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Sudden Onset of Wheezing at Work

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Eric J. Adkins, MD

Fellow

Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Matthew Exline, MD

Assistant Professor

Internal Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).

History

A 33-year-old African American male without significant past medical history, was transferred for evaluation of acute onset of dyspnea (< 48 hours), wheezing and a cough productive of blood-tinged sputum. The patient denied a personal or family history of pulmonary disease. He was previously able to participate in athletic events without symptoms. He denied the use of tobacco, alcohol or drugs. He was employed as an industrial insulation application specialist. Approximately one day prior to presentation, he admitted to an unprotected exposure to a maleic anhydride gas cloud (used as a resin in fiberglass insulation). The patient denied any history of previous exposures. At the time of presentation, the patient did not have a fever or chills and did not report recent weight gain or lower extremity swelling. He had no chest pain, but did complain of chest tightness. He denied nausea, vomiting, diarrhea or abdominal pain. The remainder of his review of systems was unremarkable.

Physical Exam

The patient's weight was 229 pounds. Blood pressure 138/86 mm Hg, pulse 92 beats/minute and oxygen saturation 95% on room air. His initial respiratory rate was 28/min in the Emergency Department and had improved to 22/min at the time of examination. In general, he appeared stable without the use of accessory muscles for respiration. He was able to give us his history without significant dyspnea. Head and neck exam was within normal limits and without evidence of stridor. His lungs revealed fair air movement without wheezing or rhonchi. His cardiac exam was regular rhythm without an S3 gallop or evidence of peripheral edema.

Lab

  • Serum chemistry panel and liver function tests were normal.
  • Autoimmune serologies including: erythrocyte sedimentation rate (ESR), antinuclear antibodies (ANA) and anti-neutrophil cytoplasmic antibody (ANCA) were negative.
  • Complete blood count (CBC) was unremarkable with a normal cellular differential.
  • Urinalysis was normal.

Figures

See chest radiograph in Figure 1.

A CT scan of the chest was unremarkable.

Transthoracic echocardiogram during the acute presentation showed mild left ventricular dilation with no evidence of pericardial effusion and an ejection fraction of 25%.  A follow-up echocardiogram at 3 months showed resolution of previous abnormalities and a normal ejection fraction.

Pulmonary function testing (PFT) obtained 48 hours after his acute presentation showed a forced vital capacity (FVC) of 3.59 L (88%), a forced expiratory volume in 1 second (FEV1) of 3.10 L (91%), and an FEV1 / FVC of 86.4%.  Lung volumes were normal.  The diffusing capacity for carbon monoxide was 59%.  On 6-minute walk testing, he ambulated 1658 feet with an oxygen saturation of 98% at rest and 94% during exercise.


Figure 1. PA and lateral chest radiographs from the patient. The images show mild elevation of right hemi-diaphragm, normal lung fields and cardiomegaly.

Question 1

At this point in the patient’s presentation, what would be the most likely diagnosis?

References

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