Dyspnea and Multiple Pulmonary Nodules

Abstract

Dr. Adam Levine: Today's case is that of a 67-year-old man, a retired physician of Indian origin, who was referred to the emergency department (ED) by his primary care physician for a 2-day history of increasing shortness of breath and an outpatient computed tomography (CT) scan that showed multiple pulmonary nodules. The patient stated that he was well until 2 months previously, when he acutely developed lower back pain. His primary care physician ordered magnetic resonance imaging (MRI) of the lumbar spine, which showed L2/3 spinal stenosis. The patient subsequently received steroid injections on two occasions. Of note, he reported receiving significant dental work during the same time period. A week after the spinal injections, the patient developed a low grade fever and night sweats. He began to suffer from continuous back pain and stiffness as well as pain in the pelvic girdle. The primary care physician noted an erythrocyte sedimentation rate (ESR) of 70 mm/hour and diagnosed him with polymyalgia rheumatica. She started him on 20 mg prednisolone QD (daily), but the patient noticed no substantial improvement after 1 week's use. He subsequently developed jaw pain and was referred to a rheumatologist, who diagnosed him with temporal arteritis and increased the dose of prednisolone to 60 mg QD. The fever subsided and the lethargy seemed to improve. However, 1 month preceding presentation to the ED, the patient became increasingly lethargic and lost 10–12 pounds. He developed dyspnea on exertion as well as a non-productive cough. The lethargy and dyspnea were evaluated by a hematologist, who ordered an outpatient chest CT scan and blood cultures. Several days later, the patient's dyspnea worsened acutely. The chest CT scan revealed multiple pulmonary nodules, and blood cultures grew “Gram-positive cocci in chains and pairs.” The patient was advised to proceed directly to the ED.