Internal Medicine Case Challenge: A Teacher’s Assistant With Bipolar Disorder Has Lung Problems

Jonathan Katz, MD; Shivani Garg, MD, MS


January 09, 2023

Editor's Note:
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 46-year-old woman (G1P1) with a history of congenital splenomegaly and thrombocytopenia, who follows up with the hematology service, presents to the hospital as a transfer for worsening lung infiltrates. The patient also has a history of asthma, bipolar disorder, migraines, and recurrent lower-extremity deep venous thrombosis (DVT), with two positive tests for lupus anticoagulant (12 weeks apart) while taking apixaban.

She initially presented to another hospital with several days of worsening fatigue and fevers. At the other hospital, she underwent chest imaging, which demonstrated right-sided multifocal patchy ground glass opacities and a right-sided multiloculated effusion. Antibiotic therapy was started, and her symptoms improved; however, repeated CT showed new left upper lobe infiltrates with stable right lung findings. The new findings prompted her transfer for further workup and evaluation.

The patient notes that she has experienced several weeks of poor appetite and intermittent abdominal pain associated with her fevers and fatigue. She has a 6-month history of oral ulcers and a 2-year history of bilateral hand, wrist, and elbow pain, with intermittent swelling, erythema, and stiffness that has progressed for the past 6 months. The remainder of her review of systems is notable for Raynaud phenomenon and a history of photosensitivity, which manifests as profound fatigue after sun exposure.

Before her hospitalization, the patient had sought medical attention for her abdominal pain. At that visit, a CT scan showed new trace perisplenic fluid and laboratory results demonstrated leukopenia with thrombocytopenia, for which she underwent a bone biopsy several days before her current presentation. The results of the biopsy are pending.

She has no family history of rheumatologic or pulmonary disease. She works as a teaching assistant, and her social history is notable for rare alcohol use and a 30–pack-year smoking history.


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