March 2022 Pulmonary Case of the Month: A Sore Back Leading to Sore Lungs

Lewis J. Wesselius MD¹

Brandon T. Larsen MD PhD²

Departments of ¹Pulmonary Medicine and ²Pathology

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

An 82-year-old woman from Colorado was referred because of progressive shortness of breath over the past year. Her primary care physician had prescribed Trelegy® which did not improve her dyspnea. An outside pulmonologist noted abnormal findings on her thoracic CT scan and a bronchoscopy with bronchoalveolar lavage (BAL) was preformed which was positive for Mycobacterium Avium Complex (MAC). She was treated with a 3-drug regimen (azithromycin, rifampin, ethambutol) for 6 months with mild improvement. After the treatment was stopped, she noted more dyspnea and required supplemental oxygen. She underwent a fundoplication and initially improved but a month later her shortness of breath seemed to worsen. She was started on prednisone which was tapered to 10 mg/day. She was referred to the Mayo Clinic for possible VATS lung biopsy.

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

PMH

• Hiatal Hernia/GERD
• Ulcerative Colitis
• Hypertension
• Chronic Back pain
• Prior breast implants

SH

• Former smoker (24 pack-years, quit 1988)
• Social use of alcohol, no drug use
• No exposure to birds or down
• No occupational dust exposures
• Home humidifier
• Has indoor hot tub used frequently for back pain

FH

• Unremarkable

 Medications

• Prednisone 10 mg daily
• Pantoprazole 40 mg bid
• Pregabalin 25 mg at bedtime
• Oxycodone 5 mg q 6 hours prn pain
• Ondansetron 4 mg tablet q 8hhours prn nausea

Physical examination

• BMI 31.9
• Oxygen saturation at rest 95% on 4 lpm, 88% on RA
• Chest: scattered crackles
• Cardiovascular: regular rate without murmur
• Extremities: no clubbing or edema

Which of the following should be done next? (Click on the correct answer to be directed to the second of seven pages.)

1. Pulmonary function testing
2. Open surgical lung biopsy
3. Review thoracic CT scan
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ, Larsen BT. March 2022 Pulmonary Case of the Month: A Sore Back Leading to Sore Lungs. Southwest J Pulm Crit Care Sleep. 2022;24(3):36-39. doi: https://doi.org/10.13175/swjpccs011-22 PDF 

April 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 63-year-old woman with a prior diagnosis of possible rheumatoid arthritis was referred for dyspnea with more vigorous activities in Prescott where she now lives (elevation 5367 ft.). She is receiving hydroxychloroquine 400 mg/day.

Past Medical History, Social History and Family History

She has a past medical history of hypertension. She smoked about a pack per day from age 20 to 40. There is a history of colon cancer in her mother and  lung cancer in a sister.

Physical Examination

• Vitals: BP 155/102, SpO2 93% on room air
• Chest: slightly decreased breath sounds but clear
• Cardiovascular:  regular rhythm without murmur
• Extremities:  no cyanosis, clubbing or edema
• The remainder of the physical examination is normal

What testing would you perform at this time? (Click on the correct answer to proceed to the second of five pages)

1. Chest X-ray
2. Pulmonary function testing
3. Rheumatoid factor
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. April 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(4):129-33. doi: https://doi.org/10.13175/swjpcc040-17 PDF

February 2016 Pulmonary Case of the Month

Ashley Garrett, MD

Karen Swanson, DO

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 77-year-old woman presented with dyspnea on exertion which was progressive for several years.  She remains active but is "winded" with vigorous exercise or altitude. She denied cough, orthopnea , paroxysmal nocturnal dyspnea, chest pain or a prior history of pulmonary infections.  

Past Medical, Social and Family History

She has a history of a seizure disorder and fibromyalgia. She has never smoked or drank and has no history of occupational exposures. There was no family history of respiratory disease.

Physical Examination

Her physical exam was unremarkable.

Current Medications

Topamax and alprazolam.

Radiography

A chest radiograph was performed (Figure 1).

Figure 1. Initial chest radiography.

Which of the following describe the initial chest x-ray? (Click on the correct answer to proceed to the second of five panels)

1. The chest x-ray is normal
2. There is a left lower mass
3. There is bronchial dilatation and edema
4. There is hyperinflation
5. Three is a retrocardiac left lower pneumonia

Cite as: Garrett A, Swanson K. February 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;12(2):34-40. doi: http://dx.doi.org/10.13175/swjpcc012-16 PDF

March 2014 Pulmonary Case of the Month: The Cure May Be Worse Than the Disease

Sudheer Penupolu, MD 

Philip J. Lyng, MD

Lewis J. Wesselius, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 51 year old woman was seen with a chief complaint of gradually increasing shortness of breath. She was at baseline five months prior to presentation but noticed dyspnea on minimal exertion initially at a higher altitude, gradually progressing to dyspnea at rest. She was tried on 2 courses of antibiotics with no significant improvement. In addition to the dyspnea, she has some non productive cough but no fevers.

PMH, SH, FH

She had a renal transplant in 1997 for IgA disease and has a history of type II diabetes and hypertension.

She is a life long nonsmoker and has only occasional alcohol use. She is employed as a utility designer and has no exposure to any dusts, fumes or exotic animals.

Family history is noncontributory.

Medications

• Atenolol
• Lasix
• Prednisone 2 mg q daily
• Rosuvastatin
• Sirolimus 2 mg po q daily

There have been no changes in the doses in the past few years.

Physical Examination

Physical examination reveals no abnormalities and her lung auscultation is clear.

Laboratory

Her complete blood count (CBC), urinanalysis, liver function tests, and calcium were all within normal limits.

Radiology

An x-ray of the chest is shown in Figure 1. 

Figure 1. Initial PA chest radiograph.

Which of the below is the best interpretation of her chest x-ray?

1. Cardiomegaly
2. Left upper lobe consolidation
3. Normal
4. Right upper lobe consolidation
5. All of the above

Reference as: Penupolu S, Lyng PJ, Wesselius LJ. March 2014 pulmonary case of the month: the cure may be worse than the disease. Southwest J Pulm Crit Care. 2014;8(3):142-51. http://dx.doi.org/10.13175/swjpcc005-14 PDF