Fever, Cough and Breathlessness

Presentation

A 60-year-old female is seen in clinic after having a persistent fever, cough and malaise for several weeks. She has also been experiencing increasing breathlessness with moderate exertion and has gone off her food with a 2-stone loss in weight. She was given a course of antibiotics by her GP which hasn’t helped her symptoms.

Her past medical history is otherwise unremarkable.

She has never smoked cigarettes and has not travelled abroad over the last few years. She doesn’t have any pets and previously worked as a school teacher.

She is currently not taking any medications, but recently finished a week’s course of amoxicillin and clarithromycin. She has no known allergies.

Click the CXR tab.

CXR

Question: The GP requested a chest x-ray (Fig 1). What is your interpretation of it?

Click here for the answer.

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Fig 1 Chest x-ray

Question: The GP requested a chest x-ray (Fig 1). What is your interpretation of it?

Answer: The x-ray demonstrates areas of bilateral patchy consolidation, more prominent in the right lower zone.

Click the Examination tab.

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Fig 1 Chest x-ray

Examination

After examination (Fig 1), the patient is referred to hospital for further investigations.

On admission, she is started on a course of IV antibiotics.

When you have reviewed the examination results, click the Initial Inv tab.

Fig 1 Select the forward or back arrow to display the examination results

Initial Inv

Before clicking on the links below, consider what you are looking for in carrying out these initial investigations.

Blood tests (Fig 1)

Sputum culture (Fig 2)

Blood cultures (Fig 3)

Legionella/Pneumococcal urine antigen test (Fig 4)

ABG (Fig 5)

PFTs (Fig 6)

Click the HRCT tab when you are ready to move on.

Fig 1 Blood test results

Fig 2 Sputum culture

Fig 3 Blood cultures

Fig 4 Legionella/Pneumococcal urine antigen tests

Fig 5 Arterial blood gases results

Fig 6 Pulmonary function test

HRCT

Click the links below.

Despite being treated with broad spectrum IV antibiotics and supplemental oxygen therapy for several days, the patient’s symptoms do not improve. A CT chest is requested.

Check both of the patient’s HRCT chest images, then compare your findings with the results below.

Fig 1

Fig 2

HRCT chest results

Click the Other Inv tab when you are ready to move on.

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Fig 1 HRCT chest

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Fig 2 HRCT chest

HRCT chest results

The images show multiple areas of bilateral patchy consolidation and ground glass opacification.

Which would be the most useful investigation(s) to obtain the diagnosis for this patient?

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Possible answers:

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A. Incorrect. Bronchoscopy performed for bronchoalveolar lavage can be helpful in terms of sampling secretions for causative infections as well as demonstrating a mixed inflammatory cellular pattern that can be seen with this condition, but such results are not diagnostic.

B. Correct.

C. Correct.

D. Incorrect.

Surgical open lung biopsy or VATS lung biopsy is the most useful investigation to secure the diagnosis for this patient.

The patient undergoes VATS lung biopsy which demonstrates areas of alveolar epithelial injury with necrosis and infiltration of inflammatory cells within the alveolar interstitium. There are also areas of intra-alveolar fibrosis. There is no evidence of any atypical cells. Microscopy, culture, sensitivities, and TB culture of histological samples show no growth [11].

Click the Diagnosis tab.

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What is the likely diagnosis in this case?

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A. Correct. COP should be suspected in a patient with unresolving bilateral patchy consolidation and restrictive lung function pattern. The CT and histological findings from this patient also support this diagnosis.

B. Incorrect.

C. Incorrect.

D. Incorrect.

Click the Treatment tab.

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Given the diagnosis, which of the following treatment options is the patient likely to respond to?

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A. Incorrect.

B. Incorrect.

C. Correct. COP may respond to corticosteroids with rapid clinical and radiological improvement [4].

D. Incorrect.

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Summary

COP is an organising pneumonia with no definite aetiology but has been associated with infections, malignancies and iatrogenic causes, i.e. medications and radiation [11].

Diagnosis requires excluding other possible causes as well as obtaining histology, ideally from a surgical lung biopsy. However, often these patients may be too ill to undergo such invasive procedures and may be given a trial of treatment without having obtained a histological diagnosis.

COP may respond well to corticosteroids with rapid improvement in the patient’s clinical condition. However, relapses are common after withdrawal of steroid therapy, and sometimes a longer duration of treatment is required [4].

Click Next to complete the session with a short Self Assessment.