This is a 77-year-old woman who presented with significant cough, dyspnea and hypoxemia and was found to have pulmonary infiltrates. She has been started on aggressive good antibiotic therapy, but continued to have an elevated white blood cell count, dyspnea and cough so we were consulted. No previous label of COPD; never smoked; no heart disease; no odd exposures.
She had not been able to produce significant amounts of sputum. She was also found to be hyponatremic with significant fluctuation of her sodium during her initial hospital stay. Urine and serum Osms were consistent with some SIADH and she improved with fluid restriction. Unremarkable U/A and normal renal function.
She then developed some respiratory distress, mild hemoptysis, worsening hypoxemia and had to be intubated and had the changes seen on the second CxR. (Some cuts from the CT from that day are included).
What would you want to know/do next?
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Lack of abx response makes bacterial pneumonia less likely. Non-infectious pneumonias top of list would include AIP. Also I would include COP. BAC is another possibility.
I would bronch. Could also start with thoracentersis and send for cytology.
Bronch was consistent with diffuse alveolar hemorrhage.
Did you tret with steroids and was there a response? Autoimmune workup...
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