title: Dyspnoea in a patient with hepatitis C.
abstract: A 60-year-old man had a long history of chronic hepatitis C. He presented to the emergency department with 2 days of progressive dyspnoea. Clinical manifestations included respiratory distress, cyanosis, digital clubbing, spider naevi on the upper chest and shifting dullness in the abdomen (see online supplementary figure S1). The ECG showed sinus tachycardia and left axis deviation. The chest radiography depicted blunting of right costophrenic angle with small pleural effusions and bilateral prominent pulmonary vascular markings (see online supplementary figure S2). The dyspnoea was exacerbated by upright posture and improved with recumbency. The hypoxaemia could not be corrected with administration of 100% oxygen. Contrast-enhanced transthoracic echocardiography was performed with injection of agitated saline (see figure 1 and online supplementary video). CT scan of the chest revealed some vascular abnormalities (see online supplementary figure S3-S6).
  
  
  
  Which of the following is the next best step in management?Catheter-based closure of intracardiac shuntLiver transplantationPulmonary angiography and embolisationThoracentesisTransjugular intrahepatic portosystemic shunt.
authors: Department of Critical Care Medicine, En Chu Kong Hospital, New Taipei City, Taiwan.|Department of Internal Medicine, En Chu Kong Hospital, New Taipei City, Taiwan.|School of Medicine, Ph.D. Program in Nutrition and Food Science, College of Medicine, Graduate Institution of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan.
authors: Jia-Feng
authors: JF
authors: Chang
authors: Department of Critical Care Medicine, En Chu Kong Hospital, New Taipei City, Taiwan.
authors: Cheng-Hsien
authors: CH
authors: Hsieh
authors: Department of Electronic Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan.|Graduate Institute of Clinical Medicine Jointly Appointed, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors: Jian-Chiun
authors: JC
authors: Liou
authors: Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan.
authors: Jen-Kuang
authors: JK
authors: Lee
mesh_terms: D004417:Dyspnea / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D004452:Echocardiography; D019698:Hepatitis C, Chronic / Q000150:complications* / Q000175:diagnosis; D020065:Hepatopulmonary Syndrome / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed