Unveiling the diagnostic conundrum: cardiac asthma masquerading as bronchial asthma (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 delves into the journey of a 52-year-old male patient, whose initial diagnosis of bronchial asthma failed to capture the complexity of his condition. Despite previous misinterpretations, his recent presentation, characterized by wheezing and symptoms suggestive of heart failure, unveiled a deeper diagnostic puzzle. This case underscores the paramount importance of thorough history-taking and physical examination, particularly in remote or resource-limited settings, where access to advanced diagnostic tools may be limited. By dissecting the clinical narrative of this patient, we aim to shed light on the nuances of cardiac asthma and underscore the critical role of clinical acumen in navigating diagnostic uncertainties.

Patient and observation     

Patient information: a 52-year-old male, farmer, married, with 3 children. Has no formal education, is not insured, has a history of smoking equivalent to 10 pack years and alcohol consumption.

Timeline: he presented with a 2-year history of chronic heart failure symptoms characterized by easy fatigue, persistent nocturnal dry cough, orthopnea, and occasional mild wheezing, until a day ago when on top of these symptoms, he presented at our emergency department with signs and symptoms of acute decompensated heart failure. There is no known family history of chronic diseases like hypertension, diabetes mellitus, or asthma. Has no history of surgeries or blood transfusions.

Clinical findings: he presented to the internal medicine department from the emergency department (ED) with a diagnosis of cardiac asthma as per presentation of severe dyspnea, audible wheezes, use of accessory muscles for breathing, raised jugular venous pressure, oxygen saturation of 85-88% on room air and improving marginally to 92% with supplemental oxygen at 3 liters per minute, and bilateral lower limb edema and systemic examination revealed bi-basal crackles and diffuse wheezes all over the chest, on cardiac exam had rapid heart rate with no added sounds.

Diagnostic assessment: he was diagnosed with cardiac asthma based on clinical presentation. Chest X-ray revealed signs of congestion and possible coexisting chronic obstructive pulmonary disease. Cardiac ultrasound estimated an ejection fraction of 30-40%. Initial misdiagnosis of bronchial asthma highlights the importance of thorough history-taking and physical examination. Lack of prior diagnosis of hypertension or diabetes, coupled with no family history of chronic diseases, complicates early detection of underlying cardiac issues.

Therapeutic interventions and outcomes: he was managed with oxygen supplementation, loop diuretics, intravenous hydralazine, losartan, and spironolactone. The patient responded positively, with significant improvement in congestive symptoms, despite limited resources and guideline-directed therapies.

Implications and recommendations: successful management in resource-constrained settings underscores the importance of adaptable, context-specific approaches to address heart failure. Awareness and training for healthcare providers in remote areas are crucial for early diagnosis and intervention.

Follow-up and outcomes/prognosis: the prognosis of the patient is fair but due to various factors surrounding him, including her low economic status hindering his follow-up visits, medication refills, and proper diet acquisition.

Patient perspective: our patient reported that he was satisfied with the care and treatment he received at Women Health Pavilion, Kigutu Hospital.

Informed consent: written informed consent was obtained from the patient to publish this case report and any accompanying images.

Discussion     

This case illustrates the diagnostic challenges posed by cardiac asthma, which can closely mimic bronchial asthma. Both conditions present with wheezing and dyspnea, necessitating a thorough clinical assessment and diagnostic workup to differentiate between them. Key distinguishing features include the presence of cardiac risk factors, physical examination findings suggestive of heart failure, and diagnostic tests such as echocardiography to assess cardiac function. Failure to recognize cardiac asthma can lead to delayed diagnosis, inappropriate treatment, and potentially adverse outcomes.

Research findings indicate that the prevalence of asthma among individuals aged 65 years and older fall between 6.5% and 10.4%, as reported in various studies, including the cardiovascular health study, where an 8% prevalence was noted [1]. Similarly, data from the National Health Interview Survey conducted by the National Center for Health Statistics, CDC, revealed a 7.5% prevalence in this age group [2]. However, within the elderly population diagnosed with congestive heart failure, approximately 35% exhibit wheezing consistent with cardiac asthma [3], surpassing the prevalence of asthma in this demographic by more than 3.5 times. This suggests that a significant proportion of asthma diagnoses in the elderly may represent cases of cardiac asthma.

Treatment guidelines typically advocate for vasodilators like nitrates or non-invasive ventilation, such as continuous positive airway pressure (CPAP), in managing cardiac asthma. However, access to such modalities may be limited in remote and rural areas. In such contexts, loop diuretics are often the mainstay, albeit suboptimal when used alone. In this case, a pragmatic approach was adopted, combining hydralazine, a vasodilator, with furosemide to enhance diuresis by optimizing renal blood flow. Additionally, the patient received losartan and spironolactone for heart failure management. This comprehensive regimen led to significant improvement, as evidenced by the resolution of wheezing and successful recovery.

Conclusion     

Cardiac asthma represents a diagnostic dilemma, often masquerading as bronchial asthma. Clinicians must maintain a high index of suspicion for cardiac etiologies, especially in patients with known cardiovascular risk factors or atypical asthma presentations. Timely recognition and appropriate management are paramount for optimizing patient care and preventing unnecessary misdiagnosis-related morbidity and mortality. This case underscores the importance of a comprehensive approach to respiratory symptoms, integrating clinical judgment, diagnostic testing, and therapeutic interventions tailored to the underlying etiology.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Loïc Habarugira, Peter Shadrack Mabula, Herve Jean Marc Ndorimpa, Didier Nshemezimana, Fabrice Nshimirimana, Nesar Hamraz, and Mark Paul Mayala, admitted the patient and were his attending physicians in the ward. Mark Paul Mayala guided the preparation of the manuscript. All authors read and approved the manuscript.

Acknowledgments     

The authors acknowledge the cooperation they got from the patient.

References