Whistling in the Dark

A CLINICAL PROBLEM-SOLVING article by Daniel Solomon from Brigham and Women's Hospital, Boston.
A 38-year-old woman presented  with shortness of breath, fever, and cough productive of yellow sputum soon after the birth of her third child. She received a course of antibiotics for a presumed respiratory tract infection, and her symptoms resolved. Soon thereafter, however, she returned to her physician with an intermittent, nonproductive cough, wheezing, and shortness of breath. She was unable to identify any specific exposures that might have provoked these symptoms, although she noted that her symptoms tended to worsen at night. She reported no fever, orthopnea, leg swelling, or aspiration with swallowing, but she had a history of episodic retrosternal burning that was consistent with gastroesophageal reflux.
The patient's other active medical problems included depression and seasonal allergic rhinitis. She had smoked cigarettes for approximately 10 years and quit 10 years before presentation.  Her examination was notable for her body-mass index, which was 45.4, and loud, diffuse expiratory wheezing in both lungs.
A presumptive diagnosis of asthma was made. However, confirmatory evidence was lacking.
During the ensuing 5 years, the patient required hospitalization as often as once yearly for episodes of severe shortness of breath and wheezing.
After a move from Florida to New Hampshire, her symptoms worsened. During the next 3 years, she required hospitalization every 3 to 4 months for respiratory distress.
An interactive medical case related to this article is available at NEJM.org [Original Article]