Cardiogenic shock in a 38-year-old female lady, diagnostic and management challenges, in a remote limited resource area: a case report

¹Village Health Works, Women Health Pavilion, Kigutu Hospital, Kirungu, Burundi

^&Corresponding author
Mark Paul Mayala, Village Health Works, Women Health Pavilion, Kigutu Hospital, Kirungu, Burundi

Introduction    

This case report details the clinical course of a 38-year-old female patient who presented with the wet and warm type of cardiogenic shock, accompanied by sepsis, acute renal injury, pulmonary hypertension and suspected pulmonary embolism. Notably, the patient had no documented history of chronic disease and had been managed in several occasions for three years under a diagnosis of pneumonia. The unique clinical journey of this patient brings to light the critical role of a comprehensive history and physical examination in a remote, limited-resource area. It underscores the challenges and complexities encountered in diagnosing and managing this under-recognized and highly mortal form of shock. Amidst the absence of prior chronic illness, the patient's evolution from a diagnosis of pneumonia to the emergence of cardiogenic shock emphasizes the need for meticulous clinical assessment in resource-limited settings. This case exemplifies the pivotal significance of a detailed history and physical examination in unraveling the underlying manifestation of cardiogenic shock, particularly in scenarios where advanced diagnostic resources may be unavailable. The objective of this report is to shed light on the diagnostic and management challenges inherent in atypical clinical presentations of cardiogenic shock, especially within remote and limited resource environments. By providing a detailed account of this specific case, we aim to underscore the critical influence of thorough clinical evaluation and the need for adaptable diagnostic strategies in similar clinical setting. This revised introduction expands upon the original content, providing greater context and setting the stage for a detailed exploration of the challenges and implications associated with diagnosing and managing cardiogenic septic shock in resource-constrained environments.

Patient and observation     

Patient information: a 38-year-old female, with no formal education, none insured, non-alcoholic, non-smoker, with 3 children, all delivered through spontaneous vaginal delivery, with no complications, husband is a farmer.

Timeline: has history of several hospital visits due to difficulty in breathing, persistent productive cough, easy fatigue, poor appetite, good urine output and with none of the visits with a mention of high blood pressure or blood sugar. She has been on several antibiotic uses on and off as treatment for pneumonia. There is no known family history of chronic diseases like hypertension, diabetes mellitus or autoimmunity. Has no history of surgeries or blood transfusions.

Clinical findings: presented to internal medicine department from emergency department (ED) with a diagnosis of cardiogenic shock as per presentation of hypotension, dyspnea, anorexia, productive cough, nocturnal dyspnea, and easy fatigue. On top of the symptoms, patient was desaturating off oxygen to 80-89%, hypotensive with mean arterial pressure (MAP) ranging between 53-55 mmhg, tachycardic, tachypneic, distended jugular venous pressure, no lower limb edema and systemic examination revealed diffuse crackles all over the chest, on cardiac exam had rapid heart rate with no added sounds.

Diagnostic assessment: upon presentation to the internal medicine department, the patient exhibited classic signs of cardiogenic shock, including hypotension, dyspnea, distended jugular veins, and acute renal failure. Notably, there was pneumonic changes on a simple chest X-ray on the right lower lobe and mild left sided pleaural effusion (Figure 1), the diagnosis of a heart failure with reduced ejection fraction, estimated at 30.58%, was confirmed by a quick cardiac ultrasound (Figure 2). Clinical suspicion of coexisting conditions such as pulmonary hypertension (Figure 3) and potential pulmonary embolism further diagnostic challenges. The patient's initial clinical history of recurrent respiratory symptoms leading to antibiotic treatments without a definitive diagnosis highlights the difficulties in identifying and managing cardiovascular conditions in settings with limited access to advanced diagnostic tools. The absence of a prior diagnosis of high blood pressure or blood sugar, coupled with the lack of family history of chronic diseases, further complicates the early detection of underlying cardiac pathology. The added complexity to the diagnosis, emphasize the need for comprehensive evaluation even in the absence of advanced radiological resources.

