No othe significant PMHx or exposures.
Her exam reveals decreased BS on the L with faint crackles and her CxR is seen below:
What would you do next?
Monday, October 31, 2005
Abnormal CxR
We were asked to see this 74 y/o woman for dyspnea and atypical chest pain. She has a long TOB Hx (>50 p/y) and continues to smoke. Last year she had a "lump" in her neck (it was benign) and had an unremarkable neck and chest CT scan. For the past 2 weeks she has had worsening dyspnea and a cough productive of blood-streaked clear sputum.
No othe significant PMHx or exposures.
Her exam reveals decreased BS on the L with faint crackles and her CxR is seen below:
No othe significant PMHx or exposures.
Her exam reveals decreased BS on the L with faint crackles and her CxR is seen below:
Drop in ETCO2
This was an interesting consult: 75 y/o woman with depression (lost her husband a month ago) and chronic back pain came in for an elective laminectomy. She received rapid induction with Propofol and succinylcholine and was intubated rapidly. She then had sudden bradycardia and hypotension with hypoxemia and her continuous end-tidal CO2 indicator dropped precipitously.
They cancelled the surgery and gave her dopamine and fluids. She had a rebound tachycardia with dopa, was given neosyn. and cardiology and I were consulted.
What other info would you want?
They cancelled the surgery and gave her dopamine and fluids. She had a rebound tachycardia with dopa, was given neosyn. and cardiology and I were consulted.
What other info would you want?
Update on Picture Friday case
This is the 65 y/o man with FUO and palmar and plantar lesions.
Since the post his temperature curve has come down nicely on ceftriaxone and doxy. He still has the skin lesions and blood Cxs (after 7 days incubation) are still negative. He is having a TEE today and RMSF and Coxiella serologies are pendng. His RF was negative but he had a +ANA with +Anti-RNP (Anti-DS-DNA, Anti SSA and SSB and other SLE markers are negative) and his CRP has come down from 30s to 20. Any other ideas?
Since the post his temperature curve has come down nicely on ceftriaxone and doxy. He still has the skin lesions and blood Cxs (after 7 days incubation) are still negative. He is having a TEE today and RMSF and Coxiella serologies are pendng. His RF was negative but he had a +ANA with +Anti-RNP (Anti-DS-DNA, Anti SSA and SSB and other SLE markers are negative) and his CRP has come down from 30s to 20. Any other ideas?
Friday, October 28, 2005
Pulmonary infiltrates from etanercept
So to make a complicated story more complicated- when I spoke to our pathologist about the biopsy results he said "I never seen anything quite like this in my career." A prominent lung pathologist from another institution was in agreement.
I've posted their description of the findings below:
Lung, right, middle lobe, wedge biopsy:
Chronic interstitial pneumonia and patchy interstitial fibrosis; chronic active bronchiolitis with focal proliferative-type bronchiolitis obliterans and organizing pneumonia pattern; focally necrotic granulomatous inflammation.
A constellation of pathologic findings are present in this case. The alveolar parenchyma manifests chronic inflammatory cell infiltrates as well as patchy
fibrosis. Lymphoid aggregates are present, and many of the interstitial cells are plasma cells. Superimposed on this picture are numerous granulomas, some of which show focal necrosis and acute inflammation. A few of the granulomas appear bronchiolocentric. Rare bronchioles contain intraluminal foci of granulation tissue. Special stains are negative acid-fast bacilli and fungi.
The background interstitial inflammation and fibrosis may be related to the patient's rheumatoid arthritis.
A recent publication (Modern Pathology 2005 18:651) describes a series of patients who developed persistent pulmonary infiltrates and granulomatous inflammation associated with etanercept use. The histopathologic changes noted in those patients was similar to what my patient had; here is a pic:
In that series, all of the patients improved with a combination of immunosuppressive therapy and discontinuing etanercept.
This patient has clinically stabilized but has been slow to improve.
Posted by Jennings for Dan.
