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Native vertebral osteomyelitis — ABIM Board MCQ

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HardInfectious DiseaseNative vertebral osteomyelitisABIM Board

A 54-year-old woman with cirrhosis has progressive dyspnea that worsens when upright. Room-air PaO2 is 58 mm Hg. Echocardiography shows normal ventricular function and no intracardiac shunt; agitated-saline microbubbles appear in the left atrium after five cardiac cycles. Which diagnosis best explains the findings?

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Correct answer: E — Hepatopulmonary syndrome from intrapulmonary vascular dilatation

The best answer is “Hepatopulmonary syndrome from intrapulmonary vascular dilatation”. Delayed left-sided appearance of agitated-saline microbubbles after three to six cardiac cycles indicates passage through dilated pulmonary vessels, whereas an intracardiac shunt appears earlier. Cirrhosis, impaired oxygenation, platypnea-orthodeoxia, and documented intrapulmonary vascular dilatation establish hepatopulmonary syndrome. Portopulmonary hypertension is a precapillary pulmonary vascular disorder diagnosed hemodynamically and does not cause this delayed-bubble pattern.

Reference: Cirrhosis outpatient management: hepatopulmonary syndrome: https://pmc.ncbi.nlm.nih.gov/articles/PMC10579555/