A Crazy Cause of Dyspnea

A CLINICAL PROBLEM-SOLVING article by Amy Miller from Brigham and Women's Hospital, Boston.
An 18-year-old black woman with a history of asthma presented with fever, ear pain, and dull discomfort on the right side of her chest. On examination, her temperature was 38.8°C, and her right tympanic membrane was inflamed. Radiography revealed air-space opacities in both lower lobes. Azithromycin was prescribed. Her symptoms resolved within 24 hours. Several months later, the patient returned, reporting a nonproductive cough and dyspnea on exertion. Initially, the dyspnea occurred only with coughing, but it slowly progressed to the point of limiting her functional capacity, despite the use of inhaled albuterol. She was given a spacer and peak-flow meter, began using a fluticasone–salmeterol inhaler, and was given a prescription for loratadine. Over the next 2 months, symptoms progressed to the extent that the patient noted considerable dyspnea while walking and occasional dyspnea while talking. She continued to have episodes of nonproductive cough and had occasional night sweats. She had lost about 1.5 kg since her initial presentation.
A chest radiograph revealed the presence of extensive pulmonary opacities, with the most severe in the left perihilar region, and diffuse bilateral involvement sparing the apexes.
In this case, the persistence of symptoms after multiple courses of antibiotics suggested a cause other than community-acquired pneumonia and demanded a broadened differential diagnosis and more aggressive evaluation.
An Interactive Medical Case related to this article is available at NEJM.org. [Original Article]

Notes

• apexes /éɪpəsìːz，ˈæp‐/
• albuterol /̀ælbj́utɚɔl/