Lewis Wesselius MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
History of Present Illness
A 53 year old woman from Indiana was seen who had a history of nonproductive cough for several years. She had a prior diagnosis of asthma but continued to have cough despite asthma treatment. She was also treated for gastroesophageal reflux and had a Nissen fundoplication. This resolved in some improvement in the cough. In May 2013 she noted increasing dyspnea on exertion.
An echocardiogram was performed which was notable for a 16% left ventricular ejection fraction. A thoracic CT demonstrated some nodules and a question was raised of sarcoidosis. She was admitted to a hospital in Indiana and had a biventricular pacemaker placed. Bronchoscopy with transbronchial biopsy was performed with no diagnostic findings. No granulomas were seen on the biopsy. Bronchoalveolar lavage showed a CD4/CD8 ration of 0.84. Optic nerve swelling was noted at that time. Due to the cardiac, pulmonary, and optic nerve findings a clinical diagnosis of sarcoidosis with a dilated cardiomyopathy was made and she was treated with prednisone initially, then a combination of prednisone and methotrexate.
PMH, FH, SH
Her past medical history was as above and family history was noncontributory. She does not smoke or drink.
- Methotrexate 15 mg weekly
- Prednisone 5 mg daily
- Furosemide 40 mg daily
- Potassium chloride 20 meq daily
Afebrile. SpO2 96% on room air. The physical exam was unremarkable.
Which of the following should be performed at this time?