March 2014 Critical Care Case of the Month: Interstitial Lung Disease

Sunday, March 2, 2014 at 8:00AM
Rick Robbins, M.D. in acute exacerbation, asbestos, bronchoalveolar lavage, cryptogenic organizing pneumonia, exacerbation, glucocorticoids, idiopathic pulmonary fibrosis, interstitial lung disease, mechanical ventilation

Seongseok Yun, MD PhD

Konstantin Mazursky, DO

Kahroba Jahan, MD

Enas Al Zaghal, MD

 

Department of Medicine

University of Arizona

Tucson, AZ 85724

   

History of Present Illness

An 80 year-old man with a history of chronic obstructive pulmonary disease, asbestosis and interstitial lung disease, presented to the outpatient clinic with cough, sinus congestion and mild sputum. He was sent home with amoxicillin for the treatment of a sinus infection. However, he came back to emergency department with worsening respiratory symptoms including shortness of breath and persistent cough. He required 8-10 L/min of oxygen to maintain an oxygen saturation above 90 %.

PMH

• COPD
• Asbestosis
• Interstitial lung disease
• Diabetes mellitus,  type II
• Hypertension
• Aortic valve replacement

Medications

• Fluticasone-salmeterol 250-50 mcg inhaler
• Mometasone 50 mcg/actuation nasal spray
• Furosemide 40 mg PO daily
• Felodipine 5 mg PO BID
• Warfarin 3 mg PO daily
• Insulin aspart 5 units SC injection before meals
• Insulin glargine 15 units SC injection night time

Social History

• 50 pack-year prior smoking history
• No ethanol or recreational drugs
• No recent travel history      

Physical Examination

Vital signs: temperature 37.2 °C, pulse 116 beats/min, respiratory rate 32-34 breaths/min, blood pressure 179/77 mmHg, SpO2 90 % on 10 L/ min non-rebreathing mask (NRB).

General: Alert and oriented but appearing distressed, tachypneic and dyspneic

Skin: Diaphoretic, no rash or lesions noted.

HEENT: Unremarkable.

Respiratory: Diffuse rales but no wheezing or stridor.

CVS: Tachycardic, regular rhythm, soft systolic murmur.

Abdomen: Soft, non-tender, no tenderness, no guarding, no hepato-splenomegaly

Lymph: No cervical lymphadenopathy

Extremities: No peripheral edema, normal tone, normal range of movement  

Laboratory

CBC: WBC 20.2 X 10³ /μL, hemoglobin 9.3 g/dL, hematocrit 29.8 %, platelets 272,000/μL.

Chemistries: Na⁺ 134 meq/L, K⁺ 4.8 meq/L, Cl^- 108 meq/L, CO₂ 19 mmol/L, blood urea nitrogen (BUN) 58 mg/dL, creatinine 1.7 mg/dL, glucose 272 mg/dL, calcium 9.7 mg/dL, albumin 2.2 g/dL, liver function test-within normal limits.

Prothrombin time (PT) 28.0 sec, international normalized ratio (INR) 2.5, partial thromboplastin time (PTT) 44.5 sec

An old chest x-ray and CT scan were reviewed (Figure 1).     

Figure 1. Old PA (panel A) and lateral (Panel B) and representative image from an old CT scan (panel C).

 

Which of the followings are the findings of asbestos related disease on chest x-ray? (click on correct answer to move to next panel)  

1. Reticular or patchy opacity
2. Calcified pleural plaque
3. Bilateral consolidation
4. Pulmonary edema
5. 1 + 2
6. 3 + 4

Reference as: Yun S, Mazursky K, Jahan K, Al Zaghal E. March 2014 ciritcal care case of the month: interstitial lung disease. Southwest J Pulm Crit Care. 2014;8(3):152-60. doi: http://dx.doi.org/10.13175/swjpcc013-14 PDF

Article originally appeared on Southwest Journal of Pulmonary, Critical Care and Sleep (https://www.swjpcc.com/).