Case 9--Acute Respiratory Failure in an Elderly Man

Clinical summary: A 69-year-old, retired mechanic was admitted to the hospital for progressive dyspnea, fatigue, and weakness. The weakness and fatigue had persisted following a bout of pneumonia 4 months earlier. At that time he was admitted for fever (104°) and non-productive cough for 4 days. Physical examination was remarkable for crackles about a third of the way up the chest. WBC was 11.4 k/µl. A chest film showed bilateral, diffuse, alveolar opacities. Oxygen saturation on room air was 96%. He responded to empiric antibiotics and was discharged 6 days later.

Four days before the current admission, he developed a cough productive of brownish sputum. Two days before, he felt feverish and had several episodes of vomiting. He denied other complaints, recent travel, and exposure to sick persons. He had a history of gastric reflux with nausea and vomiting for which he was taking Omeprazole. He did not smoke or drink alcohol. On physical examination, temperature was normal; pulse, 117/min; and respiratory rate, 38/min. Oxygen saturation on air was 70%. Chest examination revealed crackles 1/2 way up. There were no wheezes or dullness. A chest radiograph showed bilateral abnormalities. WBC was 52 k/µl with a left shift, and hematocrit was 37.5%. BUN and creatinine were slightly elevated, and there was mild hematuria. He was treated with oxygen and antibiotics for a community-acquired pneumonia. Blood and sputum cultures remained negative. Breathing became more labored, radiographic opacities increased, and he was transferred to the intensive care unit, where ventilation was assisted. A concern for a pulmonary-renal syndrome prompted serologic tests for ANCA and anti-GBM antibody, both of which were negative. There was no response to antibiotics, and he was intermittently febrile. A thoracoscopic biopsy was performed on day 8.

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