Case 19--Dyspnea, Cough, and Weight Loss in a Smoker

Clinical summary: A 45-year-old, white, homeless man presented to the chest clinic complaining of increasing dyspnea and non-productive cough for 9 months. He denied hemoptysis. He also reported a 20 lb weight loss and night sweats. He had recently traveled to Arizona and New Mexico. Past medical history was significant for crack cocaine and tobacco (30 p-y) use, as well as remote intravenous drug use. He did not take any medicines and had no pertinent work exposure (previously worked as a machinist) or exposure to animals. Physical examination and laboratory studies were unremarkable except for the presence of antibodies against hepatitis B and C. He was a thin man with pulse 90/min, BP 120/70 mmHg, respiratory rate 20/min, and oxgen saturation 96%. Breath sounds were decreased. There was no clubbing. PFTs showed mild airway obstruction: FEV1/FVC 68% and FEF25-75 33% predicted. There was no reversal of obstruction after administration of an inhaled bronchodilator. DLCO was mildly decreased at 69% predicted.

A flow-volume curve showed decreased maximal expiratory gas flow (upper curves) at mid and low lung volumes. The squares indicate a normal pattern.

What diagnoses should be considered? Answer

A chest radiograph was obtained.

Histologic changes: Image 1 | Image 2 | Image 3 | Image 4 | Discussion

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Answer--Diagnoses to be considered include: