Loss of Taste, Rash, and Dyspnea in a 46-Year-Old With GERD

Unnikrishnan Pillai, MD; Jameel Muzaffar, MD; Santosh G. John, MD; Pascale Salem, MD; Philip B. Vaidyan, MD

Disclosures

August 10, 2022

Physical Examination and Workup

Upon physical examination, the patient's heart rate is 88 beats/min, blood pressure is 88/54 mm Hg, and respiratory rate is 22 breaths/min. She has an oxygen saturation of 99% while breathing room air.

Pertinent findings on clinical examination include bilateral subconjunctival hemorrhaging; periorbital ecchymoses; multiple ecchymotic lesions around the anterior neck, chest, and abdomen (Figure 1); and bilateral pitting pretibial and pedal edema. Localized swelling with imprinted tooth marks (Figure 2) are noted on the lateral aspect of the tongue.

Figure 1.

Figure 2.

Jugular venous distention of 12 cm with normal first and second heart sounds, decreased air entry with mild rales at both lung bases, and bilateral proximal leg weakness are also found.

Other relevant findings include a B-type natriuretic peptide level of 1026 pg/mL (reference range, < 100 pg/mL), mildly elevated cardiac enzyme levels, and a chest radiograph showing cardiomegaly along with bilateral basal air space opacities. CT of the thorax shows bilateral pleural effusion (which is greater on the right than the left) and a small pericardial effusion. A urine analysis reveals mild proteinuria, but no red blood cells, white blood cells, or casts are detected. A 24-hour urine protein collection reveals proteinuria of 135 mg. ECG demonstrates low-voltage complexes with poor R-wave progression. A serum ferritin level and a panel of autoimmune tests are all normal. Transthoracic echocardiography is performed (Figure 3).

Figure 3.

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