A 36-Year-Old Woman With a Worsening Cough and Hearing Loss

Nicole Davey-Ranasinghe, MD; Constantine K. Saadeh, MD

Disclosures

September 05, 2019

Physical Examination and Workup

Upon physical examination, the patient is afebrile. Her respiratory rate is 18 breaths/min, and her heart rate is 105 beats/min. She has atopic dermatitis on the extensor surface of her elbows. She also has bilateral otitis media. Periorbital edema is observed, with darkening of the periorbital skin. She has clear nasal discharge and nasal polyposis. She has bilateral expiratory wheezing and mild crackles upon examination. She has no necrotic nasal lesions and no evidence of cutaneous vasculitis. Her neurologic examination findings are unremarkable. No murmur, rubs, or gallops are noted during her cardiovascular examination; however, mild tachycardia is detected.

Sinus radiography reveals findings consistent with chronic sinusitis, including mucosal thickening and air fluid levels in the bilateral maxillary sinuses (Figures 1-3). Near complete opacification of the bilateral frontal sinuses is noted. Chest radiography reveals diffuse interstitial changes (Figures 4 and 5).

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

This prompts high-resolution CT to be ordered, which reveals peribronchial thickening and widely scattered patchy infiltrates. ECG findings reveal sinus tachycardia with no other abnormality. Pulmonary function testing reveals a moderate obstructive defect; lung diffusion capacity is mildly decreased, at 70%.

A complete metabolic panel with differential reveals an eosinophil count of 7500 eosinophils/µL. Her erythrocyte sedimentation rate is elevated, at 85 mm. Her C-reactive protein level is elevated, at 5.6 mg/dL. Test results for antineutrophil cytoplasmic antibodies (ANCAs) are positive for myeloperoxidase ANCAs and negative for proteinase-3 ANCAs. Urinalysis is unremarkable. Troponin test results are negative. Rheumatoid factor test results are positive, with a low titer of 1:40. Antinuclear antibody test results are negative. C3 and C4 levels are within normal limits.

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