Clinically Suspected Triple-hit Respiratory Failure in Kyphoscoliosis, COPD and Systemic Sclerosis: A Case Report

Abstract

Background: Respiratory failure in patients with coexisting pulmonary and extrapulmonary disorders may be diagnostically challenging. Kyphoscoliosis can impair chest-wall mechanics and contribute to restrictive ventilatory dysfunction, chronic obstructive pulmonary disease (COPD) may add airflow limitation and ventilation-perfusion mismatch, and systemic sclerosis may further compromise respiratory status through pulmonary vascular or parenchymal involvement. Case presentation: A 55-year-old female with known kyphoscoliosis, COPD, and limited systemic sclerosis presented with progressive breathlessness, generalised weakness, abdominal pain, cough with thick whitish expectoration, and low-grade fever. She was somnolent but arousable, with oxygen saturation of 65% on room air, improving to 94% with oxygen at 4 L/min. Arterial blood gas analysis showed type II respiratory failure with respiratory acidosis (pH 7.31, pCO₂ 60 mmHg, and HCO₃⁻ 30.2 mmol/L). Laboratory evaluation showed leukocytosis and mild anaemia, while renal and hepatic parameters were within normal limits. Previous echocardiography showed right atrial and right ventricular dilatation, mild pulmonary hypertension, and preserved ejection fraction. Pulmonary function testing, previous spirometry, current echocardiography, right-heart catheterisation, and advanced thoracic imaging were unavailable. The patient was managed with controlled oxygen therapy, non-invasive ventilation using BiPAP, antibiotics, corticosteroids, bronchodilators, and supportive care. Her clinical condition improved, and she was discharged in a stable condition. Conclusion: This case highlights clinically suspected multifactorial acute-on-chronic type II respiratory failure in the setting of kyphoscoliosis, COPD, and limited systemic sclerosis.