June 2014 Pulmonary Case of the Month: "Petrified"

Steven W. Purtle, MD

University of Colorado Hospital, Denver, CO

steven.purtle@ucdenver.edu

History of Present Illness

A 52 year old expatriated Iraqi man presents to pulmonary clinic with complaints of chronic dyspnea. While a young man living in Iraq, he had been disqualified from service in the Iraqi Air Force after a screening chest x-ray was found to be abnormal. He had no respiratory symptoms at the time of his disqualification, and he remained asymptomatic for the next twenty five years. Beginning five years ago, he had an insidious onset of breathlessness and exertional intolerance. Over the past several years, he has developed diffuse pleuritic chest pain, non-productive cough, and fatigue. He denies any fevers, chills, night sweats, arthralgias, rash, or visual symptoms. After moving to Denver, Colorado three years ago, he has developed a continuous oxygen requirement of two liters per minute.

PMH, FH, SH

He has no significant past medical or family history. While living in Iraq, he worked as a photographer, but he is currently unemployed. He is a lifelong non-smoker and uses no illicit drugs. He has never had any pets. He denies any exposure to inorganic dusts.

Medications

None

Physical Examination

Physical examination reveals a thin, middle-aged man in no acute distress. Vital signs were notable for an oxygen saturation of 90% on 2 liters per minute of supplemental oxygen. Pulmonary examination was notable for fine inspiratory crackles heard best at the bilateral bases. There was no clubbing or peripheral edema. The remainder of his physical examination was unremarkable.

Laboratory Analysis

Serum chemistries are within normal limits. Complete blood count shows a normal white blood cell count, hematocrit, and platelet count.

Pulmonary Function Tests

Pulmonary functions tests are shown in Figure 1.

Radiography

A chest x-ray (Figure 2) and chest CT (Figures 3 and 4) were performed.

Figure 2. Admission AP (Panel A) and lateral (Panel B) chest x-ray.

Figure 3. Static thoracic CT images displayed in lung windows (Panels A-D) and soft tissue windows (Panels E-H).

Figure 4. Movies of thoracic CT scan in lung windows (Panel A, top) and soft tissue windows (Panel B, bottom).

Which of the following features best describes the pattern seen on the patient’s chest CT? (Click on the correct answer to proceed to the next panel)

1. Diffuse microcalcifications
2. Honeycombing
3. Mosaicism
4. Patchy ground glass opacifications
5. Pleural plaques

Reference as: Purtle SW. June 2014 pulmonary case of the month: "petrified". Southwest J Pulm Crit Care. 2014;8(6):299-304. doi: http://dx.doi.org/10.13175/swjpcc069-14 PDF