Shortness of breath with phrenic nerve paralysis

Submission
60 year old woman with sarcoidosis by mediastinal biopsy 1978 doing well, never requiring steroids. 2 mos prior developed SOB - smothering type of feeling even at rest but also on exertion. A CXR during a routine physical showed a left paralyzed hemidiaphragm.

Pmhx
sarcoid as above
NQWMI 1991 Echo on f/u showed torn chordae and LV "contractile abnormality" on a thallium test.


Three fluorouscopies revealed unilateral paralysis. Scheduled for EMG studies

Patient also adds:
"I am 60 y/o and live a quiet life but my legs are now getting weak and I am unable to bend down in a sitting position and get up. I failed to mention that I had a lumbar puncture which was normal. MRI showed cervical problems but nothing serious I guess. The pons area of my brain showed vascular changes due to aging. I also had strabismus during all of this and had a prism put in my glasses because of a convergence problem with my eyes. Could this all be connected? Myasthenia gravis I guess has been ruled out and they are calling this idiopathic phrenic nerve paralysis. Should I pursue this any further?I have about 40% function of my left lung."

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Shortness of breath

Submission from outside reader:

Hi I have been looking at this blog for since 2005 on a weekly basis and wonder if you take questions from patients. Your site is informative it is a pity you are not getting the hits.

I am a 38yo M and I have a chronic symptoms now for many years with NO DIAGNOSIS despite pressing for one.

I have a hacking cough with some sputum in the morning, I also have nearly constant SOB with an inability to get a deep breath. A feeling of stiffness in my lungs. I feel constantly like my breathing is not good. This has been with me since 2003. Excercise tolerance is ok i.e. I could run a mile in 10min but I struggle to breathe throughout.

Pleurisy type pain on and off weekly, specifically located in same location at upper left back. Lower rib pain on left.

Asthma as a child, allergic rhinitis as a teenager and young adult, smoked in college (10 a day) and socially (30 at weekend) till I was 33. On and off asthma meds since 1994. Tried Singulair, Symbicort, Spiriva etc. Tried also extensive courses of Zoton, Nasocort etc.

Have been evaluated many times over the years by 3 pulmos spent '000$ and the best they can give me as a diagnosis is " a chronic inflammation similar to chronic bronchitis with little or no asthma but we are reluctant to give it a title "

Here is the dilemma, all tests normal my FEV1 is 4.45…101%, FVC 5.8…104%, FEV/FVC 76. DLCO Normal. FEF25-75 83% Lung Vols Normal


Here is the question:

Why do I have symptoms if all tests are normal. What do you guys think.. have you seen this before, normal tests but chronic symptoms with dyspnea.

Chest xray x 4 Normal
2 x HRCT (1 year between) Normal, Body Ples Normal. Methacholine Normal
ECG Stress Test Normal
Echo Cardio Normal
Bloods Normal, 2 x HRCT (1 year between) Normal, Body Ples Normal. Methacoline Normal

MRI ordered by Rheumo .. Normal

Not in my brain either!! I have loads of other stuff to worry about like kids, my stressful job as a broker, mortgages etc

Pulmicort discontinued?

Has anyone else heard that Astra Zeneca will be discontinuing pulmicort? Were they not making a profit on this? Anecdotally, I see a lot of patients on Pulmicort.

This is from The FDA site:

NDA 20-441, PULMICORT TURBUHALER 200 mcg (budesonide inhalation powder) will no longer be available at AstraZeneca.

The introduction of PULMICORT FLEXHALER (budesonide inhalation powder, 90 & 180 mcg), NDA 21-949, will be accompanied by the phasing out of PULMICORT TURBUHALER so as to minimize confusion in the marketplace.

AstraZeneca has no further plans to manufacture NDA 20-441, PULMICORT TURBUHALER 200 mcg (budesonide inhalation powder).

Worsening dyspnea in a patient with IPF

71 year olf woman with idiopathic pulmonary fibrosis diagnosed by open lung 2004 (UIP on biopsy). Since that time she has been stable with good exercise tolerance, and able to get around with little difficulty. PFT's also stable during that time frame with FVC in low 80% since 2004. Over the last 2 months she reports increased dyspnea on exertion and fatigue. Her ambulation has decreased over the last 3 or 4 months because of pain of her left hip, which for the last 6 months she had been getting injections for. She is due to get left total hip replacement. She has difficulty getting out of the chair because of pain in her hip. She does still try to get around, but her ambulation she does admit has decreased over the last 3 months because of this pain. She denies any nocturnal shortness of breath or orthopnea. She has no chest pain. There is no fevers, chills, night sweats. No appreciable weight gain subjectively. No anorexia. No cough.

Her physical exam is a pleasant woman sitting in a chair, in no acute distress. Blood pressure 123/59, pulse is 77, respiration is 20, O2 sat is 97% on room air, her weight is 228 pounds. Her weight in March 21st on another scale at another clinic was 221 pounds and her weight on our scale in January 2007 was 231 pounds. HEENT: Trachea midline, no lymphadenopathy. The JVP seems to be about 4 to 5 cm. The lungs have crackles basilarly and laterally about the third of the way up. Heart is regular rate and rhythm with a positive S3, no murmurs or rubs. Abdomen: Benign. There is trace pitting edema bilaterally at the ankles.

Spirometry shows the ratio of 84%. FEV1 of 1.87 (83% of predicted), FVC of 2.21 (74% of predicted). DLCO 65% of predicted. In May 2006 FVC was 80% of predicted and DLCO 74% of predicted.
CXR this visit:


CXR from 2 years ago:


What are your thoughts and/or what would you do next?

Acute on chronic Blogemia

Sorry there have been no new posts. Baleeiro and I are essentially the last surviving members of the blog (functionally, not literally - the others are not dead; they just lost interest) and our motivation for daily posts has somewhat diminished given lack of participation from outside readers, previous contributors and anyone else who might come across this blog. I will most likely leave a post or two a week and we will see where this goes. We have been steadily building a database over 2 years of pulmonary cases (with discussion) and all categorized, so it is a bit of a shame that it goes this way. Hopefully we can wean the blog off of the proverbial vent and not proceed to comfort care measures....

-JJ