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Man With Worsening Cough and Dyspnea

Man With Worsening Cough and Dyspnea

A previously healthy 49-year-old man who resides in the central valley area of California presents with a 4-week history of worsening dry, irritating cough and dyspnea. He can barely walk a few steps on level ground and has to sleep propped up.

Chest Film

Chest Film

At the onset of his illness, the patient had fever with rigors and profuse night sweats and felt exhausted. He was evaluated several times at different urgent care centers, and several courses of oral antibiotics were prescribed. These included azithromycin, trimethoprim/sulfamethoxazole, levofloxacin and, most recently, telithromycin. There was little improvement in his symptoms.

The patient has lost 16 lb in the past month and complains of poor appetite. He denies hemoptysis, chest pain, and ankle edema. He has no rash, nausea, vomiting, diarrhea, or abdominal pain. There is no history of headache, vision problems, weakness, paresthesias, syncope, seizures, urinary symptoms, or exposure to persons with tuberculosis or viral syndromes.

The patient is in a monogamous married relationship. He does not smoke, drink alcohol, or use illicit drugs. He has had a pet dog for the past 4 years. There is no history of transfusions, tattoos, or foreign travel.

The patient's mother has diabetes. His father has hypertension and coronary artery disease that are managed with oral medications.

Examination. This well-built, well-nourished man looks chronically ill and is in moderate respiratory distress. His heart rate is 94 beats per minute and regular; temperature, 37.3°C (99.1°F); respiration rate, 28 breaths per minute; and blood pressure, right upper limb, 132/72 mm Hg. Hydration status is good. Examination of the head and neck reveals no icterus, erythema, or evidence of candidal infection. There is no palpable adenopathy.

Respiratory examination reveals normal chest contours and symmetric movement. The trachea is centrally located. The chest is resonant to percussion. Harsh bronchovesicular breath sounds with prolonged expiration and diffuse bilateral wheezing are noted. The jugular vein pulse and the apex beat are normal. Heart sounds are normal with no murmur or gallop. Findings from the remainder of the systemic examination are unremarkable.

Laboratory studies. White blood cell (WBC) count, 9200/µL, with 68% polymorphonuclear leukocytes, 13% lymphocytes, 15% eosinophils, and 4% monocytes; hemoglobin level, 13.6 g/dL; platelet count, 300,000/µL; erythrocyte sedimentation rate, 88 mm/h. Urinalysis results, normal. Blood urea nitrogen, 16 mg/dL; creatinine, 1 mg/dL; serum sodium, 137 mEq/L; potassium, 3.6 mEq/L. Blood glucose, 108 mg/dL; total bilirubin, 1.2 mg/dL; total protein, 6.9 g/dL; albumin, 3 g/dL; alkaline phosphatase 12 U/L; aspartate aminotransferase, 19 U/L; alanine aminotransferase, 2.9 U/L. Brain natriuretic peptide, 62 pg/mL. d-Dimer, 436 µ/L. ECG shows sinus tachycardia. Arterial blood gases: pH, 7.38; PO2, 62 mm Hg; PCO2, 31 mm Hg. Oxygen saturation, 88% on room air.

Chest radiographs are ordered.

Based on the clinical, laboratory, and radiographic findings, what is the most likely diagnosis?
A. Pneumocystis pneumonia

B. Sarcoidosis

C. Pulmonary tuberculosis

D. Hemosiderosis

E. Pulmonary coccidioidomycosis (diffuse coccidioidal pneumonia)

(Answer and discussion on the next page.)

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