An Unusual Cause of Cough and Dyspnea in an Immunocompromised Patient (original) (raw)

A 79-Year-Old Man With Dyspnea and a Cold Shock

Chest, 2019

A 79-year-old man was brought to the ED with progressive dyspnea, dizziness, tachycardia, and arterial hypotension, which developed over the last 48 h. Personal medical history revealed past smoking. On presentation, his vital signs were a respiratory rate of 36 breaths/min, heart rate of 130 beats/min, arterial pressure of 90/60 mm Hg, oxygen saturation of 98% breathing oxygen at a flow of 4 L/min, and axillary temperature of 36 C. Physical examination showed a severely distressed patient, with dyspnea, effortful tachypnea, cold and pale skin and mucous membranes, and skin mottling over the thighs and knees. He did not manifest chest or abdominal pain. Cardiac auscultation showed rapid and regular heartbeats, with no audible S3, S4, or murmurs. Peripheral pulses were filiform. Lung auscultation was normal. The abdomen was nontender. Surface ECG showed sinus tachycardia, a 1-mm ST elevation in aVR, and a 1-mm ST depression from V2 to V5. Laboratory data showed a blood hemoglobin level of 8.5 g/dL, a WBC count of 17,000 cells/mL

A 35-Year-Old Man with Chronic Cough and Worsening Dyspnea

NEJM evidence, 2023

Morning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report examines the case of a 35-year-old man who presented to the emergency department with cough and dyspnea on exertion. The cough began 2 years prior and has persisted despite multiple treatment courses of antibiotics. He began to feel dyspneic 1 year ago; it has progressively worsened, and he now has difficulty climbing up a flight of stairs. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a diagnosis is made. Reason for presentation: cough Part 1: The Patient's Story History of Present Illness: A 35-year-old man presented to the emergency department with cough and shortness of breath. The cough began 2 years prior; it was dry and intermittent. Over the past year, he had become short of breath. He initially noticed it only on maximal exertion, but recently, he needed to use a slow walking pace for any distance longer than a few blocks. Since his symptoms began, he had received treatment with antibiotics multiple times for presumed bacterial pneumonia, but the symptoms persisted. He lost 15 pounds over 2 years but had not changed his diet or levels of activity. He had no hemoptysis, fevers, chills, or chest pain. He sought emergency department evaluation because of increasing frequency of coughing episodes and inability to walk up a flight of stairs without feeling short of breath.

51 Year-Old Male with Dyspnea and Hypoxia

Respiratory Medicine CME, 2010

A 51 year-old man presented with 10 days of progressive dyspnea. His symptoms began as an upper respiratory infection, but had progressed to include chills with a cough productive of yellow sputum. He had also developed dyspnea at rest. Initially, moxifloxacin and bronchodilators produced some symptomatic improvement. His past medical history was significant for pulmonary hypertension, confirmed by right heart catheterization four months prior, with a mean PA pressure of 42 mmHg.

An 84-Year-Old Man With Acute Dyspnea and Chronic Radiographic Findings

CHEST Journal, 2013

A n 84-year-old man presented to the ED with acuteonset shortness of breath. He denied cough, sputum production, hemoptysis, wheezing, pleuritic chest pain, fever, leg pain or swelling. He was active and in his normal state of health until the onset of this acute episode of dyspnea. He did not have a history of a recent hospitalization, surgery, or long travel. He denied chronic respiratory symptoms before the current episode. His medical history was unremarkable except for hypothyroidism for which he was taking levothyroxine. The patient had no history of pulmonary TB or fungal infection. He had a 5-pack-year smoking history and quit before age 40 years. He worked as a dental technician for. 40 years. Physical Examination Findings Physical examination revealed a cachectic elderly man in mild respiratory distress. His BP was 111/80 mm Hg; heart rate, 81/min; respiratory rate, 19/min; and pulse oximetry, 98% saturation on 2 L/min oxygen through nasal cannula. He had no clubbing, cyanosis, or lymphadenopathy. Chest auscultation was normal and revealed no adventitious sounds. The rest of his clinical examination was unremarkable. Diagnostic Studies Laboratory investigation revealed a normal blood cell count and basic chemistry panel. Troponin levels were elevated to 0.23 m g/L, and D-dimer was. 20.0 m g/mL fi brinogen equivalent units. ECG showed normal sinus rhythm with right bundle branch block. The admission chest radiograph is shown in Figure 1. CT scan and pulmonary angiogram were performed; representative sections are shown in Figure 2. Three sputum samples were negative for acid-fast bacillus. Tuberculin skin test was negative.