I've posted their description of the findings below:
Lung, right, middle lobe, wedge biopsy:
Chronic interstitial pneumonia and patchy interstitial fibrosis; chronic active bronchiolitis with focal proliferative-type bronchiolitis obliterans and organizing pneumonia pattern; focally necrotic granulomatous inflammation.
A constellation of pathologic findings are present in this case. The alveolar parenchyma manifests chronic inflammatory cell infiltrates as well as patchy
fibrosis. Lymphoid aggregates are present, and many of the interstitial cells are plasma cells. Superimposed on this picture are numerous granulomas, some of which show focal necrosis and acute inflammation. A few of the granulomas appear bronchiolocentric. Rare bronchioles contain intraluminal foci of granulation tissue. Special stains are negative acid-fast bacilli and fungi.
The background interstitial inflammation and fibrosis may be related to the patient's rheumatoid arthritis.
A recent publication (Modern Pathology 2005 18:651) describes a series of patients who developed persistent pulmonary infiltrates and granulomatous inflammation associated with etanercept use. The histopathologic changes noted in those patients was similar to what my patient had; here is a pic:
In that series, all of the patients improved with a combination of immunosuppressive therapy and discontinuing etanercept.
This patient has clinically stabilized but has been slow to improve.
Posted by Jennings for Dan.
Thursday, October 27, 2005
Picture Friday
We were asked to see this patient with FUO. This is a 65 y/o man with CHF (EF~25-30%) with 6 weeks of daily fevers, now with arthralgias. He has been admitted twice with multiple negative Cxs and no diagnosis yet.
He has clear lungs, no arthritis (just arthralgias) and the following findings on hands and feet:
He has clear lungs, no arthritis (just arthralgias) and the following findings on hands and feet:
Wednesday, October 26, 2005
Radiograph of the day
87 year old man with no PMH presented to his PCP with mild SOB. No cough. No constitutional symptoms. He is a non-smoker.
The CXR is shown:
Answer below with discussion.
The CXR is shown:
Answer below with discussion.
Tuesday, October 25, 2005
Fever and chest pain post-EGD
This is my Wednesday case; feel free to email the posting schedule, however.
35 yo female post-partum x 7 weeks (healthy newborn girl; no complications with pregnancy or with birth) with no PMH presented with the sensation of food getting caught in her throat after eating a large steak meal.
EGD was performed with foodstuff visualized in the proximal esophagus. It was pushed successfully into the stomach.
Post-procedure, the patient had onset of fever (38.5) on one occassion and mild chest pain that resolved without intervention.
Her WBC count was normal and did not change throughout her hospital course.
A CT chest was obtained to evaluate.
How would you proceed?
Answer below with discussion.
35 yo female post-partum x 7 weeks (healthy newborn girl; no complications with pregnancy or with birth) with no PMH presented with the sensation of food getting caught in her throat after eating a large steak meal.
EGD was performed with foodstuff visualized in the proximal esophagus. It was pushed successfully into the stomach.
Post-procedure, the patient had onset of fever (38.5) on one occassion and mild chest pain that resolved without intervention.
Her WBC count was normal and did not change throughout her hospital course.
A CT chest was obtained to evaluate.
How would you proceed?
Answer below with discussion.
Dyspnea
After "Nodule Week" maybe we should have "Dyspnea w/up week"...
Anyway, I see a lot of older patients with no obvious structural pulmonary or cardiac abnormalities and just want to compare notes.
To ilustrate it, yesterday I saw this 60 y/o woman with "episodic DOE". She is fairly healthy, exercises regularly on a treadmill and was sent by the cardiologists after a normal radionuclide stress test (normal EF too). She notices dyspnea with chest tightness when she tries and exerts herself "faster than usual" like racing up the stairs. Her daughter got married a few weeks ago and everytime she went up to get something she would get dyspneic. No F/C/NS/cough.
No TOB. Occ social ETOH.
