Clinical Images

Airtight Assessment

Authors: Imran Sayeedi M.D., Nyasha Mufuka M.D.

A 57-year-old male with past medical history of chronic obstructive pulmonary disease (COPD), interstitial lung disease, rheumatoid arthritis, and hypertension presented to the hospital with progressively worsening shortness of breath over the past week. Home medications included azathioprine, plaquenil, sulfasalazine and prednisone. On physical exam, vital signs were within normal limits and lungs were clear to auscultation. Chest x-ray showed diffuse bilateral interstitial infiltrates, and labs were significant for leukocytosis (WBC 19.4 K/uL) and elevated LDH (>1000 U/L). Broad spectrum antibiotic therapy with vancomycin and ampicillin-sulbactam was initiated along with trimethoprim-sulfamethoxazole for Pneumocystis jiroveci pneumonia coverage. Bronchoscopy with bronchoalveolar lavage was performed. During the bronchoscopy, the patient became uncooperative and the procedure was stopped early. An hour later, he developed generalized burning, substernal chest pain. Physical exam was significant for increased respiratory rate, and acute hypoxia with desaturation on 40% FiO2. Heart rate and blood pressure remained within normal limits post-procedurally. Auscultation above the precordium revealed a crunching noise synchronous with the heartbeat. The patient remained intubated due to respiratory compromise with increasing FiO2 requirements. EKG was obtained along with chest x-ray (Figure 1).

MCQ:

Which of the following is most consistent with this patient’s diagnosis?

1. Tension pneumothorax
2. Acute non-ST elevation myocardial infarction
3. Post-bronchoscopy pneumopericardium
4. Aortic dissection
5. Cardiac tamponade

Click for MCQ Answer and Discussion

Author information:

Drs. Imran Sayeedi and Nyasha Mufuka are internal medicine residents at Flushing Hospital Medical Center in New York.