Case 6/2017 - A 28-Year-Old Man with Anasarca And Restrictive Heart Disease

DOI: 10.5935/abc.20170184 The patient was a 28-year-old male, born and living in the city of São Paulo, who sought medical care complaining of dyspnea and edema. He reported abdominal pain and abdominal volume increase five years before, when he sought medical care. On the occasion a gastroenterological investigation began, and a biopsy was suggested, but refused by the patient, who remained without an etiological diagnosis. One year later, edema of the lower limbs appeared, followed by dyspnea on intermediate exertion two years later. The patient reported worsening of the abdominal volume increase, edema of the lower limbs and dyspnea even at rest in the past two months. He was then referred to our hospital. His physical examination (Aug 11, 2005) showed a regular general state of health, heart rate of 120 bpm, and blood pressure of 90/60 mm Hg. His lung auscultation showed rales up to the middle third of the left hemithorax. His heart auscultation showed arrhythmic cardiac sounds and systolic murmur in mitral area and left sternal border. The liver was palpated 4 cm from the right costal margin. There were ascites and edema of the lower limbs. His electrocardiogram (Aug 11, 2005) showed atrial fibrillation, low-voltage QRS complexes, parallel SÂQRS + 90° (Figure 1). Decompensated heart failure and left pleural effusion were diagnosed, and the patient was hospitalized for treatment. His laboratory tests (Aug 13, 2005) revealed: hemoglobin, 14.7 g/dL; hematocrit, 44%; leukocytes, 6400/mm3; platelets, 210,000/mm3; urea, 30 mg/dL; creatinine, 1.1 mg/dL; potassium, 5.6 mEq/L; sodium, 134 mEq/L; INR, 2.2; TTPA(rel), 1.3; and normal urinalysis. His serologies for Chagas disease, hepatitis, HIV and syphilis were negative. His antinuclear antibody and rheumatoid factor tests were negative, as were the tests for the following antibodies: anti-smooth muscle (kidney and stomach), anti-mitochondrial, anti-parietal cell, anti-liver cytosol, anti-microsomal fraction, liver/kidney microsomal. Serum copper was normal, and ceruloplasmin was high.