December 2022 Pulmonary Case of the Month: New Therapy for Mediastinal Disease

Lewis J. Wesselius MD

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 43-year-old woman complained of persistent cough over 1 year with mild increasing dyspnea on exertion. She denied fever, sweats or weight loss. She had noted fatigue and dry cough, as well as shortness of breath, particularly when supine.

Past Medical History (PMH), Social History (SH), Family History (FH)

• An outside bronchoscopy done in 2019 with washings and biopsy showing only some non-specific inflammation
• Life-long nonsmoker
• Not on any chronic medications
• Had only lived in Arizona, although has travelled in other states
• There is no significant family history

Physical Examination

• Prominent vascularity on anterior chest

What should be done at this time? (Click on the correct answer to be directed to the 2nd of 6 pages)

1. Chest X-ray
2. Obtain old x-rays
3. Pulmonary function testing
4. Serology for coccidioidomycosis
5. All of the above

Cite as: Wesselius LJ. December 2022 Pulmonary Case of the Month: New Therapy for Mediastinal Disease. 2022;25(6):92-96. doi: https://doi.org/10.13175/swjpccs054-22 PDF

Repeat Episodes of Massive Hemoptysis Due to an Anomalous Origin of the Right Bronchial Artery in a Patient with a History of Coccidioidomycosis

Blerina Asllanaj, MD

Elizabeth Benge MD

Yi McWhworter DO

Sapna Bhatia MD

Department of Internal Medicine

HCA Healthcare

Mountain View Hospital

Las Vegas, NV, USA

Abstract

Anomalous bronchial arteries originate outside the space bound by the T5 and T6 vertebrae at the major bronchi. Here, we highlight a case of a 37-year-old man with a past medical history of coccidioidomycosis and who presented with massive hemoptysis. A bronchial angiogram showed the patient had a right bronchial artery originating anomalously from the left subclavian artery. The patient ultimately underwent a bronchial artery embolization, after which he achieved symptomatic remission.

Introduction

Hemoptysis from primary coccioidomycosis is unusual and should prompt a search for other causes (1). These could include bronchitis, malignancy, or rarely, a fungus ball. Anomalous bronchial arteries have origins outside the space bound by the T5 and T6 vertebrae at the level of the major bronchi (2). Bronchial artery embolization is the standard treatment for patients with ruptured anomalous bronchial arteries and resultant hemoptysis (3). Here, we present a unique case of a 37-year-old male with a past medical history of coccidioidomycosis and previous episodes of massive hemoptysis who was found to have an anomalous right bronchial artery originating in his left subclavian artery. Symptomatic remission was achieved with bronchial artery embolization. To our knowledge, this is the only reported case of a patient with a history coccidioidomycosis and a ruptured anomalous right bronchial artery that was successfully treated with bronchial artery embolization.

Case Presentation

Our patient is a 37-year-old man with a past medical history significant for coccidioidomycosis (resolved nine years prior) and previous episodes of massive hemoptysis who presented to our emergency room with multiple episodes of hemoptysis over the course of one day. On admission, he reported a five-pack year smoking history. He denied hematemesis, dyspnea, and angina, a history venous thromboembolism and alcohol and recreational drug use.

In the emergency department, the patient was afebrile, his blood pressure was 177/119 mmHg, heart rate was 96 beats/min, respiratory rate was 16 breaths/minute, and his oxygen saturation was 95% on room air. The patient’s physical exam revealed diffuse rales throughout the right lung and decreased breath sounds in the right lower lobe. The remainder of the patient’s physical exam was negative for acute abnormalities.

His lab values on admission were significant only for an elevated D-dimer at 1.28 mcg/mL; his hemoglobin was 14.2 gm/dL and his INR was 0.93 sec/mL. His chest radiograph showed ill-defined patchy parenchymal densities over the bilateral lower lobes (Figure 1).

Figure 1. Chest x-ray reveals ill-defined patchy parenchymal densities over the lower lobes suggest evolving multifocal pneumonia or atypical viral pneumonia.

He experienced a witnessed episode of hemoptysis, expectorating 300 cc’s of blood, prompting an emergent bronchoscopy. During the bronchoscopy, bloody secretions were noted to in his right lower lobe. A five centimeter dark red gelatinous material was removed and sent for pathology studies alongside bronchoalveolar lavage washings. Two mL’s of 2% epinephrine were administered, after which no active oozing was noted. The patient was then intubated for airway protection and admitted to the intensive care unit.   

A repeat chest radiograph revealed opacification throughout the right lung with evidence of volume loss (Figure 2).

Figure 2. Chest x-ray showing interval development of opacification throughout the right lung with evidence of volume loss including rightward mediastinal shift. The left lung is clear.

The patient was empirically treated for atypical pneumonia with azithromycin, ceftriaxone, dexamethasone, and albuterol breathing treatments. A computed tomography angiogram (CTA) of the chest with contrast showed multifocal flocculent and nodular infiltrate posterolateral aspect right lower lobe as well as mild mucous plugging and bronchial edema. Bronchial angiography confirmed the branching of the right bronchial artery from the left subclavian artery (Figure 3) and evidence of shunting to the right lower lobe (Figure 4).

Figure 3. Bronchial angiography prior to embolization- right bronchial artery directly arising from the left subclavian artery and is unusually large in caliber.

Figure 4. Bronchial angiography confirms opacification of the right lower lobe.

After the aberrant artery was confirmed on bronchial angiogram, the patient underwent a right bronchial artery embolization. He was subsequently extubated. Pathology and bronchoalveolar lavage studies revealed blood; the patient’s infectious and autoimmune work-up were entirely negative. He was discharged home with self-care. To date, the patient has only experienced one episode of hemoptysis status-post embolization.

Discussion

Differential diagnoses for massive hemoptysis include pulmonary infections, such as coccidioidomycosis, invasive aspergillosis and Mycobacterium tuberculosis, and cardiovascular causes, including anomalous origin of bronchial arteries. A thorough diagnostic evaluation is needed to identify the causative underlying pathology, site of bleeding, and vascular anatomy, so that the appropriate treatment can be initiated (3).

Common origins of the bronchial arteries include the inferior aortic arch, distal descending thoracic aorta, subclavian artery, brachiocephalic trunk, thyrocervical trunk and coronary artery (5). A bronchial angiogram was pivotal in the evaluation of the anatomy of the bronchial arteries in our patient’s case, as it allowed for the optimal artery embolization due to the identification of an anomalous artery early in his treatment course.

The bronchial arteries can become dilated and tortuous due to chronic inflammatory diseases such as bronchiectasis, coccidioidomycosis and tuberculosis, and are prone to vascular remodeling; rendering them fragile (6). The new collateral vessels have thin walls, making them prone to rupture and bleeding. In our patient’s case, chronic inflammation related to his prior coccidioidomycosis infection contributed to the remodeling of his anomalous right bronchial artery, rendering it prone to rupture and therefore the likely culprit of his massive hemoptysis.

Conclusion

Overall, this case emphasizes the importance of recognizing the fragility of anomalous bronchial arteries. A history of previous episodes of hemoptysis can alert clinicians to the possibility of a congenital abnormality exacerbated by subsequent infection.   

References

1. Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63(6):e112-46. [CrossRef] [PubMed]
2. Battal, B., Saglam M, Ors F et al. Aberrant right bronchial artery originating from right coronary artery–MDCT angiography findings. Br J Radiol. 2010;83(989): e101–e104. [CrossRef] [PubMed]
3. Keller FS, Rosch J, Loflin TG, Nath PH, McElvein RB. Nonbronchial systemic collateral arteries: significance in percutaneous embolotherapy for hemoptysis. Radiology. 1987 Sep;164(3):687-92. [CrossRef] [PubMed]
4. Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Int. 2017 Jun 5;114(21):371-381. [CrossRef] [PubMed]
5. Hartmann IJ, Remy-Jardin M, Menchini L, Teisseire A, Khalil C, Remy J. Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 2007 Aug;17(8):1943-53. [CrossRef] [PubMed]
6. Kathuria H, Hollingsworth HM, Vilvendhan R, Reardon C. Management of life-threatening hemoptysis. J Intensive Care. 2020 Apr 5;8:23. [CrossRef] [PubMed]

