Midwest Midwinter Lung Conference: CPC Session
Case 2
Douglas B. Hornick, M.D. and Carl Lawyer, M.D.
Peer Review Status: Not Peer Reviewed
45
y.o. WF with multiple symptoms and abnormal Chest x-ray
Other than a history of mild asthma, this patient was previously
healthy until 4 months prior to presentation. At that time she noted
the onset of right-sided pleuritic chest pain, generalized myalgias,
night sweats, fatigue, and some dyspnea on exertion. She received
several courses of oral antibiotics, but the symptoms persisted. She
lost weight unintentionally (10 pounds over 4 months), noticed
worsening dyspnea, and reported difficulty working eight hours a day
at a desk job due to fatigue. Chest
x-ray obtained just prior to referral was felt to be compatible
with pneumonia and she was re-started on clarithromycin. Her past
history is remarkable for asthma onset at age 14. She used only
inhalers to control symptoms during the spring months. She is a
lifetime nonsmoker, denies exposure to TB, is PPD and HIV negative,
and has not traveled outside the state. She reported that her office
is near a construction site, but no other potential exposures were
elicited. In addition to clarithromycin, medications she has been
taking were albuterol and cromolyn inhalers each 4 times a day and
multiple vitamins. Review of systems revealed only that she had noted
the onset of a pruritic rash at both ankles the last 3-4 weeks and
believed it was a skin allergy, but had been unable to identify the
offending agent.
Physical exam revealed decreased breath sounds and occasional
wheeze in the right base and a rash diffusely on the ankles that was
erythematous and papular. Notable laboratory results were BUN/Cr.
5/0.5; WBC 11.5, 50% eosinophils; C-reactive protein elevated at
2.17; rheumatoid factor 240; ANA negative; ACE normal; O2 saturation
94% at rest and 86% after walking 200 feet. The
chest x-ray upon referral was
unchanged.
A diagnostic test was performed and therapy was initiated. Upon
return two months later the patient and follow-up chest x-ray showed
substantial improvement.
Click on small images below to magnify
Chest x-ray
(PA and
lateral) when symptoms were
most severe
Chest x-ray
after diagnosis and treatment
What is the diagnosis, the diagnostic test, and which therapy
likely resulted in the improvement?