A 65-Year-Old Man With Abdominal Distension and Shortness of Breath

A 65-year-old man with a history of paroxysmal atrial fibrillation, hypertension, and OSA was admitted to the hospital with worsening dyspnea on exertion and generalized edema. He had no history of malignancy, immunosuppression, surgery, radiation, or autoimmune conditions. He was born in the United States with no recent travel, substance use, or homelessness. He did not report any fevers, night sweats, joint pain or swelling, phalangeal discoloration, nail or skin lesions, or ocular concerns. Transthoracic echocardiography demonstrated preserved systolic function. The patient was discharged with a presumed diagnosis of heart failure with preserved ejection fraction (HFpEF) after demonstrating clinical improvement with diuresis. He was readmitted after several weeks with worsening ascites, functional decline, and transaminitis. Paracentesis demonstrated an elevated ascitic total protein with a borderline serum ascitic albumin gradient slightly < 1.1 g/dL. The patient was discharged with gastroenterology follow-up to evaluate for malignancy. Several weeks later, he was readmitted to cardiology for worsening hypervolemia and suspected HFpEF exacerbation, despite adherence to outpatient diuretics.