Immersion pulmonary edema in a patient on maintenance dialysis: A case report.

Immersion pulmonary edema (IPE) is a rare condition observed in divers. We report a case of a 66-year-old man on maintenance dialysis who developed acute dyspnea and blood-tinged sputum after scuba diving. Vital signs on admission were significant for elevated blood pressure at 209/63 mmHg and hypoxia with an oxygen requirement of 6 L/min. Physical examination was remarkable for bilateral coarse crackles and systolic ejection murmur. Chest radiography revealed bilateral pulmonary edema. Echocardiography showed aortic stenosis and diffuse hypokinesis of left ventricular wall motion. We started bilevel positive airway pressure and administered nitroglycerin and nicardipine to maintain adequate oxygenation and reduce blood pressure. We started hemodialysis and extracorporeal ultrafiltration to remove excess fluid. His dyspnea subsided and oxygen was no longer required on Day 3. His long-standing hypertension, increased afterload due to vasoconstriction induced by cold water, increased capillary pressure due to impaired left ventricular motion and increased preload caused by exertion, and aortic stenosis probably contributed to pulmonary congestion. We propose maintenance dialysis as a novel risk factor for IPE due to its tendency to induce volume overload, increase pulmonary capillary pressure, and increase aortic stenosis risk. Patients on hemodialysis should refrain from diving to prevent this life-threatening condition.