Monday, June 20, 2005

Pleuritic pain and Fatigue

39-year-old woman with chief complaint of fatigue and pleurisy.

No major medical history except the following:

3 months ago had R. sinus infxn treated with Augmentin but persisted and was started on Azithromycin b/c of persistent symptoms.

She presented to ED shortly thereafter with R. flank pain, nausea, vomiting and pleuritic chest pain. She had some cough streaked with blood. A CT Abd demonstrated multiple punctate caliceal stones and patchy air space opacities in the lower lobes noted on the higher cuts.

Since her visit to the ED, she has had continued pleuritic chest pain R>L. She also feels more fatigue doing her regular work.

Other Hx Asthma for last 4-5 years. Dx based upon peak flows no PFTs. Allergies. She has a 7-year history of smoking, but quit over 15 years ago. Two years ago, she owned several parakeets, but they resulted in allergies in her children and therefore she removed the animals from her home.

Family history Notable for ulcerative colitis in her father, renal calculi inher sister. The patient has been found to have increased urinary calcium on recent studies reportedly.

Medications Flovent 110 two puffs a day, albuterolor Maxair, which she uses less than once a month.

Patient brought in follow up CT chest from OSH.

Posted by Hello

Physical exam Athletic, slim, woman appearing younger than stated age in no acute distress. Weight 136 pounds, blood pressure 118/64, pulse 84, and respirations 16. Exam is unremarkable.

Data PPD (-) PFTs: Nl mechanics, volumes, gas exchange.

What do you think of the CT? What's your differential? What would you do next?

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

Jennings said...

A few thoughts,all of which may but wrong but I'll give it a go.
First, The previous diagnosis of asthma might suggest that someone in the past heard wheezing on exam. I point this out in the present patient because it might point to small airway involvment. The CT on first glance looks like multpile tiny nodules right > left; however it looks more like small airway filling of mucous plugging, with some areas looking like tree in bud pattern. She also seems to have some central bronchiectasis. With these three things - wheezing in the past, small airway mucous plugging, and central bronchiectasis, I would think the differential should include causes of bronchiectasis such as APBA or ABPM, cystic fibrosis (since she's relatively young) hypogammglobulinemia, etc.

The tree in bud pattern would also suggest other infections such as MAI or other atypical mycobacteria.

I would bronch, sending BAL for infection, cell count with diff. The the serum IgE, peripheral eosinohilia.

The pleurisy might also suggest an autoimmune condition such as lupus but I don't know how to put this with the other CT findings. ALso, you didnt include a soft tissue cut so I don't know if there is small pleural effusions.
Also, in the context of the differential Dx above, was she short of breath at all?

Baleeiro said...

Jennings has made several good points. One of the main clinical questions is whether she indeed had asthma and now has a new process or whether she was misdiagnosed with "asthma" and her underlying process has now blossomed.
She has tiny pulmonary nodules well described by Jennings. On the first slice I can see some of nodules aligned along the bronchovascular bundle, placing sarcoid high on my differential. It could account for her hypercalcemia, wheezing and other respiratory symptoms.

Baleeiro said...

However, with sarcoid I would expect to see more subpleural nodules as well. Either my eyes or the resolution of the post are not letting me see much of that (though sarcoid still a consideration).
That bronchovascular distribution is also concerning for lymphangitic spread of carcinoma (cervical Ca would be the one in someone so young) though it seems awfully asymmetric.
Jennings has also listed infectious etiologies and I will add disseminated (miliary) fungal infections such as Hysto (fairly prevalent up in MI).

Baleeiro said...

RB-ILD can have these fuzzy nodules pointing to small airway involvement but would be unusual since she quit smoking so many years ago.

Jeff H said...

I'd add the possibility of Churg-Strauss with all of the other things mentioned.

ABetens said...

The micronodules/tree-in-bud pattern suggest small airway disease/bronchiolitis. Jennings' differential is pretty good - nontuberculous mycobacteria (could also be TB), cystic fibrosis, or mucus plugging from asthma/ABPA. I would definitely add mycoplasma and viral infections to the list as these would be most common in a younger adult. Mycoplasma has not had much published with regards to this presentation, but it probably is underdiagnosed as most do not get a CT when presenting with this infection.

Mendez said...

Great comments. The history may be a bit of a distractor here. This Dx was based upon a peak flow and limited other hx. No previous spiro had been performed until this evaluation. She did not report dyspnea.

The CT don't reproduce as well so it is difficult to interpret, but Baleeiro correctly pointed out the most prominent finding of nodules in a bronchovascular distribution. There were no pleural effusions on the lower cuts.

A diagnostic procedure was performed the results of which I will post later in the day.

Tom said...

I agree with Jeff Jennings about the CT and differential diagnosis(surprisingly). This CT suggests bronchiectasis. Cystic Fibrosis is possible but unlikely based on the distribution of abnormalities. Otherwise I like is differential. Before bronch I would try hard to obtain sputum for bacteria and mycobacterial. An ABPA workup is also reasonable.

Anonymous said...

Well? How did it turn out?

Mendez said...

Sorry I missed the f/u. Transbronchial bx's revealed multiple epithelioid granulomas. Special stains for AFB and fungi were negative.

Symptoms improved after treatment with oral prednisone which was tapered over several months.

F/U Chest CT (6 months later) revealed interval regression of peribronchovascular nodularity. Previously enlarged hilar/mediastinal lymph nodes no longer enlarged.

Final Dx: Stage II Sarcoid

Jennings said...

Fllow-up can be found here:

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