May 2018 Pulmonary Case of the Month

Kenneth K. Sakata, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 70-year-old man was referred because of new anemia and a heme-positive stool. Esophagogastroduodenoscopy (EGD) was performed which revealed gastritis. Ascites developed and a chest x-ray noted a left pleural effusion. He was managed with weekly high-volume thoracentesis and paracentesis. He was referred to pulmonary medicine.

Past Medical History, Social History and Family History

He has a history of coronary artery disease having undergone coronary bypass grafting in 2016. He also has type 2 diabetes mellitus managed by diet and recently diagnosed orthostasis. He smokes about ½ pack of cigarettes per day but does not drink alcohol. He denies any inhalational exposures. He is Native American and works as a judge. There is no family history of any similar disorders.

Physical Examination

• No acute distress
• Slight bruise to left eye
• No lymphadenopathy
• Decreased breath sounds on left
• Protuberant distended abdomen
• Significant left leg edema
• Discoloration of a few nails

A point of contact ultrasound is performed (Figure 1).

Figure 1. Image from the point of contact ultrasound.

What should be done next? (Click on the correct answer to proceed to the second of seven pages)

1. Needle biopsy of pleural mass
2. Thoracentesis
3. Thoracic surgery consultation for video-assisted thorascopic surgery (VATS)
4. 1 and 3
5. All of the above

Cite as: Sakata KK. May 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(5):237-44. doi: https://doi.org/10.13175/swjpcc059-18 PDF 

January 2017 Pulmonary Case of the Month

Jamie Bering, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

The patient is a 53-year-old woman transferred for acute respiratory failure and hemoptysis. She has a prior history of antiphospholipid syndrome and recurrent diffuse alveolar hemorrhage (DAH). She was admitted to another hospital about 2 weeks prior to transfer with hypoxic respiratory failure which ultimately required intubation. Bronchoscopy revealed a bloody aspirate raising concerns for recurrent DAH. She was started on high-dose solumedrol and extubated after 4 days. One week later, her respiratory status decompensated and her chest x-ray showed worsening diffuse bilateral opacities concerning for recurrent DAH. She was transferred to the Mayo Clinic Arizona for further evaluation. Upon arrival, she required 50% FiO2 by face mask to maintain adequate oxygenation and was started on broad-spectrum antibiotics. Her corticosteroids were tapered to 20 mg prednisone daily.

Past Medical History, Social History and Family History

She has a history of a mitral valve replacement with a St. Jude’s mechanical mitral valve and was on chronic anticoagulation with warfarin. In addition, there was a history of moderate aortic stenosis with moderate aortic insufficiency.

She had a history of diffuse alveolar hemorrhage, antiphospholipid antibody syndrome and possible systemic lupus erythematosus.

Medications

• Dapsone 100mg daily
• Ethacrynic acid 75mg daily
• Gabapentin 900mg QHS
• Lisinopril 20mg daily
• Meropenem 1g Q8 hrs
• Metoprolol 50 mg BID
• Prednisone 20mg daily
• Simvastatin 40mg QHS
• Vancomycin 1.5g Q12 hrs
• Warfarin 4mg T,F; 3mg SMWRSa

Physical Examination

• Vitals: T 36.3^◦ C; HR 79 beats/min; BP 100/63 mm Hg; RR 26 breaths/min; SpO2 99% face mask
• Gen: no acute distress
• HEENT: hematoma on chin
• Lungs: clear to auscultation and percussion
• Cardiac: Mechanical valve click

Laboratory

• CBC: WBC 15,900 cells per microliter (mcL); Hemoglobin 9.1 g/dL; hematocrit 29%; platelet count 156,000 cells per microliter.
• Electrolytes: within normal limits.
• BUN and creatinine: within normal limits.
• Blood sugar: 220 mg/dL.

Radiography

Her initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of four pages)

1. Diffuse lung consolidation
2. Previous median sternotomy
3. Previous mitral valve replacement
4. 1 and 3
5. All of the above

Cite as: Bering J, Wesselius LJ. January 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;14(1):1-5. doi: https://doi.org/10.13175/swjpcc146-16 PDF