Mark Crislip, MD


December 01, 2010

Clinical Presentation

A 45-year-old man was admitted 6 months ago to the hospital with community-acquired pneumonia that required intubation and ventilatory treatment. No etiology was found for the pneumonia; a review of the medical records suggests that it was an atypical pneumonia (diffuse infiltrates, negative gram stain, and cultures) and after a week he was extubated and eventually discharged to home on a 14-day course of ciprofloxacin.

He returned to the same hospital 4 weeks later with slightly increased shortness of breath and, after a work-up that did not include a lung biopsy, he was diagnosed with bronchiolitis obliterans with organizing pneumonia (BOOP) and started on prednisone.

Over the next 5 months he became progressively dyspneic and oxygen dependent to the point where he was wheelchair bound and his prednisone was increased gradually to 60 mg a day.

While visiting a friend he had a seizure and was admitted to the hospital.

History and Physical Examination


The patient's past medical history was significant for reactive airway disease. His history otherwise revealed:

  • Habits: smoked 1 pack per day and occasional marijuana until his pneumonia;

  • Work: landscaper;

  • Pets: cat and parakeet;

  • Travel: none recently; stationed in Korea while in the Army; and

  • PPD: negative in the past.

Physical examination

On physical examination, the following were noted:

  • Vital signs: afebrile, pulse 90 beats per minute, respirations 18 breaths per minute;

  • HEENT: "moon facies";

  • Lungs: diffuse "Velcro" crackles, predominantly in the upper lobes;

  • Heart: normal;

  • Abdomen: normal;

  • Extremities: normal; and

  • Neurologic: slight right facial droop and right-sided weakness.

Laboratory value and imaging results

  • WBC: 10 X 109 cells/L. Differential: normal;

  • All other labs normal, including lactate dehydrogenase (LDH);

  • HIV negative;

  • Chest x-ray: diffuse bilateral interstitial/nodular infiltrates throughout with predominance in the upper lobes. No adenopathy or effusions; and

  • CT: 3-ring enhancing: 2-cm masses, read as infection, but less likely tumor.

A brain biopsy was also performed.


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