Cite as: Asllanaj B, Benge E, McWhworter Y, Bhatia S. Repeat Episodes of Massive Hemoptysis Due to an Anomalous Origin of the Right Bronchial Artery in a Patient with a History of Coccidioidomycosis. Southwest J Pulm Crit Care. 2021;23(3):89-92. doi: https://doi.org/10.13175/swjpcc037-21 PDF 

September 2021 Pulmonary Case of the Month: A 45-Year-Old Woman with Multiple Lung Cysts

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 45-year-old woman presented with increasing dyspnea on exertion and a history of recurrent pneumothoraces. In March 2018 she had laparoscopic ovarian cyst removal and noted some subsequent shortness of breath. In August 2018 she developed a right pneumothorax requiring chest tube placement. In September 2018 she had recurrent right pneumothorax and had video-assisted thoracoscopic surgery (VATS) with a right pleurodesis. The operative note from the outside VATS indicates a RUL bleb was removed and a wedge biopsy was done from posterior segment of the RUL. Pathology from the wedge biopsy reported “minimal emphysematous disease without other diagnostic abnormality”. She continued to be short of breath after the operation.

PMH, SH, and FH

• In 1975 she reportedly had pulmonary tuberculosis.  
• In 2018 the pneumothoraces, pleurodesis and the right ovarian cyst resection noted above.  
• She is a never smoker and has no family history of lung disease or pneumothoraces.

Medications

• Advair 115-21
• Hydroxyzine

Review of Systems

• In addition to her dyspnea she also reported a dry mouth.

Physical Examination

• Vital Signs: BP 143/93, afebrile, SpO2 99% at rest, Body Mass Index (BMI) 25.9
• Chest:  breath sounds diminished, no crackles
• CV: regular, no murmur
• Ext:  no clubbing or edema

Radiography

Prior outside CT scans are available from January 2019 (Figure 1) and December 2020.

Figure 1. Representative images from January 2019 high resolution thoracic CT scan in lung windows.

The thoracic CT scan in Figure 1 shows which of the following. (Click on the correct answer to be directed to the second of six pages)

1. Pleural thickening and scarring
2. A subpleural pulmonary nodule in the RUL
3. Multiple lung cysts
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2021 Pulmonary Case of the Month: A 45­-Year-Old Woman with Multiple Lung Cysts. Southwest J Pulm Crit Care. 2021;23(3):64-72. doi: https://doi.org/10.13175/swjpcc036-21 PDF

June 2021 Pulmonary Case of the Month: More Than a Frog in the Throat

Michael B. Gotway, MD

Department of Radiology, Mayo Clinic Arizona

Phoenix, Arizona 85054

A 66-year-old woman with a history of GERD and previous renal transplant due to lithium toxicity was seen in the clinic complaining of a shortness of breath and nonproductive cough. She was on immunosuppression due to her renal transplant done about 5 months ago. These include daily trimethoprim (TMP) – sulfamethoxazole (SMX). She also had asthma and was on a long-acting bronchodilator with an inhaled corticosteroid. Because of a previous history of oropharyngeal candidiasis (thrush), she was doing nystatin swish and swallow four times a day.

Which of the following should be included in your differential diagnosis in this clinical setting? (Click on the correct answer to be directed to the second of 5 pages. Multiple guesses are allowed.)

1. Candida esophagitis
2. COVID-19 Infection
3. Cytomegalovirus esophagitis
4. Group A Streptococcus infection
5. All of the above

Cite as: Gotway MB. June 2021 Pulmonary Case of the Month: More Than a Frog in the Throat. Southwest J Pulm Crit Care. 2021;22(6):109-13. doi: https://doi.org/10.13175/swjpcc017-21 PDF 

