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Progressive breathlessness in a middle-aged man
  1. F Lodge1,
  2. A Shah1,
  3. R Mitra2
  1. 1Cardiology Department, Cardiff University, University Hospital of Wales, Cardiff, UK
  2. 2Cardiology Department, Royal Glamorgan Hospital, Pontyclun, Rhondda Cynon Taff, UK
  1. Correspondence to Dr Freya Lodge, Cardiology Department, Cardiff University, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK;freyalodge{at}doctors.org.uk

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CLINICAL INTRODUCTION

A 60-year-old diabetic, hypertensive, non-smoking man was admitted to hospital in 2009 with new-onset breathlessness, lethargy and pedal oedema. Examination revealed an S4 gallop and dullness at the right lung base. The jugular venous pressure was elevated to the earlobe. Troponin T was 60 ng/mL (0–14 ng/mL); blood tests were otherwise unremarkable.

A chest radiograph confirmed a right pleural effusion, which was transudative. ECG showed diffuse T-wave flattening with low voltage inferior complexes. Echocardiography demonstrated septal bounce with normal valvular and biventricular systolic function (see online supplementary video). Coronary angiography established minor irregularities only and spirometry demonstrated a mild restrictive defect, likely related to the pleural effusion. An autoimmune screen, protein electrophoresis and pituitary screen were negative.

Two years previously, he had been treated for antigen-positive Legionella …

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