Heart, Lung and Circulation

Resting Hypoxia and a Strongly Positive Bubble Test: Do Not Forget Hepato-Pulmonary Syndrome

Published:August 15, 2022DOI:
      A 40-year-old male presented to the hospital with a tender right calf, right-sided pleuritic chest pain, and haemoptysis. He has a strong family history of anti-thrombin-3 deficiency and unprovoked deep-vein thrombosis in many of his paternal family members. Computed tomography (CT) pulmonary angiography demonstrated a segmental pulmonary embolism (PE) and associated pulmonary haemorrhage/infarct in the right middle lobe (Panel-A). X-ray chest demonstrated mild pulmonary congestion (Panel-B). Resting oxygen saturation on room air (RA) was 81%; disproportionately low for his presentation with PE, however, the patient did not complain of dyspnoea. As oxygen saturation failed to improve with high-flow oxygen therapy, the patient was intubated. His haemoglobin level was 173 gram/litre; the rest of the blood work was unremarkable. CT abdomen-pelvis identified cirrhosis of the liver with splenomegaly and oesophageal varices. Transthoracic echocardiogram demonstrated normal-sized cardiac chambers and bubble injection quickly opacified the left-sided cardiac chambers within three-heart beats, raising concern for this to be a patent foramen ovale mediated right-to-left shunt (Video-1).


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