May 2012 Pulmonary Case of the Month: Things Are Not Always as They Seem

Lewis J. Wesselius, MD

Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 69 year old woman was seen for side effects of corticosteroids. She is a winter visitor to Arizona. She was hospitalized in March 2008 with increased dyspnea and cough and had an abnormal CT chest. A VATS lung biopsy was performed. The pathology of the lung biopsy interpreted as bronchiolitis obliterans. She was started on prednisone 60 mg/day.

Subsequently, she returned to Minnesota and was seen by rheumatologist with a diagnosis made of possible rheumatoid arthritis. She was treated with methotrexate (12.5 mg weekly) and continued prednisone at 20 mg/day from 2008 to 2011.  At that time a question was raised of methotrexate lung toxicity and it was stopped but she continued on prednisone 20 to 40 mg/day.  She is currently having issues with steroid side effects and seen for a second opinion.

PMH, SH and FH

She has a history of knee and other joint pains.  She had knee replacement surgery in Jan 2008 with worsening of her dyspnea and cough.  She has a history of diabetes which was apparently induced by the corticosteroids. Her current medications include prednisone 20 mg/day, insulin, metformin, lovastatin. She is a former smoker with 25 pack-years but quit 25 years ago. She has no family history of lung disease.

Physical Examination

She was an obese woman appearing somewhat Cushingoid in no acute distress. On chest auscultation she had diminished breath sounds but no crackles or wheezes. Examination of her joints revealed no abnormalities. The remainder of her physical examination was normal.

Chest X-ray

Her chest x-ray was interpreted as normal.

Which of the following are indicated?

1. Pulmonary function testing
2. Pulmonary CT scanning
3. Rheumatologic evaluation
4. Repeat of open lung biopsy
5. All of the above

Reference as: Wesselius LJ. May 2012 pulmonary case of the month: things are not always as they seem. Southwest J Pulm Crit Care 2012;4:142-8. (Click here for a PDF version of the case)