tag:blogger.com,1999:blog-12660458.post113986329229831452..comments2023-09-01T10:33:09.297-04:00Comments on Pulmonary Roundtable: 66 year old with shortness of breathUnknownnoreply@blogger.comBlogger3125tag:blogger.com,1999:blog-12660458.post-1140114591212079092006-02-16T13:29:00.000-05:002006-02-16T13:29:00.000-05:00The patient does not speak English so the history ...The patient does not speak English so the history is from the daughter; nonethess, no exposure history could be ascertained; no birds. No unusual hobbies. No occupation. There is no known TB exposures.<BR/>I agree that the most likely diagnoses are HP (despite success in obtaining a positive exposure history) and COP (previously known as idiopathic BOOP).<BR/>The single poorly-formed granuloma seen on tbbx is interesting but I think an open lung will be needed...Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1139937491956205732006-02-14T12:18:00.000-05:002006-02-14T12:18:00.000-05:00Agree with JCH's differential. I would move HP to ...Agree with JCH's differential. <BR/><BR/>I would move HP to the top of my list given the acuity, the lack of a lobar infiltrate and the fine rales.<BR/><BR/>BOOP should give a more lobar infiltrate. <BR/><BR/>Can you give more history on any exposures, funky pets, or work/home environment?<BR/><BR/>Other studies I would get would be:<BR/>ESR, CRP, RF, ANA, hypersenstivity pneumonitis panel and bilateral knee films.<BR/><BR/>Unless something jumps out at you on these studies, I would get a SLB.Mike Lhttps://www.blogger.com/profile/12177750268091750583noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1139924581132453712006-02-14T08:43:00.000-05:002006-02-14T08:43:00.000-05:00There is a moderately severe restrictive ventilato...There is a moderately severe restrictive ventilatory defect and impaired gas exchange. The CXR shows a diffuse bilater reticulonodular pattern with some areas of focal increased opacity.<BR/><BR/>The CT scan shows diffuse, patchy, bilateral, upper and lower lobe ground glass opacities. There are no soft-tissue windows included, so I'm not sure about lymph nodes. There do seem to be some abnormalities in the pre-vascular, A-P window, and pre-tracheal regions; so if these are nodes, they are calcified.<BR/><BR/>In the differential, I would consider BOOP/COP, idiopathic interstitial pneumonias (not typical for IPF, lack of smoking history makes DIP/RBILD unlikely, AIP is possible, especially in light of the acuity, but rare, and NSIP remains a possibility although the onset would be rapid). <BR/><BR/>I agree that we need to consider granulomatous disease: the distribution is not typical for sarcoid or HP, althoug acute HP could have this presentation. Endemic fungi and TB are also in the realm of possibility. <BR/><BR/>Other bacterial infections are possible, but would not explain the restriction.<BR/><BR/>Malignancy- BAC in particular, could look like this, but again, the acuity would be very atypical.<BR/><BR/>My best guess(es) at this point: 1) BOOP, 2) Acute HP, 3) Infection<BR/><BR/>Regardless, I would proceed with bronchoscopy (with BAL and TBBx primarily to evaluate for infection), and then a surgical lung biopsy.Jeff Hhttps://www.blogger.com/profile/01209432708535732499noreply@blogger.com