1. Caso Clínico - Case Report -
Serviço de Pneumologia
Centro Hospitalar de Vila Nova de Gaia/Espinho, 2014
João Cordeiro da Costa
Interno de Formação Específica em Pneumologia

2. Identification
M.N.G.R.M., male sex, 66 years-old, retired (previously restaurant owner).
Farmer (small farm) in the past 8 years
Contact with horses, rabbits and pigeons.

3. Clinical History Observed in Emergency Room at 02-08-2013:
Dyspnea to medium efforts and asthenia (with 1,5 years of evolution)
Chronic cough with clear sputum
Fever and sore throat in the week before
Worsened dyspnea
Diarrhea in the day before (self resolution)

4. Medical Prescription:
Clinical Background
Rheumatoid Arthritis for 4 years
Chronic B Hepatitis
Benign Prostate Hyperplasia
Previous Surgeries: 2 inguinal hernias
No Pulmonary disease known
Non-smoker
Medical Prescription:
Prednisolone 10mg (for 2 years)
Leflunamide 10mg (for 2 years)
Methotrexate 20mg po/wk
Lamivudine 100mg
Omeprazole
D vitamin
Diclofenac (SOS)

5. Physical Examination (ER)
No neurologic deficits
Polypnea.
No fever.
AP: 150/70 mmHg | HR: 90 |
SpO2 (O2 4L/min): 97% (92% with conversation)
Lung auscultation: bilateral normal respiratory sounds; crackles in the lung bases.
Heart auscultation: normal
No peripheral edema.

6. Laboratory Hemoglobin: 12,9 g/dl (13,0-18,0)
Leucocyte count: 3750/ul (61% neutrophils; lymphopenia 810/ul [1,0-4,8])
Creatinine: 1,66 mg/dl | Urea: 47 mg/dl
Calcium: 11,2 mg/dl [8,4-9,7]
CRP: 3,43 mg/dl [0-0,5]
Urinary antigens (S. Pneumoniae / Legionella): Negative
Blood Gases (4L/min O2): pH 7,46 pCO2 37 pO2 74 HCO3 26,3 Sat 95%

7. Chest Radiograph

8. Thoracic AngioCT

9. Summary 66 years, male, retired.
Hobby: farmer.
Non-smoker, no pulmonary disease known.
Reumatoid arthritis, chronic B hepatitis (leflunamide, methotrexate, lamivudine)
Chronic dyspnea, chronic cough, mucous sputum.
Acute symptoms: worsening dyspnea, fever.
Anemia, leucopenia.
Ground-glass appearance on both lungs, from apices to bases, subpleural sparing.
Admitted to Hospital and initiated treatment with ceftriaxone, azithromycin, trimethoprim-sulfamethoxazole (TMP-SMX). Immunossupressors suspended.

10. Differential Diagnosis
Pneumonia in immunossupressed patient
Drug induced lung toxicity
Alveolar hemorrhage
Acute exacerbation in patient with previous ILD
Acute hypersensivity pneumonitis

11. Diagnostic Investigation
Laboratory:
ANA, ANCA ab. normal
Serologies: negative to leptospire, aspergillus, CMV, HSV (I, II), Mycoplasma pn., chlamydia pn., EBV, varicela zoster, legionella.
HIV / HCV negative
Blood (2), urine and sputum cultures negative
Pharyngeal Exsudate: negative to Influenza A / B, Adenovírus, Parainfluenza 1 / 2 / 3.

12. Diagnostic Investigation
Bronchoscopy
Abundant purulent secretions.
Bronchial lavage:
Mycobacteria / mycology / bacteria: negative.
Pneumocystis jiroveci negative.
Cytology: inflammation. Perls staining negative.
Differential leucocyte count in BAL not performed because of patient intolerance.

13. Evolution
Good clinical evolution with complete clinical and imagiological resolution.

14. Diagnosis??
Drug induced lung toxicity?

15. The end