NYU Medical Grand Rounds Clinical Vignette

Pavan Bhatraju MD, PGY-II

October 11, 2011

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 38 y/o M Firefighter presented 13 days after the 9/11 World Trade Center attack with 2 days of

• myalgias • fever • dry cough • pleuritic chest pain • progressive dyspnea with minimal exertion

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Usual state of good health when he arrived at the World Trade Center terrorist attack 20 minutes after the first tower collapsed

•Worked 16 hr days and did not use respiratory protection for 10 of 13 days

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 11 days PTA he developed a productive cough with blackish sputum that self-resolved in one day

• 2 days PTA he developed, cough, fever, myalgias, anterior pleuritic chest discomfort, and dyspnea on exertion with less than one block

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History•Past Medical and

•None

•Surgical History•None

•Social History:•Smoking – 5 pack year history, stopped 20 years ago

•Family History:•Non-contributory

•Allergies: •None

•Medications:•none

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination•General: muscular adult male, diaphoretic, in moderate distress

•Vital Signs: • T:38.6 BP:130/90 HR:120 RR:35 • O2 sat: 90% on room air

•Pulmonary: accessory muscle use, bibasilar decreased breath sounds

•Remainder of Physical Exam was Normal.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings•CBC:

•WBC – 22,600 cells/mm3, • Differential (N = 91%, L = 3% M = 5% E = 1%)

•Remainder of CBC was within normal limits

•Basic Metabolic panel and Hepatic Panel: •Within normal limits

•Arterial Blood Gas on Room Air:•pH 7.46 •paO2 53 mmHg •paCO2 32 mmHg •HC03 23 mEq/L •O2 sat 89%

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•Chest X-Ray and CT Scan:

• Patchy ground glass opacifications

• Thickening of respiratory airways

• Bilateral pleural effusions.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Lung Injury– Dust Induced– Infection Related

• Bioterrorism induced Pneumonia (Anthrax)

Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– He was admitted to the MICU and treated with

• oxygen • levofloxacin • methylprednisolone

– Bronchoalveolar Lavage - 730,000 cells/ml (normal <250,000 cells/ml)

• Differential E = 70%, M = 18%, L = 8% N = 4%

– Total IgE was 58 ng/ml (normal <180 ng/ml)

– BAL fluid IgE was 0.4 ng/ml

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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Elemental Analysis

• Hospital Day 9:– Clinically improved with repeat CT showing near complete

resolution.

– He was discharged with 3 weeks of corticosteroid therapy

• Pulmonary Function Tests:• FEV1 = 2.6 L (71%)

• FVC = 3.8 L (86%)

• FEV1/FVC = 68%

• DLCO = 23.1 ml/mmHg/min (77%)

• His oxygen saturation at rest (94%) dropped to 87% after a brisk walk of 150 ft.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Worked as a firefighter for the next 3 years

• Developed increasing dyspnea and irritant sensitivity

• Repeat PFTs showed worsening airflow obstruction with a bronchodilator response

• Received disability retirement for reactive airways disease

Post-Discharge

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Acute Eosinophilic Pneumonia

• Subsequent onset of reactive airways disease

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS