A 44-year-old man presents to an urgent care clinic with gradually progressive leg edema and shortness of breath during the previous 2 months, which has become significantly worse within the last 2 days. He denies any history of cardiac or pulmonary disease, but he does have a known history of chronic diarrhea with protein wasting thought to be due to his prior gastric bypass surgery. He denies chest pain, fever or cough, or any other new symptoms within the past week.

On physical examination, his vitals are notable for a blood pressure of 133/83 mm Hg, a pulse of 143 beats per minute, and a respiratory rate of 24 breaths per minute. He is afebrile, and his pulse oximetry is 92% on room air. The head and neck exam are normal, but due to his weight you cannot adequately assess for jugular venous distension. His lungs are clear without wheezing or rales, and his heart sounds are tachycardic and irregular, but otherwise normal. His abdomen is benign. His legs are notable for 1-2+ bilateral pitting edema with a negative Homan’s sign and no erythema.

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An EKG is performed and demonstrates atrial fibrillation at a rate of 128 beats per minute with nonspecific ST changes. A complete blood count is normal. A chemistry panel is remarkable for the following: sodium 151 mg, chloride 128 mg, carbon dioxide 13 g/mol, anion gap 12 mEq/L, blood urea nitrogen (BUN) 52 mg/dL, creatinine 1.7 mg/dL, magnesium low at 1.2 mg/dL, and albumin 1.7 g/dL. Troponin is undetectable, and his brain natriuretic peptide (BNP) level is normal.

Below is his chest X-ray.

What diagnostic finding is shown on this X-ray? What is the diagnosis?

HINT: Hypoproteinemia may be a risk factor for this condition.


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