A 29-year-old woman with a history of asthma presents with progressive worsening of respiratory function. She reports that her symptoms have developed gradually over the past few months, with occasional fevers and episodes of mild hemoptysis. She denies any weight loss, skin changes, or diarrhea. Her medications include inhaled albuterol as needed and OCPs. She has no family history of cancer, no recent travel, and no recent sick contacts. She works as an accountant and does not smoke or use any illicit drugs. On examination, she has a low-grade fever with scattered wheezes and rhonchi over bilateral lung fields. After coughing vigorously, a brown mucus plug is expectorated. Her laboratory values show eosinophilia with an elevated total serum IgE. A chest x-ray shows interstitial infiltrates in the upper lobes with some areas of atelectasis bilaterally, and a CT scan shows enlarged airways primarily in the upper lobes with bronchial wall thickening.
Which of the following is the most likely diagnosis?
Allergic bronchopulmonary aspergillosis. The key to answering this question is knowing what conditions are associated with an underlying diagnosis of asthma. Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus colonization in the bronchi. These patients may develop worsening respiratory function with hemoptysis, and can eventually develop bronchiectasis, which was seen on this patient’s CT scan. Be suspicious about this diagnosis in patients with asthma, peripheral eosinophilia, and elevated IgE, and imaging findings of lung infiltrates and bronchiectasis. Diagnosis is further suggested by a skin prick test to assess for reactivity to Aspergillus antigens. Treatment is with systemic glucocorticoids and itraconazole.
Other important associations with asthma include aspirin allergy (asthma with sensitivity to aspirin and nasal polyps), Churg–Strauss (asthma with vasculitis), and the atopic triad (asthma with eczema and allergic rhinitis). (A) The patient has no risk factors for tuberculosis, and this would not present with eosinophilia and enlarged airways (chronic untreated tuberculosis could cause airway destruction and bronchiectasis, but an acute infection would not). (B) Pseudomonas is a common cause of pulmonary infection in cystic fibrosis patients, but this patient lacks other findings that suggest cystic fibrosis (pancreatic insufficiency, family history, etc.). (C) Strongyloides stercoralis is a parasitic nematode that can penetrate the skin and migrate to the lungs, resulting in wheezing and coughing. Eosinophilia and elevated IgE may be seen in parasitic infections; however, she has no apparent risk factors for S. stercoralis and the CT scan is consistent with ABPA, not S. stercoralis infection. (E) Carcinoid syndrome is caused by a neuroendocrine tumor that is usually in the GI tract or bronchus. There is a lower rate of carcinoid syndrome in bronchial tumors than in GI tumors due to less production of serotonin and other vasoactive amines. Other symptoms of carcinoid syndrome include cutaneous flushing and diarrhea. Infiltrates and bronchiectasis on imaging cannot be explained solely by worsening asthma.
A 52-year-old man is hospitalized for an acute COPD exacerbation and agrees to treatment with 3 days of IV methylprednisolone followed by a taper of oral prednisone over 10 days.
Which of the following is this patient most likely to experience as a potential adverse effect of these medications?
Hyperglycemia. Systemic corticosteroids have a long list of adverse effects when used chronically; however, there is debate as to the frequency of adverse effects when used over a short period of time. All of the answer choices are potential consequences of chronic therapy, but the one answer choice that most commonly occurs with a short course of steroids is hyperglycemia. Other notable side effects of chronic steroids (i.e., iatrogenic Cushing syndrome) are cataracts, dyslipidemia, pancreatitis, hypokalemia, and VZV reactivation (herpes zoster).
A 59-year-old woman with a history of hypertension and COPD presents to the hospital with shortness of breath. She recently visited her grandchildren and noticed several days later that her chronic cough became worse with an increase in yellow sputum production. She has also had to decrease her activities because of worsening dyspnea with any exertion. Her medications include hydrochlorothiazide, tiotropium, and inhaled albuterol and ipratropium as needed. She has a temperature of 37.6°C, blood pressure of 138/88 mmHg, heart rate of 96 beats per minute, respiratory rate of 28 breaths per minute, and oxygen saturation of 87% on room air. She is anxious and is using respiratory accessory muscles to breathe. There is hyper-resonance to percussion along both lung fields with wheezes and rhonchi heard bilaterally. Cardiac examination, as well as the rest of the physical examination, is unremarkable. The patient is admitted and her chest x-ray is shown in Figure below.
Which of the following is NOT an appropriate first-line treatment for the patient at this time?
