A 47-Year-Old With Progressive Dyspnea and Weepy Nodules

Dora E. Izaguirre, MD; Jesus Lanza, MD

Disclosures

November 19, 2021

Physical Examination and Work-up

Physical examination reveals an alert and oriented male with a regular pulse of 94 beats/min, blood pressure of 130/85 mm Hg, respiratory rate of 22 breath/min, temperature of 98.8°F, and O2 saturation of 92% on room air. The neck is supple, without jugular venous distention or lymphadenopathy. Cardiac examination reveals normal S1 and S2 findings, and no audible murmurs, rubs, or gallops are noted. Chest examination shows bilateral equal decreased air entry with scattered wheezes, but no rhonchi or rales are heard upon auscultation.

The abdomen is soft, nontender, and nondistended, with evidence of mild hepatomegaly. No lower-extremity edema, cyanosis, or clubbing is seen. The peripheral arterial pulses are palpable. Skin examination reveals painful and weepy cutaneous nodules on the patient's right forearm (Figure 1).

Figure 1.

Neurologic examination findings are normal. Laboratory work-up, including a complete blood count, and a comprehensive metabolic panel showed mild elevation of aminotransferases. The cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA) titer was positive, and serum levels of alpha-1 antitrypsin (AAT) were 10 µmol/L (reference range, 20-60 µmol/L).

Pulmonary function testing revealed an FEV1 of 1.82 L (52% of predicted), with an FEV1/FVC ratio of 68%. FEV1 didn't improve with albuterol treatment (postbronchodilator increase in FEV1 of 9%). He was also found to have a reduced diffusing capacity or transfer factor of the lung for carbon monoxide (DLCO) of 17.72 mL/min/mm Hg (62% of predicted) and evidence of air trapping with a residual volume of 3.26 L (127% of predicted). Chest radiography (Figure 2) revealed hyperlucent areas in bilateral lower lobes. Chest CT is shown in Figure 3.

Figure 2.

Figure 3.

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