On a PPI, Calcium and prn Tylenol.
Normal exam (normal BMI!).
Normal PFTs (FEV1 and ratio, TLC, no air trapping and DLCO~101%).
She had had a normal chest CT and we did a Mathacholine test which was negative (~10% change in FEV1 after 25mg).
What would you do next in this case? Do you see a lot of this less obvious cases of DOE?
Anyway, I see a lot of older patients with no obvious structural pulmonary or cardiac abnormalities and just want to compare notes.
To ilustrate it, yesterday I saw this 60 y/o woman with "episodic DOE". She is fairly healthy, exercises regularly on a treadmill and was sent by the cardiologists after a normal radionuclide stress test (normal EF too). She notices dyspnea with chest tightness when she tries and exerts herself "faster than usual" like racing up the stairs. Her daughter got married a few weeks ago and everytime she went up to get something she would get dyspneic. No F/C/NS/cough.
No TOB. Occ social ETOH.
On a PPI, Calcium and prn Tylenol.
Normal exam (normal BMI!).
Normal PFTs (FEV1 and ratio, TLC, no air trapping and DLCO~101%).
She had had a normal chest CT and we did a Mathacholine test which was negative (~10% change in FEV1 after 25mg).
What would you do next in this case? Do you see a lot of this less obvious cases of DOE?
Sunday, October 23, 2005
Asthma mystery
From Doug:
This is not so much a diagnostic dilemma, as a therapeutic curiosity. Think of it as a riddle. This is a very nice lady whom I cared for about 5 years before she was lost to follow up because of an insurance change. She initially came to my clinic after being followed by another colleague who left the University after finishing training. This lady had very severe asthma, with persistent symptoms, and frequent exacerbations that required steroid burst & tapers. She was also quite obese and as a result had some restrictive physiology that was not accompanied by any evidence for interstitial disease on full PFTs and HRCT scans done on multiple occasions throughout the years. After a while I ran completely out of options for her. She was compliant on 6 puffs of Flovent bid, Serevent, Accolate (this was before Singulair), et., and was still ending up in an emergency room every 4-6 weeks.
I started her on a drug that we shall henceforth refer to as "Mystery Drug". I had a biologic rationale for it, but NO DATA whatsoever, other than I knew it to be acceptably safe. I will see if anyone can guess what I started her an and why, then post some follow up.
This is not so much a diagnostic dilemma, as a therapeutic curiosity. Think of it as a riddle. This is a very nice lady whom I cared for about 5 years before she was lost to follow up because of an insurance change. She initially came to my clinic after being followed by another colleague who left the University after finishing training. This lady had very severe asthma, with persistent symptoms, and frequent exacerbations that required steroid burst & tapers. She was also quite obese and as a result had some restrictive physiology that was not accompanied by any evidence for interstitial disease on full PFTs and HRCT scans done on multiple occasions throughout the years. After a while I ran completely out of options for her. She was compliant on 6 puffs of Flovent bid, Serevent, Accolate (this was before Singulair), et., and was still ending up in an emergency room every 4-6 weeks.
I started her on a drug that we shall henceforth refer to as "Mystery Drug". I had a biologic rationale for it, but NO DATA whatsoever, other than I knew it to be acceptably safe. I will see if anyone can guess what I started her an and why, then post some follow up.
Thursday, October 20, 2005
Cough with bronchiectasis
A 44 y/o woman was referred to me for possible atypical mycobacterium. Several years ago, she was diagnosed with MAC and treated for 6 months with Rifampin, Ethambutol, and Biaxin. Her therapy was stopped because of optic neuritis. Over the following several years, she remained stable, but in poor general health. Recently, she has developed recurrent sinusitis, and has had several complicated sinus surgeries. She was referred because of persistent cough.
The remainder of her history is unremarkable, with the exception that she continues smoking regularly (1ppd x 20+ years).
On exam, she is thin, but in no distress. Her general exam is unremarkable, although she has some scattered wheezes and rales bilaterally.
Her pulmonary function shows mild obstruction, with normal gas exchange.
A high resolution CT scan shows mild bilateral bronchiectasis, primarily in the upper lobes, middle lobe, and lingula.
How would you approach this patient? I'll post some follow-up as we go...
The remainder of her history is unremarkable, with the exception that she continues smoking regularly (1ppd x 20+ years).
On exam, she is thin, but in no distress. Her general exam is unremarkable, although she has some scattered wheezes and rales bilaterally.
Her pulmonary function shows mild obstruction, with normal gas exchange.
A high resolution CT scan shows mild bilateral bronchiectasis, primarily in the upper lobes, middle lobe, and lingula.
How would you approach this patient? I'll post some follow-up as we go...
Follow-up to pulmonary nodule
This has been "Pulmonary Nodule Week on Pulmonary Roundtable"!
This is a follow-up on the 65 y/o former smoker with poor PFTs and the suspicious lesion. After the poor response to bronchodilators we did perform a PET: it revealed significant uptake by the nodule and no other abnormal areas. We discussed it with our CT surgeons who felt very hesitant about a lobectomy. Instead they did a mini-thoracotomy wedge resection of the area. It revealed a 2x2x1.8 cm poorly differentiated squamous cell-Ca. We have consulted hem-onc and since this was a wedge and not a full lobectomy they have recommended ChemoTx/xRt. We don't do RF ablation here so I felt the wedge with follow-up Tx was as close to it as we would get. She has done very well post-op and should be home soon (surgery was 2 days ago) with hem-onc f/up.
This is a follow-up on the 65 y/o former smoker with poor PFTs and the suspicious lesion. After the poor response to bronchodilators we did perform a PET: it revealed significant uptake by the nodule and no other abnormal areas. We discussed it with our CT surgeons who felt very hesitant about a lobectomy. Instead they did a mini-thoracotomy wedge resection of the area. It revealed a 2x2x1.8 cm poorly differentiated squamous cell-Ca. We have consulted hem-onc and since this was a wedge and not a full lobectomy they have recommended ChemoTx/xRt. We don't do RF ablation here so I felt the wedge with follow-up Tx was as close to it as we would get. She has done very well post-op and should be home soon (surgery was 2 days ago) with hem-onc f/up.
Wednesday, October 19, 2005
More pulmonary nodules
This 49 y/o woman was referred to me with an anormal CT scan. She has a 30 pack/year Hx and has quit smoking when told about the CT. She has no symptoms (she had had a "screening" CxR which prompted the CT), her exam is quite unremarkable and she has normal PFTs (FEV1 and FVC are >85% though the ratio is a bit low).
Her CT showed multiple non-calcified nodules (some a depicted below) with no adenopathy.
What would you do next?
Her CT showed multiple non-calcified nodules (some a depicted below) with no adenopathy.
What would you do next?
Tuesday, October 18, 2005
Answer to Mike's Pulmonary nodules
Meanwhile, Mike L has posted the f/up and diagnosis on his pulmonary nodules case.
Check it out and leave your comments.
Check it out and leave your comments.
Pulmonary nodule
This is a 65 y/o former smoker who was sent to us for evaluation of a pulmonary nodule. She has COPD, has baseline DOE and while having an AECB had a CxR (outside films). The CxR revealed a nodule which is better characterized on the CT below.
She has had no F/C/NS, no hemoptysis.
Her exam was fairly benign. Her FEV1 however, was only 700cc on Combivent?
What would you do next?
She has had no F/C/NS, no hemoptysis.
Her exam was fairly benign. Her FEV1 however, was only 700cc on Combivent?
What would you do next?
Followup to shortness of breath
Doug picked up on the subtle clue of chronic UTI's on past history.
Here is the xray
On nitrofurantoin
1 month after stopping the nitrofurantoin:
Her shortness of breath resolved and the DLCO (which was 56%) became 86%.
