Affiliate NetWork Online Puzzler - July 2009
Online Puzzler
Clinical presentation
The patient is a 76-year-old African-American man referred for evaluation of shortness of breath and cough. His shortness of breath had progressively worsened over the last 2 months. He also had a history of productive cough with clear sputum for 2 months.
Review of systems
No hemoptysis. No orthopnea or paroxysmal nocturnal dyspnea. No fever, chills, night sweats, or weight loss. The patient complained of feeling fatigued for several months.
Past medical and surgical history
- Myelofibrosis diagnosed with bone marrow biopsy in 2000. The patient was initially treated with hydroxyurea for thrombocytosis, but this was discontinued due to severe anemia.
- Prostate cancer diagnosed in 2001 with Gleason 3+4, T2aN0M0 and treated with Zoladex and radiation therapy
- Hypertension
- Diabetes mellitus
Social history
The patient retired after working in the post office. He quit smoking in 1979 and had a prior 25 pack-year smoking history. He has no history of alcohol or drug abuse. He has no history of exposure to animals and has not traveled recently.
Family history
None contributory
Allergies
None
Current medications
- Finasteride
- Simvastatin
- Glyburide, metformin
- Felodipine, losartan, hydrochlorothiazide
- Allopurinol
- Aspirin
Physical examination
BP = 124/78; heart rate = 71; respiratory rate = 18; temperature = 98.2; oxygen saturation on room air = 90%
HEENT: Sinuses are nontender; anicteric sclera
PULM: Basal crackles on inspiration
CV: Regular, with no audible murmurs, rubs, or gallops. No loud P2
ABD: Splenomegaly 3 cm below left costal margin
EXT: No cyanosis, clubbing, or edema
Labs
- WBC count = 6900 μL; hemoglobin = 9.5 g/dL; platelet count = 720 x 103/μL
- Electrolytes within normal limits
- Coagulation profile: normal
- BNP: 34 pg/mL
- Liver function tests: normal, except albumin of 3.2 g/dL
- TSH: Normal
- EKG: Sinus rhythm with no acute ST-T changes
Chest radiographs
The patient’s chest radiographs are shown in Figures 1 and 2.
Figure 1. Chest radiograph, anteroposterior view.
Figure 2. Chest radiograph, lateral view.
Pulmonary function tests
The patient’s pulmonary function test results are shown in Figure 3.
| A |  |
| B |  |
| C | |
| D |
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Figure 3. Pulmonary function tests. A, Lung volumes. B, Spirometry results. C, Diffusing capacity. D, Flow.
Due to the patient’s hypoxemia and restrictive pattern with low diffusion capacity seen on pulmonary function tests, a CT scan of the chest was done (Fig 4).
| A |  |
| B |  |
| C |  |
Figure 4. CT chest. A, B, Interstitial infiltrates. C, Mediastinal adenopathy.
Connective tissue workup was done which yielded negative restults. HIV test results were negative. Additional testing revealed an elevated LDH of 1970 U/L. Flexible bronchoscopy was performed and no endobronchial lesions were seen. A transbronchial needle aspiration was done at station 4R, and a transbronchial lung biopsy was done in the right upper lobe.
The tissue specimens were examined histologically and are shown in Figures 5, 6, 7, and 8.
Figure 5. Pathologic findings of lung tissue showing thickened interstitium with cellular infiltrate (hematoxylin-eosin, original x 40).
Figure 6. Pathologic findings of lung tissue showing megakaryocyte in interstitium (hematoxylin-eosin, original x 100).
Figure 7. Pathologic findings of lung tissue showing erythroid precursor cell and immature myeloid cell (hematoxylin-eosin, original x 400).
Figure 8. Pathologic findings of lung tissue showing myeloid precursors and megakaryocyte (hematoxylin-eosin, original x 400).
Case Puzzlers
- Case Puzzlers are a brief clinical vignette on various educational topics. Developed by members of the American College of Chest Physicians' NetWorks, it provides you an opportunity to sharpen your skills.
