A 54-year old man was admitted to the Johns Hopkins Hospital for evaluation of cough and shortness of breath.

The patient is a 54-year old man who presents to JHH with one week of worsening cough and shortness of breath.

Two months prior to admission, he was evaluated at an outside facility for cough and sinus congestion. He was treated with a 10-day course of antibiotics. When there was no improvement, a chest radiograph was taken and demonstrated bilateral abnormalities. He was told he had bronchitis and another 10-day course of antibiotics was prescribed. After completing that second course of antibiotics, the patient remained symptomatic and he was told his radiograph was worse. He was admitted to the hospital where he received a chest CT scan, echocardiogram, PPD (negative), and pulmonary function tests. While he does not know what treatments he received, he felt better and was discharged after 5 days in the hospital. He does recall being told that his radiographic infiltrates were in the upper lobes of his lungs and that a sinus CT showed diffuse abnormalities.

Since discharge, his symptoms have gradually returned. He reports a dry generally non-productive cough, marked dyspnea on exertion within 25-50 feet without audible wheezing, occasional night sweats, and anorexia with a 5 pound weight loss. He has not taken his temperature to document fevers. He has occasional sharp left upper chest pain that is worse with inspiration. There is no history of hemoptysis, loss of consciousness, exertional chest pain, orthopnea, or PND.

The patient has no significant respiratory history; he denies asthma, pneumonia, sputum production, allergic rhinitis, or prior dyspnea. He has a 25 year history of smoking but quit with his first respiratory symptoms 2 months ago.

He now seeks another opinion at JHH.

No past history of cardiac, gastrointestinal, autoimmune, neurological disorders.

None

Father died of myocardial infarction at 74. He has two children in the 20's that are healthy.

He lives on the Eastern Shore with his wife and works as an airline pilot. His flights are all domestic but include the Midwest and California. He has had no recent foreign travel. He denies use of alcohol or illicit drugs. His hobbies include horseback riding; he owns a horse that he keeps on his property.

None on admission. Prior to his respiratory illness he'd taken no medications. He'd received two courses of undetermined treatment at the outside hospital.

Azithromycin (rash)

Non-contributory. Prior to this illness he had no significant symptoms and led an active lifestyle.

• The patient is a well-nourished male in no acute distress
• Vital signs: T=96.9 C, HR=87, RR=24, BP=145/79, O2 saturation 92% on room air, falls to 85% with ambulation
• Head and neck: Pupils equal, round and reactive, extraocular movements intact, oropharynx clear without erythema or exudates, shotty (<1cm) bilateral cervical lymphadenopathy that is nontender; nasopharynx injected without polyps
• Lungs: Normal respiratory excursion bilaterally. No paradoxical respiration or accessory muscle use at rest. Pan-inspiratory crackles in right and left mid-lung region and right lung base. No wheezes. No dullness to percussion or tactile fremitus.
• Cardiovascular: Regular rate and rhythm, I-II/VI systolic ejection murmur at left upper sternal border, normal JVP and PMI, no gallops
• Abdomen: Soft and nontender, no hepatosplenomegaly, bowel sounds present, stool heme negative.
• Extremities: No edema, 2+ peripheral pulses

WBC 9.6 (12% Lymphocytes, 3% Monocytes, 65% PMNs, 19% Eosinophils), Hct 43%, Plt 183, Na 140, K 4, Cl 103, C02 23, BUN 7, Creatinine 1.1, Ca 8.6, troponin <0.06, ESR 110, C-reactive protein 20.8. Urine analysis showed no cells, casts, or protein.

Normal sinus rhythm @ 75 bpm, normal axis, no ST-T wave changes

A chest x-ray showed marked bilateral middle lobe infiltrates. A chest CT showed patchy alveolar filling and ground-glass opacities in both lungs, diffuse but irregular in distribution. In addition, there was mediastinal and bilateral hilar lymphadenopathy with some nodes measuring >2 cm (Images 1-4).

The patient received trimethoprim-sulfamethoxazole and gatifloxacin in the emergency department. Following admission, the pulmonary team was consulted. After a diagnostic procedure and treatment was instituted, there was marked improvement in all radiologic findings (Image 5).

What is your differential diagnosis?
What was the procedure for evaluation of the abnormal findings?
What was the treatment?