Mystery Quiz

June 16, 2011

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 62 year old man presenting with increasing breathlessness for the past six weeks. The patient first noted symptoms of mild shortness of breath and cough productive of yellow sputum that he attributed to his yearly winter cold. The sputum cleared and at presentation the patient had largely unproductive cough. A construction worker until six months earlier, the patient’s unlimited exercise tolerance was now limited to minimal exertion. He denied current fever, hemoptysis, night sweats, arthralgias, rash, and exposure to people with TB, but did note recent bilateral ankle swelling. The patient denied recent travel. Upon further questioning, the patient said that he maintained up to twenty finches in his apartment and had kept them until two weeks prior to admission. The patient had a 45 pack year smoking history but stopped 2 weeks earlier due to worsening shortness of breath. On exam, the patient was tachypneic at rest with pulse oximetry showing 90% saturation while breathing ambient air, a heart rate of 110 bpm and a chest exam that was unremarkable.

CXR and Chest CT are shown below:

 


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3 Responses to Mystery Quiz

  1. Jonathan Young on June 8, 2011 at 9:13 am

    The subacute development of pulmonary symptoms coupled with interstitial
    infiltrative pattern on CXR and CT favors some form of atypical pneumonia.
    The pattern does not resemble CHF, and the time course of development + imaging features makes silicosis and pneumoconiosis less likely.
    There are no mediastinal lymphadenopathies characteristic of sarcoidosis or lymphoma.
    According to contact history, psittacosis may be possible but lack of fever is not very typical. IPF and lymphagioma carcinomatosis should still be considered.

  2. R. lalwani on June 8, 2011 at 10:53 am

    1. 6 week of s/s – subacute
    2.no systemic s/s other then cough/sob/ ankle edema
    3.Finches(not a psittacine bird and rare cause for psitticosis)as pet
    4. 45 pack yr smoking, construction work
    5.CT findings centrilobular, not periheral lungs
    Based on above I favor hypersensitivity pneumonitis to bird dropping/feathers/construction work.
    differential includes lymphangitic carcinomatosis ( 2nd choice) and IPF

  3. [...] answer to the mystery quiz is lymphangitic carcinomatosis (LC). The diffuse interstitial and infiltrative pattern seen on CXR [...]

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