Case 4: 72 Year Old Male

Elderly Male Headshot

MALE, 72 YEARS OF AGE

History of diabetes, recently developed a cough.

Ex-smoker, 25 pack-years.

 

Physical Exam & Review
of Symptoms

Patient Medical History Icon

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

Key Findings

  • Has restrictive pattern on PFTs
  • Positive Cladosporium
  • HRCT features: ground-glass; traction bronchiectasis
  • Histopathology: poorly formed granulomas; bronchiolocentric with UIP
Case study courtesy of and used with permission from Marilyn Glassberg, MD.

Patient history

Patient Medical History Icon

Past Medical/Surgical History

  • Diabetes
  • Hypertension
  • Erectile dysfunction
Heart icon blue

Past Social and Family History

  • No Family History noted
  • Married
  • 25-pack-year smoker, quit 2 years ago
  • Social ETOH, No Drug use
  • Works at a sugar mill
Medications Icon

Medications Prescribed Prior to Initial Visit

  • Oral antihyperglycemic medication
  • Angiotensin-converting enzyme (ACE) inhibitor
  • Fish oil
  • Vitamin D
  • Erectile dysfunction medication (Phosphodiesterase-5 inhibitor)
Case study courtesy of and used with permission from Marilyn Glassberg, MD.

HRCT

Bitmap
Low Magnification Photomicrograph Expiratory Features
 
 
 

Your radiologist tells you the CT scan has the following features:

Reticulation air trapping ground glass opacity icon


Images courtesy of and used with permission from Steven Nathan. MD.

Back

Physical Exam & Review
of Symptoms

Physical Exam Icon

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

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%)
Back
Case study courtesy of and used with permission from Marilyn Glassberg, MD.

Surgical lung biopsy

HRCT of Poorly Formed Granulomas / Bronchiolocentric With UIP

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

Serology Icon

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

    Sarcoidosis

  • Rheumatoid Arthritis

    Rheumatoid Arthritis

  • Hypersensitivity Pneumonitis

    Hypersensitivity Pneumonitis

  • IPF

    IPF

Correct!

Correct Icon

Hypersensitivity Pneumonitis

This is correct!

Incorrect!

X icon blue

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.

Select another test

Incorrect!

X icon blue

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.

Select another test

Incorrect!

X icon blue

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.

Select another test

Find out the answer

Final Answer Icon

Hypersensitivity Pneumonitis