The Virtual Hospital: Book Name: Section Name: Document Name

Midwest Midwinter Lung Conference: CPC Session

Case 1

Douglas B. Hornick, M.D. and Carl Lawyer, M.D.
Peer Review Status: Not Peer Reviewed

77 yo WF with chronic cough and abnormal chest x-ray
IS is an active lifelong nonsmoker with no previous lung problems except over the 5 months prior to presentation complains of persistent intermittently productive cough. When she first saw her physician for this problem the chest x-ray was interpreted as compatible with pneumonia. She received ciprofloxacin and her cough transiently improved, but returned and failed to clear with multiple other courses of antibiotics. A follow-up chest x-ray after 3 months was reported as unchanged compared to the initial one. Upon referral she admits to mild dyspnea and occasional night sweats in addition to the cough, but she denies fevers, weight loss, fatigue, chest pain and hemoptysis. She has a positive PPD since childhood, but no history of active TB or TB therapy.

Her past medical history is also remarkable for gastroesophageal reflux, diet controlled type II DM x 10 years, hypertension, H/O of CABG 2 years prior, left nephrectomy for transitional cell carcinoma (grade III) diagnosed two years prior and she is currently receiving BCG intravesicularly with no evidence of disease progression. She is a retired school teacher but states the schoolroom she taught in was loaded with asbestos. She also lived on a farm and helped her husband ìpitch hayî when needed. Her medications included diltiazem, digoxin, atenolol, and ranitidine.

Physical exam was only remarkable for rales at the bases, that cleared with cough. Pulmonary function tests revealed FVC 2.2 L (87% predicted), FEV1 1.7 L (95% predicted), TLC 5.5 (122% predicted), RV 3.2 (166% predicted), DLCO 103% predicted. ABG on room air revealed pH 7.41, pCO2 36, pO2 68. See the current chest x-ray and chest CT sample cuts A and sample cuts B.

Click on small images below to magnify

Chest x-ray from first pneumonia episode

Chest x-ray at 3 month follow-up

Chest x-ray from the current evaluation

Chest CT sample cuts A

Chest CT sample cuts B

What is your differential diagnosis and choose the most likely diagnosis.

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