Platypnea Orthodeoxia Due to a Patent Foramen Ovale and Intrapulmonary Shunting After Severe COVID-19 Pneumonia

Abstract

BACKGROUND Platypnea orthodeoxia syndrome (POS) presents with positional dyspnea and hypoxemia defined as arterial desaturation of at least 5% or a drop in PaO2 of at least 4 mmHg. Causes of POS include a variety of cardiopulmonary etiologies and has been reported in patients recovering from severe COVID-19 pneumonia. However, clinical presentation and outcomes in a patient with multiple interrelated mechanisms of shunting has not been documented. CASE REPORT An 85-year-old man hospitalized for hypertensive emergency and severe COVID-19 pneumonia was diagnosed with platypnea orthodeoxia on day 28 of illness. During his disease course, the patient required supplemental oxygen by high-flow nasal cannula but never required invasive mechanical ventilation. Chest imaging revealed evolving mixed consolidation and ground-glass opacities with a patchy and diffuse distribution, involving most of the left lung. Echocardiography was ordered to evaluate for intracardiac shunt, which revealed a patent foramen ovale. Closure of the patent foramen ovale was not pursued. Management included graded progression to standing and supplemental oxygen increases when upright. The patient was discharged to a skilled nursing facility and his positional oxygen requirement resolved on approximately day 78. CONCLUSIONS The present case highlights the multiple interrelated mechanisms of shunting in patients with COVID-related lung disease and a patent foramen ovale. Eight prior cases of POS after COVID-19 pneumonia have been reported to date but none with a known patent foramen ovale. In patients with persistent positional oxygen requirements at follow-up, quantifying shunt fraction over time through multiple modalities can guide treatment decisions.

Figure 1.

(A) Chest X-ray (CXR) on day 1 of first diagnosis showing no baseline cardiopulmonary abnormalities. (B) CXR on day 3 of illness demonstrating significant multifocal opacities. (C) CXR on day 1 of second hospital admission, day 16 of illness demonstrating interval improvement in right multifocal opacities, evidence of scarring in right upper lobe. (D) CXR showing continued improvement but persistent scarring in right upper lobe (black arrows). Figures created using eUnity v7.0.0.1.3. Client Outlook, Inc. Ontario, Canada and macOs Big Sur operating system Version 11.4.

Figure 2.

(A) Coronal and (B) axial CT views showing multifocal ground-glass opacities and consolidation involving the entire left lung, right posterolateral upper lobe, and posterior right lower lobe (black arrows). Figures created using eUnity v7.0.0.1.3. Client Outlook, inc, Ontario, Canada and macOs Big Sur operating sytem Version 11.4.

Figure 3.

Transthoracic echocardiography, subcostal view, color Doppler showing flow through the atrial septal defect (white arrow). Positive bubble study not shown. Figures created using eUnity v7.0.0.1.3. Client outlook Inc. Ontario, Canada and macOs Big Sur operating system Version 11.4.

Figure 4.

Platypnea orthodeoxia syndrome etiology [1,27]. * Patent foramen ovale, atrial septal defect, atrial septal aneurysm with associated septal defect, partial anomalous pulmonary venous return, unroofed coronary sinus, and other possible mechanisms of shunting. Black arrows represent mechanisms of shunting in current case. Orange arrow represents other possible causes in COVID patients. Created using Microsoft Word, Washington, USA and macOs Big Sur operating system Version 11.4.