The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
A 44-year-old woman with seropositive rheumatoid arthritis and allergy-induced asthma reports progressive dyspnea and cough at a follow-up visit. Rheumatoid arthritis was diagnosed 1 year ago after joint pain and swelling developed in her wrists, hands, and ankles, and serum rheumatoid factor and cyclic citrullinated peptide antibody tests were positive. Methotrexate was initially prescribed but had to be stopped 6 months before presentation because of elevated liver enzyme levels. Adalimumab was started shortly after methotrexate was discontinued.
For 3 months, the patient has had progressive dyspnea upon exertion, with a cough intermittently productive of yellow sputum. Her symptoms persist despite changes in her environment and location throughout the week. Her dyspnea has not impaired activities of daily living but has made exercise more difficult. She reports that her rheumatoid arthritis is well controlled. She denies fever, night sweats, unintentional weight loss, lymphadenopathy, and hemoptysis. Results of a cardiac and gastrointestinal review of systems are benign.
The patient tried a combination of fluticasone nasal spray, nonsedating daily antihistamine, and albuterol inhaler as needed, which provided only minimal improvement. A 5-day course of azithromycin was prescribed at an urgent care visit 1 month before presentation, without any change in symptoms.
Significant exposures include a chicken coop at home that is cleaned regularly and a hot tub filled from a filtered well water source. The hot tub is drained twice a year, cleaned thoroughly, and allowed to dry before being refilled. The patient has no history of recent travel and denies any history of tobacco use. Historically, she had a negative interferon-gamma release assay, with no known tuberculosis contacts.
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Cite this: A Woman Who Owns a Hot Tub and Chickens Has Dyspnea, Cough - Medscape - Sep 22, 2022.