NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette

Lucy Doyle MD, PGY-2 March 24, 2010

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

A 54-year-old male smoker presents with progressively worsening dyspnea for several years.

Chief Complaint


History of Present Illness


• The patient was in his usual state of health until 8 years prior to admission when he first began to experience dyspnea on exertion.

• During an early emergency room visit, a chest CT demonstrated ground glass opacities, sub-pleural honeycombing and fibrosis.

• Over the next several years, however, that patient did not return for further medical attention.



• As the patient’s symptoms progressed, the patient returned four years later for evaluation.

• Pulmonary function tests were obtained and consistent with restrictive physiology and mildly decreased diffusion capacity.

• The patient was reluctant to undergo bronchoscopy and again did not return for medical care for several years.



• Several months prior to admission, the patient returned complaining of cough, worsened dyspnea and further decreases in exercise tolerance.

• Bronchoscopy with trans-bronchial biopsy was performed but non-diagnostic.

• The patient now presents for further evaluation of his markedly worsened symptoms and functional status.

Additional History


Past Medical History• PPD (+)

• Treated in 1999

Past Surgical History• None

Family History• Father: Lung cancer

Social History• Former steel worker• Current smoker

• 1/2 pack per day• 35 pack-years

• Social alcohol use• Remote drug use

• Cannabis • Cocaine

Outpatient Medications


Albuterol metered dose inhaler as needed

Allergies: None

Physical Examination


General: Well-appearing man in no acute distress

Vitals: T 98.7 F, BP 107/78, HR 100, RR 16O2 saturation: 95% on room air, 98% on 2L nasal cannula

Lungs: Bilateral basilar dry ralesExtremities: Bilateral clubbing

The remainder of the physical exam was normal.

Initial Studies


• CBC: Within normal limits

• Basic Metabolic Panel: Within normal limits

• ACE: 38 (within normal)

• LDH: 246

• Anti-SCL-70: 108 (0-99)

• ANA: negative

Chest X-ray


Imaging Reports


Chest X-Ray

• No new consolidations or pleural effusions

• Interstitial lung disease, unchanged

Chest CT

• Interstitial lung disease with honeycombing and traction bronchiectasis most significant in the upper airways.

• New diffuse bilateral airspace disease which may represent pulmonary edema.

Working Diagnosis


Interstitial lung disease, unknown etiology


Hospital Course

• The patient underwent open lung biopsy of right middle and lower lobes.

• The biopsy revealed dense fibrosis with honeycomb changes and fibroblastic foci, consistent with usual interstitial pneumonia.

• The patient tolerated the procedure well, but eventually required intubation for hypoxic respiratory failure.

• In accordance with the patient’s wishes, further care was not escalated, and the patient passed away 2 weeks later.


Final Diagnosis

Usual Interstitial Pneumonia


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