Hypoxemia, high alveolar-arterial gradient and bubbles in both sides of heart: a case of Hepatopulmonary Syndrome in the setting of Covid-19 Pandemic.

36-year-old man with past medical history of liver cirrhosis presented to the ED during COVID-19 pandemic peak with a history of shortness of breath on minimal exertion, mild cough and fever. Findings on physical examination included hypoxic, tachypnoea, ascites, pedal edema and digital clubbing. No abnormal sounds were heard on lung and heart auscultation. Due to the high suspicion of COVID-19, tests were performed. Thoracic CT scan demonstrated neither ground glass opacities nor consolidation. SARS-CoV-2 testing was negative. ABG showed a PaO2 of 51 mm Hg with an A-a gradient of 68 mm Hg. A targeted history revealed platypnoea-orthodeoxia syndrome. Contrast echocardiography with saline was consistent with a diagnosis of hepatopulmonary syndrome. Patient was discharged with long-term oxygen. Currently, the patient is on the waiting list for a liver transplant.