G. Zacharia Reagle DO
Andreas Escobar-Naranjo MD
Department of Internal Medicine
Division of Pulmonary and Critical Care
History of Present Illness
A 65 year-old woman who recently quit smoking presented to the ER for the third time in the preceding month with dyspnea and cough. She reported some subjective fevers and cough productive of white sputum as well as a seven kilogram unintentional weight loss in the prior four to eight weeks. She had been diagnosed with COPD in the past and on both prior ER visits was treated with oral steroids and antibiotics. She would feel some relief with the steroids but once the course was over she would quickly experience a return of her symptoms. On the third ER presentation she was admitted to the hospital.
Past Medical History:
Past Surgical History:
- C-section x 2
- TAH and BTL
Levothyroxine 0.15mg daily
Budesonide 40/formoterol 4.5 twice daily
Tiotropium 18 mcg daily
Fluoxetine 20mg daily
Hydroxyzine 50mg three times daily
Hydrochlorothiazide 50/triamterene 75 daily
As needed albuterol
Allergies: No Known Drug Allergies
A lifelong Californian, she was divorced with two healthy adult children. She is a United States Air Force veteran who served as a broadcaster from 1974-78 including a deployment to Asia. After leaving the service she worked as a Registered Nurse in burn, rehab and home health nursing. A former tobacco smoker with 35+ pack years of tobacco exposure – she quit smoking one month prior to the current admission. She is currently homeless, living in a homeless veteran’s shelter. She is a recovering alcoholic and cannabis addict.
General: Alert, mild respiratory distress, mildly anxious.
Vitals: BP: 134/80 HR: 104 RR: 18, SpO2 93% on room air T: 98.4ºF
HEENT: NC/AT, PERRL, neck supple without JVD noted.
Lungs: equal chest expansion, scattered bilateral wheezes with decreased airflow on the left
Heart: Regular with a good S1 and S2, no murmurs or gallops were appreciated.
Abdomen soft, Non-tender, good bowel sounds.
Extremities No edema, nor clubbing.
Neurological: She was alert and oriented with a Glasgow Coma Score of 15, no focal defects noted.
Skin: No rashes noted.
CBC: WBC 6.9 X 109 cells/L, hemoglobin13.4 g/dL, hematocrit 39.4, platelet count 329 X 109 cells/L
Chemistries: Na+ 139 mEq/L, K+ 3.5 mEq/L Cl- 106 mEq/L, CO2 26 mEq/L BUN 8 mg/dL, creatinine 0.6 mg/dL, glucose 149 mg/dL, magnesium 2.0 mg/dL, phosphate 3.4 mg/dL
Mycoplasma IgM: (-)
S. pneumoniae urinary antigen: (-)
Legionella urinary antigen: (-)
Blood Cultures: (-)
On admission a chest CT was preformed (Figure 1).
Figure 1. Representative images from the thoracic CT scan showing central and upper zone predominate bronchiectasis, and total collapse of the left upper lobe. There also was some emphysema noted.
Which of the following causes of bronchiectasis should be considered in this case? (Click on the correct answer to proceed to the second of six panels)
- Allergic bronchopulmonary aspergillosis
- Autoimmune diseases including rheumatoid arthritis and Sjogren’s syndrome
- Congenital pulmonary conditions including cystic fibrosis and primary ciliary dyskinesia
- Immunoglobulin deficiency
- All of the above are possible causes of bronchiectasis
Reference as: Reagle GZ, Escobar-Naranjo A. June 2015 pulmonary case of the month: collapse of the left upper lobe. Southwest J Pulm Crit Care. 2015;10(6):315-22. doi: http://dx.doi.org/10.13175/swjpcc072-15 PDF