case_images: PMC5932523_01
case_images: Preintubation CXR shortly after ICU admission.
case_images: CRICC2018-3417259.001.jpg
case_images: PMC5932523_01_CRICC2018-3417259.001.jpg
case_images: fig1
case_images: A preintubation CXR is shown (Figure 1).
case_images: Repeat CXR on ICU day 11; ongoing hypoxia despite successful diuresis.
case_images: CRICC2018-3417259.002.jpg
case_images: PMC5932523_01_CRICC2018-3417259.002.jpg
case_images: fig2
case_images: Despite radiological and clinical resolution of pulmonary oedema the oxygen requirements were largely static; one week after admission he was still requiring FiO2 0.6 to maintain PaO2 9-10 kPa; a later CXR is shown (Figure 2).
case_images: Transverse section of upper abdominal viscera; images acquired during CTPA.
case_images: CRICC2018-3417259.003.jpg
case_images: PMC5932523_01_CRICC2018-3417259.003.jpg
case_images: fig3
case_images: Incidental imaging of the upper abdominal viscera showed a nodular and cirrhotic liver with ascites around both the liver and spleen (Figure 3).
case_images: Screenshot of sequential FiO2 and SpO2 values at one-minute intervals upon moving the patient from a semirecumbent to supine position.
case_images: CRICC2018-3417259.004.jpg
case_images: PMC5932523_01_CRICC2018-3417259.004.jpg
case_images: fig4
case_images: Marked orthodeoxia was demonstrated; the FiO2 required to achieve fixed SpO2 rapidly fell from 0.66 to 0.46 upon moving from a semirecumbent to supine posture (Figure 4); however, a test-dose of methylene blue did not improve oxygenation.
case_images: (a) Contrast/"bubble" TTE at time of injection. (b) Contrast/"bubble" TTE showing extensive opacification of the left heart in 4-5 cardiac cycles.
case_images: CRICC2018-3417259.005.jpg
case_images: PMC5932523_01_CRICC2018-3417259.005.jpg
case_images: fig5
case_images: This showed extensive opacification of the left heart within four to five cardiac cycles, consistent with an intrapulmonary shunt (Figure 5 & supplementary material (available here)); this confirmed the diagnosis.