Case 33--New "Miliary" Opacities

A 59-year-old African-American, female, clerical worker with a history of hypertension, chronic venous stasis, and obesity, presented with a four-month history of worsening shortness of breath. While several months before she had been able to walk up one flight of stairs without dyspnea, she now became short of breath walking around her apartment and complained of mild orthopnea at night. She denied chest pain, cough, fever, sweats, rashes, and joint pain. A PPD was reported to be negative. She had never smoked cigarettes and had no exposure to pets. On physical examination, she was an obese woman in no distress. Her oxygen saturation was 93% on air but dropped to 86% with walking. Her lungs were clear to auscultation. Heart sounds were normal except for a loud pulmonic second sound. Her extremities revealed bilateral 2+ pitting edema. A cardiac evaluation revealed no evidence of ischemia. An echocardiogram indicated normal left ventricular size and function with an ejection fraction of 80%, and pulmonary hypertension with a PA systolic pressure of 61 mmHg. Right ventricular size and function were normal. Her pulmonary hypertension was attributed to possible obstructive sleep apnea or an obesity-hypoventilation syndrome. PFTs revealed moderate obstruction with an FEV1 of 0.9 L and an FVC of 1.6 L. Obstruction had been documented on prior PFTs (see table), but had increased compared to 10/96.

Forced vital capacity

Forced vital capacity, 1 sec

% Expired, 1 sec

Peak Flow

10/96

1.7 L, 60% predicted

1.2 L, 52% predicted

71%

4.8 L/sec, 70% predicted

8/99

1.6 L, 59% predicted

0.9 L, 43% predicted

58%

3.3 L/sec, 55% predicted

A chest radiograph showed a diffuse miliary pattern, which was reported as suspicious for tuberculosis or metastatic cancer. A subsequent HRCT showed diffuse pulmonary nodules and hilar enlargement. A ventilation/perfusion scan was read as low probability for pulmonary embolism. Three sputum samples were negative for acid fast bacilli.

The patient underwent bronchoscopy with transbronchial biopsy for evaluation of her pulmonary nodules. During the procedure, she became acutely hypoxic and experienced mild hemoptysis. Her post-bronchoscopy chest radiograph revealed a large right pleural effusion, which was found to be bloody (hematocrit 32%). A chest tube was placed and drained 1950 ccs of bloody fluid over 3 days. She was eventually discharged with an oxygen saturation of 88% on supplemental oxygen.

Radiology | Clinical summary continued | Image 1 | Image 2 | Image 3 | Image 4 | Image 5 | Image 6 | Discussion

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