Here is the xray
On nitrofurantoin
1 month after stopping the nitrofurantoin:Her shortness of breath resolved and the DLCO (which was 56%) became 86%.
Monday, October 17, 2005
Shortness of breath
74 year-old woman who reports gradual onset of dyspnea on exertion over the past year. No chest pain, fevers chills or night sweats. She has a minor non-productive cough.
ROS: Some minor arthralgias, probably OA; o/w unremarkable.
PmHx: chronic UTI's followed by urology otherwise negative.
SH: Lifelong nonsmoker. Occupation was secretary.
FH: 2 daughters with fibromyalgia.
Travel Hx: Thailand in the past year.
On exam initially the lungs were clear to auscultation, but subsequent exams over the next year revelaed bilateral crackles, as can be imagined based on xrays shown below.
So over the next year she became more and more short of breath with the following progression on chest xray.
First CXR
CXR a few months later
CXR more months later with worsening dyspnea.
Here is a few CT slices around the time of the second chest xray (above):
ct up
ct mid
ctlow
What additional information would you like to know?
RF and ANA were low in the past.
ROS: Some minor arthralgias, probably OA; o/w unremarkable.
PmHx: chronic UTI's followed by urology otherwise negative.
SH: Lifelong nonsmoker. Occupation was secretary.
FH: 2 daughters with fibromyalgia.
Travel Hx: Thailand in the past year.
On exam initially the lungs were clear to auscultation, but subsequent exams over the next year revelaed bilateral crackles, as can be imagined based on xrays shown below.
So over the next year she became more and more short of breath with the following progression on chest xray.
First CXR
CXR a few months later
CXR more months later with worsening dyspnea.
Here is a few CT slices around the time of the second chest xray (above):
ct up
ct mid
ctlow
What additional information would you like to know?
RF and ANA were low in the past.
Friday, October 14, 2005
Multiple pulmonary nodules (case#2)
86 yo male with PMH of colon cancer dx 30 years ago s/p Left hemicolectomy presented to the hospital after a syncopal event. He had an URI about 1 week prior to admission and that had largely resolved with conservative treatment (OTC AH/DC).
His syncope was probably related to orthostasis (frankly orthostatic on presentation).
On hospital day #2, he complained of abd pain. A CT of the abd showed bilateral pulmonary nodules. A corresponding CT of the chest (cuts below) showed multiple small pulmonary nodules.
He is a lifetime non-smoker.
His colon cancer was "cured" with surgery; an exploratory lapartomy 10 years ago for a PSBO showed adhesions but o/w was normal. A colonoscopy 1 year ago was completely normal.
No other important findings
CT scan:
Now what?
Answer below.
His syncope was probably related to orthostasis (frankly orthostatic on presentation).
On hospital day #2, he complained of abd pain. A CT of the abd showed bilateral pulmonary nodules. A corresponding CT of the chest (cuts below) showed multiple small pulmonary nodules.
He is a lifetime non-smoker.
His colon cancer was "cured" with surgery; an exploratory lapartomy 10 years ago for a PSBO showed adhesions but o/w was normal. A colonoscopy 1 year ago was completely normal.
No other important findings
CT scan:
Now what?
Answer below.
Thursday, October 13, 2005
Followup on lung lesion
Remember this case of the Jehova's witness with the growing lesion in the RLL? A bronch showed some greenish secretions. The BAL was cloudy but colorless. It was negative for actinomycetes and nocardia (no growth x 6 days so far). There were 4000 cfu/mL of alpha hemolytic strep with > 1 PMN per oil immersion field. The cytology was read as "acute inflammation". Do you all think this whole thing is due to a chronic a-hemolytic strep infection?
Wednesday, October 12, 2005
PFT dilemna
What causes severe obstruction (40%)with no post-bronch reversibility, and a normal DLCO (80%) in a non-smoker? Here are some extra things: her PFT's on and off Advair were not changed. Her CXR:
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