Differential Diagnosis

The patient's presentation of pulmonary edema, chest pain, bilateral lower limb edema, and acute kidney injury (AKI) with a background of severe eczema, high IgE, and asthma requires a comprehensive differential diagnosis. The following categories outline potential diagnoses:

• Single Most Likely Diagnosis

  • Acute Heart Failure: The combination of pulmonary edema, chest pain, and bilateral lower limb edema strongly suggests acute heart failure. The patient's AKI stage 3 with an eGFR of 4 further supports this diagnosis, as cardiac and renal functions are closely linked. The high IgE and asthma could be related to an allergic or atopic predisposition but do not directly influence the likelihood of heart failure in this acute presentation.

• Other Likely Diagnoses

  • Acute Coronary Syndrome (ACS): Given the chest pain, ACS should be considered, especially if the chest pain is suggestive of myocardial ischemia. The pulmonary edema could be a consequence of ischemic cardiomyopathy.
  • Pulmonary Embolism (PE): Although less likely given the bilateral lower limb edema and the absence of specific risk factors mentioned, PE could cause pulmonary edema and chest pain. It's essential to consider, especially if there are signs of deep vein thrombosis or risk factors for thromboembolism.
  • Anaphylaxis: Given the patient's history of severe eczema, high IgE, and asthma, anaphylaxis could potentially lead to pulmonary edema and cardiovascular collapse. However, the gradual onset over 4-5 days makes this less likely.

• Do Not Miss Diagnoses

  • Cardiac Tamponade: Although less common, cardiac tamponade can cause pulmonary edema, chest pain, and hypotension leading to renal impairment. It's crucial to consider and quickly diagnose with echocardiography if suspected.
  • Aortic Dissection: This is a life-threatening condition that can cause chest pain and, depending on the extent, can lead to acute heart failure, AKI, and limb edema due to aortic branch involvement. The high clinical suspicion warrants immediate imaging.
  • Sepsis: Sepsis can lead to AKI, pulmonary edema, and cardiovascular instability. Given the patient's complex medical history, an infectious cause should not be overlooked, especially if there are signs of infection.

• Rare Diagnoses

  • Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome): Given the patient's history of asthma and high IgE, this rare vasculitis could be considered, especially if there are other systemic symptoms or eosinophilia. However, it's less likely given the acute presentation focused on cardiac and renal symptoms.
  • Löffler's Syndrome: A rare condition characterized by eosinophilic pneumonia, which could potentially cause pulmonary edema. However, the lack of specific respiratory symptoms and the presence of cardiac and renal involvement make this less likely.