April 2014 Pulmonary Case of the Month: DIP-What?

Lewis Wesselius MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 53 year old woman from Indiana was seen who had a history of nonproductive cough for several years.  She had a prior diagnosis of asthma but continued to have cough despite asthma treatment.  She was also treated for gastroesophageal reflux and had a Nissen fundoplication.  This resolved in some improvement in the cough. In May 2013 she noted increasing dyspnea on exertion.

An echocardiogram was performed which was notable for a 16% left ventricular ejection fraction. A thoracic CT demonstrated some nodules and a question was raised of sarcoidosis. She was admitted to a hospital in Indiana and had a biventricular pacemaker placed. Bronchoscopy with transbronchial biopsy was performed with no diagnostic findings. No granulomas were seen on the biopsy. Bronchoalveolar lavage showed a CD4/CD8 ration of 0.84. Optic nerve swelling was noted at that time. Due to the cardiac, pulmonary, and optic nerve findings a clinical diagnosis of sarcoidosis with a dilated cardiomyopathy was made and she was treated with prednisone initially, then a combination of prednisone and methotrexate.

PMH, FH, SH

Her past medical history was as above and family history was noncontributory. She does not smoke or drink.

Medications

• Methotrexate 15 mg weekly
• Prednisone 5 mg daily
• Furosemide 40 mg daily
• Potassium chloride 20 meq daily

Physical Examination

Afebrile. SpO2 96% on room air. The physical exam was unremarkable.

Which of the following should be performed at this time?

1. Pulmonary function testing
2. Repeat echocardiogram
3. Repeat thoracic CT scan
4. 1 and 3
5. All of the above

Reference as: Wesselius LJ. April 2014 pulmonary case of the month: DIP-what? Southwest J Pulm Crit Care. 2014;8(4):195-203. doi: http://dx.doi.org/10.13175/swjpcc024-14 PDF