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A 51-year-old female transferred to Johns Hopkins with shortness of breath, nonproductive cough, and wheezing.
History of Present IllnessThe patient is a 51-year-old female with a history of asthma, first diagnosed two years ago. She has had multiple exacerbations of her asthma, causing approximately 15 hospitalizations since diagnosis. Her asthma typically responds to high dose intravenous and oral steroids but she has limited control with inhalers, nebulizers and theophylline. She has been requiring oral corticosteroids to control her asthma symptoms for the past year.
The patient presented to the emergency department at an outside hospital for sudden onset of shortness of breath, nonproductive cough, and wheezing. Her symptoms did not resolve with use of home medications. She was started on oxygen, IV steroids, and antibiotics and then transferred to The Johns Hopkins Hospital for further asthma management.
Review of SymptomsThe patient reports increased fatigue and 50 lb weight gain over past year. The patient denies fever, chills, night sweats. She denies chest pain, hemoptysis, sore throat.
Past Medical HistoryObesity, Diabetes mellitus, Hypertension, Gastroesophageal reflux disease (all chronic conditions).
Past Surgical History* Tonsillectomy/Adenoidectomy (remote)
* Total abdominal hysterectomy (remote, benign pathology)
* Appendectomy (remote)
* Cholecystectomy (remote)
Mild tobacco use for 6 months as a youth, no occupational exposure, denies home asthma triggers, no pets.
Family HistoryNone
AllergiesPenicillin (tongue swelling), Bactrim (rash), Keflex (rash), Codeine, Glucophage, Hydrochlorothiazide (cough), ACE inhibitors (cough)
Medications* Albuterol/Atrovent nebulizers q4hr
* Theophylline 300 mg bid
* Singulair 10mg po qd
* Prednisone 120 mg po qd
* Diltiazem 300 mg qd
* Losartan 100 mg qd
* Clonidine 0.2 mg po bid
* Trazodone 50 mg po qhs
* Guaifenesin 1200 mg po bid
* Pantoprazole 40 mg po bid
* Glipizide 10 mg po bid
* General: Obese female with moon facies, truncal obesity, audible
wheezing
* Vital signs: T 38.4C, BP 176/94, P 100, R 22 (sat 94% on 3L O2)
* Head/Neck: Oral thrush, otherwise normal
* Chest: Expiratory wheezing throughout, stridor, no crackles/rhonchi
* Cardiac: Mild tachycardia
* Abdomen: obese, otherwise normal
* GU: WNL
* Skin: WNL
* Neurological: WNL
WBC 16, 000, HCT 43, Na 139, K 3.5, Cl 98, bicarbonate 30, BUN 24, Cr 0.6, glucose 308, TSH 0.06, T4 5.8, T3 0.43
Pulmonary Function Tests - FEV1 0.98 (48%), FVC 1.21 (48%), FEV1/FVC 80, TLC 2.2 (57%), RV 1.04 (77%)
Radiologic StudiesChest X-ray: patchy infiltrates in bilateral mid lung zones (Figure 1A, 1B)
Chest CT - large substernal goiter narrowing upper trachea; right middle lobe of lung shows subtle nodular infiltrate, ground glass infiltrates in lingula and left lower lobe; small pericardial effusion (Figure 2A, 2B, 2C).
Echocardiogram - 60-65% ejection fraction, mildly dilated left atrium and ventricle.
Clinical CourseFollowing transfer to JHH, the patient appeared to improve slightly on high dose IV steroids and continued empiric antibiotics for community acquired pneumonia. Flexible laryngoscopy showed moderate interarytenoid edema, but was otherwise normal. She remained tachypneic and hypoxemic requiring supplemental oxygen. One morning soon after admission, the patient was found on the floor of the bathroom of her room unresponsive. Despite resuscitative efforts, she expired. An autopsy was performed.
QuestionsWhat is the most likely cause of the patient's respiratory symptoms and her radiographic infiltrates?
What is the most likely cause of the patient's demise?
Images Click on an image below to enlarge.
Figure 1a |
Figure 1b |
Figure 2a |
Figure 2b |
Figure 2c |
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