By Ahmed Abuzaid, MBChB, George Mansour, MD, Ariel M. Modrykamien, MD, FACP, FCCP
A 46-year-old Caucasian man with a 30-pack-year history of smoking presented with a 3-day history of worsening dyspnea. His symptoms included a barking productive mucopurulent cough, low grade fever, and frequent nocturnal wheezing, specifically during decumbency. There was also a progressive unintentional weight loss during the past 6 months. There was no history of hemoptysis, voice hoarseness or chest pain. His medical history included recurrent pneumonias with subsequent hospitalizations, hypertension and paroxysmal atrial fibrillation. Family history was unremarkable for chest or heart disorders. His medication list included inhaled Albuterol as needed, Aspirin and Diltiazem. On physical examination he was tachycardic (heart rate of 118 beats per min) and tachypneic (respiratory rate of 26 breaths per min). His arterial oxygen saturation was 92% on room air. Lungs were notable for diffuse bilateral wheezing. Cardiac examination was significant for irregular heart sounds. The rest of the examination was unremarkable. Initial blood tests showed white count of 15.000 k/UI (normal: 4-11) and PMN of 86% (normal 46-76%). Imaging studies of the chest and lungs, including a computed tomography (CT) scan is shown in figures 1-2. Echocardiograph was unremarkable. All sputum smears, cultures and cytology were negative.
Figure1. CT of the chest (transverse view): Showing bilateral Bullae and tracheal enlargement with a diameter of 3.8 cm.
Figure2. CT of the chest (Coronal view): Showing tracheal, right and left main bronchi enlargement with a diameter of 4.1, 2.6 and 3.13cm respectively.
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