Unexpected cause of respiratory distress.

To cite: Sotto Mayor J, Lages A, Esperança S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2015-213408 DESCRIPTION An 80-year-old woman with a history of pyrosis, chronic obstructive pulmonary disease (diagnosis details unknown) and dementia syndrome, presented to the emergency room after 4 days of productive cough with mucopurulent sputum and progressive worsening dyspnoea. There was no history of trauma. On physical examination, she was depressed with signs of respiratory distress. There were no alterations in heart auscultation and lung auscultation revealed overall decreased breathing sounds, fine bibasilar crackles and scattered ronch. Blood tests showed C reactive protein 26 mg/dL and leucocytes 9700 mL. Arterial blood gas analysis at FiO2 21% showed hypoxaemia with hypercapnia. There were no alterations in ECG; chest X-ray was remarkable for extreme enlargement of the mediastinum, with increased density in the lower 2/3 of the lung parenchyma associated with obliteration of the costophrenic angle bilaterally (figure 1). To clarify these findings, a thoracic CT scan was performed, revealing ‘dilation of the esophagus and large hiatal hernia with content composed of stomach and transverse colon’ (figure 2) without other significant changes. Bowel obstruction was ruled out. Despite the clinical and X-ray suggesting the presence of cardiac failure, the absence of changes on ECG, and normal heart auscultation, made us question this diagnosis. This case is relevant for the potential of a voluminous hernia to exacerbate respiratory symptoms in a patient with chronic respiratory disease in her medical history. Since this diagnosis was made in the presence of an acute exacerbation of her respiratory disease, increasing surgical risk, treatment of the hiatal hernia had to be postponed. Of note, this patient also had a significant history of gastroesophageal reflux disease—if this had been investigated in a timely manner, we may not have been faced by a patient in such an extreme condition.