Thursday, September 01, 2005

Recurrent pneumonias

Mrs S. is a 72-year-old female with a history of asthma,mitral valve prolapse, and positive PPD (treated with INH), and diabetes. She has a history of longstanding asthma which has been well controlled with long-acting bronchodilators and inhaled corticosteroids. In 2000, she was found to have interstitial infiltrates on CXR and CT and was seen by a pulmonologist, who thought the abnormalities were either due to old granulomatous disease or possibly an idiopathic interstitial pneumonia. Pulmonary function studies at that time (June 2000): FEV1 1.48 (59%),FEC 2.15 (69%), TLC 4.98 (95%), and DLCO 19.1 (95%). She was also found to have a significant bronchodilator response with 12% improvement in her FEV1.

In January 2005, she developed worsening symptoms of chronic cough and dyspnea. She was hospitalized 3 times over the next 6 months for “pneumonia” and treated with several courses of antibiotics, steroids and a 1 month prednisone taper without significant improvement.

She was referred for evaluation of recurrent pneumonias. At her visit in 6/05 she reported a persistent dry cough and DOE walking 100 feet. She denies any rheumatologic Sx, purulent sputum, exposures. She had been off oral steroids for 4-5 weeks.
She has also lost 15 pounds since January 05.

PMHx: asthma, DM, MVP, +PPD Rx 9 mos INH

Meds: Cardizem, Lipitor, aspirin, Singulair, Flovent 2 puffs b.i.d., Serevent 1 puff b.i.d., Fosamax, and Allegra.

Social history: married and lives in the metro area. She is lifelong nonsmoker. Denies any significant use ofalcohol. She denies any pulmonary exposures or travel outside the United States.

FH: (-)

Exam: Normal

PFT: FEV1: 1.43 (69%)FVC 2.06 (71%)FEV1/FVC 98%TLC 4.38 (96%)DLCO 13.2 (64%)

CXR: see below

Outside PE-CT scan (3/05): No evidence of pulmonary thromboembolic disease. There was diffuse, but basilar predominant, interstitial and airspace disease with associated pleural thickening and mild bronchiectasis.

Bronch: Normal airways, bacterial GS/culture (-), fungal/AFB smears (-) cultures pending, cell count 480 wbc (68%N 10%L 0%E) rbc 150Cyto: (-)TBBx Right lower lobe of lung: Fragments of alveolar parenchyma with mild interstitial fibrosis. No granulomas. No virocytes. No evidence of malignancy. Abnormal, non-diagnostic biopsy.

A surgical lung biopsy would be risky given her age and functional status...
What do you think she has and how would you proceed at this point?

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

krayem said...

couple questions here:
how does this CXR compare to the one from 2000? is this similar, or very different?
occupational history? asbestos exposure (herself or her husband)? family hisory of IIP?
it seems her symptoms are worse than her PFT numbers. FEV1 and FVC have remained stable over 5 years, there is some decline in TLC, and mostly in DLCO....
it looks like a case of IIP, as was suspected in 2000. typically IPF should have progressed faster, unless there is a secondary cause.
I would start with getting a HRCT and serologic studies (ANA, RhF, anti SCL70.......). I also would get a 2 D echo with attention to the PA pressures (what if this DLCO decline is from a secondary Pulmonary hypertension???).
possibilities here are many, and with HRCT we may be able to shorten the list. I also think that a biopsy can still be obtained by VATS with a reasonable risk, however I would start with HRCT and proceed according to the findings.

Mike L said...

Nice discussion by Krayem.
I think that I agree with almost every point. Her diff dx is essentially tied up in an isolated DLCO abnormality from 2000 to the present (pulm htn, ILD, COPD).
Do her CXR's on admission for "pneumonia" actually show infiltrates? If so, BOOP should be considered in the diff dx.
I would also get a HRCT (having either Dr. Gross or Kazarooni read it) and an echo. The lack of steroid responsiveness is somewhat concerning for a bad IIP.
If these studies do not give you anything a VATS and SLB would be my next step.

Jennings said...

I also agree with Krayem (but since he was my fellow last year I have to take *some* credit for his ddx, right?).
Another thing to consider might be a chronic eosinophilic pneumonia. Also, is there anything on exposure history to suggest a chronic hypersensitivity pneumonitis?