Plugin-cpc December 6 2005

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Clinicopathological ConferenceHurd Hall

December 6, 2005

A 54-year-old man with cough and

shortness of breath

Albert J. Polito, M.D.Faculty Discussant


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Origins of the CPC Walter B. Cannon Harvard medical student

The idea of using printed records of cases as centres ofinterest in studying medicine occurred to me some two yearsago. Since that time I have been watching carefully forevery possible opportunity to apply the method, and have

tried to see all the objections which might be raised againstthe plan. It was only when I was fully convinced that a studyof real histories could be made feasible that the scheme wasbrought forward.

Address to the Boston Society for Medical Improvement, March 5, 1900


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Cannons Inspiration

Roommate was a Harvard law student

Law students learn their law not by

dreary grubbing at text-books or lecturenotes, but by vigorously threshing out acase with one another


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Salient Features of the Case

Demographics History

Physical Exam

Laboratory Data

Radiographic Data

Other Data


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Salient Features of the Case Demographics

54 year old man

History 2 months of symptoms 2 courses of antibiotics

without improvement Abnormal chest and sinus CT

Dry cough, DOE, nightsweats, anorexia, wt. loss,pleuritic CP

Smoker; owns horse; lives onEastern Shore, travel to

Midwest and California Physical Exam

O2 sat with exertion Inspiratory crackles

Laboratory Data Normal WBC, 19% eosinophils Normal BMP and U/A

ESR, CRP

Radiographic Data Patchy ground glass/alveolar

infiltrates, mid- to upper lungs

Mediastinal/hilar adenopathy

Other Data No obstruction on spirometry Normal ECG


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Generating a Differential Diagnosis

Vascular Infection

Neoplasm

Drugs Inflammatory / Idiopathic

Congenital

Autoimmune Trauma

Endocrine / Metabolic


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Vascular

Infection

Neoplasm


Congenital

Autoimmune Trauma



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Vascular

Infection

Neoplasm


Congenital

Autoimmune Trauma



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What Are the Pertinent Positives? Demographics

54 year old man








ESR, CRP






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Vascular

Infection

Neoplasm

Drugs

Inflammatory / Idiopathic

Congenital

Autoimmune Trauma



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Is Infection Likely?

2 courses of antibiotics without improvement

Probably not bacterial

Travel to Midwest and CaliforniaHistoplasmosis?

Coccidioidomycosis?

EosinophiliaParasitic?

No evidence of immune dysfunctionTB and PCP unlikely


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Is Infection Likely?

2 courses of antibiotics without improvement

Probably not bacterial

Travel to Midwest and CaliforniaHistoplasmosis?

Coccidioidomycosis?

EosinophiliaParasitic?

No evidence of immune dysfunctionTB and PCP unlikely


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Could It Be Cancer?


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Could It Be Cancer?

Primary lung cancerBronchoalveolar cell carcinoma (BAC)

Adenopathy usually not present with BAC

Pulmonary lymphoma Infiltrates too extensive Exception: Angioimmunoblastic lymphadenopathy

with dysproteinemia (AILD) but generalizedadenopathy usually present

Lymphangitic carcinomatosis Infiltrates not characteristic


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Could It Be Cancer?

Primary lung cancerBronchoalveolar cell carcinoma (BAC)

Adenopathy usually not present with BAC

Pulmonary lymphoma Infiltrates too extensive Exception: Angioimmunoblastic lymphadenopathy

with dysproteinemia (AILD) but generalizedadenopathy usually present

Lymphangitic carcinomatosis Infiltrates not characteristic


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Vascular

Infection

Neoplasm

Drugs


Congenital

Autoimmune

Trauma



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Features ofAutoimmune Diseases

Constitutional symptoms Joint and muscle involvement

Skin involvement

Renal involvement

Elevated ESR and CRP

Positive serologies


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Features ofAutoimmune Diseases

Constitutional symptoms Joint and muscle involvement

Skin involvement

Renal involvement

Elevated ESR and CRP

Positive serologies

Nonspecific


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Vascular

Infection

Neoplasm

Drugs


Congenital

Autoimmune

Trauma



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Vascular

Infection

Neoplasm

Drugs


Congenital

(Autoimmune)

Trauma



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Salient Features of the Case Demographics

54 year old man








ESR, CRP





Earliest sign of interstitial lung disease

(correlates with DLCO)


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Differential DiagnosisInflammatory/Idiopathic Disorders

Sarcoidosis Chronic eosinophilic pneumonia

Bronchiolitis obliterans organizing

pneumonia (BOOP) Hypersensitivity pneumonitis

Desquamative interstitial pneumonia (DIP) Pulmonary alveolar proteinosis


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Desquamative interstitial pneumonia (DIP)


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Pulmonary alveolar proteinosis (PAP)


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What about the response totreatment?


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Final Diagnosis

Chronic eosinophilic pneumonia

Diagnostic Procedure

Fiberoptic bronchoscopy with

bronchoalveolar lavage (BAL) anddetermination of cell count of (BAL)

TreatmentCorticosteroids

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