A Case of Acute-Onset Pitting Edema and Palpitations in a Young Woman on Hormonal Therapy

Case at a Glance

A 26-year-old female with a history of Supraventricular Tachycardia (SVT) presented to the emergency department with new-onset palpitations, significant recent weight gain, and acute, severe bilateral pitting edema of the lower extremities. Her symptoms developed over the two months following a change in her hormonal therapy regimen for Premenstrual Dysphoric Disorder (PMDD).

Patient's Story

The patient is a 26-year-old female with a known history of SVT and PMDD. Three months prior to presentation, she was started on Prostap (a GnRH agonist) injections for her PMDD. Her initial add-back therapy was Tibolone, but this was switched to Estrogel two months ago. Over the past two months, she began experiencing palpitations, which she described as feeling like 'little gallops' in her chest, distinct from her previous SVT episodes. These episodes, initially lasting only a second, gradually increased in duration to 2-3 seconds and occurred multiple times per hour. Concurrently, she noted a 30 lb (13.6 kg) weight gain over three months, which she had attributed to an increased appetite. Five days before presenting to the Emergency Department (A&E), she saw her General Practitioner (GP) for the palpitations and was referred for routine outpatient blood tests and an ECG.

Initial Assessment

The patient presented to the A&E after discovering severe pitting edema in her lower leg following minimal pressure. On arrival, her triage vital signs were notable for a heart rate of 126 bpm and a blood pressure of 165/102 mmHg. Physical examination revealed severe, non-tender, bilateral pitting edema of the lower extremities, extending from the ankles and shins up to the knees. The indentations were described as over half a centimeter deep and took more than a minute to resolve. The patient also reported a generalized feeling of 'puffiness' but had no other focal swelling or signs of respiratory distress.

The Diagnostic Journey

In the A&E, an initial workup was performed to rule out acute life-threatening conditions. An ECG and chest X-ray were both normal. Blood tests, including a full blood count, coagulation screen, and a chemistry panel, were also within normal limits. The A&E physician's working diagnosis was dependent edema, though a specific underlying cause was not identified at that time. The combination of new-onset palpitations, hypertension, tachycardia, significant fluid retention, and recent initiation of hormonal therapy raised a broad differential diagnosis. Key considerations included:

1. Cardiogenic edema: Possible new-onset heart failure or cardiomyopathy, potentially precipitated by the tachycardia or hormonal therapy. A previous echocardiogram during a pregnancy three years prior was normal, but new pathology could not be excluded.
2. Drug-induced edema: Fluid retention is a known side effect of both GnRH agonists and estrogen therapy.
3. Renal pathology: Conditions such as nephrotic syndrome needed to be considered, which would require further investigation with urinalysis and more detailed renal function tests.
4. Endocrine causes: While less likely to be so acute, conditions like hypothyroidism were also considered.

Final Diagnosis

The final diagnosis remained pending further investigation. The A&E assessment successfully ruled out an immediate cardiorespiratory emergency, but the underlying cause of her profound fluid retention and hemodynamic changes required a more detailed outpatient workup.

Treatment Plan

The patient was discharged from the A&E with a plan for both symptomatic management and further diagnostics.

1. Medication: She was prescribed Propranolol 10mg daily for two weeks to help control her heart rate and palpitations.
2. Cardiology Referral: An urgent outpatient referral to cardiology was made for Holter monitoring to characterize her palpitations and assess for arrhythmias.
3. Imaging: The A&E physician requested that her GP arrange an outpatient echocardiogram to evaluate her cardiac structure and function.

Outcome and Follow-up

The patient was advised to follow up closely with her GP to coordinate the specialist referrals and to discuss the potential role of her current hormonal therapy in her symptom presentation. The results of the Holter monitor and echocardiogram would be crucial to guide further management. Depending on the findings, management could involve adjusting or discontinuing the Prostap and Estrogel, initiating diuretic therapy for the edema, and/or starting specific cardiac medications if an underlying cardiac condition was identified.