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Unexplained Dyspnea in a Patient with Rheumatoid Arthritis
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A1796 - Unexplained Dyspnea in a Patient with Rheumatoid Arthritis
Author Block: L. Khalid1, G. E. Holt2; 1Pulmonary and Critical Care, Jackson Memorial Hospital/University Of Miami, Miami, FL, United States, 2Univ of Miami, Miami, FL, United States.
We report a case of a 62 year old female with seropositive rheumatoid arthritis who was evaluated for unexplained fatigue, muscle spasms and dyspnea on exertion. After a six minute walk test, she was found to have a lactic acid level of 9.5mmol/L after walking 335 meters with pO2 that went from 67mmHg before exercise to 69.4mmHg after exercise. This raised the concern for issues with oxygen metabolism that was evaluated by a graded cardiopulmonary exercise test with exhaled gas analysis and arterial blood gas analyses. She exercised for 12 minutes and achieved a maximum VO2 (ml/kg/min) of 14.9 (59% predicted) and performed 101 watts of work. At maximum exercise, she achieved a heart rate of 144 (91%), oxygen pulse of 13.7 (116%) and a blood pressure of 173/78 (11%). At peak exercise, her maximum minute ventilation was 90 (134% predicted based on FEV1 x 40 or 100% based on MVV). Her tidal volume increased to 1.232L (160%) and her dead space decreased from 0.30 to 0.20 at peak exercise). Measurement of her lactate level by arterial line revealed a baseline measurement of 1.1 that increased to 2.2 on unloaded pedaling. The lactate rapidly increased from 3.5 after one minute of loaded pedaling to 13.9 at peak exercise. As she demonstrated a hyperventilatory and hypercirculatory exercise response without hypoxemia on arterial blood gas measurement, a concern for oxygen metabolism at the cellular level was suggested. Subsequent confirmation of the diagnosis is pending a muscle biopsy and rheumatologic work up. The characteristic physiological profile as demonstrated by our patient should be very useful when considering evaluation of fatigue and dyspnea in patient and will help in the diagnostic evaluation of mitochondrial myopathy. Mitochondrial diseases have a wide spectrum of clinical phenotypes ranging from mild exercise intolerance to multisystem disease affecting high energy requiring tissues. Once, believed to be rare, recent evidence suggests that these disorders are much more common than once believed.
Author Block: L. Khalid1, G. E. Holt2; 1Pulmonary and Critical Care, Jackson Memorial Hospital/University Of Miami, Miami, FL, United States, 2Univ of Miami, Miami, FL, United States.
We report a case of a 62 year old female with seropositive rheumatoid arthritis who was evaluated for unexplained fatigue, muscle spasms and dyspnea on exertion. After a six minute walk test, she was found to have a lactic acid level of 9.5mmol/L after walking 335 meters with pO2 that went from 67mmHg before exercise to 69.4mmHg after exercise. This raised the concern for issues with oxygen metabolism that was evaluated by a graded cardiopulmonary exercise test with exhaled gas analysis and arterial blood gas analyses. She exercised for 12 minutes and achieved a maximum VO2 (ml/kg/min) of 14.9 (59% predicted) and performed 101 watts of work. At maximum exercise, she achieved a heart rate of 144 (91%), oxygen pulse of 13.7 (116%) and a blood pressure of 173/78 (11%). At peak exercise, her maximum minute ventilation was 90 (134% predicted based on FEV1 x 40 or 100% based on MVV). Her tidal volume increased to 1.232L (160%) and her dead space decreased from 0.30 to 0.20 at peak exercise). Measurement of her lactate level by arterial line revealed a baseline measurement of 1.1 that increased to 2.2 on unloaded pedaling. The lactate rapidly increased from 3.5 after one minute of loaded pedaling to 13.9 at peak exercise. As she demonstrated a hyperventilatory and hypercirculatory exercise response without hypoxemia on arterial blood gas measurement, a concern for oxygen metabolism at the cellular level was suggested. Subsequent confirmation of the diagnosis is pending a muscle biopsy and rheumatologic work up. The characteristic physiological profile as demonstrated by our patient should be very useful when considering evaluation of fatigue and dyspnea in patient and will help in the diagnostic evaluation of mitochondrial myopathy. Mitochondrial diseases have a wide spectrum of clinical phenotypes ranging from mild exercise intolerance to multisystem disease affecting high energy requiring tissues. Once, believed to be rare, recent evidence suggests that these disorders are much more common than once believed.
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