Bilateral Diaphragmatic Paresis Due to an Iatrogenic Injury of the Phrenic Nerve: A Case Report

Bilateral diaphragmatic paresis is a rare entity with unknown incidence and is associated with severe respiratory dysfunction. In this case report we present a 69-year-old patient who sought emergency services due to dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. The patient denied other complaints and mentioned that these symptoms began after being discharged from a hospitalisation for emphysematous acute cholecystitis, where he underwent laparoscopic cholecystectomy, which was complicated by extensive hemorrhage of the abdominal wall. On the physical examination, paradoxical breathing and peripheral oxygen saturation between 80-93% in supine and standing positions, respectively, were notable. The patient was admitted for further investigation, during which thoracic radiographs in inspiration and expiration showed no positional variation of the diaphragm, respiratory function tests revealed a restrictive pattern and electromyography demonstrated acute bilateral diaphragmatic neuropathic injury compatible with phrenic nerve injury. Therefore, by temporal correlation and exclusion of other apparent causes, an etiology in the context of the cholecystectomy was inferred. The patient was evaluated in a multidisciplinary manner and is currently undergoing a cardiopulmonary rehabilitation program in the Physical Medicine and Rehabilitation service, although with limited progress and still requiring non-invasive ventilation.