UNEXPLAINED HYPOXIA: A CASE OF HEPATOPULMONARY SYNDROME AS THE HERALD OF CHRONIC LIVER DISEASE

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Platypnea-orthodeoxia is a syndrome characterized by dyspnea and hypoxemia worse in the upright position improved while supine. It has wide range differential diagnoses which could be cardiac, pulmonary, or abdominal origin. CASE PRESENTATION: A 56-year-old female with past medical history treated hepatitis C chronic lymphedema presented worsening bilateral lower extremity swelling, right more than left. She reported for 3 months, when sitting standing, did not have any other symptoms. Pulse oximetry on room air showed 89-90% supine, 88% sitting, 74% ambulation. Physical exam revealed holosystolic murmur loudest tricuspid area, pitting edema erythema, no stigmata liver disease (CLD). Chest X-ray was unremarkable. Bilateral ultrasound negative DVT but groin abscess. Transthoracic echocardiogram (TTE) moderate regurgitation, mildly dilated ventricle, markedly inferior vena cava. Further evaluation chest CTA included upper abdomen ruled out pulmonary embolism cirrhosis portal hypertension. Repeat limited TTE bubble study significant to left shunt bubbles that crossed after 5th beat indicating intrapulmonary shunt, leading diagnosis hepatopulmonary (HPS). received treatment cellulitis discharged oxygen plans follow up gastroenterology CLD work transplant evaluation. DISCUSSION: HPS triad disease, arterial hypoxemia, vascular dilatation (IPVD). prevalence 4-32% among adults end-stage disease. unusual first manifestation as our index case. IPVDs cause ventilation-perfusion mismatch reduced diffusion hypoxemia. specific symptom pathognomonic. Diagnostic aims demonstrate presence shunting. and/or blood gas analysis supine standing will show Contrast reveal an shunt. Supplemental beneficial patients definitive transplant. CONCLUSIONS: severe lung complication warrants early diagnosis. should presenting unexplained hypoxia REFERENCE #1: Phillips C, Harris Broughton N, Pulimood T, Ring L. An Unusual Refractory Hypoxia ICU. Critical Care. Vol. 2018; Article ID 3417259, 5 pages. https://doi.org/10.1155/2018/3417259 #2: Campanile A, Colombo Del Pinto M, Cavallini C. Persistent Unexplained Dyspnea: Hepatopulmonary Syndrome. Cardiology. 2017; 1469893, https://doi.org/10.1155/2017/1469893 #3: Tumgor G. Cirrhosis syndrome. World J Gastroenterol. 2014;20(10):2586-2594. DISCLOSURES: No relevant relationships Fatima Agha, source=Web Response Lisa Ezegbu, Maryam Hussain, Naresh Kumar, Areej Lalani,