An Unusual Case of Granulomatous Lung Disease: A Clinical Pathology Conference Held by the Department of Rheumatology at Hospital for Special Surgery

Abstract

A 28-year-old Hispanic female was transferred to New York Presbyterian Hospital in December for pneumonia, unresponsive to antibiotics. She had been in her usual state of health until the preceding summer, when she developed progressive shortness of breath and a cough. Her cough was initially nonproductive, but she eventually developed blood-tinged green sputum, pleuritic chest pain, and persistent fevers and chills. The patient was admitted to an outside hospital in the fall, but left against medical advice and was readmitted 2 months later. An admission arterial blood gas demonstrated a pH of 7.50, PaCO2 of 43 mm Hg and PaO2 of 68 mm Hg on 28% inspired oxygen. A chest film revealed bilateral lower lobe infiltrates and effusions, and a chest computed tomography (CT) scan showed diffuse bilateral airspace disease. Over the course of her admission, the patient was treated with multiple antibiotics including vancomycin, levofloxacin, meropenem, imipenem, linezolid, and amikacin, without significant response. She was ultimately transferred to our institution for further diagnostic workup and treatment. Review of systems upon transfer was notable for a 20-lb weight loss over 2 months, intermittent nausea and vomiting, and mild frontal headaches. She also described bilateral eye pain and redness occurring over the summer, which had resolved spontaneously. The patient had no history of alopecia, rash, oral ulcers, photosensitivity, myalgias, parasthesias, focal weakness, or Raynaud’s symptoms. She had occasional arthralgias, but no morning stiffness. Her medical history was remarkable for morbid obesity, chronic anemia with sickle cell and thalassemia traits, cholelithiasis, and recurrent upper respiratory infections occurring two to three times per year. She had undergone three previous Caesarian sections and had no history of spontaneous pregnancy loss. The patient was single with two living children and studying to be a medical assistant. She had no history of alcohol, tobacco, or illicit drug use, no pets, and no sick contacts. Her last travel was to Puerto Rico at age 11. A tuberculosis purified protein derivative (PPD) skin test yielded negative results 5 years prior to admission, and a test for human immunodeficiency virus (HIV) was also negative. Her family history was remarkable for parents with diabetes and hypertension, a father with alcohol abuse, and a sister with latent tuberculosis, who reportedly completed treatment with isoniazid. She had no known family history of pulmonary or connective tissue disease, and no known drug allergies. Upon transfer to our institution, her medications were imipenem, linezolid, amikacin, prevacid, lopressor, albuterol and atrovent via nebulizer, subcutaneous heparin, and insulin on a sliding scale. Physical examination revealed an obese Hispanic female in moderate respiratory distress. She was febrile (39.6-C) with a heart rate of 106 beats/min and blood pressure of 127/85 mm Hg. She was tachypneic with a respiratory rate of 20 breaths/min and an oxygen saturation of 96% on a 40% face mask. Her cardiopulmonary exam was notable for a grade II/VI systolic murmur and scattered coarse rales throughout both lung fields. Her abdomen was obese but benign, her extremities were without edema and had strong pulses, her skin was without rashes, and her joints exhibited full range of motion without warmth, synovitis, or effusion. Her neurologic exam was unremarkHSSJ (2006) 2: 191–197 DOI 10.1007/s11420-006-9009-0