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Pulmonary puzzle
An unusual case of diaphragm paralysis
  1. S Freilich1,
  2. J C Janssen1,2,
  3. M I Polkey1
  1. 1NIHR Respiratory Biomedical Research Unit, The Royal Brompton Hospital & Imperial College, London, UK
  2. 2Chelsea and Westminster Hospitals, London, UK
  1. Correspondence to Professor M Polkey, Respiratory Muscle Laboratory, Royal Brompton Hospital, London SW3 6NP, UK; m.polkey{at}

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Our patient was a 62-year-old retired accountant of previous good health. He was not taking any medications and had no family history of neurological disease. He was involved in a minor road traffic accident in which his car was shunted from behind. No immediate injuries were sustained; however, he presented to his general practitioner 4 days later with lumbar spine discomfort. He was prescribed a codeine–paracetamol combination pill and diclofenac. Immediately after taking the first dose of these medications he developed severe dizziness and marked vomiting, which culminated in mild haematemesis, indicative of a Mallory–Weiss tear. Subsequently he discovered that he was dyspnoeic lying flat. He presented to his local emergency department with symptoms including marked orthopnoea, and dyspnoea on water immersion past his costal margin and on bending forward.

Physical examination showed gross paradoxical abdominal motion and mild breathlessness when recumbent. Respiratory system, some left basal crackles; cardiovascular system, normal; abdomen, normal; neurology, normal.

Arterial blood gas measurements showed a Pao2 of 11.1 kPa and a Paco2 of 5.1 kPa. A chest radiograph showed an elevated left hemidiaphragm with some atelectasis above it. A CT pulmonary angiogram excluded any diaphragmatic rupture or pulmonary embolus as an underlying cause of orthopnoea. His sniff nasal inspiratory pressure (SNIP) was measured at 22 cm H2O. Detailed testing showed no response to bilateral anterior magnetic phrenic nerve stimulation or to right unilateral phrenic nerve stimulation, with a greatly reduced response to left-sided stimulation (twitch transdiaphragmatic pressure 1.3 cm H2O; normal >8 cm H2O). Pulmonary function tests (performed in …

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