Content area
Full Text
JGIM
Clinical Vignettes
Unilateral Diaphragmatic Paralysis in a Diabetic Patient: A Case of Trepopnea
Fawad Aslam, MD1, Anna Kolpakchi, MD2, Daniel Musher, MD2, and Lee Lu, MD1
1Department of Internal Medicine, One Baylor Plaza, Baylor College of Medicine, Houston, Texas, USA; 2Department of Internal Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
Dyspnea is a common presenting complaint. Trepopnea, an under-recognized form of dyspnea, is difficult breathing in only one lateral decubitus position. One cause of trepopnea is unilateral diaphragmatic paralysis, which in itself is an uncommon diagnosis. We report a unique case of a 55-year-old diabetic man who presented with trepopnea and was found to have unilateral diaphragmatic paralysis secondary to isolated diabetic phrenic neuropathy. This case highlights the importance of recognizing trepopnea as an early clinical symptom of diaphragmatic paralysis and discusses diabetic phrenic neuropathy which can occur in the absence of peripheral neuropathy.
KEY WORDS: trepopnea; diabetes; neuropathy; phrenic; diaphragm; paralysis; dyspnea; sniff-test.
J Gen Intern Med 26(5):5558DOI: 10.1007/s11606-010-1587-3 Society of General Internal Medicine 2010
INTRODUCTION
Shortness of breath is a common presenting symptom. In the spectrum of the "pneas," orthopnea, and platypnea are commonly recognized. An often forgotten type of dyspnea is trepopnea. Trepopnea depicts having difficulty breathing in one lateral recumbent position and originates from the Greek word trepo meaning to twist or turn1,2. Originally described by Francis Wood and initially known as rotopnea," the phenomenon was later renamed to trepopnea." This clinical sign was commonly described in patients with congestive heart failure (CHF) in the literature from the middle part of the 20th century but suffered from disuse over the years. Trepopnea reemerged recently in case reports of aneurysms of the sinus of valsalva, right-to-left inter-atrial shunts, recurrent lung cancer and cardiac tumors36.
Hitherto, trepopnea has not been described in association with unilateral diaphragmatic paralysis, which in itself is an uncommon cause of respiratory complaints that may be caused by diverse etiologies. We present a unique case of a diabetic patient with unilateral diaphragmatic paralysis who presented with trepopnea.
CASE REPORT
A 55-year-old white man with diabetes mellitus, hypertension, and a history of cerebrovascular accident (CVA) presented to
the emergency room with a two month history of shortness of breath of an insidious onset. He...