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Case 235


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29-year-old female patient, admitted in emergency department due to a dyspnea starting a week ago, of progressive type, exacerbated by recumbency, as well as persistent dry cough and sporadic low-grade fever. Previously healthy. On examination: Blood pressure: 124x84mmHg, Cardiac frequency: 124bpm, Respiratory frequency: 36irpm, SO2: 92% (oxygen through nasal catheter 3L / min), Axillary temperature at 36.7 ° C. Conscious, pale, hydrated, acyanotic. Cardiac auscultation with regular rhythm, no accessory sounds or murmurs. Respiratory auscultation with fine end-insipratory crackles through the middle third of the chest, bilaterally.

Considering the clinical history and the presented radiography, which of the differential diagnosis is the less likely?

a) Acute respiratory distress syndrome due to H1N1


b) Non-cardiogenic pulmonary edema associated with hemorrhagic Dengue


c) Miliary tuberculosis associated with HIV


d) Primary pulmonary neoplasia


Image analysis

Image 1: Thoraxradiography shows diffuse opacity of cotton wool aspect,, affecting both lungs, more importantly in the inferior 2/3 of their areas.


- Acute respiratory insufficiency(ARI) is suspected by signs of respiratory distress and is confirmed by arterial gasometry.

- The initial goal is to quickly correct acute changes in gas exchange.

- Reversal of ARI depends on the recognition and correction of their underlying cause.

- Once obtained a clinical stabilization, anamnesis and complete physical examination, as well as laboratory tests, assist in the diagnosis of the underlying disease.

- Arterial gasometry and chest radiography are necessary and sufficient in many cases to point to the correct diagnosis, but in other cases, other tests may be needed.

- Specific treatment varies greatly according to the etiology.


  • - AHMED Azeemuddin, Graber Mark A. Evaluation of the adult with dyspnea in the emergency room. Uptodate. AcessedinApril 28th of 2016. Available in:

  • - GIVERTZ Michael M. Noncardiogenic pulmonary edema. Uptodate. AcessedinMay 5Th of 2016. Available in:

  • - HANSEN-FLASCHEN John, SIEGEL Mark D. Acute respiratory distress syndrome: clinical features and diagnosis in adults. Uptodate.Accessed in: May 5Th of 2016. Available in:

  • - MARTINS Erlon Saraiva, et al. Emergências clínicas: abordagem prática. 8 ed. revisada e atualizada. Barueri, SP: Manole, 2013.

  • - SCHWARZ Marvin I. The diffuse alveolar hemorrhage syndromes. Uptodate.May 5Th of 2016. Available in:

  • - SIEGEL Mark D. Acute respiratory distress syndrome: epidemiology, pathophysiology, pathology, and etiology in adults. Uptodate. AcessedinApril 28th of 2016. Available in:


Bárbara Cecília Borges Moreira,6th year medical student at Universidade de Minas Gerais.

E-mail: barbaracbm[at]


Bárbara de Queiroz e Bragraglia, 6th year medical student at Universidade de Minas Gerais.

E-mail: barbara.bragaglia[at]


Milena Marcolino MD, doctor and professor of the Medical Clinics Department at Medical School of Universidade Federal de Minas Gerais.

E-mail: milenamarc[at]


Daniela Braga, Fellype Borges, Fernanda Padilha, Fabio M. Satake, Cairo Mendes and professor Viviane Parisotto.

Translated by

Giovanna Vieira Moreira, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: giovieiramoreira[at]


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