Case 4: 72 Year Old Male
MALE, 72 YEARS OF AGE
History of diabetes, recently developed a cough.
Ex-smoker, 25 pack-years.
Physical Exam & Review
of Symptoms
Case Review
- Male, 72 years of age.
- History of diabetes recently developed a cough.
- Ex-smoker, 25 pack-years.
- Completed comprehensive medical exam, family, social, and medical history
Key Findings
- Has restrictive pattern on PFTs
- Positive Cladosporium
- HRCT features: ground-glass; traction bronchiectasis
- Histopathology: poorly formed granulomas; bronchiolocentric with UIP
Patient history
Past Medical/Surgical History
- Diabetes
- Hypertension
- Erectile dysfunction
- No Family History noted
- Married
- 25-pack-year smoker, quit 2 years ago
- Social ETOH, No Drug use
- Works at a sugar mill
Medications Prescribed Prior to Initial Visit
- Oral antihyperglycemic medication
- Angiotensin-converting enzyme (ACE) inhibitor
- Fish oil
- Vitamin D
- Erectile dysfunction medication (Phosphodiesterase-5 inhibitor)
HRCT
Your radiologist tells you the CT scan has the following features:
Images courtesy of and used with permission from Steven Nathan. MD.
Physical Exam & Review
of Symptoms
Physical Exam
- BP: 140/88 mmHg, HR: 76, RR: 20
- Temperature: 98.6
- Weight: 189 lbs
- Height: 5’10”
- SpO2: 95%
- Well appearing
- Lungs: scattered end-inspiratory crackles
- Physical exam unremarkable
PFTs
- FVC 2.00 (44%)
- FEV1 1.78 (58%)
- FEV1/FVC Ratio 125%
- TLC 3.41 (50%)
- VC 2.42 (46%)
- RV 1.27 (49%)
- DLCO 11.40 (50%)
Surgical lung biopsy
Images courtesy of and used with permission from Vijayalakshmi Ananthanarayanan, MD.
VATS Pathology
- Poorly formed granulomas/ bronchiolocentric with UIP based on Inflammatory cellular infiltrates with widened interstitial space.
Additional note from the pathologist:
NOTE: Loose, ill-formed, interstitial and peribronchiolar granulomas with background of inflammation.
Serology Testing
Serologies
- Specific immunoglobulin panel
- positive
- Cyclic citrullinated peptide (CCP) - negative
- Rheumatoid factor (RF) - normal
- Sjögren's syndrome-A (anti-Ro; SS-A) - negative
- Sjögren's syndrome-B (anti-La; SS-B) - negative
- Anti-nuclear antibody (ANA) - negative
- Scleroderma-70 (SCL-70; Topoisomerase I) - negative
Additional Information about pos immunoglobulin panel:
- Positive Cladosporium: 5 times normal
Case study courtesy of and used with permission from Marilyn Glassberg, MD.
Which is the correct
Diagnosis?
Sarcoidosis
Rheumatoid Arthritis
Hypersensitivity Pneumonitis
IPF
Correct!
Hypersensitivity Pneumonitis
This is correct!
Incorrect!
Idiopathic Pulmonary Fibrosis
While the smoking history and age are consistent with an lPF diagnosis, the upper lung process in HRCT is inconsistent with UIP/IPF.
Incorrect!
Rheumatoid Arthritis
The patient had negative CCP and RF antibodies, both of which are associated with rheumatoid arthritis. Further, the patient had no joint involvement or other signs and symptoms of rheumatoid arthritis.
Incorrect!
Sarcoidosis
While the HRCT indicates upper-lung process, the fibrotic pattern is not typical of sarcoidosis, in which nodules and/or conglomerate masses are evident. Furthermore, there are no nodular lesions in SLB.
Find out the answer
Hypersensitivity Pneumonitis