title: Platypnea-orthodeoxia syndrome in the right lateral decubitus position: a case report.
abstract: BACKGROUND
  Platypnea-orthodeoxia syndrome is a rare syndrome characterized by dyspnea and hypoxia when the patient is sitting or standing. Here we report a case of platypnea-orthodeoxia syndrome caused by a right hemidiaphragmatic elevation with giant liver cyst that triggered a right-to-left shunt through the patent foramen ovale. This case report is the first presentation of a case secondary to hemidiaphragmatic elevation with giant liver cyst. In addition to this, a malposition of the pacemaker lead could be associated with platypnea-orthodeoxia syndrome in this case.
  
  
  METHODS
  A 91-year-old Japanese woman presented to our hospital with hypoxia of unknown origin. Severe hypoxia and cyanosis were observed only in the right lateral decubitus position. A chest X-ray and computed tomography scan revealed right hemidiaphragmatic elevation, which was probably compressing the right atrium. A transesophageal echocardiogram showed a compressed right atrium and shunt blood flow in both directions: from the left to the right atrium and vice versa. The shunt flow was exacerbated by postural changes from the left to the right lateral decubitus. A transesophageal echocardiogram also confirmed compression of the right atrium due to giant liver cyst and a malposition of the pacemaker lead abnormally placed in the left atrium through patent foramen ovale. We concluded that the cause of hypoxia was platypnea-orthodeoxia syndrome with right-to-left interatrial shunt through patent foramen ovale. Surgical closure of patent foramen ovale was not performed due to the age of our patient, surgical difficulties, and failure to obtain informed consent. For these reasons she was discharged after receiving medical advice about her posture.
  
  
  CONCLUSIONS
  Platypnea-orthodeoxia syndrome is rare and difficult to diagnose. The present case suggests that hypoxia due to postural changes should be considered a differential diagnosis of platypnea-orthodeoxia syndrome.
authors.affiliation: Department of Internal Medicine, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan. tsuzuki1122@gmail.com.
authors.forename: Ippei
authors.initials: I
authors.lastname: Tsuzuki
authors.affiliation: Department of Internal Medicine, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan.
authors.forename: Kamon
authors.initials: K
authors.lastname: Iigaya
authors.affiliation: Department of Cardiology, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Matsubara
authors.affiliation: Department of Cardiology, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan.
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Takagi
authors.affiliation: Department of Cardiology, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan.
authors.forename: Taku
authors.initials: T
authors.lastname: Inohara
authors.affiliation: Department of Cardiology, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan.
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Ohgino
authors.affiliation: Department of Internal Medicine, Hiratsuka city Hospital, 1-19-1 Minamihara, Hiratsuka city, Kanagawa, 254-0065, Japan.
authors.forename: Toshio
authors.initials: T
authors.lastname: Imafuku
mesh_terms: D000369:Aged, 80 and over; D004417:Dyspnea / Q000209:etiology* / Q000503:physiopathology; D015150:Echocardiography, Doppler; D017548:Echocardiography, Transesophageal; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006343:Heart Septal Defects / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D000860:Hypoxia / Q000209:etiology* / Q000503:physiopathology; D011187:Posture; D013577:Syndrome
keywords: Case report; Giant liver cyst; Hemidiaphragmatic elevation; Pacemaker lead; Patent foramen ovale; Platypnea-orthodeoxia syndrome