April 2012 Pulmonary Case of the Month: Could Have Fooled Me!

Bridgett A. Ronan, MD

Robert Viggiano, MD

Lewis J. Wesselius, MD

Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 60 year old man was seen by his primary care physician with cough for 2 weeks which was dry and worse with deep breathing. He had been exposed to smoke from industrial storage fire just prior to the onset of his cough. He had developed fever for the past 3 days.

PMH, SH and FH

He has a history of osteopenia and was found to have a +PPD in high school for which he was never treated with isoniazid. Originally from New York he has lived in Arizona for 14 years. He was a former smoker having a 45 pack-year history having quit in 2007. He drives a delivery truck. His sister had tuberculosis which was treated and his father has emphysema.

Physical Examination

He had mild rhonchi in the right upper lung field. Otherwise, the physical exam was unremarkable.

Laboratory and Chest X-ray

A CBC was performed which revealed a hemoglobin of 11.7 g/dL, white blood cell (WBC) count of 11.9 X 1000 cells/ml with 79% neutrophils, and a platelet count of 337 X 1000/mL. Coccidioidomycosis serologies were drawn. A chest x-ray was taken (Figure 1).

Figure 1. Chest x-ray taken by the patient’s primary care physician which shows bilateral lung consolidations with multiple poorly defined bilateral lung nodules.

Considerations at this point include:

1. Community acquired pneumonia
2. Coccidioidomycosis
3. Tuberculosis
4. Pneumonitis from smoke inhalation
5. Pulmonary embolism
6. All of the above

Reference as: Ronan BA, Vigianno R, Wesselius LJ. April 2012 pulmonary case of the month: could have fooled me! Southwest J Pulm Crit Care 2012;4:122-9. (Click here for a PDF version of the case)