NYU Medical Grand Rounds Clinical Vignette Pavan Bhatraju MD, PGY-II October 11, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: WBC – 22,600 cells/mm 3, 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 paO 2 53 mmHg paCO 2 32 mmHg HC mEq/L O 2 sat 89% U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Chest X-Ray and CT Scan: Patchy ground glass opacifications Thickening of respiratory airways Bilateral pleural effusions. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Lung Injury –Dust Induced –Infection Related Bioterrorism induced Pneumonia (Anthrax) Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Mg Fe Au Ca Si Asbestos Glass Fly Ash 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: FEV 1 = 2.6 L (71%) FVC = 3.8 L (86%) FEV 1 /FVC = 68% D L CO = 23.1 ml/mmHg/min (77%) His oxygen saturation at rest (94%) dropped to 87% after a brisk walk of 150 ft. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Acute Eosinophilic Pneumonia Subsequent onset of reactive airways disease Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS