Tuesday, July 05, 2005

Cough and abnormal CT

I think we can handle 2 posts on the same day, given that they are both short. Plus, I do want to get your thoughts on what you would do with this patient.

56 y/o AA man with no Pmhx. In January he developed the flu and since then has chronic cough, scant white and now yellow sputum. More recently also with some nasal congestion with post nasal drip. He saw a PCP who got PFT's that showed mild obstruction (normal DLCO) and gave him albuterol, doxy and prednisone which made him feel somewhat better. On social, minimal smoking - 12 pack-yrs, quit 9 years ago. Nothing occupationally. Labs showed WBC 5 with 39% N, 36% L and 19% eos.
CXR here:

The HRCT was normal except for some bilateral upper lobe ground glass:

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

Baleeiro said...

A couple thoughts come to mind. He may have had a true lower resp tract infection, had some post-infectious bronchospasm with airway inflammation and persistent symptoms with post-nasal drip. This gets a little more complicated because he came to you after some prednisone and that may have helped with the bronchospasm/airway inflammation.
ICS may help with symptom relief.
However, he has 19% Eos and maybe he had acute eosinophilic penumonia (GGOs, acute febrile illness, short course, some response to prednisone) and you are not getting a more full-blown picture because of the previous steroid Tx.
Perhaps obtaining an IgE level and a F/up CBC will help.

Jennings said...

I literally had the same thoughts as you mentioned and did everything you said: ICS, IgE level and follow up repeat CBC/diff. The only other thing in a guy with eosinophils - IF they were in the lung, maybe churgg-straus although I do realize he hasnt had long standing asthma and he has no skin problems. Maybe, therefore, getting a p-anca would not be helpful....
Would you repeat a CT on return visit (if he's still symptomatic) and then brinch him if still gnd glass?

Mendez said...

Baw, baw, baw. Couldn't this just be regular old post bronchitic asthma with some Eos? Were the Eos high on presentation, or is the 19% after prednisone?

Jennings said...

Baw, you're like Hemmingway; simple yet poignant. True that's all it could be. The interventions currently include a bit of ICS, a skin test and a touch of IgE. I will then get spiro and return and see how he's doing.
You thus, in the end, are lilely correct.

Jennings said...

BTW, he had a 5-day course of steroids last month or so. A month later, the eos with CBC was done and that is the 19%. No other CBC's with diff were done.