Inhaled corticosteroids. This patient is presenting with a history of COPD with an acute exacerbation, which is defined as an increase in any of the chronic symptoms of COPD (increased frequency/ severity of cough, increased dyspnea, or increased sputum amount or change in color). The majority of acute exacerbations are caused by respiratory infections, with common etiologies including viruses, Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, and Pseudomonas aeruginosa. Any other process involving the lungs can cause an exacerbation, including heart disease, environmental/toxic exposures, and pulmonary embolism. The chest x-ray above shows hyperinflated lungs with flattening of the diaphragm and elongation of the heart border, which is consistent with her diagnosis of COPD.
(A, B, C) Management of acute COPD exacerbations should be differentiated from the management of chronic disease. Important therapies during an exacerbation include oxygen administration targeting an SaO2 of 90% to 94% (dependent on whether or not they are a chronic CO2-retainer), inhaled bronchodilators (anticholinergics and β2 agonists), systemic corticosteroids (prednisone or methylprednisolone), and antibiotics. Antibiotics such as amoxicillin show some benefit in COPD exacerbations, although the type of antibiotic does not matter unless a specific organism can be targeted. (D) Although inhaled corticosteroids are useful in the chronic treatment of COPD, there is no evidence for their use in acute exacerbations and should not be used instead of systemic corticosteroids.
A 29-year-old man is diagnosed with testicular cancer and undergoes orchiectomy. He is followed afterward, and the cancer recurs. He elects to undergo treatment with bleomycin, etoposide, and cisplatin for four cycles. Several months after finishing chemotherapy, he returns for follow-up. On examination, he has bilateral dry crackles over both lung fields. His laboratory values are significant for a hemoglobin of 9.4 g/dL and a creatinine of 2.4 mg/dL (baseline 1.1 mg/dL).
Which of the following is most likely responsible for the lung findings on examination?
Bleomycin. Bleomycin is an antineoplastic antibiotic used in the treatment of many cancers including testicular cancer, Hodgkin lymphoma, and squamous cell carcinomas. A very common and important adverse effect of this drug is pulmonary fibrosis, which is concerning in this patient given the diffuse dry crackles on lung examination. Other adverse effects include hepatotoxicity and nephrotoxicity. This patient also has anemia and renal failure, which are potential adverse effects of all three of the antineoplastic drugs in the answer choices. It is important to remember the other iatrogenic causes of pulmonary fibrosis, which include amiodarone, thiazides, isoniazid, cyclophosphamide, methotrexate, and radiation therapy. (A) Tumor metastases to the lungs would not cause the findings on examination in this patient. (C) Etoposide is another antineoplastic drug that acts as a topoisomerase inhibitor with adverse effects including congestive heart failure and Stevens–Johnson syndrome. (D) Cisplatin is a platinum-based antineoplastic drug with important toxicities that include neuropathy and nephrotoxicity.
A 57-year-old woman presents to the hospital with shortness of breath. Her medical history is significant for seasonal allergies and hypertension, with no personal or family history of heart disease. She has smoked 2 packs of cigarettes daily for the past 20 years. During hospitalization, she is treated with oxygen, steroids, and bronchodilators. She is discharged and follows up as an outpatient to get pulmonary function tests, which are shown below.
Chronic obstructive pulmonary disease. It is very important to know how to interpret pulmonary function tests for the Internal Medicine shelf examination. This woman has a smoking history and presented to the hospital with dyspnea that resolved with oxygen, bronchodilators, and steroids, making an obstructive lung disease a likely diagnosis. On spirometry, obstructive lung diseases will typically present with an FEV1/FVC ratio less than 0.70. Once this is established, asthma can be differentiated from COPD by administering a bronchodilator and seeing the response in FEV1. If the FEV1 improves by >12%, then the diagnosis is asthma. This patient had an FEV1 that improved by 6%, and therefore she has COPD. DLCO measures how much carbon monoxide diffuses into the blood after inhalation of a small sample. Diseases that decrease the functional surface area of gas exchange will have a decreased DLCO. This patient has a decreased DLCO, indicating that she has both a chronic bronchitis component as well as an emphysematous component, since the parenchymal destruction that accompanies emphysema will decrease the surface area for gas exchange and cause diffusion impairment. Table below presents a summary to distinguish between obstructive and restrictive patterns on pulmonary function testing.
(A) Neuromuscular disorders can cause fatigue and hypercapnic respiratory failure. These patients will have a restrictive pattern on spirometry with a normal DLCO. (B) Asthma would be the correct answer if the patient’s FEV1 increased by >12% after albuterol, and the DLCO was normal. (D) Interstitial lung disease would present with a restrictive pattern and a decreased DLCO.
Obstructive and Restrictive Patterns on Pulmonary Function Testing:
Click to expand