January 2015 Pulmonary Case of the Month: More Red Wine, Every Time

Uzair Ghori, MD (UGhori@salud.unm.edu)

Shozab Ahmed, MD  (Sahmed@salud.unm.edu)

University of New Mexico

Albuquerque, New Mexico

History of Present Illness

A 41-year-old man travelling from Texas to Las Vegas, Nevada presents to the Emergency Room in Albuquerque, New Mexico with petechial rash, photophobia and headache of 2 weeks duration. The patient complains of general malaise, arthralgia, trouble sleeping, shortness of breath associated with cough and intermittent bilateral lower extremity swelling of 3 weeks duration.

PMH, SH & FH

The patient was prescribed lisinopril and metformin for hypertension and diabetes mellitus, respectively. He admitted occasional drinking, smoking a variable quantity for 30 years but currently not smoking. He denied any illicit drug use.

Physical Exam

Vitals: Heart Rate-92, Blood Pressure-116/45 mm Hg, Respiratory Rate-44 breaths/min, Temperature- 37.2ºC, SpO2-98% on non-rebreather mask.

General: His mental status was not altered.

HEENT: No papilledema was appreciated on eye exam.

Neck: JVP not appreciated.

Lungs: he had diminished breath sounds bilaterally on auscultation.

Heart: His heart had a regular rate and rhythm with no murmurs rubs or gallops.

Abdomen: No abdominal distention or lower extremity edema appreciated.

Skin: A petechial rash was noted most prominently in the lower extremities.

Based on the initial presentation the most appropriate investigations would be? (Click on the correct answer to proceed to the 2nd of 6 panels)

1. CBC, CT head, echocardiogram, blood cultures, metabolic panel, inflammatory markers
2. CBC, UA, lumbar puncture, chest x-ray, inflammatory markers, metabolic panel
3. Echocardiogram, CBC, UA, venous blood gases, bronchoscopy, CT head
4. Stress test, CXR, inflammatory markers, lumbar puncture, ultrasound abdomen, metabolic panel
5. UA, lumbar Puncture, bronchoscopy, echocardiogram, CT head, inflammatory markers 

Reference as: Ghori U, Ahmed S. January 2015 pulmonary case of the month: more red wine, every time. Southwest J Pulm Crit Care. 2015;10(1):1-7. doi: http://dx.doi.org/10.13175/swjpcc155-14 PDF

April 2012 Pulmonary Case of the Month: Could Have Fooled Me!

Bridgett A. Ronan, MD

Robert Viggiano, MD

Lewis J. Wesselius, MD

Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 60 year old man was seen by his primary care physician with cough for 2 weeks which was dry and worse with deep breathing. He had been exposed to smoke from industrial storage fire just prior to the onset of his cough. He had developed fever for the past 3 days.

PMH, SH and FH

He has a history of osteopenia and was found to have a +PPD in high school for which he was never treated with isoniazid. Originally from New York he has lived in Arizona for 14 years. He was a former smoker having a 45 pack-year history having quit in 2007. He drives a delivery truck. His sister had tuberculosis which was treated and his father has emphysema.

Physical Examination

He had mild rhonchi in the right upper lung field. Otherwise, the physical exam was unremarkable.

Laboratory and Chest X-ray

A CBC was performed which revealed a hemoglobin of 11.7 g/dL, white blood cell (WBC) count of 11.9 X 1000 cells/ml with 79% neutrophils, and a platelet count of 337 X 1000/mL. Coccidioidomycosis serologies were drawn. A chest x-ray was taken (Figure 1).

Figure 1. Chest x-ray taken by the patient’s primary care physician which shows bilateral lung consolidations with multiple poorly defined bilateral lung nodules.

Considerations at this point include:

1. Community acquired pneumonia
2. Coccidioidomycosis
3. Tuberculosis
4. Pneumonitis from smoke inhalation
5. Pulmonary embolism
6. All of the above

Reference as: Ronan BA, Vigianno R, Wesselius LJ. April 2012 pulmonary case of the month: could have fooled me! Southwest J Pulm Crit Care 2012;4:122-9. (Click here for a PDF version of the case)