Tuesday, December 20, 2005

Pulmonary infiltrates

This is a 68 y/o man with a very remote TOB Hx (quit >20 years ago) who had an interesting initial presentation of persistent neck adenopathy since 1995. He had had many non-diagnostic biopsies over the years and was treated for toxo. He finally had an excisional Bx of an 8x6 cm neck node and was found to have Hodgkin's. He had mediastinal adenopathy at the time (7/05) and has received 3 cycles of ABVD. He was set up for another cycle in early December but presented to the hospital with worsening dyspnea, cough (non-productive) and fatigue and was found to be hypoxemic. He is not neutropenic but is quite hypoxic and I have posted his CxR and CT chest below.
What is your DDx and what would you do next?

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

Arenberg said...

This looks like a drug reaction to the "B" in ABVD most likely, but could also be eosinophilic pneumonia, HP, or opportunistic infection. A bronch with BAL, cell count/diff, and transbronchial biopsies is what I expect came next.

If the bronch showed no evidence of PCP or pther pathogens, I'd give him prednisone at 1 mg/kg, and base the rate of the taper on whether there was eosinophilia on the BAL. I'd also be VERY worried about giving this guy oxygen at a high FiO2 if this is bleo-toxicity, and about the further use of bleomycin.

Baleeiro said...

This is an ongoing case so I will give you a little update. We had the same concerns described by Doug: we titrated his O2 to keep his Sats 88-90% trying to avoid further oxidative toxicity with the Bleo. He was started on broad-spectrum ABTx including Bactrim and steroids and just had a bronch.
I will post result as they become available.