NYU Medical Grand Rounds Clinical Vignette

Karen Kan, MD

Class of 2014

February 26, 2013

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 49 year old non-smoking, Bangladeshi woman who presents with 3 years of dyspnea on exertion

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Lived on a rural farm in Bangladesh• Responsible for cooking and domestic chores• Dyspnea on exertion began 3 years prior to admission • Daily cough productive of clear sputum

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

• Dyspnea progressively worsened

• Limiting her exercise tolerance to “a few blocks”

• Her family brought her to the US and she subsequently presented to Bellevue Hospital

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

• Past Medical & Surgical History: None• Social History:

• No tobacco, alcohol or drug use• Originally from Bangladesh • Lived on a farm with no nearby factories• Worked indoors cooking for her family

• No family history of pulmonary disease• Home Medications: None• No Known Drug Allergies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

• The patient was a well-appearing woman, in no acute distress

• Vital Signs: 98°F, BP 110/70, HR 60, RR 14 and oxygen saturation 97% on room air

• Her pulmonary exam was notable for mild bibasilar inspiratory crackles

• The remainder of the exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

• Arterial blood gas on room air: pH 7.48, PaO2 88 mmHg, PaCO2 39 mmHg

• ESR 44 mm/hr (17 mm/hr)

• The CBC, BMP and hepatic panel were unremarkable

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies• Chest X-Ray

• Low lung volumes with scattered small nodules throughout all lung zones

• Chest CT

• Numerous 2-3 mm irregular nodules scattered throughout both lungs, sparing the pleural surface

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies• Induced Sputums: Negative for AFB

• Pulmonary Function Tests:

• FVC 2.06L (80%), FEV1 1.72L (79%), FEV1/FVC 83%,

• FRC 2.88L (124%), TLC 3.84L (95%), RV 1.72L (117%)

• Diffusing capacity for CO 22.06 mL/min mmHg (130%)

• No response to bronchodilatorsUNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Chronic bronchitis from an environmental exposure

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient remained in respiratory isolation until induced sputums were negative for AFB

• After imaging and spirometry were performed, she underwent bronchoscopy

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Bronchoscopy showed numerous dark plaques on the bronchus intermedius and the BAL was grossly gray in appearance and had a normal cell differential

• Transbronchial biopsy specimens showed anthracosis with thickening of the basement membrane

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Domestically Acquired Particulate Lung Disease (DAPLD) or “hut lung”

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS