December 2019 Pulmonary Case of the Month: A 56-Year-Old Woman with Pneumonia

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 56-year-old woman complained of 6 weeks of increasing cough and shortness of breath. She had been treated for pneumonia with antibiotics, but when she failed to improve, she was begun on prednisone. She was receiving oxygen at 4 L/min by nasal cannula at the time she was seen.

PMH, SH, and FH

Her past medical history, social history and family were unremarkable other than a previous history of silicone breast implants. She was a nonsmoker.

Physical Examination

Her physical examination showed bibasilar crackles but was otherwise unremarkable.

Radiography

Her chest x-ray is shown in Figure 1.

Figure 1. Patient’s chest x-ray taken 6 weeks after the beginning of her illness.

Which of the following should be done at this time? (Click on the correct answer to be directed to the second of seven pages)

1. Coccidioidomycosis serology
2. Sputum gram stain and culture
3. Thoracic CT scan
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. December 2019 Pulmonary case of the month: a 56-year-old woman with pneumonia. Southwest J Pulm Crit Care. 2019;19(6):149-55. doi: https://doi.org/10.13175/swjpcc067-19 PDF

June 2015 Pulmonary Case of the Month: Collapse of the Left Upper Lobe

G. Zacharia Reagle DO

Andreas Escobar-Naranjo MD

Department of Internal Medicine

Division of Pulmonary and Critical Care

UCSF Fresno

Fresno, CA

History of Present Illness

A 65 year-old woman who recently quit smoking presented to the ER for the third time in the preceding month with dyspnea and cough. She reported some subjective fevers and cough productive of white sputum as well as a seven kilogram unintentional weight loss in the prior four to eight weeks. She had been diagnosed with COPD in the past and on both prior ER visits was treated with oral steroids and antibiotics. She would feel some relief with the steroids but once the course was over she would quickly experience a return of her symptoms. On the third ER presentation she was admitted to the hospital.

Past Medical History:

• Asthma
• HTN
• Hypothyroidism

Past Surgical History:

• C-section x 2
• TAH and BTL
• Appendectomy
• Tonsillectomy

Medications:

• Levothyroxine 0.15mg daily
• Budesonide 40/formoterol 4.5 twice daily
• Tiotropium 18 mcg daily
• Fluoxetine 20mg daily
• Hydroxyzine 50mg three times daily
• Hydrochlorothiazide 50/triamterene 75 daily
• As needed albuterol

Allergies: No Known Drug Allergies

Social History:

A lifelong Californian, she was divorced with two healthy adult children. She is a United States Air Force veteran who served as a broadcaster from 1974-78 including a deployment to Asia. After leaving the service she worked as a Registered Nurse in burn, rehab and home health nursing. A former tobacco smoker with 35+ pack years of tobacco exposure – she quit smoking one month prior to the current admission. She is currently homeless, living in a homeless veteran’s shelter. She is a recovering alcoholic and cannabis addict.

Physical Exam:

General: Alert, mild respiratory distress, mildly anxious.

Vitals: BP: 134/80 HR: 104 RR: 18, SpO2 93% on room air T: 98.4ºF

HEENT: NC/AT, PERRL, neck supple without JVD noted.

Lungs: equal chest expansion, scattered bilateral wheezes with decreased airflow on the left

Heart: Regular with a good S1 and S2, no murmurs or gallops were appreciated.

Abdomen soft, Non-tender, good bowel sounds.

Extremities No edema, nor clubbing.

Neurological: She was alert and oriented with a Glasgow Coma Score of 15, no focal defects noted.

Skin: No rashes noted.

Laboratory:

CBC: WBC 6.9 X 10⁹ cells/L, hemoglobin13.4 g/dL, hematocrit 39.4, platelet count 329 X 10⁹ cells/L

Chemistries: Na+ 139 mEq/L, K+ 3.5 mEq/L Cl- 106 mEq/L, CO2 26 mEq/L  BUN 8 mg/dL, creatinine 0.6 mg/dL, glucose 149 mg/dL, magnesium 2.0 mg/dL, phosphate 3.4 mg/dL

Mycoplasma IgM: (-)

S. pneumoniae urinary antigen: (-)

Legionella urinary antigen: (-)

Blood Cultures: (-)

Imaging:

On admission a chest CT was preformed (Figure 1).

Figure 1. Representative images from the thoracic CT scan showing central and upper zone predominate bronchiectasis, and total collapse of the left upper lobe. There also was some emphysema noted.

Which of the following causes of bronchiectasis should be considered in this case? (Click on the correct answer to proceed to the second of six panels)

1. Allergic bronchopulmonary aspergillosis
2. Autoimmune diseases including rheumatoid arthritis and Sjogren’s syndrome
3. Congenital pulmonary conditions including cystic fibrosis and primary ciliary dyskinesia
4. Immunoglobulin deficiency
5. All of the above are possible causes of bronchiectasis

Reference as: Reagle GZ, Escobar-Naranjo A. June 2015 pulmonary case of the month: collapse of the left upper lobe. Southwest J Pulm Crit Care. 2015;10(6):315-22. doi: http://dx.doi.org/10.13175/swjpcc072-15 PDF