Diagnosis 1--Acute interstitial pneumonia

Comment: This clinical-pathologic entity represents acute respiratory distress syndrome (ARDS)/organizing diffuse alveolar damage without a known cause.


Clinical summary continued: High-dose corticosteroid therapy was begun. Gradually, he became more responsive, crackles diminished, and the chest radiograph improved. All cultures remained negative, but intermittent fever and leukocytosis of 79,000/µl occurred. When he was extubated after 11 days, he had no gag reflex. Cough was weak, and he had difficulty clearing secretions but improved gradually with aggressive tracheal suctioning and physical therapy. A swallowing study showed aspiration of liquids, and he was taught preventive measures prior to discharge, 5 weeks after admission. He was admitted again one month later for dyspnea and cough of several days' duration. WBCs rose to the leukemoid range, 131 k/µl, and he was treated with antibiotics and discharged 2 weeks later, still on prednisone, 60 mg/da. He was readmitted 2 weeks later for the same symptoms. During this admission, an inferior vena caval filter was placed for high probability of pulmonary embolus. He improved on corticosteroids and antibiotics, the chest radiograph cleared, and he was discharged after 1 week.

At home he required nasal oxygen for routine activities. About 1 month later, he developed productive cough and progressive dyspnea and returned to the hospital. Temperature was normal, but pulse was 140/min and respirations, 36/min. Chest examination showed diffuse wheezes and bi-basilar crackles. WBC was 44.2 k/µl and hematocrit 32%. A V/Q scan showed intermediate probability for pulmonary embolism, but an angiogram was negative. He developed abdominal pain, hypotension, and loose stools. Antibiotics were begun but he died on hospital day 4.

Autopsy findings: The lungs weighed 860 g (right) and 740 g (left) (normal 500 g combined). The cut surfaces appeared normal. No pulmonary thromboemboli were found. All other organs were unremarkable except for the colon, which showed small, raised plaques of pseudomembranous colitis from the ileocecal valve to the rectum.

Clinical summaryImage 5

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