Tuesday, November 15, 2005

2 weeks of dyspnea

Carlos' case:
We were consulted on this is a 28 y/o man with no previous PMHx who presented to the ER with progressive worsening DOE over the past 2-3 weeks with some dry cough. Occasional chills but no fevers or night sweats. In the ER he was febrile and hypoxic (7.47/33/58) and was admitted for further care.

PMHx: No lung Dz.

SHx: Occasional ETOH, TOB 1ppd x 10 years, no occupational exposures, no IVDA, lives with same-sex partner.

On exam, AAOx3 in minimal resp discomfort. Clear lungs B/L. S1/S2 RRR and benign abdomen.

CxR:


The ER did a CT-angio (on everybody), which showed no PE but the following changes:


What is your DDx and what would you do next?

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

Mendez said...

Well the CT certainly looks like diffuse yet patchy GGO. Maybe even crazy paving. This finding is often linked with Pulm Alveolar Proteinosis. However, it is definitely not a specific finding and can be found in many other disease processes.
With these findings and symptoms of subacute dyspnea the differential is still quite broad. Since he was febrile, I would consider infectious etiologies first:
Atypical PNAs including viral
PCP
less likely fungal

non-infectious:
HP
RBILD or DIP
PAP
Connective tissue disease
CHF

Given the lack of other symptoms and the subacute nature of his dyspnea I would put infectious causes at the top of my list followed by the smoking related diseases (RBILD, PAP). There doesn't seem to be anything the Hx to go for HP but I would delve further into hobbies and pets. W/o more convincing labs or physical exam connective tissue ds possibilities seem less likely.

In terms of what to do next:
Besides the regular panel of labs (CBC, comp) - I think blood cultures in ED would be useful. HIV status as well (PCP). Ultimately, I would want a bronch w/ particular interest in the nature of the BAL return (?DAH or PAP), cytology and cultures of BAL as well cell count and diff.

Jeff H said...

I think Mendez has hit this one on the head. Only things I'd add at this point: sputum for PCP, and a UA to look for red-cell casts. My top two on the differential for this CT are PCP (although I don't see any cystic lesions), and acute HP (unclear exposure history).

Arenberg said...

I agree with what's been stated so far, but you have to add rrug reactions to this list as well. Sub-acute HP and non-cardiogenic pulmonary edema are common drug toxicities in the lungs and can be cuased by lots of different agents.

I'd want to see a list of the medications (prescriptionor not) this person has taken.

Arenberg said...

If I could tpye I'd be dangerous.

I meant DRUG reactions...not rrug.