February 2018 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 75-year-old woman was diagnosed with a thymic carcinoid tumor in April, 2015 (Figure 1).

Figure 1. Representative image from the preoperative CT scan performed in April 2015 showing an anterior mediastinal mass (arrow).

This was treated with surgical resection followed by radiation therapy.

She began having cough and dyspnea 1 to 2 months later and in August, 2015 had a thoracic CT scan of her chest (Figure 2).

Figure 2. Representative image in lung windows from the second thoracic CT scan performed in August 2015.

Which of the following are true? (Click on the correct answer to proceed to the second of six pages)

1. Bronchoscopy should be performed
2. She should be given an empiric course of antibiotics
3. The most like diagnosis is radiation pneumonitis
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. February 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(2):55-61. doi: https://doi.org/10.13175/swjpcc020-18 PDF 

April 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Rodrigo Cartin-Ceba, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 75-year-old woman who presented with a chest mass incidentally found on chest x-ray. She was asymptomatic

Past Medical History, Social History and Family History

She has no significant past medical history and has never smoked. Family history is noncontributory.

Physical Examination

Physical examination was unremarkable.

Radiography

A thoracic CT scan was performed (Figure 1).

Figure 1. Representative thoracic CT scan in soft tissue windows showing  a mass (arrow).

Which of the following are possible causes of the mass? (Click on the correct answer to proceed to the second of four panels)

1. Lymphoma
2. Teratoma
3. Thymoma
4. Thyroid carcinoma
5. All of the above 

Cite as: Wesselius LJ, Cartin-Ceba R. April 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4):126-9. doi: http://dx.doi.org/10.13175/swjpcc032-16 PDF 

June 2013 Pulmonary Case of the Month: Diagnosis Makes a Difference

Lewis J. Wesselius, MD¹

Henry D. Tazelaar, MD²

Departments of Pulmonary Medicine¹ and Laboratory Medicine and Pathology²

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 64 year old man from Southern Arizona was referred for a second opinion on a diagnosis of chronic eosinophilic pneumonia that was poorly responsive to corticosteroid therapy. The patient first became ill February 2012 with cough and congestion.  His wife was ill at the same time. Both were treated with antibiotics. His wife improved but he never fully recovered with ongoing symptoms of cough and some dyspnea.

He was admitted to another hospital in August 2012 due to worsening shortness of breath and pulmonary infiltrates on chest x-ray. During this admission he underwent bronchoscopy with bronchoalveolar lavage (BAL) that demonstrated 78% eosinophils. A video-assisted thorascopic (VATs) lung biopsy was done and the patient was diagnosed with chronic eosinophilic pneumonia. He was begun on therapy with high dose prednisone (80 mg/day) but had only slight improvement in symptoms.

He was followed by a pulmonologist and continued on prednisone who questioned the possible development of pulmonary fibrosis. Earlier this year he was started on mycophenolate mofetil and the dose was increased to 1000 mg bid while the prednisone was tapered to 5 mg every other day. He was also being treated with fluticasone/salmeterol 250/50 twice a day. The patient continues to have dyspnea with limited activity. His last pulmonary function testing was done in December 2012. At that time his forced vital capacity (FVC) was 51% of predicted and his diffusing capacity for carbon monoxide (DLco) was 40% of predicted.

PMH, SH, FH

He had a history of obstructive sleep apnea (OSA) and had undergone an uvulopharyngoplasty (UPPP). There was also a history of gastroesophageal reflux disease (GERD) and he had a prior Nissen fundoplication. He had a history of osteoarthritis and had undergone a right shoulder replacement.

He had a remote smoking history, a history of modest alcohol use, but no history of using recreational drugs.  He worked as an airline pilot.

His present medications included mycophenolate mofetil 1000 mg twice a day, prednisone 5 mg every other day, voriconazole 200 mg daily (started after BAL showed a few colonies of Aspergillus), and fluticasone/salmeterol 250/50 twice a day.

Physical Examination

Blood pressure 134/88 mm Hg.  Resting oxygen saturation 96%.

Chest:  bibasilar crackles but no wheezes.

Cardiovascular: the heart had a regular rhythm but no murmur.

Extremities: no clubbing or edema.

The remainder of the physical examination was unremarkable.

Chest Radiography

His chest x-ray is shown in figure 1.

Figure 1. Initial chest x-ray.

Which of the following diseases has/have been associated with increased eosinophils in bronchoalveolar lavage fluid?

1. Interstitial lung diseases
2. Acquired immunodeficiency syndrome (AIDS)-associated pneumonia
3. Idiopathic eosinophilic pneumonia
4. Drug-induced lung disease
5. All of the above

Reference as: Wesselius WJ, Tazelaar HD. June 2013 pulmonary case of the month: diagnosis makes a difference. Southwest J Pulm Crit Care. 2013;6(6):247-54. PDF 

August 2012 Pulmonary Case of the Month

All Eosinophilia Is Not Asthma

Lewis J. Wesselius, MD

Departments of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 73 year old man was seen with a one month history of shortness of breath. He dated this to an emergency room visit for an arm injury for which he had a DPT vaccination. Previously, he had been able to swim regularly, but he is now unable to swim due to worsening dyspnea. He also had some cough that was nonproductive.

PMH, SH and FH

He has a past medical history of coronary artery disease with prior stenting of his right and left anterior descending artery in 2010. He also has a history of hypertension, dysplipidemia, a carotid endarterectomy and a single seizure after a corneal transplant.

His present medications include:

• Atorvastatin
• Lisinopril
• Metoprolol
• Warfarin

He has a minimal smoking history and denied use of alcohol, drugs or unusual exposures. 

Physical Examination

His vitals signs were normal and he was afebrile but he was receiving supplemental oxygen at 3 lpm.

Chest examination revealed bilateral crackles but no wheezes.

Cardiovascular examination showed a regular rhythm with a Grade 2/6 systolic ejection murmur.

He had no clubbing or edema.

The remainder of the physical examination was either normal or noncontributory.

Chest X-ray

His admission chest x-ray is shown in Figure 1.

 Figure 1. Admission chest x-ray showing the PA (Panel A) and lateral (Panel B).

Which of the following are possible causes of the patient’s clinical picture?

1. Coccidioidomycosis (Valley Fever)
2. Allergic reaction to the DPT vaccination
3. Pulmonary edema
4. A + C
5. All of the above

Reference as: Wesselius LJ. August 2012 pulmonary case of the month: all eosinophilia is not asthma. Southwest J Pulm Crit Care 2012;5:58-64. (Click here for a PDF version of the case presentation)