Transcript NYU Medical Grand Rounds Clinical Vignette Karen Kan, MD Class of 2014

NYU Medical Grand Rounds
Clinical Vignette
Karen Kan, MD
Class of 2014
February 26, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 49 year old non-smoking,
Bangladeshi woman who presents
with 3 years of dyspnea on exertion
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Lived on a rural farm in Bangladesh
• Responsible for cooking and domestic
chores
• Dyspnea on exertion began 3 years
prior to admission
• Daily cough productive of clear sputum
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Dyspnea progressively worsened
• Limiting her exercise tolerance to “a
few blocks”
• Her family brought her to the US and
she subsequently presented to
Bellevue Hospital
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Past Medical & Surgical History: None
• Social History:
• No tobacco, alcohol or drug use
• Originally from Bangladesh
• Lived on a farm with no nearby factories
• Worked indoors cooking for her family
• No family history of pulmonary disease
• Home Medications: None
• No Known Drug Allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• The patient was a well-appearing woman,
in no acute distress
• Vital Signs: 98°F, BP 110/70, HR 60, RR
14 and oxygen saturation 97% on room air
• Her pulmonary exam was notable for mild
bibasilar inspiratory crackles
• The remainder of the exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• Arterial blood gas on room air:
pH 7.48, PaO2 88 mmHg, PaCO2 39 mmHg
• ESR 44 mm/hr (17 mm/hr)
• The CBC, BMP and hepatic panel
were unremarkable
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Chest X-Ray
• Low lung volumes with scattered
small nodules throughout all lung
zones
• Chest CT
• Numerous 2-3 mm irregular
nodules scattered throughout both
lungs, sparing the pleural surface
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Induced Sputums: Negative for AFB
• Pulmonary Function Tests:
• FVC 2.06L (80%), FEV1 1.72L (79%),
FEV1/FVC 83%,
• FRC 2.88L (124%), TLC 3.84L (95%), RV
1.72L (117%)
• Diffusing capacity for CO 22.06 mL/min
mmHg (130%)
• No response to bronchodilators
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Chronic bronchitis from an
environmental exposure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Patient remained in respiratory
isolation until induced sputums were
negative for AFB
• After imaging and spirometry were
performed, she underwent
bronchoscopy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Bronchoscopy showed numerous dark
plaques on the bronchus intermedius
and the BAL was grossly gray in
appearance and had a normal cell
differential
• Transbronchial biopsy specimens
showed anthracosis with thickening of
the basement membrane
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Domestically Acquired Particulate
Lung Disease (DAPLD) or “hut
lung”
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS