Rejected by the New England Journal of Medicine in 2005.

To the Editor:

Two features of case 5-2005 (1) deserve comment.

First, hyperacute (“flash”) pulmonary edema did not occur. Suggestive X-ray signs of stage 2 pulmonary edema were present initially, but not appreciated. Resting tachycardia and relative hypotension were also present initially, further suggesting a circulatory system nearing its compensatory limits. Only after normal saline administration did frank pulmonary edema become manifest. Missed diagnosis and iatrogenesis should be added to the differential diagnosis of hyperacute pulmonary edema in the case discussion.

Second, like the proverbial elephant in the living room that is scrupulously not discussed, the claim that “the general physical [examination] disclosed no abnormalities” should have been the discussants’ focus. It stretches probability to believe that all physical signs of heart failure, advanced endocarditis, and aortic valvulopathy were initially absent, yet one discussant accepts this, and another partially excuses it. The patient’s vital signs, marked first-degree heart block, and history of hospitalization for heart disease should, from the beginning, have prompted a directed cardiovascular examination in the emergency room.

(1) Biddinger PD, Isselbacher EM, Fan D, Shepard JA. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 5-2005. A 53-year-old man with depression and sudden shortness of breath. N Engl J Med. 2005 Feb 17;352(7):709-716.   PubMed 15716566

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