Case Report ABSTRACTS

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3. Kardaun SH, Sekula P, Valeyrie-Allanore L, et al. Drugh reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study. Br J Dermatol 2013; 169:1071
An unusual case of breathlessness Caroline Tait NHS <strong>Case</strong> <strong>Report</strong> Breathlessness is a common presenting complaint on the acute medical post take ward round, and there is a broad range of differential diagnoses. This case highlights a rare but important cause of breathlessness. A 62 year old man was admitted with a two week history of progressive breathlessness, affecting him when lying flat. He reported a recent diarrhoeal illness, but no other cardiovascular, respiratory or neurological symptoms. He was a lifelong non-smoker, and had no occupational or environmental risk factors for lung disease. Clinical examination was normal apart from the onset of acute dyspnoea upon attempting to lie flat. Routine blood tests, ECG and D-dimer were normal, however his chest X-ray (CXR) showed bilateral elevated hemi-diaphragms. Pulmonary function tests showed an extra-pulmonary restrictive defect and sniff inspiratory muscle pressures were markedly reduced, indicating a diaphragmatic weakness. He was diagnosed with bilateral phrenic nerve palsies and referred to the Neurology team. He went on to have a lumbar puncture which showed an elevated protein count, and nerve conduction studies showed absent phrenic response bilaterally. He was diagnosed with Guillain-Barre Syndrome and was treated with intra-venous immunoglobulin and respiratory support with nocturnal non-invasive ventilation. Phrenic nerve palsies should be considered in patients who present with exertional dyspnoea and orthopnoea, with apparent normal cardiac function and CXR appearances. Symptoms are more pronounced in bilateral palsies, though these are much rarer. Common causes include metastatic infiltration of the spinal cord, trauma and inflammatory neuropathies. Suspicion of phrenic nerve palsy can be confirmed with spirometry demonstrating an extra-thoracic restrictive pattern and a significant reduction in sniff inspiratory mouth pressures. Patients with underlying lung disease or bilateral palsies have a worse prognosis and they are more likely to require long term ventilator support.
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Case Report ABSTRACTS

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