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A 67-Year-Old Man with Pulmonary Infiltrates and Hemoptysis

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BACKGROUND
A 67-year-old man presents to the emergency department (ED) with severe, progressive shortness of breath that started 4-5 days prior to presentation. He also reports an associated cough that produces blood-tinged sputum, as well as generalized weakness, lack of appetite, and weight loss. The patient has no fever or chills and denies any chest pain, orthopnea, and swelling of the lower extremities. He has no history of recent travel or immobilization for long periods of time, has not had any sick contacts or toxic exposures, and has not been in any high-risk environments for tuberculosis (eg, incarceration, shelters). His past medical history is significant only for cardiac disease, including paroxysmal atrial fibrillation, coronary artery disease leading to a myocardial infarction, and congestive heart failure (with an estimated ejection fraction of 35%). An automatic implanted cardiac defibrillator (AICD) has been placed for frequent episodes of ventricular tachycardia. There is no history of cigarette use. His medications include amiodarone, metoprolol, and simvastatin.

On physical examination, the patient appears ill, with diaphoresis and moderately labored respirations at a rate of 26 breaths/min. His blood pressure is 110/74 mm Hg, with a regular heart rate of 62 beats/min. The patient’s oral temperature is elevated, at 100.4°F (38°C), and his oxygen saturation rate while breathing room air is 86%. Crackles are auscultated in the right upper lung field. No murmurs or rubs are noted on the cardiac examination; however, a faint third heart sound (S3) is noted. No jugular venous distention, hepatojugular reflux, or peripheral edema is present, and there is no evidence of cervical, axillary, or inguinal adenopathy. The distal pulses are equal and 2+.

An arterial blood gas analysis on room air reveals a pH of 7.42, a partial O2 pressure of 44 mm Hg, and a partial CO2 pressure of 41 mm Hg. Laboratory investigations, including a complete blood count, coagulation profile, serum electrolyte panel, and renal function tests (including creatinine level), are unremarkable. A brain natriuretic peptide assay is measured at 80 pg/mL. An urgently performed transthoracic echocardiogram shows a decreased ejection fraction and normal valvular function (unchanged from studies prior to this presentation). The chest radiograph reveals a right upper lobe infiltrate (see Image 1). A follow-up computed tomography (CT) scan of the patient’s chest shows evidence of a more extensive pulmonary process than can be appreciated on his chest radiograph, with diffuse bilateral infiltrates (Image 2).

What is the diagnosis?
CASE DIAGNOSIS
HINT
This condition resulted from a medication with known potential pulmonary toxicity.
Authors:
Said B. Iskandar, MD,
Fellow in the Cardiology Division,
Quillen College of Medicine,
East Tennessee State University,
Johnson City, Tenn.

Ryland P. Byrd, Jr, MD,
Chief of Pulmonary Medicine,
Medical Director of Respiratory Therapy,
Quillen Mountain Home Veterans
Affairs Medical Center,
Professor, Department of Internal Medicine,
Division of Pulmonary Diseases
and Critical Care Medicine,
James H. Quillen College of Medicine,
East Tennessee State University

Thomas M. Roy, MD,
Chief of the Division of Pulmonary Diseases
and Critical Care Medicine
and Professor of Medicine Department
of Internal Medicine,
James H. Quillen College of Medicine,
East Tennessee State University

eMedicine Editors:
Erik D. Schraga, MD,
Department of Emergency Medicine,
Kaiser Permanente,
Santa Clara Medical Center, Calif

Rick G. Kulkarni, MD,
Assistant Professor,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery,
Attending Physician,
Medical Director,
Department of Emergency Services,
Yale-New Haven Hospital, Conn
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