A 38 year old male patient was admitted to the Urology of our hospital with the chief complaint of "edema of both lower extremities for 4 months, aggravated with scrotal edema for 5 days". Four months ago, the patient gradually developed edema in both lower limbs, presenting as pitting edema. They sought medical attention at a local community clinic in Suzhou and were treated with oral medication for four days (Specific drug unknown), but there was no significant reduction in edema. During this period, he did not seek medical attention. On January 20th, the patient gradually developed abdominal distension, with a significant increase in abdominal circumference and a decrease in activity tolerance, accompanied by an increase in scrotum. The patient went to the Second Affiliated Hospital of Suzhou University for treatment. After completing the relevant examinations, the doctor suggested that he be hospitalized for treatment. The patient then went to our urology department for treatment and hospitalization.
Admission examination:T:36.5℃, P:82 times/minute, R:22 times/minute,BP:144/88mmHg. Sanity, cyanosis of the lips, difficulty breathing, obesity, slight congestion of the pharyngeal mucosa, bilateral tonsil II degree enlargement, soft palate prolapse, and bilateral lateral pharyngeal cord hypertrophy. The respiratory sounds in both lungs are clear, no dry or wet rales are heard, the heart rhythm is consistent, and no pathological murmurs are heard in the auscultation area of each valve. The whole abdomen is swollen, with concave edema in the abdomen and obvious scrotal edema. Dented edema of both lower limbs, normal skin temperature of both lower limbs, and pigmentation of both lower leg skin. The patient was 175cm tall and weighed 130kg, and has a body mass index of 42.45kg/m2.
Auxiliary examination: Blood routine test: WBC: 9.8 × 109/L, neutrophils: 6.7 × 109/L, red blood cell: 8.09 × 1012/L, hemoglobin: 210g/L, hematocrit; 70.3%, mean corpuscular hemoglobin content 25.9pg, mean corpuscular hemoglobin concentration 299.00g /L, coefficient of variation of Mean corpuscular volume distribution width 16.0%. Biochemical: Total protein: 58.8g/L, albumin: 29.7g/L, creatinine: 118umol/L, urea: 7.4mmol/L, uric acid: 688umol/L. Abdominal CT shows significant fat accumulation in the abdominal wall and abdominal cavity, and no obvious abnormalities are found on pelvic plain scan. (The Second Affiliated Hospital of Suzhou University January 25, 2023). Arterial blood gas analysis after admission: pH: 7.34, PO2: 39.9 mmHg, SpO2: 76.50%, PCO2: 71.1 mmHg, actual base surplus (ABE): 8.30 mmol /L, standard base surplus (SBE): 12.20 mmol /L, standard Bicarbonate concentration (SBC): 31.3 mmol /L, actual Bicarbonate concentration (HCO3-): 38.0 mmol /L. Hemoglobin: 18.0g/dL. (January 30, 2023) Urinary routine examination: light yellow, transparent, glucose (-), protein (+3), urine specific gravity 1.030, occult blood (+-), red blood cells: 0/uL, white blood cells: 0/uL. (January 30, 2023) Coagulation function: Prothrombin time (PT): 31.42s, activity (PT%): 25.54%, international standardized ratio INR: 2.54, partial Prothrombin time (APTT): 48.20s, fibrinogen: 3.44g /L, D-dimer: 1.42mg /L. (January 29, 2023) .
24-hour urine protein; 3605.12mg/24h, 24-hour urine creatinine: 8.30mmol/24h, 24-hour protein/creatinine: 434.35mg/mmol/L, urine protein concentration: 536.30mg/L, urine volume: 6.4L. (February 1, 2023). Ultrasound findings: enlargement of the right heart and left atrium (left and right ventricular diameter 43mm), with a normal range of left ventricular lumen diameter. The thickness of ventricular septum and left and right ventricular walls is normal, Motor coordination is coordinated, the contraction amplitude is normal, and the Tricuspid valve valve lobe is not significantly thickened, it can be opened, and the closure is poor. No obvious abnormalities were found in the shape, structure, and opening and closing movements of the remaining valves. The relationship and diameter of the major arteries are normal, and there is no obvious abnormality in the pericardial cavity. The diameter of Inferior vena cava is 25mm, and the collapse rate with respiration is less than 50%. Doppler examination: The anterior flow of the mitral valve shows a bimodal pattern, with E/A>1, E '/A'<1, and E/E "≈ 11. The area of Tricuspid valve regurgitation is about 3.2 square centimeters. Ultrasound showed that Right ventricle and left atrium were enlarged, Tricuspid valve regurgitation was slight, pulmonary hypertension was moderate, and Inferior vena cava was widened. (January 30, 2023) .
Because of scrotal edema, the first department that the patient visited was Urology. Through multidisciplinary consultation, the basic diseases of the patient were obesity hypopnea syndrome (OHS) and obstructive sleep apnea hypopnea syndrome (OSAHS). After understanding the pathological and physiological characteristics of the disease, it is easy to explain the patient's condition: the patient suffers from OHS and OSAHS due to excessive obesity, tonsil hypertrophy, soft palate prolapse, and bilateral lateral pharyngeal hypertrophy. This will lead to long-term chronic hypoxia, secondary Polycythemia and pulmonary hypertension, pulmonary hypertension will lead to overload of the right heart, which will lead to blocked venous blood flow.High urinary protein will lead to protein loss and hypoproteinemia. Hyperemia will also lead to edema of lower limbs and scrotum. Hypoproteinemia will further aggravate edema of lower limbs and scrotum. After a clear diagnosis, treatment is relatively simple. First, noninvasive mechanical ventilation was given to correct hypoxemia and Hypercapnia; Sildenafil was given orally to improve pulmonary hypertension; Furosemide diuresis, reduce right ventricular preload; Preventive anticoagulation with low molecular weight heparin; Glutathione liver protection therapy; Human albumin corrects Hypoproteinemia; Nutritional consultation, providing comprehensive treatment such as weight loss meals. Treat for 8 days in the intensive care unit and 11 days in the general ward. The patient had a weight of 130kg upon admission and 105kg upon discharge. The swelling of the scrotum, lower limbs, and abdomen completely subsided, and the activity level significantly improved compared to before admission. After discharge, the patient will wear a household non-invasive ventilator at night and continue to lose weight. They will receive follow-up visits from otolaryngology and respiratory clinics.