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)
- Diffuse lung consolidation
- Previous median sternotomy
- Previous mitral valve replacement
- 1 and 3
- 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