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Diagnostic Puzzlers: A case of new-onset wheezing during pregnancy

Diagnostic Puzzlers: A case of new-onset wheezing during pregnancy

A 24-year-old Korean woman, who was 20 weeks' pregnant, was referred to an allergist for an elimination diet and evaluation of the risk of allergies to her unborn child. She had a several-year history of perennial allergic rhinitis with seasonal exacerbations.

One year earlier, she had undergone skin testing; the results were positive for allergy to animal dander, dust mite, and pollens. She took loratadine/pseudoephedrine for 4 months, with good results. Results of skin tests were also positive for allergy to milk and soy, and she had nonbloody diarrhea after ingestion of these foods.

Before her office visit, she discontinued loratadine and reported nonproductive nocturnal cough and wheezing. She denied a history of cardiac problems, asthma, and other lung diseases. She also denied shortness of breath, rhinorrhea, fever, pain, vomiting, rashes, and ankle swelling. She was receiving regular prenatal care and vitamins.

The patient was a nonsmoker, worked as a data entry coordinator, and had a pet rat. Her family history was unknown because she was adopted. Her past medical history revealed mild depression and an allergic reaction to penicillin.

On physical examination, the patient's respiration rate was 16 breaths per minute; heart rate, 93 beats per minute; and blood pressure, 127/81 mm Hg. She was in no distress. Her nasal mucosa was pale, and there was no swelling. She had good respiratory effort, with bilateral lower lobe wheezing on expiration. There were no rales.

Findings from the cardiac examination were normal, and there was no clubbing, cyanosis, or edema. Her abdomen was round and nontender, with normal bowel sounds and no ascites.

Spirometric results were normal: forced vital capacity (FVC) was 81% of predicted; forced expiratory volume in 1 second (FEV1), 84% of predicted; and forced expiratory flow between 25% and 75% of vital capacity (FEF25%-75%), 76% of predicted. After the patient had received 0.5 mg of nebulized albuterol, the FEV1 increased to 87% of predicted and the FEF25%-75% increased by 21%. By the time auscultation was repeated, the wheezing had resolved. Chest radiography was deferred because of pregnancy.

A presumptive diagnosis of asthma was made. She was given 400 µg of budesonide twice daily via a dry-powder inhaler and albuterol, as needed.

At a follow-up visit after 8 weeks, the patient reported mild symptoms of a viral upper respiratory tract infection with cough but no wheezing. Her FEV1 was 88% of predicted. She continued taking budesonide and albuterol (as needed) for 8 weeks. At her follow-up visit, she denied nocturnal cough and wheezing and reported that she had not taken albuterol. This time, her FEV1 was 85% of predicted.

The patient was instructed to continue taking the same medications and to return for follow-up after delivery. One week later (37 weeks' gestation), she presented to her obstetrician, complaining about progressive shortness of breath over the past 4 days, which had not been relieved by taking albuterol. The patient was admitted to the hospital.

On admission, the patient appeared to be in respiratory distress. Her blood pressure was 137/98 mm Hg; pulse rate, 124 beats per minute; and respiration rate, 48 breaths per minute. She had trace peripheral edema. Her lungs were clear to auscultation.

Figure 1 is the patient's preadmission chest radiograph.

What do you suspect? How would you proceed?

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