January 2017 Pulmonary Case of the Month

Jamie Bering, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

The patient is a 53-year-old woman transferred for acute respiratory failure and hemoptysis. She has a prior history of antiphospholipid syndrome and recurrent diffuse alveolar hemorrhage (DAH). She was admitted to another hospital about 2 weeks prior to transfer with hypoxic respiratory failure which ultimately required intubation. Bronchoscopy revealed a bloody aspirate raising concerns for recurrent DAH. She was started on high-dose solumedrol and extubated after 4 days. One week later, her respiratory status decompensated and her chest x-ray showed worsening diffuse bilateral opacities concerning for recurrent DAH. She was transferred to the Mayo Clinic Arizona for further evaluation. Upon arrival, she required 50% FiO2 by face mask to maintain adequate oxygenation and was started on broad-spectrum antibiotics. Her corticosteroids were tapered to 20 mg prednisone daily.

Past Medical History, Social History and Family History

She has a history of a mitral valve replacement with a St. Jude’s mechanical mitral valve and was on chronic anticoagulation with warfarin. In addition, there was a history of moderate aortic stenosis with moderate aortic insufficiency.

She had a history of diffuse alveolar hemorrhage, antiphospholipid antibody syndrome and possible systemic lupus erythematosus.

Medications

• Dapsone 100mg daily
• Ethacrynic acid 75mg daily
• Gabapentin 900mg QHS
• Lisinopril 20mg daily
• Meropenem 1g Q8 hrs
• Metoprolol 50 mg BID
• Prednisone 20mg daily
• Simvastatin 40mg QHS
• Vancomycin 1.5g Q12 hrs
• Warfarin 4mg T,F; 3mg SMWRSa

Physical Examination

• Vitals: T 36.3^◦ C; HR 79 beats/min; BP 100/63 mm Hg; RR 26 breaths/min; SpO2 99% face mask
• Gen: no acute distress
• HEENT: hematoma on chin
• Lungs: clear to auscultation and percussion
• Cardiac: Mechanical valve click

Laboratory

• CBC: WBC 15,900 cells per microliter (mcL); Hemoglobin 9.1 g/dL; hematocrit 29%; platelet count 156,000 cells per microliter.
• Electrolytes: within normal limits.
• BUN and creatinine: within normal limits.
• Blood sugar: 220 mg/dL.

Radiography

Her initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of four pages)

1. Diffuse lung consolidation
2. Previous median sternotomy
3. Previous mitral valve replacement
4. 1 and 3
5. All of the above

Cite as: Bering J, Wesselius LJ. January 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;14(1):1-5. doi: https://doi.org/10.13175/swjpcc146-16 PDF