What is the diagnosis and management approach for a patient presenting with cough and anasarca, with normal albumin and normal random urine protein levels?

Diagnosis: Congestive Heart Failure

The combination of cough and anasarca with normal albumin and normal urine protein strongly suggests congestive heart failure as the primary diagnosis, not nephrotic syndrome. 1

Key Diagnostic Reasoning

The clinical presentation is critical here:

• Anasarca with normal albumin excludes nephrotic syndrome as the primary cause, since nephrotic syndrome characteristically presents with hypoalbuminemia (typically albumin <2.5-3.0 g/dL) 2, 3
• Normal random urine protein further excludes nephrotic syndrome, which requires significant proteinuria (>3.5 g/day) for diagnosis 2, 4
• Cough plus anasarca points to cardiac etiology, as congestive heart failure commonly presents with both pulmonary congestion (causing cough) and systemic fluid overload (causing anasarca) 1, 3

Immediate Diagnostic Workup

Obtain chest radiograph immediately to evaluate for:

• Cardiomegaly 3
• Pulmonary edema or pleural effusion 3
• Evidence of congestive heart failure 1

Perform echocardiography to assess:

• Cardiac output and ejection fraction 3
• Valvular function 3
• Evidence of high-output vs. low-output heart failure 3

Laboratory evaluation should include:

• BNP or NT-proBNP to confirm heart failure 3
• Complete metabolic panel including renal function 5
• Thyroid function tests (thyrotoxicosis can cause high-output failure) 3
• Thiamine level if nutritional deficiency suspected (beriberi heart disease) 3

Management Algorithm

Initial treatment for congestive heart failure:

1. Diuretic therapy with furosemide (typically 40-80 mg/day initially, titrate based on response) to reduce fluid overload 3
2. Consider ultrafiltration or continuous hemofiltration if diuresis is inadequate or renal function is compromised 3
3. ACE inhibitor or ARB therapy once volume status is optimized 6
4. Treat underlying cardiac etiology based on echocardiographic findings 3

If thiamine deficiency (beriberi heart disease) is identified:

• Administer thiamine 50-100 mg IV daily until clinical improvement, then transition to oral supplementation 3
• This can result in dramatic improvement in high-output heart failure within days 3

Critical Pitfalls to Avoid

Do not assume nephrotic syndrome without hypoalbuminemia and significant proteinuria - the normal albumin and normal urine protein in this case exclude this diagnosis 2, 3

Do not delay cardiac evaluation - chest radiograph and echocardiography should be obtained urgently when anasarca is present with cough 1, 3

Do not overlook nutritional causes - beriberi heart disease can present with severe anasarca and is reversible with thiamine supplementation, but altered nutritional status may mask underlying conditions 3

Consider alternative causes if cardiac workup is negative:

• Severe anemia causing high-output failure 3
• Thyroid disease 3
• Systemic amyloidosis (though this typically presents with proteinuria) 4
• Constrictive pericarditis 1

Expected Clinical Course

With appropriate diuretic therapy for congestive heart failure, expect:

• Increased urine output within 24-48 hours 3
• Significant weight loss (potentially 40-70 kg over days to weeks depending on severity) 3
• Resolution of pulmonary symptoms including cough as pulmonary congestion improves 3
• Improvement in dyspnea and exercise tolerance 3