A 51-Year-Old Man With Congestive Heart Failure and Renal Abnormalities

Introduction. A 51-year-old man who works in the delivery services industry presented with bilateral leg edema, weight loss, and fatigue. He has lost more than 4.5 kg (10 lbs) in the past 4 months without dieting. In recent weeks, the formation of a leg edema has noticeably worsened, according to the patient. Most recently, a degree of exertional dyspnea has developed. The patient has no paroxysmal nocturnal dyspnea nor chest pain. His medical history is unremarkable. He has no history of severe hypertension, coronary artery disease, or diabetes mellitus. He occasionally uses non-steroidal anti-inflammatory drugs for osteoarthritis, but he is not a drinker nor a smoker.

Physical examination. The patient presented with a temperature of 37˚C, blood pressure of 100/68 mm Hg, respirations resting 14 minutes, and a pulse of 98 beats/min. A head, eyes, earss, nose and throat (HEENT) examination is unremarkable. Chest is clear with no cardiac murmurs. There is no hepatosplenomegaly. Pulses are strong in all extremities. There is 4(+) pitting edema to mid-calf bilaterally.

Diagnostic testing. The patient has complete blood count and blood glucose levels within normal limits. The serum creatinine is 1.8 mg/dL with creatinine clearance of 40 cc/min. There is proteinuria, which was measured at 3.3 gms/24 hrs. An echocardiogram revealed diffuse increased wall thickness including the interventricular septum without regional wall abnormalities or valvular abnormality. The ejection fraction was 50%, but there was significant restrictive diastolic filling. A serum protein electrophoresis revealed a small, 0.4 g/dl m-protein.