March 2013 Pulmonary Case of the Month: Don’t Rein Me In

Robert W. Viggiano, MD

Michael B. Gotway, MD

Departments of Pulmonary Medicine and Radiology

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 70 year old man was referred for a pleural effusion. The patient had pitting edema of the lower extremities noted in March, 2013. At that time a myocardial perfusion study and an echocardiogram were interpreted as being normal with an ejection fraction of 55%. His primary care physician stopped the amlodipine he was taking for hypertension and his edema resolved. However, the amlodipine was restarted a few weeks later for blood pressure control.

PMH, SH, FH

He has a past medical history of hypertension and asthma. He was diagnosed with prostrate cancer in mid 2012. At that time a CT scan of his abdomen/pelvis and a MRI of his pelvis were negative for metastatic disease. He underwent robot assisted radical prostatectomy and bilateral pelvic lymph node dissection in August 2012. His final diagnosis was Gleason 4+5 disease present throughout the prostate with focal extraprostatic extension and lymphovascular and perineural invasion and invasion of right seminal vesicle. He was staged T 3B.

Present medications

• Amlodipine 5 mg at bedtime
• Omelsartan (Benicar®) 40 mg/day
• Salmeterol/fluticasone (Advair®) 100/50 1 puff twice a day
• Clonazepam 0.5 mg twice a day
• Lycopene 10 mg daily

He has a 10 year smoking history but no alcohol or drug use.

Family history is unremarkable.

Physical Examination

Vital signs: Normal

Lungs: Decreased breath sounds in both lung bases

Heart: Elevated JVP; Normal S1 and S2

Abdomen: Negative

Extremities: 2-3+ pitting edema

Laboratory

• CBC: normal
• Electrolytes: normal
• Serum creatinine: 1.0 mg/dL
• Total protein: 6.8 g/dL
• Albumin: 4.3 g/dL
• NT-pro brain naturetic peptide (BNP): 255 pg/ml

Radiography

Chest x-ray is shown in figure 1.

Figure 1. PA (panel A) and lateral (panel B) chest radiography.

Which of the following is false?

1. The patient’s chest x-ray shows bilateral pleural effusions right larger than left
2. A NT-pro BNP 255 pg/ml makes heart failure an unlikely diagnosis
3. His pleural effusion is most likely due to metastatic prostate cancer
4. A normal heart size on chest x-ray excludes heart failure
5. A normal echocardiogram excludes heart failure

Reference as: Viggiano RW, Gotway MB. March 2013 pulmonary case of the month: don't rein me in. Soutwest J Pulm Crit Care. 2013;6(3):93-102. PDF

February 2013 Pulmonary Case of the Month: One Thing Leads to Another

Elijah Poulos, MD

Erica Peterson, MD

Robert A. Raschke, MD

Good Samaritan Regional Medical Center

Phoenix, AZ

History of Present Illness

A 63 year-old man from Minnesota with a history of sarcoidosis managed with low-dose prednisone (average 6 mg/day with periodic bursts) for the past 15 years was transferred to our hospital for a higher level of care.  Eight weeks prior to admission he was in Costa Rica for a 3 week vacation where he engulfed himself in local traditions, swam in marine and fresh water, slept in rural areas, ate unprocessed foods, wore no insect repellent and had no prophylactic vaccines or medications. He returned to northern Minnesota and visited his cabin where he noted numerous dog tics.

Four weeks prior to admission he developed intermittent fevers to 102°, rigors and drenching night sweats. Workup initiated in Minnesota was unrevealing. Specifically he had negative malaria smears, blood cultures, leptospirosis and hepatitis panels. Transaminases were elevated in the 100s. An empiric 1 week trial of doxycycline resulted in no improvement.

One week prior to admission he came to Arizona for a golfing trip. He noted ongoing fevers, chills, and sweats as before but now had a left conjunctival hemorrhage, lethargy, ataxia, dysarthria, jaundice and dyspnea. He was taken to the emergency room of another hospital where he was noted to have a fever of 104°, transaminitis, pancytopenia, and hypoglycemia. He was transferred to our care.

Physical Exam

Upon arrival, the patient was a well-nourished male who appeared fatigued, diaphoretic, and in mild respiratory distress. Vitals signs upon admission revealed a temperature 39.4° C, heart rate 118, blood pressure 111/70, respiratory rate 22, and oxygen saturation 93% on 2 liters via nasal cannula. Bibasilar crackles and diffuse wheezes were present on lung auscultation. A left conjunctival hemorrhage, mild jaundice, and upper extremity petechiae, purpura and bruising were present. Abdominal exam revealed hepatosplenomegaly.

Laboratory

CBC: WBC 1.4 X 10³ cells/mcL (47 segs, 29 bands, 5 NRBC, 4 metas, 5 myelos), Hgb 10.2 g/dL, and platelets 14 X 10³ cells/mcL. A peripheral smear was unremarkable except for pancytopenia.

Metabolic studies: BUN 41 mg/dL, creatinine 1.5 mg/dL, glucose 50 mg/dL, AST 362 U/L, ALT 227U/L, LDH 1100 U/L, total bilirubin 3.6 mg/dL, alkaline phosphatase 331 U/L..

Coagulation tests: Prothrombin time 18.2 secs, activated partial thromboplastin time (aPTT) 55 secs, fibrinogen 115 mg/dL, D-dimer 12.8 ng/ml D dimer units.

Lumbar puncture: 2 WBC, glucose 59 mg/dL, protein 56 mg/dL. Cultures were negative.

Miscellaneous: erythrocyte sedimentation rate (ESR) 13 mm/hr: C-reactive protein (CRP) 121 mg/L; ferritin >40,000 ng/ml; triglycerides 272 mg/dL.

