A 51-year-old woman was in her usual state of good health until she presented to a local emergency department reporting dyspnea of 2 days' duration. Her dyspnea was worse with exertion and with lying flat, but was not associated with chest pain, cough, or fever. Bilateral lower extremity edema had developed over the few weeks preceding her presentation.
Two to three weeks prior to the emergency department visit, she noticed a blister on her left third toe. She was diagnosed with cellulitis and was started on cephalexin. After initiating antibiotic therapy, she developed a diffuse, pruritic, maculopapular rash, and her treatment was switched to doxycycline. The patient stopped taking doxycycline after 2 days because of nausea, and the blister resolved without further therapy.
In the emergency department, the patient was hypertensive and tachycardic, with blood pressure (BP) of 210/110 mm Hg and a heart rate of 105 beats/minute. Her temperature was 98.2ยฐF and her oxygen saturation was 100% on room air. Physical examination revealed bibasilar crackles, pitting edema of both lower extremities, and a dusky area on her left third toe. Her laboratory studies showed a hematocrit of 25.2%, blood urea nitrogen level of 90 mg/dl (normal range 6 -20), and serum creatinine level of 9.7 mg/dl (normal range 0.4 -1.1).
A chest radiograph showed mild pulmonary vascular congestion with small bilateral pleural effusions. There were no pulmonary infiltrates or nodules. Her hypertension was treated with metoprolol (5 mg intravenously) and her pulmonary edema was treated with furosemide (40 mg via intravenous push). However, she remained hypertensive and was transferred to our institution.