An Unusual Heart Failure

A 53-year-old white woman presented to the emergency department with severe dyspnea. She reported progressively worsening dyspnea during the previous 3 months. The patient had no prior history of any cardiovascular disease or relevant family history. The chest radiograph showed a typical picture of congestive heart failure with cardiomegaly, vascular redistribution, and bilateral pleural effusions (Figure, A). The ECG (Figure, B) showed low-voltage QRS complexes in the limb leads and poor R-wave progression in the chest leads. Such characteristics were particularly evident when compared with a previous ECG executed 4 years before (Figure, C). Holter monitoring did not reveal any significant arrhythmias. Initial laboratory analysis detected a marked increase of natriuretic peptide levels (N-terminal pro-brain natriuretic peptide 4556 pg/mL, with normal levels ≤270 pg/mL) and mild hypogammaglobulinemia; the other parameters, including blood cell count, renal and liver function, and cardiac-specific troponin concentration, were normal.Figure. A , Chest radiography at time of admission to …