Cardiopulmonary instability evoked by exaggerated Chilaiditi syndrome

Excerpt

This 31-year-old obese Greek man presented with severe dyspnea and generalized edema. He showed severe disturbances in blood gas tensions (p _aO₂ 61 mmHg, p _aCO₂ 111 mmHg), was put on mechanical ventilation, and transferred to our ICU with suspected pneumonia. Pulmonary artery catheterization and transesophageal echocardiography revealed pulmonary artery hypertension (mean pressure 55 mmHg) and right heart failure that were treated with nitric oxide and iloprost inhalation. History was consistent with Pickwickian syndrome, obstructive pulmonary disease, and abuse of marihuana and alcohol. Admission chest X-ray showed an elevated right diaphragm and possible lingular infiltrates (Fig. 1a), with Chilaiditi sign as an ancillary finding in the abdominal CT scan. Chilaiditi sign, called Chilaiditi syndrome when accompanied by clinical symptoms, is defined as colonic interposition between the liver and diaphragm, as first described in 1910 by the radiologist Demetrius Chilaiditi [1, 2]. The patient’s condition subsequently improved. However, during weaning from mechanical ventilation his condition became progressively unstable and he developed arrhythmias. Chest X-ray and CT scans showed a gas-filled colon in the right hemithorax and mediastinal shifting (Fig. 1b, c, d), and intrathoracic visceral herniation could not be excluded. On laparotomy, however, the diaphragm was found intact and cardiopulmonary impairment resolved after intestinal decompression by a colonic tube. Four days later he was transferred in good condition for respiratory rehabilitation and treatment of Pickwickian syndrome.

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