March 2021 Pulmonary Case of the Month: Transfer for ECMO Evaluation

Nicholas G. Blackstone, MD

April Olson, MD

Angela Gibbs, MD

Bhupinder Natt, MD

Janet Campion, MD

University of Arizona College of Medicine – Tucson

Tucson, AZ USA

History of present illness

A 31-year-old male fire fighter with a history of recurrent “atypical pneumonia”, environmental and drug allergies, nasal polyps, asthma, and Crohns disease (not on immunosuppressants) was transferred from an outside hospital for management of acute hypoxic respiratory failure with peripheral eosinophilia. Prior to admission he reported a 2-week history of worsening dyspnea, productive cough and wheezing, prompting an urgent care visit where he was prescribed amoxicillin-clavulanate for suspected community acquired pneumonia. Despite multiple days on this medication, his symptoms significantly worsened until he was unable to lie flat without coughing or wheezing. He was ultimately admitted to an outside hospital where his labs were notable for a leukocytosis to 22,000 and peripheral eosinophilia with an absolute eosinophil count of 9700 cells/microL. His blood cultures and urine cultures were negative, and a radiograph of the chest demonstrated bilateral nodular infiltrates. With these imaging findings combined with the peripheral eosinophilia there was a concern for Coccidioidomycosis infection and he was subsequentially started on empirical fluconazole in addition to ceftriaxone and azithromycin. Bronchoalveolar lavage (BAL) was performed revealing 80% eosinophils, 14% polymorphic nuclear cells (PMNs), 4% monocytes and 2% lymphocytes, no pathogens were identified. The patient’s clinical status continued to decline despite antimicrobial therapy, and he was intubated for refractory hypoxia. At this point, the patient was transferred to our hospital for further care.

What is the most likely diagnosis in this patient? (Click on the correct answer to be directed to the second of four pages.)

1. Acute asthma exacerbation
2. Bacterial pneumonia
3. Coccidioidomycosis pneumonia
4. Eosinophilic pneumonia
5. Rocky Mountain Spotted Fever

Cite as: Blackstone NG, Olson A, Gibbs A, Natt B, Campion J. March 2021 Pulmonary Case of the Month: Transfer for ECMO Evaluation. Southwest J Pulm Crit Care. 2021;22(3):69-75. doi: https://doi.org/10.13175/swjpcc069-20 PDF

July 2017 Pulmonary Case of the Month

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

The patient is a 19-year-old woman who went to a local Emergency Room 12/23/15 for chest pain she described as pleurisy. She was told she had pneumonia and a chest x-ray was reported to show a lingular infiltrate (Figure 1).

Figure 1. PA (A) and lateral (B) chest radiograph taken 12/23/15.

She was treated with antibiotics and improved. She was well until 9/2/16 when she again returned to the emergency room complaining of hemoptysis. A chest x-ray was reported as showing a lingular infiltrate (Figure 2). 

Figure 2. PA (A) and lateral (B) chest radiograph taken 9/2/16.

She was treated with azithromycin but her cough persisted sometimes with a small amount of blood in her sputum. She was referred because of her persistent symptoms and her abnormal chest x-ray.

Past Medical History, Social History and Family History

• She is now taking fluoxetine daily.
• She has a history of pediatric autoimmune neuropsychiatric disorder associated with Group A Streptococcus and was treated with antibiotics for 4-5 years.
• Nonsmoker.

Physical Examination

Her physical examination was unremarkable.

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

1. Her chest radiographs are consistent with pneumonia
2. Lung cancer is an unlikely consideration in a 19-year-old
3. The chest x-ray findings represent a well-known complication of pediatric autoimmune neuropsychiatric disorder
4. 1 and 3
5. All of the above

Cite as: Viggiano RW. July 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;15(1):1-6. doi: https://doi.org/10.13175/swjpcc082-17 PDF 

November 2014 Pulmonary Case of the Month: BAL Eosinophilia

Salma Imran Patel, MD, MPH

Lewis J. Wesselius, MD

Laszlo T. Vaszar, MD

Departments of Internal Medicine and Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 62 year-old- was admitted to the hospital for 2 weeks of worsening cough, yellowish sputum production, shortness of breath and pleuritic chest pain. The patient has had asthma since the 1970s and presently uses salmeterol/fluticasone and albuterol as a rescue inhaler. He was intubated once four years ago, and has had a total of three hospitalizations for his asthma and 15 courses of prednisone. He is sensitive to cold/hot air, all animals, aspirin and acetaminophen.

PMH, FH, SH

In addition to the asthma, he has a history of type 2 diabetes mellitus, hypertension, gastroesophageal reflux disease, and chronic abdominal pain.

Physical Examination

Vital signs: T 36.6º C, HR 98, BP129/69, RR 20 and SPO2 96% on 2 L of oxygen by nasal cannula. He was mildly distressed and coughing. His pulmonary exam showed diffuse inspiratory and expiratory wheezes. The remainder of his exam was unremarkable.

