ejection fraction of 55%. His primary care physician stopped the amlodipine he was taking for hypertension and his edema resolved. However, the amlodipine was restarted a few weeks later for blood pressure control.

PMH, SH, FH

He has a past medical history of hypertension and asthma. He was diagnosed with prostrate cancer in mid 2012. At that time a CT scan of his abdomen/pelvis and a MRI of his pelvis were negative for metastatic disease. He underwent robot assisted radical prostatectomy and bilateral pelvic lymph node dissection in August 2012. His final diagnosis was Gleason 4+5 disease present throughout the prostate with focal extraprostatic extension and lymphovascular and perineural invasion and invasion of right seminal vesicle. He was staged T 3B.

Present medications

• Amlodipine 5 mg at bedtime
• Omelsartan (Benicar®) 40 mg/day
• Salmeterol/fluticasone (Advair®) 100/50 1 puff twice a day
• Clonazepam 0.5 mg twice a day
• Lycopene 10 mg daily

He has a 10 year smoking history but no alcohol or drug use.

Family history is unremarkable.

Physical Examination

Vital signs: Normal

Lungs: Decreased breath sounds in both lung bases

Heart: Elevated JVP; Normal S1 and S2

Abdomen: Negative

Extremities: 2-3+ pitting edema

Laboratory

• CBC: normal
• Electrolytes: normal
• Serum creatinine: 1.0 mg/dL
• Total protein: 6.8 g/dL
• Albumin: 4.3 g/dL
• NT-pro brain naturetic peptide (BNP): 255 pg/ml

Radiography

Chest x-ray is shown in figure 1.

Figure 1. PA (panel A) and lateral (panel B) chest radiography.

Which of the following is false?

1. The patient’s chest x-ray shows bilateral pleural effusions right larger than left
2. A NT-pro BNP 255 pg/ml makes heart failure an unlikely diagnosis
3. His pleural effusion is most likely due to metastatic prostate cancer
4. A normal heart size on chest x-ray excludes heart failure
5. A normal echocardiogram excludes heart failure

Reference as: Viggiano RW, Gotway MB. March 2013 pulmonary case of the month: don't rein me in. Soutwest J Pulm Crit Care. 2013;6(3):93-102. PDF