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January 2018 Pulmonary Case of the Month

Lewis J. Wesselius, MD

 Departments of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA


History of Present Illness

A 67-year-old man from Idaho was seen in November 2017 for a second opinion. He has a history of slowly progressive dyspnea on exertion for 7 to 8 years. He has a significant smoking history of 50 pack-years, but is still smoking “a few cigarettes”.

He saw an outside pulmonologist in September 2017 and was noted to have abnormal pulmonary function testing with the primary abnormality being a low DLco. A thoracic CT Scan was reported to be abnormal with evidence of interstitial lung disease. He underwent video-assisted thorascopic surgery and the biopsies were reported to show usual interstitial pneumonitis (UIP). His pulmonologist questioned whether this was interstitial pulmonary fibrosis or UIP associated with rheumatoid arthritis.

PMH, SH and FH

He has a history of rheumatoid arthritis and had been treated with methotrexate for approximately 8 years. His methotrexate had been discontinued in September with no change in symptoms. FH is noncontributory.


Prednisone 5 mg/daily and tiotropium (these also did not change his dyspnea).

Physical Examination

  • Chest:  bibasilar crackles.
  • Cardiovascular:  regular rhythm without murmur.
  • Ext:  no clubbing, no edema, no joint deformity noted

Which of the following are indicated at this time? (Click on the correct answer to proceed to the second of five pages)

  1. Obtain a complete blood count and rheumatoid factor
  2. Begin pirfenidone or nintedanib
  3. Review his pulmonary function testing and radiographic studies
  4. 1 and 3
  5. All of the above

Cite as: Wesselius LJ. January 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(1):8-13. doi: PDF

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