Intravenous diuretics and angiotensin converting enzyme inhibitors were added. Patient was started on heart failure treatment protocol. (b) Computed tomography chest showing ground glass opacities, interlobular septal thickening, and bilateral effusion (a) Chest radiograph showing pulmonary edema and bilateral pleural effusion. With this clinical and investigational profile, possibility of biventricular failure was suspected. A contrast-enhanced computed tomography (CECT) of chest done in a secondary care hospital was brought by the patient, which revealed ground glass opacities, particularly in the perihilar area, thickened interlobular septa, and bilateral pleural effusion. Chest X-ray revealed picture of pulmonary edema with evidence of bilateral pleural effusion. Cardiac troponins were normal and D-dimer was negative. Serum electrolytes and lipid profile were normal. Biochemistry revealed the following values: Random blood glucose- 276 mg%, blood urea nitrogen- 20 mg%, serum creatinine- 0.9 mg%, serum aspartate aminotransferase- 58 U/l, serum alanine aminotransferase- 68 U/l, alkaline phosphatase- 215 U/l, and serum albumin 3.6 g%. On investigations, hemoglobin was 11.6 g% and total leukocyte count was 11,200/mm 3. Palpation of abdomen revealed tender hepatomegaly. On chest auscultation, vesicular breath sounds were heard with extensive fine end-inspiratory crackles up to the interscapular area. Examination of the cardiovascular system was normal.
Jugular venous pressure was raised up to 6 cm above the angle of Louis. Blood pressure was 160/100 mmHg in the right upper limb. At the time of admission, pulse was 100/minute and was regular. In treatment history, patient was taking combination of pioglitazone 30 mg, metformin 1 g, and glimepride 2 mg for the last 1 year. No records of previous ECG or echocardiography were available. Patient did not report any recent weight gain. There was no history of chest pain, palpitations, syncope, fever, cough, wheeze, and abdominal distension. History of pedal edema was present during that period. Patient had history of paroxysmal nocturnal dyspnea and orthopnea for the last 10 days. We report a patient who developed congestive heart failure and pulmonary edema with normal left ventricular function within 1 year of starting pioglitazone therapy.Ī 65-year-old, non-obese male, a diabetic for the last 10 years on oral hypoglycemic agents (OHA), was admitted in the emergency department with the chief complaint of progressive breathlessness for last 15 days. However, in patients with normal left ventricular systolic and diastolic function, it has not been widely reported. Heart failure is well documented in patients with known left ventricular dysfunction. The clinical use is further limited by the spectrum of side effects that include weight gain, decrease in hematocrit values, edema, heart failure, fractures, and worsening of diabetic macular edema. It was subsequently revoked, but with the boxed warning relating to bladder cancer. Due to the concerns over bladder cancer as an adverse effect, the manufacture, sale, and distribution of the drug was temporarily banned in India.
Pioglitazone was a safer option for patients till it got involved in a controversy because of the side effects. The beneficial effects extend beyond glycemic control and have positive effects on lipid metabolism, blood pressure, endothelial function, adiponectin, and C-reactive protein levels. Pioglitazone is an established insulin sensitizer hugely successful in therapeutic management of type 2 diabetes mellitus.
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