Presentation
Persistent desaturation despite treatment for pneumonia. Pulmonary embolism?
Patient Data
Extensive coarse reticulations in both lungs, accompanied by traction bronchiectasis. Bilateral hazy opacities.
Deep brain stimulator implanted subcutaneously in the right thoracic wall.
Deep brain stimulation (DBS) device in the right anterior chest wall.
No emboli in the main pulmonary arteries or their segmental branches. The main pulmonary arteries are mildly dilated. The cardiac chambers are mildly dilated, especially the atria.
Mediastinal and bi-hilar adenopathy, with maximal short axis diameter of up to 19 mm in the subcarinal location, 17 mm in the right pulmonary hilum; and 15 mm in the left hilum.
Small bilateral pleural effusion.
The lungs show extensive linear fibrosis and ground glass opacities with geographic borders, traction bronchiectasis, and subpleural/paracicatricial emphysema.
Sizable hiatal hernia containing proximal half of stomach.
A chest x-ray done 4 years earlier shows basal-predominant bilateral pulmonary fibrosis and bibasal subsegmental atelectasis.
An x-ray from 15 years earlier shows fine bibasal reticulations.
Case Discussion
History of obsessive-compulsive disorder (OCD). Reports having been inhaling bleach daily for years when cleaning the sanitary ware. Underwent implantation of a deep brain stimulation pacemaker and electrodes for the OCD after unsuccessful treatment with escitalopram.
Present disease: vomiting and diarrhea several days before arrival to the emergency department, then productive cough and rhinorrhea. Worsening shortness of breath. Vital signs at presentation: blood pressure 103/56 mmHg; pulse 98 BPM; saturation 89% in room air, 97% with oxygen mask; temperature 39.3°C. Weakness and pallor; tachypnea. Diffuse rhonchi on auscultation. Lab tests notable for known leukopenia.
Treated with inhalation of ipratropium bromide, albuterol, and budesonide, and started on levofloxacin, taking into account hypersensitivity to several antibiotics. Due to persistent desaturation ~85% despite treatment, she had a CTPA to rule out pulmonary embolism. The CT scan ruled out pulmonary emboli showed extensive pulmonary fibrosis due to chronic chemical pneumonitis in greater detail than the x-ray done one day earlier.