Friday, July 22, 2005

Cough and dense infiltrates

53 Y/O F with no significant PMHx presented to her PCP 8 weeks ago with nasal congestion, post nasal drip, dry cough and low grade fevers. Her symptoms persisted and she was treated with a course of azithromycin with no improvement followed by a course of levofloxacin. Her cough gradually worsened and remained dry, and her fevers continued with temps to 101 F at home. 2 weeks ago she developed dyspnea on exertion with climbing 1 flight of stairs. No other associated symptoms including rash, arthralgia, chest pain, LE edema, neurologic Sx.
No Pets, no significant exposures, no HIV risk factors, no recent travel outside US, no sick contacts, no weight loss. Prior to 8 weeks ago she was asymptomatic and ran 4-5 miles 3X/week.

Meds: levofloxacin, codeine cough syrup

PMH: breast augmentation

SH: Married, lives in Michigan, college math professor, lifelong non-smoker, athletic, no other hobbies, no TB exposure, negative PPD 6 mos ago

PE VSS, scattered crackles and wheezes, prolonged exp phase on lung exam,
exam o/w normal.

CXR: multifocal infiltrates.

PFT: FEV1 1.86 (72%), FVC 2.53 (74%), FEV1/FVC ratio 97%, and room air saturation 96%.

Chest CT below (click to enlarge): no LAD noted on soft tissue windows




What do you think the DDx is and how would you proceed.

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

Jennings said...

My first on the list would be BOOP. Also, AIP would be a consideration. The 10 week gradual worsening would make bacterial pneumonia less likely, espeially with the lack of responce to abx. Sometimes bronchoalveolar carcinoma can present this fast. I suppose one would have to also consider lymphoma. I would start with bronch with BAL and tbbx, but I suspect she will need an open lung biopsy.

Mendez said...

Agree. Also, there does appear to be significant subcarinal fullness adenopathy.

What do her PFTs look like? I'd like to know about DL and volumes.

I'd throw sarcoid into the mix.
Agree with bronch - for diff, Cultures. Also Wang, TBBX looking for granulomas.

Jeff H said...

Agree: BOOP seems most likely. BAC is also a good thought. Given the upper respiratory/sinus presentation first, I'll throw WG into the mix, althoug I admit this is less likely.

Agree: bronch, tbbx/cultures/cytology. Get an ANCA. Then surgical biopsy.