Jamie Bering, MD
Lewis J. Wesselius, MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Pulmonary Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Jamie Bering, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
As a result of this activity I will be better able to:
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
Current Approval Period: January 1, 2015-December 31, 2017
Financial Support Received: None
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.
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)