Our Differential Diagnosis: Diffuse Airspace Disease
Airspace disease (acute)
Pulmonary edema (cadiac and non-cardiac)
(viral: infleunza, paqrainfluenza, RSV, CMV, adenovirus, HIV) (bacterial: mycoplasma, staph, strep, anaerobes, nocardia, MTB, NTM) (fungal: histoplasmosis and blastomycosis)
Blood (goodpasture's, idiopathic pulmonary hemosiderosis, thrombo-embolic disease) Idiopathic (sarcoid, eosinophilic lung disease)
Airspace disease (chronic)
Mycobacterium tuberculosis, fungal infection, interstitial pneumonitis, lipoid pneumonia, sarcoid, pulmonary alveolar proteinosis
Granulomatous - infection; mycobacterium tuberculosis versus non-tuberculous mycobacterium
Inhalational exposure- organic vs inorganic
Idiopathic; eosinophilic granulomatosis, sarcoid
Hemosiderosis; increased venous pressure
Repeated hemorrhage; goodpasture's, idiopathic hemosiderosis
? Acute on chronic process (previous bronchopulmonary dysplasia)
She had a bronchoscopy and bronchoalveolar lavage in April 1998. The lavage was cloudy, and blood-tinged in appearance. No cell count was available. There were secretions in the RUL. Cultures were negative for viruses, bacteria and fungal stains. Her clinical status improved so she was discharged home on oxygen at 2 L/min with additional planned investigations at follow-up.
At follow-up, she continued to be hypoxemic on room air. Her cardiac evaluation (echocardiogram and EKG) was normal. The interval chest xray was worse although she only required oxygen at night. Follow-up in October 1998 (6 months after presentation), she was noted to have mild clubbing on examination. Interestingly, her father was also noted to have clubbing but no respiratory symptoms.
INVESTIGATIONS AND RESULTS
Pulmonary function tests: uninterpretable (first attempt), blood work was normal, oximetry showed that she was hypoxemic at rest, worse with exercise. One could argue about the need for a high resolution CT scan to delineate the pathology further. However, it was not done at this point.
BELOW, CHEST X-RAY from October 1998.
WHAT ARE YOUR FINDINGS. WHAT WOULD YOU DO NEXT?