A 22‐year‐old woman with a 4‐year history of active systemic lupus erythematosus (SLE) presented with a 4‐day history of fever, nonproductive cough, and shortness of breath. Two months earlier she had been admitted and treated for right upper lobe pneumonia. She had a bronchoscopy when her cough did not improve. Bronchoscopy cultures were negative for fungal and Mycobacterium tuberculosis except for 1 colony of Mycobacterium avium‐intracellulare (MAI). She was discharged home on 20 mg of prednisone twice daily for presumed flare of SLE with a taper. Her oral temperature was 38°C, heart rate was 122 beats/min, and oxygen saturation was 98% on 2 L. She had decreased air entry to the right upper lobe. She had axillary lymphadenopathy. White blood cell count was 3800/μL, hemoglobin was 10.2 g/dL, and hematocrit was 31.2%. Erythrocyte sedimentation rate was 96 mm/h (high); C3 was 62 (low). Blood cultures were negative for bacteria, fungi, and Mycobacterium. Worsening right upper lobe infiltrates as well reactive mediastinal lymphadenopathy were noted on chest CT. Vancomycin and piperacillin‐tazobactam was started for presumed health care–associated pneumonia. Azithromycin, rifampin, and ethambutol were started for possible Mycobacterium avium complex. Repeat bronchoscopy with infectious workup including fungal cultures, Pneumocystis jiroveci pneumonia, and MAI were negative. Blood for Cryptococcus was also negative. Antibiotics were discontinued. Pathology showed acute and chronic bronchiolitis obliterans. Per pulmonary recommendations, thoracoscopic right upper lobe wedge resection with extensive thoracoscopic pneumolysis was done. Anatomical pathology revealed acute and chronic inflammation of lung parenchyma, chronic pleuritis, and bronchiolitis obliterans secondary to lupus and rare noncaseating granulomas. The patient's clinical condition improved on high‐dose steroids, and she was subsequently discharged.
Recognize the clinical presentation and diagnosis of bronchiolitis obliterans in patients with SLE. Bronchiolitis obliterans organizing pneumonia occurs in patients with lupus, but there are few case reports. Patients present with cough, shortness of breath, and wheezing. Typically patients presents with bilateral patchy pulmonary infiltrates. Nodules 3–5 mm in diameter may be seen in approximately 50% of patients. Unilateral focal or lobar consolidation occurs in 5%–31% of patients. Pleural thickening and pleural effusions may be present. It is characterized by the formation of plugs of fibrous tissue in the bronchioles and alveolar ducts. The preferred method of diagnosis is by video‐assisted thoracosopic surgery or open lung biopsy. Treatment is with prednisone 1 mg/kg for 1–3 months, then 40 mg daily for 3 months, and then 10–20 mg daily for a year.
Hospitalists should consider bronchiolitis obliterans as a possibility in patients with SLE if patients continue to have pulmonary symptoms and infectious etiology is ruled out.
N. Arthur ‐ none
To cite this abstract:Arthur N. The Cough That Would Not Quit. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 233. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/the-cough-that-would-not-quit/. Accessed March 29, 2020.