ABG’s normal on 2L/min.

Radiography

Admission portable chest x-ray is shown in Figure 1.

Figure 1. Admission portable chest x-ray.

Which of the following is true?

1. A thoracic/abdominal CT scan is indicated
2. High-dose corticosteroids are indicated to suppress a  sarcoidosis flair
3. Open lung biopsy is indicated
4. Artesunic acid should be begun for malaria
5. Chloroquine should be begun for malaria

Reference as: Poulos E, Peterson E, Raschke RA. February 2013 pulmonary case of the month: one thing leads to another. Southwest J Pulm Crit Care. 2013;6(2):55-62. PDF

January 2013 Pulmonary Case of the Month: Maybe We Should Call GI

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 55 year old man from Arizona was undergoing a renal transplant evaluation because of polycystic kidney disease. He was referred for an abnormal chest x-ray. He was a nonsmoker and there were no respiratory symptoms.

PMH, FH and SH

He has a long history of polycystic kidney disease, hypertension, gout, and a history of a kidney stone. He is a life-long nonsmoker. There is no significant family history including polycystic kidney disease. He works as a border patrol agent and is originally from Honduras. His present medications include:

• Allopurinol
• Amlodipine
• Atenolol
• Hydralazine
• Sodium bicarbonate

Physical Examination

His blood pressure is elevated at 142/84, but otherwise his physical examination is unremarkable.

Chest X-ray

His chest X-ray is below (Figure 1).

Figure 1. PA (Panel A) and lateral (Panel B) chest x-ray.

The chest x-ray was interpreted as showing bilateral lower lobe nodules.

Which of the following is appropriate?

1. Obtain old chest x-rays for comparison
2. Spiral CT for pulmonary embolism
3. Coccidioidomycosis serology
4. A + C
5. All of the above

Reference as: Wesselius LJ. January 2013 pulmonary case of the month: maybe we should call GI. Southwest J Pulm Crit Care 2013;6(1):46-51. PDF

December 2012 Pulmonary Case of the Month: Applying Genetics

Lewis J. Wesselius, MD¹

Thomas D. Kummet, MD²

¹Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

²Olympic Medical Cancer Center

Sequim, WA

History of Present Illness

A 65 year old woman presented to her physician in with upper abdominal pain in August, 2007.  A CT scan of the abdomen demonstrated no abnormalities in her abdomen, but a 3.7 x 2.4 cm mass in the left lower lobe was noted.

PMH, FH and SH

She has no significant prior medical history. She is a life-long nonsmoker. There is no significant family history

Physical Examination

Her physical examination is unremarkable.

Which of the following is true?

1. Lung cancer does not occur in nonsmokers
2. The lesion is likely a rounded pneumonia based on its size
3. A family history of lung cancer is not associated with an increase in lung cancer
4. Calcification of the mass usually indicates lung cancer
5. Adenocarcinoma is the most common lung cancer seen in nonsmokers

Reference as: Wesselius LJ, Kummet TD. December 2012 pulmonary case of the month: applying genetics. Southwest J Pulm Crit Care 2012;5:272-8. PDF

November 2012 Pulmonary Case of the Month: The Wolves Are at the Door

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 49 year old female was admitted for hypoxia, lethargy, and an abnormal chest x-ray. She was recently discharged after a 10 day outside hospital stay for a diagnosis of pneumonia treated initially with azithromycin, then clindamycin and discharged on levofloxacin. Corticosteroids given during that hospitalization and she was discharged on taper. As the steroids were tapered, she had increasing dyspnea, confusion, and lethargy. She presented to the emergency room with an abnormal CT chest x-ray and was started on meropenem, vancomycin and azithromycin, and was also given IV methylprednisolone (125 mg initial dose).

PMH, FH and SH

She had her first stroke at age 18 and walks with a cane and has some expressive aphasia. There were multiple prior episodes of pneumonia (25 in 5 years). She was diagnosed with systemic lupus erythematosis (SLE) with lupus pneumonitis (based on surgical lung biopsy) about 3-4 years prior to admission. She had a St. Jude mitral valve replacement 12 years ago and had suffered a hemorrhagic stroke presumed secondary to anticoagulation. There is also a history of nephrolithiasis and recurrent urinary tract infections and anemia with multiple prior transfusions.

Her mother died at 49 reportedly due to complications of SLE.

Physical Examination

• Temperature 37.1° C;  Blood Pressure127/75 mm Hg;  Pulse 80 beats/min; SaO2 96% on 3 LPM
• HEENT: no significant abnormalities identified
• Chest: clear to auscultation and percussion
• Cardiovascular: mechanical click, no murmur
• Extremities: trace edema

Laboratory Evaluation

• Hemoglobin 10.1 g/dL   WBC  11,900  cells/μL   Platelets 137,000 cells/μL  
• INR 2.62
• Creatinine 0.9 mg/dL  BUN 15 mmol/L
• N-terminal pro-brain natriuretic peptide (NT pro-BNP) 1,294 pg/ml
• C-reactive protein (CRP) 74.7 mg/L 
• Erythrocyte sedimentation rate (ESR) 14 mm/hr
• Drug Screen:  negative

Chest X-ray

Her chest x-ray is shown below (Figure 1).

Figure 1. Portable chest radiography at the time of admission.

Which of the following are pulmonary complications of SLE?

1. Pleuritis
2. Chronic interstitial pneumonitis
3. Acute lupus pneumonitis
4. Pulmonary hypertension
5. All of the above

Reference as: Wesselius LJ. November 2012 pulmonary case of the month: the wolves are at the door. Southwest J Pulm Crit Care 2012;5: 223-8. PDF