Asthma presenting as cor pulmonale

Abstract

SummaryA 29-year-old man with asthma presenting as right sided congestive cardiac failure is reported. There was rapid resolution of the heart failure with standard bronchodilator therapy and corticosteroid therapy.KEY WORDS: asthma, cor pulmonale.Cor pulmonale is a well recognized and common sequela ofchronic airflow obstruction. It must be rare as a presenting symptom in asthma and has not to our knowledge been previously reported. Case reportA 29-year-old male, non-smoking farmer was admitted with a 5-week history of progressive swelling of the legs. On direct questioning, he admitted to a productive cough, mild dyspnoea and wheezing since his early teens. He gave no history of chest pain or haemoptysis and denied any recent deterioration in his breathing, although his family noticed that he was frequently incapacitated by breathlessness. He was taking no medication and had visited his general practitioner only once before with 'bronchitis' at the age of 12 years.On examination he was breathless, plethoric and cyanosed but had no finger clubbing. The pulse rate was 140/min, jugular venous pressure elevated and there was pitting oedema to his upper thighs. Bilateral expiratory rhonchi were heard and the liver was palpable 4 cm below the costal margin.On admission the forced expiratory volume in the first second (FEV,) was 10 litre and forced vital capacity (FVC) was 3-1 litre, improving to 16 and 3-8 litre respectively 15 min after 5 mg nebulized salbutamol. An electrocardiogram (ECG) showed right axis deviation and evidence of right ventricular hypertrophy. The chest X-ray showed cardiomegaly and hyperinflation of the lung fields.Arterial blood gases showed pH of 7-3 1, Po2 of 4-3 kPa and a Pco2 of 6-7 kPa. Haemoglobin was 20-2 g/dl with a haematocrit of 60%o. The sputum was purulent, growing Streptococcus pneumoniae and Haemophilus influenzae. Further investigations including farmers' lung and aspergillus precipitins were negative and an isotope lung scan showed no evidence of pulmonary embolus.He was treated with continuous 24% oxygen, prednisolone, nebulized salbutamol, diuretics and an antibiotic. He was venesected 1500 ml of blood.He rapidly improved and, on discharge 10 days later, he was oedema free and taking salbutamol 200 Ag and beclomethasone dipropionate 100 ,ug by inhaler four times a day and a reducing regime of prednisolone.Three weeks later, he was reviewed when he was asymptomatic, had stopped the prednisolone and his FEV,/FVC had increased to 3-65/4 65. His haemoglobin had fallen to 16 g/dl with a haematocrit of 51%. The chest X-ray had returned to normal.Since then his symptoms have been controlled by regular use of salbutamol and beclomethasone dipropionate by inhaler and a salbutamol spandet at night. When seen 3 months after admission he was well, at work and had a normal ECG, haemoglobin and chest X-ray. DiscussionCor pulmonale is common in severe chronic airflow obstruction after prolonged hypoxia. It is often accompanied by polycythaemia (Crofton and Douglas, 1975). These changes a...

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Asthma versus chronic obstructive pulmonary disease — exploring why ‘reversibility versus irreversibility’ is no longer an appropriate approach

“…Following intensive treatment, the severe impairment of FEV 1 that was found in all three patients improved substantially and clinical markers of right heart failure regressed. Two other cases reports describe asthmatic patients in their twenties with similar presentations (one case complicated by anorexia nervosa) with right heart failure [ 19, 20]. If these subjects had been over the age of 60 years, the assumption would be that COPD was the underlying diagnosis, treatment may not have been so aggressive and long‐term outcome less successful.…”

“…If irreversible airflow obstruction can arise in a proportion of patients with chronic persistent asthma, can other complications arise such as arterial hypoxaemia, pulmonary hypertension and Cor pulmonale? Three papers describe young adults with asthma who were non‐smokers or ex‐smokers and presented with Cor pulmonale [ 18–20]. Corris and Gibson describe three subjects (29, 42 and 50 years old) who had a history of untreated intermittent wheeze and cough over years and presented with progressive breathlessness, peripheral oedema and raised jugular venous pressure [ 18].…”