Steroid responsive adenopathy?

65-year-old woman presented initially for evaluation of shortness of breath. A CT thorax revealed some patchy airspace opacification RUL (see below) . She underwent bronchoscopic evaluation and it demonstrated some interstitial inflammation with hyperplastic type 2 pneumoctyes. No granulomas seen. No fungal or AFB elements on BAL. A cell count was not sent.
She was begun on a course of steroids 40mg and felt her breathing improved significantly while on them, but once she stopped them, her shortness of breath recurred. Her cough has also recurred, though it's mostly non-productive. A CT was repeated 5 monts later and is shown below.



Question: What ILD had adenopathy and is steroid responsive? The only 2 I can think of are sarcoid and berrylliosis, but the interstial inflammation would be inconsistent with that. Any thoughts out there?

Low DLCO

Here is a submission from John B: It is interesting that it is close to the very first post of this blog.

I continually test a low (60% I think) DLCO on a PFT. All other parts of that test are normal.
I have dizziness, lightheadedness, sob (random- at rest or exertion). Palpitations at times, but not nearly as often as in the past.
Occasional feeling of pressure in chest. Echo was normal, but imo it looks like values have been increasing over the past 2 years- still in normal ranges, but I do show some trace/mild tricuspid regurg and trace mitral regurg.
Two times I have done a cardiopulmonary stress test, and both times it shows a cardiovascular limitation evidenced by crossing of the anaerobic threshold earlier than I should- metabolic acidosis after exertion.
Nuclear stress test shows no blockages.
Also, my own testing with a pulse oximeter seems to indicate occasional drops in my O2 to as low as 92, but then quickly recovering to 96-98. This has never happened in doctor's office with their oximeters, so I don't know if mine is accurate (however, when testing my wife as a control subject, she always shows 96-98).

high-res CT scan of chest - normal (6 months ago)
non-invasive ct angiography (body scan) - normal lungs / lung blood vessels (1+ year ago)
- calcium score was 0 (2 years ago)

multiple echocardiograms are in normal range but show trace / mild regurgitation
- cardiopulmonary stress test shows a cardiovascular limitation evidenced by a metabolic acidosis at peak exercise
- low DLCO (+-60% of predicted - 1 month ago)
- nuclear stress test shows no blockages (1.5 years ago)
- triglycerides 270 - vldl 56 - ldl 240 - hdl 36)
- lyme disease- treated with abx in past

No one knows what to make of this. I was thinking of requesting a stress echo, to see if there is more regurgitation after exercise.
Any other tests I should have done? Would really appreciate some assistance. I can provide more specific data if needed.

-John

Portable oxygen concentrators

One of my COPD patients was asking me about purchasing a portable/travel concentrator such as this one.
Have you had much experience or feedback with portable oxygen concentrators?

Isolated DLCO

I'll start it off with a patient referred to me for dyspnea with an isolated DLCO. Leave any comments about what you might do next or other suggestions/questions. Not all of the ones you all present have to be this long.

50-year-old woman with a history of arthritis (rheumatoid factor negative in 2001) who had bilateral hip replacement (right hip in December and left hip in February 2005). Last month, one month postop, the patient noticed that she was out of breath while walking from the parking space to the local store. No CP. Since that time, she has had dyspnea on exertion with just minimal exertion such as walking from room to room. She denies any dyspnea at rest or other triggers, although on that first episode described above the air was more cold. The patient denies any acute chest pain, cough, fevers, chills, night sweats, or other constitutional symptoms. The shortness of breath is relieved with rest. She went to a local Emergency Room for this dyspnea and the workup revealed a normal BNP, negative lower extremity Dopplers, an EKG with normal sinus rhythm and a VQ scan that was read as "normal appearing." A confirmatory PE-protocol CT was not done, perhaps because she had a history of getting nauseous from the dye. Other workup included a spirometry with evidence of abnormal DLCO. Of note also, the patient did have some postop anemia, but this has been treated with iron.
PAST MEDICAL HISTORY: Arthritis, depression.
MEDICATIONS: Effexor, Xanax, and iron.
SOCIAL : ex-smoker. She did smoke half a pack a day, quit in 1999. The smoking was intermittent. Occupation is a lawyer. No known occupational exposures.

FAMILY HISTORY: Father has emphysema (smoker)

Exam: VSS Weight 145 lb Lungs: CTA. Cor: normal. Ext no edema.

Labs: Hct 40.
ABG 7.47/28/113 on RA. carboxyhemoglobin not high.
Lactate was 7.1 but this must be an error.
PFTs: everything is normal (including RV, TLC, IVC). DLCO is 61% predicted. corrected to VA (if you beleive in that) makes it still low at 68% predicted.

HRCT: No evidence of ILD. radiologist called masaic pattern on expiratory LLL but the call is soft.
PE-protocal CT was negative for embolus.
Echo showed PAP of 25 with normal vnetrical and atrium size.

Exercise test was order and not done yet.

Here is the HRCT with the possible mosaic.


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-Jeff