March 2012 Pulmonary Case of the Month: There’s Air in There

Alexis Christie, MBBS

Lewis J. Wesselius, MD

History of Present Illness

A 40 year old male was seen with a one week history of dyspnea, dry cough, weakness and abdominal pain. He has a history of acute myelogenous leukemia (AML) diagnosed in December, 2010. He underwent consolidation chemotherapy but had a complication of acute lung injury following chemotherapy thought either to be due to infection or ara-C lung toxicity. Bronchoalveolar lavage was negative and video-assisted thoracotomy revealed only organizing pneumonia.

He underwent stem cell transplantation in May 2011 from a hepatitis C +, allogenic bone marrow transplant and received lamivudine post transplant because of the hepatitis C. Unfortunately, bone marrow biopsy in June 2011 revealed recurrent AML He received two cycles of decitabine.

He had further complications of severe graft versus host disease affecting his eyes, mouth and liver and severe, recurrent C. difficile sepsis. Present medications included: co-trimoxazole (Bactrim), lamivudine, acyclovir, posaconazole, tacrolimus, and prednisone.

Physical exam

Physical exam revealed a thin, moderately short of breath man but was otherwise unremarkable.

Radiology

His chest X-ray (Figure 1) and selected images from his CT scan (Figure 2) are shown below:

Figure 1. Chest x-ray.

Figure 2. Thoracic CT scan. Lung windows.

In addition to the confluent areas of airspace and ground glass opacities throughout both lungs what other finding is present?

1. Enlarged mediastinal lymph nodes
2. Pneumothorax
3. Atelectasis of the left lower lobe
4. Pneumomediastinum
5. Large RLL lung mass

Reference as: Christie A, Wesselius LJ. March 2012 pulmonary case of the month: there's air in there. Southwest J Pulm Crit Care 2012;4:88-93. (Click here for a PDF version of the case presentation)