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Dyspnoea in a patient with hepatitis C
  1. Jia-Feng Chang1,2,3,
  2. Cheng-Hsien Hsieh1,
  3. Jian-Chiun Liou4,5,
  4. Jen-kuang Lee6
  1. 1 Department of Critical Care Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
  2. 2 Department of Internal Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
  3. 3 School of Medicine, Ph.D. Program in Nutrition and Food Science, College of Medicine, Graduate Institution of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan
  4. 4 Department of Electronic Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan
  5. 5 Graduate Institute of Clinical Medicine Jointly Appointed, Kaohsiung Medical University, Kaohsiung, Taiwan
  6. 6 Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan
  1. Correspondence to Dr Jia-Feng Chang, Department of Internal Medicine, En Chu Kong Hospital, No.399, Fuxing Rd., Sanxia District, New Taipei City 23702, Taiwan; cjf6699{at}


Clinical introduction A 60-year-old man had a long history of chronic hepatitis C. He presented to the emergency department with 2 days of progressive dyspnoea. Clinical manifestations included respiratory distress, cyanosis, digital clubbing, spider naevi on the upper chest and shifting dullness in the abdomen (see online supplementary figure S1). The ECG showed sinus tachycardia and left axis deviation. The chest radiography depicted blunting of right costophrenic angle with small pleural effusions and bilateral prominent pulmonary vascular markings (see online supplementary figure S2). The dyspnoea was exacerbated by upright posture and improved with recumbency. The hypoxaemia could not be corrected with administration of 100% oxygen. Contrast-enhanced transthoracic echocardiography was performed with injection of agitated saline (see figure 1 and online supplementary video). CT scan of the chest revealed some vascular abnormalities (see online supplementary figure S3–S6).

Question Which of the following is the next best step in management?

  1. Catheter-based closure of intracardiac shunt

  2. Liver transplantation

  3. Pulmonary angiography and embolisation

  4. Thoracentesis

  5. Transjugular intrahepatic portosystemic shunt


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  • Contributors J-FC wrote most of the main text. C-HH contributed to comments for the image study. J-KL contributed to the echocardiogram.

  • Funding This study was supported by the Ministry of Science and Technology (MOST), 104-2220-E-151-001-.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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