A 47-year-old woman with progressive dyspnea and cough

Abstract

HISTORY OF PRESENT ILLNESS This 47-year-old woman was healthy until 4 years ago. She began to notice dyspnea with physical activities such as biking, hiking, and playing volleyball. She also developed a dry cough. Having had a long history of mild chronic rhinitis attributed to allergies, her cough was attributed to this etiology. Her primary care physician treated her with as-needed oral antihistamines and nasal sprays for approximately 1 year. She was referred to an allergist 3 years ago to rule out asthma. Skin prick tests revealed a weak positive reaction to house-dust mite. Spirometry revealed airflow obstruction that worsened with exercise and only partially reversed with bronchodilator. The patient was diagnosed with asthma and placed on oral albuterol and housedust mite immunotherapy. Because of progression of symptoms to the point of shortness of breath with almost any physical activity and waking up at night with dyspnea, she was referred to a second allergist. A chest radiograph was read as unremarkable. Repeat skin tests were negative, hence she was taken off immunotherapy. Spirometry in June 1999 revealed a forced vital capacity (FVC) of 2.4 L (70% of predicted), forced expiratory volume in 1 second (FEV1) of 1.45 L (55% of predicted), and an FEV1/FVC ratio of 0.60. Obstruction was noted on expiratory loops of the flow-volume curve. Her medications were changed to fluticasone propionate metered-dose inhaler (MDI) and salmeterol MDI. The patient noted only a slight improvement in nighttime dyspnea with the change in medications. Repeat spirometry in December 1999 revealed an FVC of 2.0 L (58% of predicted), FEV1 of 1.1 L (40% of predicted), and an FEV1/FVC ratio of 0.55. An empiric trial of omeprazole for gastroesophageal reflux symptoms did not provide any benefit. Peak expiratory flow rates were always between 200 and 250 L/minute. A computed tomography (CT) scan of sinuses was normal. Six weeks before her presentation at National Jewish Medical and Research Center, the patient had three emergency room (ER) visits within 3 weeks for a flu-like illness associated with worsened dyspnea and productive cough. Her examination at the local ER revealed wheezing and rhonchi. Oxygen saturation was 90% on room air. Chest radiograph showed mild chronic fibrosis but no acute processes. Albuterol nebulizations given in the ER seemed to help. She received courses of levofloxacin and then azithromycin for acute bronchitis. She also received her first prednisone course at this time. She reported feeling somewhat better by the third week of her illness and was continued on 20 mg of prednisone daily, but with no additional improvement. When she presented to the National Jewish Center she reported dyspnea with walking 20 feet, waking up with dyspnea every 3 to 4 hours at night, and feeling tired all the time. She denied fever, weight loss, chest pain, and rashes. She had never smoked in her lifetime. Occasional finger joint stiffness was noted. She reported mild dysphagia with solids during the past year. She reported that respiratory symptoms had been about the same for the previous year with some good days and some bad days.