Laboratory

Significant findings on laboratory evaluation include an elevated white blood cell count of 13,400 cells/ɥL, an elevated absolute eosinophil count of 2,820 eosinophils/ɥL, an elevated glucose of 131 mg/dL, and a low sodium of 120 mEq/L.

Imaging

A thoracic CT scan was performed (Figure 1).

Figure 1. Representative images in lung windows from thoracic CT scan.

Which of the following best describes the CT scan? (click on the correct answer to proceed to the next panel)

1. Cavitary changes in both apices
2. Central consolidation
3. Fibrotic changes at the bases
4. Peripheral opacities
5. Normal

Reference as: Palel SI, Wesselius LJ, Vasczar LT. November 2014 pulmonary case of the month: BAL eosinophilia. Southwest J Pulm Crit Care. 2014;9(5):251-6. doi: http://dx.doi.org/10.13175/swjpcc136-14 PDF

June 2014 Pulmonary Case of the Month: "Petrified"

Steven W. Purtle, MD

University of Colorado Hospital, Denver, CO

steven.purtle@ucdenver.edu

History of Present Illness

A 52 year old expatriated Iraqi man presents to pulmonary clinic with complaints of chronic dyspnea. While a young man living in Iraq, he had been disqualified from service in the Iraqi Air Force after a screening chest x-ray was found to be abnormal. He had no respiratory symptoms at the time of his disqualification, and he remained asymptomatic for the next twenty five years. Beginning five years ago, he had an insidious onset of breathlessness and exertional intolerance. Over the past several years, he has developed diffuse pleuritic chest pain, non-productive cough, and fatigue. He denies any fevers, chills, night sweats, arthralgias, rash, or visual symptoms. After moving to Denver, Colorado three years ago, he has developed a continuous oxygen requirement of two liters per minute.

PMH, FH, SH

He has no significant past medical or family history. While living in Iraq, he worked as a photographer, but he is currently unemployed. He is a lifelong non-smoker and uses no illicit drugs. He has never had any pets. He denies any exposure to inorganic dusts.

Medications

None

Physical Examination

Physical examination reveals a thin, middle-aged man in no acute distress. Vital signs were notable for an oxygen saturation of 90% on 2 liters per minute of supplemental oxygen. Pulmonary examination was notable for fine inspiratory crackles heard best at the bilateral bases. There was no clubbing or peripheral edema. The remainder of his physical examination was unremarkable.

Laboratory Analysis

Serum chemistries are within normal limits. Complete blood count shows a normal white blood cell count, hematocrit, and platelet count.

Pulmonary Function Tests

Pulmonary functions tests are shown in Figure 1.

Radiography

A chest x-ray (Figure 2) and chest CT (Figures 3 and 4) were performed.

Figure 2. Admission AP (Panel A) and lateral (Panel B) chest x-ray.

Figure 3. Static thoracic CT images displayed in lung windows (Panels A-D) and soft tissue windows (Panels E-H).

Figure 4. Movies of thoracic CT scan in lung windows (Panel A, top) and soft tissue windows (Panel B, bottom).

Which of the following features best describes the pattern seen on the patient’s chest CT? (Click on the correct answer to proceed to the next panel)

1. Diffuse microcalcifications
2. Honeycombing
3. Mosaicism
4. Patchy ground glass opacifications
5. Pleural plaques

Reference as: Purtle SW. June 2014 pulmonary case of the month: "petrified". Southwest J Pulm Crit Care. 2014;8(6):299-304. doi: http://dx.doi.org/10.13175/swjpcc069-14 PDF

January 2014 Pulmonary Case of the Month: Too Much, Too Late

Chidinma Chima-Okereke MD  

Department of Pulmonary Medicine

Cedars Sinai Medical Center

Los Angeles, CA

Chief Complaint: Difficulty breathing

History of Present Illness

A 49-year-old gentleman with history of hepatitis C cirrhosis complicated by ascites presented to the emergency room of Olive View Medical Center in San Fernando Valley, California complaining of worsening shortness of breath. The patient reports that he occasionally has shortness of breath, usually about 2-3 times a year. However for the past 2 months, he has had worsening dyspnea on exertion and cannot walk further than 5 minutes. He also reports orthopnea and paroxysmal nocturnal dyspnea. He has been having a dry cough for the past 3-4 weeks.