Therapeutic interventions and outcomes: the management of this case was particularly challenging due to the limited resources and lack of guideline-directed medical therapy for heart failure in the remote setting. Despite these challenges, the patient responded positively to treatment, including oxygen supplementation, loop diuretics, intravenous fluids, antibiotics, and the initiation of sildenafil tablets and enoxiparin injection for suspected pulmonary hypertension and pulmonary embolism respectively. The recovery of the patient, demonstrated by remarkable improvement and achievement of a significantly increased ejection fraction of 70% (Figure 4) within nine days, underscores the critical role of stabilizing a patient in cardiogenic shock even in resource-limited environments. This case highlights the importance of thorough clinical evaluation and prompt intervention in resource-constrained settings, where reliance on advanced diagnostic tools and guideline-directed therapies may be limited. The successful management of this case, despite the lack of comprehensive treatment options, underscores the need for adaptable, context-specific approaches to address cardiogenic shock and associated conditions in similar settings. Furthermore, it underscores the necessity of raising awareness about advanced cardiac conditions and equipping healthcare providers in remote areas with effective tools and strategies for early diagnosis and intervention.

Follow up and outcomes/prognosis: the prognosis of the patient is poor due to various factors surrounding her, including her low economic status hindering her follow-ups visits, medication refills and proper diet acquition.

Patient perspective: our patient reports that she is satisfied with the care and treatment she is receiving at women health pavilion, Kigutu hospital.

Ethics declaration and consent for publication: ethical approval was not applicable. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Discussion     

Clinical outcomes remain poor for any patient with cardiogenic shock, despite recent advances, with mortality rates exceeding 40% [1]. To provide a comprehensive understanding, a comparison with relevant literature is integral to elucidate the unique aspects of this case and its broader implications. Ryota et al. showed that very little is known about cardiogenic shock complicating sepsis. Therefore, investigated the prevalence and impact on in-hospital mortality of cardiogenic shock complicating sepsis and septic shock, where the prevalence of cardiogenic shock complicating septic shock was 4.6%, and it was associated with significantly higher in-hospital mortality [2]. The study highlighted the importance of assessments of cardiac function in septic shock and further investigations. The successful outcomes observed in this case, despite the absence of guideline-directed medical therapy and limited diagnostic resources, align with the principles outlined in studies by Parker et al.(1990) [3] and Bouhemad B et al. (2009) [4]. These studies highlighted how myocardial dysfunction affects both left and right ventricles and in survivors, it is typically reversible and return to normal within 7-10 days, from the onset of septic shock as seen in our patient who recovered within 9 days. Furthermore, the prompt recovery and improved ejection fraction observed in this case are congruent with the findings from reviews reported by Sato. R and co-authors (2015). The review article underscored the positive outcomes achievable through comprehensive patient stabilization, further emphasizing the critical role of early recognition and effective intervention in cardiogenic shock within similar clinical contexts [5]. In summary, this case exhibits resonance with existing literature, shedding light on the pivotal role of a thorough clinical assessment, adaptable intervention strategies, and the potential for positive patient outcomes even in resource-limited settings. The documented successes and challenges in this case contribute to the broader discourse on diagnosing and managing cardiogenic shock in remote and limited resource environments, providing valuable insights for the development of context-specific diagnostic and management approaches.

Conclusion     

The presented case of cardiogenic shock complicated by sepsis, acute renal injury, pulmonary hypertension and suspected pulmonary embolism, in a female patient with a previous history of several treatments for pneumonia, sheds light on the critical diagnostic and management challenges faced in remote, limited-resource environments. It underscores the pivotal importance of a comprehensive history, thorough physical examination, and adaptable intervention strategies in uncovering and effectively managing atypical clinical presentations of cardiogenic shock, particularly where advanced diagnostic and therapeutic resources are constrained.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Brian Bandenzamaso, Loïc Habarugira, Peter Shadrack Mabula, and Mark Paul Mayala, admitted the patient and were his attending physicians in the ward. Peter Shadrack Mabula provided his expert opinion in the management of this patient. Mark Paul Mayala guided the preparation of the manuscript. All authors have read and agreed to the final manuscript.

Acknowledgment     

The authors acknowledge the cooperation they got from the patient.

Figures     

Figure 1: a chest X- ray PA view, showing features of right lung pneumonic changes and mild left lung pleural effusion

Figure 2: initial cardiac scan, short axis view, that estimated an ejection fraction of 30.58%

Figure 3: a short axis view of the cardiac scan showing a D-sign, as a result of right ventricular overload

Figure 4: a long axis view of the cardiac scan after 9 days of management, showing a raised ejection fraction of 70.47%

References