60 y.o. male with a medical history notable for HTN, HLD, DM, HFpEF (LVEF 65%), T2DM, CKD stage 3, HCV, obesity.

 

15 months ago

Chest pain, worsening with inspiration

CXR showed a  new triangular opacity in the right
upper lobe along the minor fissure which may represent airspace
disease. Infarction is not excluded.

Over the course of 4-5 days he developed gradually worsening dyspnea on exertion which eventually prompted presentation a CTPA study-

CT showed multiple wedge shaped consolidations with some surrounding ground glass (RUL, LUL, LLL), focal nodules and regional segmental regions of ground glass consistent with  multifocal pneumonia

However, his oxygenation steadily worsened, eventually requiring high flow and transfer to the MICU for markedly increased work of breathing. He was given antibiotics and steroids, with a rapid improvement in his clinical appearance. While the imaging was atypical, the rapid turnaround raised suspicion for acute eosinophillic pneumonia. By the time he was clinically stable to pursue bronchoscopy, yield was unrevealing with regards to eosiniophilia or microbiology (+strep agalactiae from washings but not lavage, not felt to be pathogenic for him).

Repeat CT scan 5 days later showed mild improvement in the ground glass and consollidative opacities, though with a new focus in the RUL.

 

 

Labs

APLAS, ANCA, ANA, negative.  Steroids were continued for an empiric diagnosis of organizing pneumonia, and while he clinically improved dramatically, he still desaturated with exertion, and was discharged on oxygen pending follow up, as well as 40mg prednisone to be tapered outpatient. As an outpatient his steroids were tapered to off with continued improvement in his respiratory status, apart from an additional hospitalization for volume overload felt to be exacerbated by fluid retention from the steroid.

Interval history – 5 months later

Respiratory status markedly improved from hospitalization, but feels he is hitting a plateau on his trajectory. Able to walk from the parking lot to clinic without pause, but feels dyspneic on completion. Able to climb 1-2 flights of steps. Feels limited by dyspnea somewhat, but moreso by a sense of fatigue. After diuretic adjustment by cardiology feels much better, with no orthopnea or PND, and stable weight. Endorsing some increased neuropathic pain for which he is due to see his primary care provider. He also endorses a burning sensation in his chest and back of throat, worse at night or on waking.

Current CT shows complete resolution of the previously identified multiple wedge shaped consolidations and ground glass changes