Dry cough and dyspnoea rapidly increasing to respiratory failure in a male smoker

Abstract

A 65-yr-old male, current smoker of .30 cigarettes?day -1 (total smoking history 150 pack-yrs), who was working as a bus driver, presented at the Evangelismos Hospital (Athens, Greece) complaining of increasing breathlessness on exertion and dry cough during the past 2 months. He had no animal exposure and he hadn't travelled abroad during the last few years. His medical history showed arterial hypertension, for which he was receiving treatment with an angiotension-converting enzymeinhibitor (ramipril) plus hydrochlorothiazide, as well as asymptomatic cholelithiasis and prostate hypertrophy for which he was receiving tamsulosin hydrochloride. He did not mention suffering from fever in the last few months.On admission, the patient was mildly tachypnoeic (22 breaths? min -1 ), but apparently in discrete health, with a body temperature of 36.8˚C, pulse rate 85 beats?min -1 and blood pressure 130/70 mmHg. On chest auscultation, rare fine inspiratory rales were audible over both hemithoraces. He had no clubbing. The tuberculin test was negative. The routine blood analysis and chemistry was normal. Arterial blood gas analysis while breathing room air gave results as follows: arterial oxygen tension (Pa,O 2 ) 7.95 kPa; carbon dioxide arterial tension (Pa,CO 2 ) 3.94 kPa; pH: 7.45. Chest radiography on admission is shown in figure 1. Spirometry 2 days later was compatible with a moderate restrictive pattern (forced vital capacity (FVC): 1.52 L (48% predicted); forced expiratory volume in one second (FEV1): 1.28 L?sec -1 (53.6% pred); FEV1/FVC6100 ratio: 84%). Lung volumes and diffusing capacity could not be assessed because the patient was unable to cooperate. A bronchoscopy was performed on the 4th day of hospitalisation and no endobronchial abnormalities were found. Bronchoalveolar lavage (BAL) was performed during bronchoscopy and the total cell count was 26.6610, with a differential of 82% macrophages, 12% lymphocytes and 6% neutrophils. No infective agents were detected in sputum or in bronchial secretions. Serology for HIV infection was negative, as was the urinary test for Legionella pneumophila and Streptococcus pneumoniae. Serology for common virus, and mycoplasma, ricketsiae and chlamydiae were pending. No underlying immunosuppressive condition was evident.During the 2-3 days following bronchoscopy, the patient's respiratory condition rapidly deteriorated. Respiratory rate was 34 breaths?min -1 and pulse rate 130 beats?min -1 . Arterial blood gases on supplemental oxygen and fractional concentration of oxygen in inspired gas 60% were: Pa,O 2 9.24 kPa; Pa,CO 2 4.2 kPa; pH 7.44. However, he remained afebrile and the new haematology and biochemical laboratory studies, including total and differential white cell blood count, were within the normal range.Another chest radiograph obtained on the 7th day of his hospital stay, is shown in figure 2, and the chest computed tomography (CT) obtained at the same time point is shown in figure 3. During the next few hours, the patient was admitted to the intensive care unit ...

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Desquamative interstitial pneumonia: an analytic review with an emphasis on aetiology

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Investigation of Lung Involvement in Connective Tissue Disorders

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