Pulmonary
The Southwest Journal of Pulmonary and Critical Care publishes articles broadly related to pulmonary medicine including thoracic surgery, transplantation, airways disease, pediatric pulmonology, anesthesiolgy, pharmacology, nursing and more. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.
December 2024 Pulmonary Case of the Month: Two Birds in the Bush Is Better than One in the Hand
University of Nebraska Medical Center
Omaha, NE USA
History of Present Illness
A 48-year-old man is referred for dyspnea on exertion and a nonproductive cough. He was well until 6 months prior to this visit. He feels he has had “flu-like symptoms” over the past month.
PMH, SH, and FH
He has had intermittent atrial fibrillation controlled by digoxin but also clopidogrel as an anticoagulant. He has symptoms of hay fever and had asthma as a child.
He has never smoked and rarely drinks. Pets include two dogs and a cat. He is a university English literature professor and his office is an old building but the building is clean and well maintained. Hobbies include playing guitar in a rock-n-roll band.
His family history is unremarkable.
Physical Examination
His physical examination including lungs and cardiovascular examination is unremarkable.
Which of the following are indicated for further workup? (Click on the correct answer to be directed to the second of six pages.)
June 2013 Pulmonary Case of the Month: Diagnosis Makes a Difference
Lewis J. Wesselius, MD1
Henry D. Tazelaar, MD2
Departments of Pulmonary Medicine1 and Laboratory Medicine and Pathology2
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 64 year old man from Southern Arizona was referred for a second opinion on a diagnosis of chronic eosinophilic pneumonia that was poorly responsive to corticosteroid therapy. The patient first became ill February 2012 with cough and congestion. His wife was ill at the same time. Both were treated with antibiotics. His wife improved but he never fully recovered with ongoing symptoms of cough and some dyspnea.
He was admitted to another hospital in August 2012 due to worsening shortness of breath and pulmonary infiltrates on chest x-ray. During this admission he underwent bronchoscopy with bronchoalveolar lavage (BAL) that demonstrated 78% eosinophils. A video-assisted thorascopic (VATs) lung biopsy was done and the patient was diagnosed with chronic eosinophilic pneumonia. He was begun on therapy with high dose prednisone (80 mg/day) but had only slight improvement in symptoms.
He was followed by a pulmonologist and continued on prednisone who questioned the possible development of pulmonary fibrosis. Earlier this year he was started on mycophenolate mofetil and the dose was increased to 1000 mg bid while the prednisone was tapered to 5 mg every other day. He was also being treated with fluticasone/salmeterol 250/50 twice a day. The patient continues to have dyspnea with limited activity. His last pulmonary function testing was done in December 2012. At that time his forced vital capacity (FVC) was 51% of predicted and his diffusing capacity for carbon monoxide (DLco) was 40% of predicted.
PMH, SH, FH
He had a history of obstructive sleep apnea (OSA) and had undergone an uvulopharyngoplasty (UPPP). There was also a history of gastroesophageal reflux disease (GERD) and he had a prior Nissen fundoplication. He had a history of osteoarthritis and had undergone a right shoulder replacement.
He had a remote smoking history, a history of modest alcohol use, but no history of using recreational drugs. He worked as an airline pilot.
His present medications included mycophenolate mofetil 1000 mg twice a day, prednisone 5 mg every other day, voriconazole 200 mg daily (started after BAL showed a few colonies of Aspergillus), and fluticasone/salmeterol 250/50 twice a day.
Physical Examination
Blood pressure 134/88 mm Hg. Resting oxygen saturation 96%.
Chest: bibasilar crackles but no wheezes.
Cardiovascular: the heart had a regular rhythm but no murmur.
Extremities: no clubbing or edema.
The remainder of the physical examination was unremarkable.
Chest Radiography
His chest x-ray is shown in figure 1.
Figure 1. Initial chest x-ray.
Which of the following diseases has/have been associated with increased eosinophils in bronchoalveolar lavage fluid?
- Interstitial lung diseases
- Acquired immunodeficiency syndrome (AIDS)-associated pneumonia
- Idiopathic eosinophilic pneumonia
- Drug-induced lung disease
- All of the above
Reference as: Wesselius WJ, Tazelaar HD. June 2013 pulmonary case of the month: diagnosis makes a difference. Southwest J Pulm Crit Care. 2013;6(6):247-54. PDF