NYU Medical Grand Rounds Clinical Vignette

Lucy Doyle MD, PGY-2

March 24, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

A 54-year-old male smoker presents with progressively worsening dyspnea for several years.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was in his usual state of health until 8 years prior to admission when he first began to experience dyspnea on exertion.

• During an early emergency room visit, a chest CT demonstrated ground glass opacities, sub-pleural honeycombing and fibrosis.

• Over the next several years, however, that patient did not return for further medical attention.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• As the patient’s symptoms progressed, the patient returned four years later for evaluation.

• Pulmonary function tests were obtained and consistent with restrictive physiology and mildly decreased diffusion capacity.

• The patient was reluctant to undergo bronchoscopy and again did not return for medical care for several years.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Several months prior to admission, the patient returned complaining of cough, worsened dyspnea and further decreases in exercise tolerance.

• Bronchoscopy with trans-bronchial biopsy was performed but non-diagnostic.

• The patient now presents for further evaluation of his markedly worsened symptoms and functional status.

Additional History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Past Medical History• PPD (+)

• Treated in 1999

Past Surgical History• None

Family History• Father: Lung cancer

Social History• Former steel worker• Current smoker

• 1/2 pack per day• 35 pack-years

• Social alcohol use• Remote drug use

• Cannabis • Cocaine

Outpatient Medications

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Albuterol metered dose inhaler as needed

Allergies: None

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

General: Well-appearing man in no acute distress

Vitals: T 98.7 F, BP 107/78, HR 100, RR 16

O2 saturation: 95% on room air, 98% on 2L nasal cannula

Lungs: Bilateral basilar dry rales

Extremities: Bilateral clubbing

The remainder of the physical exam was normal.

Initial Studies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• CBC: Within normal limits

• Basic Metabolic Panel: Within normal limits

• ACE: 38 (within normal)

• LDH: 246

• Anti-SCL-70: 108 (0-99)

• ANA: negative

Chest X-ray

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DEPARTMENT OF VETERANS

AFFAIRS

Imaging Reports

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Chest X-Ray

• No new consolidations or pleural effusions

• Interstitial lung disease, unchanged

Chest CT

• Interstitial lung disease with honeycombing and traction bronchiectasis most significant in the upper airways.

• New diffuse bilateral airspace disease which may represent pulmonary edema.

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Interstitial lung disease, unknown etiology

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Hospital Course

• The patient underwent open lung biopsy of right middle and lower lobes.

• The biopsy revealed dense fibrosis with honeycomb changes and fibroblastic foci, consistent with usual interstitial pneumonia.

• The patient tolerated the procedure well, but eventually required intubation for hypoxic respiratory failure.

• In accordance with the patient’s wishes, further care was not escalated, and the patient passed away 2 weeks later.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Final Diagnosis

Usual Interstitial Pneumonia

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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