Saturday, July 09, 2005

Ground glass?

Here is a case by Dan:

54 Y/O Male Karate instructor h/o epislepsy s/p closed head injury, depression, GERD and BPH presented w/ approximately 1-1.5 yr. h/o dyspnea w/ worsening over the past 6
months. Sx. tend to wax and wane. States that becomes SOB after walking approximately 200 ft. Also becomes quite dyspneic with stairs. Gave up martial arts 8 months ago due to dyspnea. Denies cough, occasional sputum and no hemoptysis. Denies fevers/chills/sweats, rash, joint pains/stiffness. Recent travel only to China approximately 1.5 yrs ago. Has had a recent negative HIV test. Denies unintentional wt. loss. Denies new drugs or exposures. Recent normal nuclear stress test.
ROS: occ. HA, h/o migraine, waxing and waning of GERD symptoms, denies aspiration
naproxen (5 pills q week)
asa 81 (which he has been non-compliant w/)
viagra prn
Soc hx: former karate instructor, on disability for closed head injury.
No tobacco, etoh, ivda. Lives on 10 acres in Howell, MI, no farm animals, has a dog. No gardening or working in soil. No exposures w/ hobbies.

Fam hx: mom copd, heavy smoker, father- adult onset DM
PE: 124/73, 87, 93% RA
No abnormal findings on focused exam.
LABS:Normal CBC, chem 10
CT Thorax: Diffuse mosaic ground glass sparing only a portion of the right middle lobe. No LAD, no effusions. No real difference on inspiratory/expiratory/prone cuts. Click to enlarge:

FEV1: 3.33 (80%)FVC: 3.96 (78%)TLC 89% DLCO 64%

HP and fungal panels (-)

Bronch: Cell count 150 WBC 36% lymphs 8% PMN 40% histiocytes CD4/CD8 ratio 1.7 AFB/fungal/bacterial smears/cultures (-)
TBBx: focal interstitial fibrosis, collections of alveolar macrophages and chronic inflammation. No malignancy. Negative for proteinaceous alveolar deposits.

What is your DDx and how would you proceed?

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

Jennings said...

Well, here are ome things I can think of that cause GG:
1. DIP - need open lung to confrm; he's not a smoker so maybe less likely.
2. Hypersensitivity pneumonitis - is there a correlation between any of the medications he's taking and the onset of the dyspnea? No inhalational agents are obvious from your post.
3. CHF/pulmonary edema - does he have an echo?

I would get an echo, get the medication onset history, and get an open lung. Also, some connective tissue disease can give GG/pneumonitis - like SLE; so maybe n autoimmune panel with an ANA would be helpful...

Jeff H said...

In addition to jennings comments:

Is he air trapping? Similar to DIP, RB-ILD is not likely as he is not smoking.

The BAL lymphocytosis can occur in NSIP, along with scleroderma and other collagen-vascular associated ILD's. BOOP is also a possibility.

I agree that the patient needs a surgical lung biopsy.

DKeena said...

He had an echo which was normal. ESR was 40, ANA, RF (-). There wasn't any correlation between his meds and the onset of symptoms. There was no clear evidence of air trapping on expiratory cuts of his HRCT.

We had initially considered PAP also (unlikely in a non-smoker as well), but his relatively clear BAL pretty much excluded that.

He had a surgical lung biopsy and I'll post the results tomorrow.