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A Case Of Diffuse Miliary Pulmonary Infiltrates In A 35 Year-Old Man

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Adam G. Manko MD

Fellow/Clinical Instructor

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Wexner Medical Center

Columbus, OH

Konstantin Shilo, MD

Associate Professor

Department of Pathology

The Ohio State University Wexner Medical Center

Columbus, OH

Jennifer W. McCallister MD

Associate Professor of Clinical Medicine

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Wexner Medical Center

Columbus, OH

Submit your comments to the author(s).

History

A 35 year-old African-American man presented from prison in southwestern Ohio with two weeks of shortness of breath, productive cough with yellow sputum, daily fevers, drenching sweats, unintentional weight loss of 20 pounds, and malaise.  He had been incarcerated for 4.5 years, and had not left the prison during that time.  He denied tuberculosis exposure or history of a positive purified protein derivative (PPD).  He noted several inmates recently diagnosed with pneumonia.  It was notable that the outdoor yard at the prison had many pigeons.

His past medical history was significant only for a testicular abscess.  His social history was positive for smoking three cigarettes daily since the age of 15.  He had no family history of pulmonary disease or malignancy.  He did not take any prescription or over the counter medications, and had no known drug allergies. 

Physical Exam

On physical examination, his temperature was 100.5oF, pulse was 103, respiratory rate was 18, blood pressure was 136/80, and oxygen saturation was 93% on 2 liters/nasal cannula.  Weight was 85.6kg with of height 1.78 meters.  He was alert and oriented, and was visibly sweating.  His neck showed no elevation of jugular venous pulsations.  His mouth showed moist mucous membranes.  Pulmonary exam was clear to auscultation bilaterally in the posterior and anterior lung fields.  Cardiac exam revealed a regular, tachycardia rhythm with a heart rate of 103, and no murmurs, rubs, or gallops.  Extremities had no edema and equal distal pulses bilaterally.  Testicular exam showed no testicular swelling or pain.  Cutaneous exam showed diaphoretic skin without any rashes or lesions.

Lab

Significant Laboratory data

White Blood cells 22.5 k/uL (4.5-11.0 k/uL)
Hemoglobin 11.9 g/dL (13.2-17.3 g/dL)
Hematocrit 36.7 % (39.0-49.0%)
Platelets 565 K/uL (150-400 K/uL)

Differential 81.4% neutrophils, 2% band, 5.3% lymphocytes, 8.6% monocytes

Sodium 129 mmol/L (133-143 mmol/L)

Streptococcus pneumonia urinary antigen – negative

Legionella urinary antigen – negative

Blood cultures – negative

Urine culture – negative

Figures


Figure 1: Chest radiograph demonstrated diffuse micro-nodular infiltrates.

Figure 2: Computed Tomography (CT) of the chest demonstrated diffuse micro-nodular infiltrates throughout both lung fields without associated lymphadenopathy

Question 1

Which of the following can present with the pattern of infiltrates seen in Figures 1 & 2 above?

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