He has a history of chronic ascites that has required multiple taps. He has been taking his prescribed diuretics however instead of taking these medications daily he takes them about every other day due to financial constraints.

However, his abdominal distention and his lower extremity swelling are stable. He reports some nausea with decreased appetite. He also has a new symptom of left-sided chest pain that radiates down his left arm and shoulder that lasts about 20 minutes and has no associated symptoms. .

He denies any fevers or chills or weight change. He has no sick contacts.

Past Medical and Surgical History

• Hepatitis C cirrhosis
• Chronic lower extremity edema
• Ascites, status post multiple large volume paracentesis
• History of chronic abdominal pain treated with morphine
• Status post chest tube when he was a 17-year-old due to a gunshot wound

Social History

• History of incarceration, released about 8 months ago
• 6-pack of beer a day – quit 12 years ago.
• Former smoker, quit 10 years ago, 7 pack-years
• IV heroin use 15 years ago
• No cocaine, amphetamines or any inhaled substances
• No recent travel, occupational, pet or bird exposures
• Lives with his fiancé in Lancaster, California

Family History

• Father died of an MI at age 56.
• Mother - SLE, DM, Stroke
• Sister - Colon cancer
• Brother - Hepatitis C cirrhosis

Medications

• Controlled-release morphine sulfate 15 mg p.o. every morning and 30 mg p.o. every evening.
• Furosemide 40 mg p.o. daily.
• Spironolactone 50 mg p.o. daily.
• Lactulose 15 mL p.o. b.i.d. p.r.n.

Review of Systems

Positive for pleuritic chest pain, night sweats, chills, dry cough - unproductive of sputum, lightening and darkening of urine, lower extremity edema, palpitations, decreased appetite, dry mouth, joint stiffness in the morning.    

Physical Examination

• Vital signs: T 97.4 BP 115/67, HR 89, RR 20, SpO2 93%/RA
• Lung exam was significant for bilateral crackles midway up the back.
• Abdominal exam was non-tender and not suggestive of ascites
• Lower extremities: 1+ bilateral pitting edema up to the knees.
• Multiple skin tattoos and erythema in his lower extremities  
• Muscle strength was 3/5 in the lower extremities, 4/5 in upper extremities bilaterally.
• Otherwise the physical exam was unremarkable.

Laboratory

• Basic Metabolic Panel was within normal limits.
• Complete blood count (CBC): White count 6.3 X 10³/mm³ with 8.3% eosinophils, hemoglobin 12.3 g/dL, platelets 130,000/µL.
• Liver function tests (LFTs): AST 78 IU/L, ALT 42 IU/L, alkaline phosphatase 115, total bilirubin 1.3 mg/dL, INR 1.3, albumin 2.7 g/dL.
• Brain naturetic peptide (BNP) 38 ng/L, troponin is 0.008 ng/ml.

Radiography

A chest x-ray was obtained (Figure 1).

Figure 1. Admission AP (Panel A) and lateral (Panel B) chest x-ray.

The chest x-ray was interpreted as poor inspiration with elevation of the right diaphragm. The heart is at least upper limits of normal in size. Pulmonary vessels are congested. The azygos vein is mildly dilated. No significant pleural effusion is detected in these two views.

A CT angiogram was obtained to rule out pulmonary embolism (Figure 2).

Figure 2. Panels A-D: Representative static axial images from the thoracic CT scan lung windows. Lower panel: movie of representative axial thoracic CT scan lung windows.

Hospital Course

He was admitted to the medicine wards, diuresed with furosemide 40 mg IV, spironolactone 100 mg by mouth and fluid restricted.

At this point which of the following are diagnostic tests that should be ordered? (click on correct answer to move to next panel)

1. Coccidiomycosis serology
2. HIV
3. Quantiferon TB and sputum AFB
4. Rheumatologic work up including anti-neutrophil cytoplasmic antibody (ANCA), ANA and subtypes, RA and anticentromere antibodies
5. All of the above

Reference as: Chima-Okereke C. January 2014 pulmonary case of the month: too much, too late. Southwest J Pulm Crit Care. 2013;8(1):4-17. doi: http://dx.doi.org/10.13175/swjpcc162-13 PDF