Tuesday, May 17, 2005

Recalcitrant cough and bronchiectasis

This is a patient from Friday clinic that I've been following for the last year. I'll present the patient's first presenation to our clinic in order to get your initial diff Dx. I'll give you the ensuing follow-up and tests after I've heard from you.

74-year-old never smoking woman referred from OSH for 6 month history of productive cough. Her other history is significant for chronic sinusitis,hypertension, and lower extremity edema.

Six months ago she noted increasing cough that was productive of gray to yellow sputum. Since that time, she has had several short hospitalizations receiving steroids and antibiotics with short lived improvement. Medication regimen includes albuterol, atrovent Neb and Advair with minimal subjective response.

No previous history of asthma.

PE protocol CT performed at OSH 6 months ago revealed central bronchiectasis and patchy peripheral GGO without filling defects. LE dopplers neg. Echo nl.
BAL was peformed 3 months ago at OSH and was negative for pathogens(AFB, fungal) ; cytology neg. Pertinent labs from that time: cANCA, ANA (-); positive pANCA; normal levels of gamma globulins, and RF of 55(nl <25).

She presents to our office for further evaluation. Her cough is still present and continuous. She sleeps poorly and is fed up. We observed frequent coughing fits productive of yellow-green sputum.
She has had weight loss of almonst 20# in last 6 months. No fevers, chills, hemoptysis. No sick contacts, pets, or recent travel.

Medications:
Norvasc, Aldactone, Actonel, Nexium, aspirin.

Social History:
Retired. Worked as surgical technician. Never smoker. Previously PPD neg.

Exam:
Afebrile, normotensive, normoxic.
Diffuse bilateral wheezes.
Normal strength.
No rashes.

Spirometry Results:
FEV1 of 1.57 (71%), FVC 3 L (96%), FEV1/FVCof 52%/71% (74%). Fev1 3 months ago was 2.38 L. Recent OSH labs: CBC and diff. wnl, ESR nl.
CT described above.

What's your differential? Other tests?

9 comments - CLICK HERE to read & add your own!:

Baleeiro said...

Was a biopsy performed at time of bronch? Do we have a CBC with diff? How about some ABPA tests (IgE, preciptins, etc)?

Mendez said...

Only a BAL was performed on the initial bronch - no diff unfortunately. Didn't have a CBC from that bronch, but cbc performed prior to that clinic visit had normal diff.

Mike L said...

Any significant exposures prior to the onset (RADS risk factors?)

Baleeiro said...

With the central bronchiectasis, ABPA would be a good possibility. Collagen-vascular Dz may cause bronchiectasis as a prominent manifestation (Sjogren's, RA) but it seems she has negative serologies. No reason to suspect congenital causes (CF, Young's, cilia dismotility) at her age. Non-smokers may have bronchoalveolar Ca with some bronchorrhea and bronchiectasis.
Amyloid can be associated with parenchymal and airway dz (any chronic dz as cause for secondary amyloid?)

Jennings said...

So the BAL did not have eosinophils? I agree about the ABPA but would say ABPM instead because another fungus can do it. I would like to know the IgE and cbc with diff (off steroids). A skin test would be in the cards if the above stuff pans out as well.

P-anca is nonspecific I realize and lack of previous asthma symtpoms make churg-straus less likely - also with lack of skin or other organs involvement and the presence of central bronchiectasis, we can prob. rule this one out - but i would like to know the BAL cell count nonetheless.

Jeff H said...

Agree with getting a serum IgE, and the possibilities already mentioned, especially ABPA/ABPM. The peripheral ground glass, though, is very atypical for all of these obstructive diseases, although I guess Churg-strauss with associated DAH can do it.

Some zebra's include an atypical presentation of BOOP, or even rarer a case of idiopathic obliterative bronchiolitis.

I'd proceed with, in addition to the serologies mentioned, an ENT evaluation for sinus cultures/drainage and possibly biopsies. If that is non-diagnostic, I'd proceed to VATS.

DKeena said...

I like ABPM based on the story so far, but idiopathic bronchiectasis with exacerbation is more likely.
Was there any objective improvment documented with steroids? The culture sensitivity for MAC and friends even on BAL is not perfect so still a possibility. The normal sed rate makes rheumatic dz unlikely.

Repeat sputum cultures?Quantitative immunoglobulins? DLCO?

Jennings said...

Comments closed. See for follow-up comments on the case.

Jennings said...

http://pulmonaryroundtable.blogspot.com/2005/05/recalcitrant-cough-and-bronchiectasis_18.html