A 67-Year-Old Man With Psoriatic Arthritis and New-Onset Dyspnea

A 67-year-old retired air force officer presented with a 6-month history of nonproductive cough, progressive exertional dyspnea, and weight loss. He was unable to walk beyond 100 m compared with his baseline of unlimited walking distance. He denied fever, hemoptysis, myalgia, or chest pain. He had a 30-year history of chronic plaque psoriasis with arthritis, which was managed by his dermatologist with emollients and vitamin D analogues. Joint involvement had previously been controlled with methotrexate, which was discontinued 15 years ago after resolution of his symptoms. He developed a polyarthritis flare a year ago, and adalimumab was initiated with good response. CHEST 2018; 154(5):e127-e134 Case Presentation The patient was an ex-smoker of 20 pack-years. He denied occupational or environmental exposures, specifically to birds, downy pillows, or mold. He was not taking other medication, including alternative medicine. Examination revealed a well-built gentleman with oxygen saturation of 93% on room air. Widespread fine inspiratory crackles were auscultated. Signs of heart failure were absent. Psoriatic skin and nail changes were present. Chest radiograph revealed interval evolution from mild left lower lobe atelectasis to extensive basal reticulations with lung volume loss in 6 months (Fig 1). Pulmonary function tests demonstrated a restrictive pattern with FEV 1 of 2.38 L (95% predicted), FVC of 2.73 L (78% predicted), FEV 1 /FVC ratio of 87, and diffusion capacity of 82% predicted. The patient walked 480 m on the 6-min walk test without desaturation, with a score of 7 units on the Modified Borg Dyspnea Index Scale. High-resolution CT (HRCT) thorax scan demonstrated bilateral subpleural patchy ground glass changes of upper lobe predominance and lower lobe reticulations with traction bronchiectasis and honeycombing (Fig 2). CBC count with differentials, electrolyte level, creatine kinase level, and urinalysis were unremarkable. Erythrocyte sedimentation rate was 59 mm/h. Antinuclear antibody was 1:640 (homogenous pattern), and anti-double stranded DNA was 532 International Units/mL (normal < 100 International Units/mL). The remaining anti-extractable nuclear antibodies, rheumatoid factor, and anti-cyclic citrullinated peptide antibody tests were negative. Antihistone antibody was 6.1 units (positive > 1.5 units) and myositis panel were positive for anti-signal recognition particle (anti-SRP) and anti-Mi2 antibodies.

A 66-Year-Old Woman With Dry Cough and Exertional Dyspnea

CHEST Journal, 2012

A 66-year-old nonsmoking woman was referred for an outpatient pulmonary evaluation because of dry cough and exertional dyspnea. Symptoms began 2 years previously and worsened slowly but progressively. Her clinical history was otherwise unremarkable. She was a housewife and had no environmental or drug exposure. Her primary care physician gave her antiesophageal refl ux medication and inhaled b 2 agonists with no improvement of the respiratory complaints. Physical Examination The patient's vital signs at rest were as follows: heart rate, 78/min (regular); respiratory rate, 16 breaths/min; oxygen saturation, 97% on room air; temperature, 36.6°C. Her BMI was 29. Chest examination revealed bilateral expiratory wheezes. The patient's oxygen saturation dropped to 90% after walking for 200 m on fl at ground. The remainder of the physical examination results were normal. Laboratory Findings Hemogram, blood chemistry, and urine studies on admission were within normal limits. Spirometry demonstrated an obstructive ventilatory defect char