This is a series of case reports presented to the high altitude experts for discussion. It is a contribution to the knowledge of high altitude disease.

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Dear high altitude friends from around the globe:

Hope all is well with you. This is the next case report. Your are invited to make your comments on the diagnosis and treatment.

Once we receive all the answers from the high altitude experts around the world we will send a follow-up on the case, with all the comments received.

NAME: A. O. F.
DATE: 21/05/2004
DATE OF INITIAL CONSULTATION: 06/05/2004
AGE:         48  SEX: F
BORN IN: LA PAZ,BOLIVIA        RESIDENT OF LA PAZ (3510 M): YES
WEIGHT:   55.2 Kg     HEIGHT:  1.44 m
BLOOD PRESSURE: 130 / 95  mmHg   PULSE:  84 x'  TEMP: 36.5 °C
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PERSONAL MEDICAL RECORD: Smoked: never. Alcoholic beverages: no ; Cups of coffee per day: none. Drugs: None. Allergies: medical tape;  Current medication: Carbamazepine and Chloramphenicol recently; Genito-urinary: Last period 1 year ago.; Gastro-intestinal: None; Other disease: Pneumonia as a girl; Surgery: gall bladder; Accidents: Trauma of the head due to loss of conscience.

FAMILY HISTORY:  Father: Died ; Mother: herpes, ulcers, cholecistectomy, diabetes. Brothers: 3 healthy brothers ; Children: none.

PHYSICAL EXAMINATION: Head: Normal. Eyes: hyperemic conjunctivae. Ears: Normal. Nose: Normal. Throat: slight edema of the tongue, with perioral cyanosis. Neck: Normal. Thorax: slightly asymmetric. Heart: Normophonetic, rhythmic, heart sounds with no heart murmurs. Lungs: mild ronchus and wheezing at bilateral apex, there is no respiratory distress. Abdomen: Depressible, not painful. Genitals: Normal. Arms: mild arthritis with finger clubbing and acrocyanosis. Legs: mild edema.

HISTORY : The patient comes to consultation because her health problems begin 4 years ago with cough and yellow green sputum. She is treated with ampicillin. But the cough continues and becomes spasmodic and persistent. Three years ago a chest x-ray is taken and she refers that it was reported as normal (She does not bring the x-rays and the report is questionable). Penicillin is prescribed and there is no improvement. Recently she has had 3 episodes of loss of conscience while coughing intensely and has consulted a neurologist. A CAT scan and an EEG performed, also were reported as normal (she does not bring them), but she is given Valpaquine and Hydantine, which she takes during one whole year with no improvement. Again she is sent to pneumology where another chest x-ray is again reported as normal, and she is started on aminophilline during 2 months, because asthma is suspected. With no improvement she interrupts treatment. This past month she presents headache and a new CAT was again reported as normal. She is given Carbamazepine and she comes to consultation because of a persistent cough.

LABORATORY  TESTS:

Hematocrit: 69 %
Hemoglobin: 23.0 gm%
RBC count: 7.7 million/mmm3

WBC count: 4800
Neuthrophils: 56%
Lymphocytes: 44%
Eosinophyls: 0 %

Urianalyses: Urobilinogen +

ARTERIAL BLOOD GASES breathing ambient air
PaO2 = 37 mmHg   (N=58-62)
PaCO2 = 43 mmHg  (N=28-32)
pH = 7.37
HCO3 = 24.3 mEq/l
SaO2 = 71 %  (N=90-92 %)

ARTERIAL BLOOD GASES on 100 % oxygen
PaO2 = 138 mmHg   (N>200)
PaCO2 = 33.5 mmHg  (N=28-32)
pH = 7.42
HCO3 = 21.2 mEq/l

BIOCHEMISTRY
Cholesterol (F):       105.6 mg/dl    (N=120-240)   HIGH
Total Proteins:             4.3  g/dl      (N=6.1-7.9)     LOW
Glucose:                  103.3 mg/dl    (N=60-110)
Creatinine:                   0.53  mg/dl (N=0.2-0.45)
Urea Nitrogen:            0.23  g/l      (N=0.20-0.45)
Tryglicerides:           102.3 mg/dl    (N=10-150)

Breath Holding test: 3 minutes
click on each of the following links to see the results (click BACK to return):
Chest x-rays (posterior-anterior),   (lateral),
Electrocardiogram page 1,     electrocardiogram page 2
Spirometry,
Flow-volume loop
Echocardiography1 with PAP (Aceleration) = 21.3 mmHg   (Normal for this altitude)
Echocardiography2 with normal pulmonary valve flow.
                                    CO = 4.48 l/min
Sleep Pulsoximetry study

17/05/2004
During the breath holding test, she is able to sustain her breath beyond 3 minutes and presents loss of conscience, requiring a decubitus supine position until recovery. Two other tests of breath holding performed the next days give the results presented here, where she did not hold her breath as long as possible because of fear of losing her conscience. A hyperoxic pulmonary shunt test shows a significant shunt reaching a PaO2 of only 138 mmHg.

The patient is currently working as a secretary in a local school in the city of La Paz 3600 m.

Sincerely,
 

Dr. Gustavo Zubieta-Calleja, M.D.
Clinica IPPA
High Altitude Pathology Institute
www.altitudeclinic.com
 

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Please answer these questions.

1)  What is your diagnosis ?.

2)  Should the increased polycythemia require bloodletting ?

3)  Can this patient remain at high altitude?

4)  Do you think this is a case of CMS ?
 

 As usual, if you wish  to keep your opinion anonymous, please let us know.

Our best regards to all of you,
 

Prof. Dr. Gustavo Zubieta-Castillo (Sr)        &         Dr. Gustavo Zubieta-Calleja
High Altitude Pathology Institute (IPPA)
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