University of Miami - Jackson Memorial Hospital, USA
Title: Cervical Hyperostosis complicated with chronic aspiration causing refractory heart failure
Juan Kusnir, a native of Argentina, is a graduate of Temple University School of Medicine in Philadelphia, PA and a current resident at University of Miami-Jackson Memorial Hospital Internal Medicine program.
Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a common yet under-diagnosed condition with rare complications including dysphagia and aspiration. Here we report a case of a 61-year-old man with progressive heart failure and 15% ejection fraction who despite advance therapies, as cardiac resynchronization, had worsening of shortness of breath requiring home oxygen. He was admitted with an acute decompensated heart failure (ADHF) and a significant unilateral right-sided pleural effusion. Despite conventional treatment, the pleural effusion remained refractory to aggressive diuresis. Fluid analysis was consistent with an exudative process and chest CT findings were suggestive of multilobar aspiration pneumonia. A swallow study demonstrated complete aspiration of fluids and neck CT revealed massive cervical osteophytes (C3-C6) compressing the esophagus and so extensive as to induce tracheal inflammation. Given his comorbidities, the patient was deemed a non-surgical candidate and conservative treatment with PEG tube placement was pursued. After a week of tube feeds and antibiotics, pleural effusion resolved and patient was discharged without oxygen. This case illustrates a rare variation of the condition DISH, in which cervical osteophytes led to chronic aspiration, causing recurrent ADHF. Although 15% of ADHF related pleural effusions are unilateral, they are responsive to diuretic treatment. Refractory effusions should prompt consideration of alternative diagnosis. Current treatment options include surgical reduction of the osteophyte(s) via an anterior or lateral neck approach.