Remembering Exceptions to the Rules

1Emory University School of Medicine, Atlanta, GA
2Emory University School of Medicine, Atlanta, GA.

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 196

Case Presentation:

A 41‐year‐old woman with a medical history significant for gastroesophageal reflux was admitted for atypical chest pain and dyspnea on exertion for 2 months. She also reported recent low‐grade fevers, drenching night sweats, anorexia, and a 25‐pound weight loss. The patient initially received antibiotic therapy but did not respond. Physical exam was unremarkable apart from bibasilar rales. Radiographic imaging revealed bilateral lower lobe consolidations with air bronchograms and pleural effusions. Thoracentesis demonstrated an exudative effusion, and serology was positive for ANA, anti‐Scl‐70 (weakly positive), and atypical antineutrophil cytoplasmic antibody (ANCA). ESR and CRP were 113 and 195, respectively. Video‐assisted thoracoscopic surgical (VATS) biopsies revealed fibrinous pleuritis and fibrosing pericarditis. Infectious disease workup was negative, and the patient was started on systemic corticosteroids. An improvement in symptoms lent credence to a diagnosis of connective tissue disease (CTD), possibly systemic sclerosis sine scleroderma.

CT of the chest showing bilateral lower lobe consolidations with air bronchograms.

Discussion:

A consolidation pattern on radiographic chest imaging may reflect conditions other than pneumonia, including pulmonary fibrosis. Lung involvement in CTDs most commonly takes the form of fibrosis. Interestingly, rheumatologic pulmonary processes appear to be more responsive to immunosuppressive therapy than idiopathic pulmonary fibrosis. Finally, although commonly used diagnostic criteria for systemic sclerosis place the bulk of emphasis on skin findings, a subset of patients may have visceral involvement without skin manifestations (systemic sclerosis sine scleroderma).

Conclusions:

A consolidating pattern on chest imaging cannot be used to definitively rule out noninfectious pathologies. A hospitalist must remain mindful that a routine admission for presumed infectious pneumonia needs to be carefully worked up if the patient does not respond to empiric antibiotic therapy. Systemic sclerosis may occasionally present without skin involvement, illustrating the need to remember rarer manifestations of relatively common disease processes.

Author Disclosure:

M. Shafiq, none; B. Purdie, none.

To cite this abstract:

Shafiq M, Purdie B. Remembering Exceptions to the Rules. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 196. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/remembering-exceptions-to-the-rules/. Accessed July 16, 2019.

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