Differential Diagnosis
The patient's presentation with cardiomegaly, pulmonary vascular congestion, and bilateral interstitial opacities on chest X-ray, along with laboratory findings, suggests a complex clinical picture. The following differential diagnoses are organized into categories:
Single Most Likely Diagnosis
- Congestive Heart Failure (CHF): The presence of cardiomegaly and pulmonary edema on the chest X-ray, along with elevated BUN and creatinine, suggests CHF as the primary diagnosis. The elevated WBC and CRP may indicate an acute exacerbation or a superimposed infection.
Other Likely Diagnoses
- Sepsis: Given the elevated WBC, CRP, and the presence of cellulitis, sepsis is a strong consideration. The elevated procalcitonin also supports this diagnosis.
- Acute Kidney Injury (AKI): The elevated creatinine and decreased GFR indicate AKI, which could be secondary to CHF, sepsis, or another cause.
- Anemia: The patient's RBC count is low, and the RDW is elevated, suggesting anemia. The MCV is high, indicating a macrocytic anemia.
Do Not Miss Diagnoses
- Pulmonary Embolism: Although less likely given the presentation, pulmonary embolism can cause pulmonary edema and must be considered, especially if there are any signs of deep vein thrombosis (DVT) or if the patient has risk factors for thromboembolism.
- Endocarditis: The presence of cellulitis and elevated inflammatory markers raises the possibility of endocarditis, especially if there are any valvular abnormalities or a history of intravenous drug use.
- Severe Sepsis or Septic Shock: The combination of cellulitis, elevated WBC, CRP, and procalcitonin, along with AKI, necessitates consideration of severe sepsis or septic shock.
Rare Diagnoses
- Cardiac Amyloidosis: Although rare, cardiac amyloidosis can cause CHF and should be considered if there are other systemic signs of amyloidosis or if CHF is out of proportion to other findings.
- Hemochromatosis: This condition can lead to cardiomyopathy and CHF, among other symptoms. It would be considered if there were signs of iron overload or a family history of the disease.
- Sarcoidosis: Sarcoidosis can cause cardiomyopathy and pulmonary findings similar to those presented. It would be a consideration if there were other systemic signs of sarcoidosis or if the patient has a history of the disease.