February 2012 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Associate Editor Pulmonary

History of Present Illness

A 49 year old female was seen for fever and shortness of breath in December 2011. She has a history of right infiltrating ductal breast cancer diagnosed in 2001 at age 38. Treatment included mastectomy with negative lymph nodes, followed by 4 courses of doxarubicin and cytoxan. She did well until March 2010 when erythema was noted over her right chest.  Biopsy showed adenocarcinoma consistent with  breast carcinoma. The biopsy was “triple negative”, i.e., negative for estrogen receptors, progesterone receptors and Her2. PET scan demonstrated multiple positive lymph nodes in the mediastinum, supraclavicular area and bone metastases. She received radiation to her chest wall and chemotherapy most recently gemcitabine, carboplatin and iniparib. In October 2011 brain metastases were noted and she was started on stereotactic brain radiation and dexamethasone.

Past Medical, Family and Social Histories

• She had a prothrombin mutation noted and was begun prophylactically on warfarin in 2010.
• There was a family history of breast carcinoma.
• She was a non-smoker with no unusual exposures.
• Current medications include omeprazole, metoprolol, and warfarin.

Physical Examination

She was receiving oxygen at 3 L/min by nasal cannula. Temperature was to 37.9°C. She had bilateral crackles on chest auscultation, most prominent at bases. Physical Examination was otherwise noncontributory.

Initial Laboratory Evaluation

• Hemoglobin/Hematocrit 11.8 g/dL/33.9%
• White blood count 5.1 X10⁹/L
• Platelets 64 X 10⁹/L
• INR 1.58 

Chest CT scan

Chest CT scan is in figure 1.

Figure 1. Selected images from the admission CT scan. The CT scan was interpreted as showing diffuse groundglass opacities and scattered centrilobular nodules. 

Which of the following diagnosis are consistent with the patient’s presentation and CT scan?

1. Pulmonary edema
2. Bacterial pneumonia
3. Fungal pneumonia
4. Drug reaction
5. All of the above

Reference as: Wesselius LJ. February 2012 pulmonary case of the month. Southwest J Pulm Crit Care 2012;4:42-7.

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