Archived case 1261 · August 11-August 18, 2020
RB/DIP
47 year old female presents as an out-patient to her primary care provider with SOB, GERD, obstructive sleep apnea, and type 2 DM.
The question posed to readers
Current everyday cigarette smoker.
Images
Imaging findings
The lung window images demonstrate pronounced mosaic attenuation on inspiration. This persisted on expiratory phase imaging (not shown). This suggests underlying small airways disease and air-trapping. The most likely consideration would be hypersensitivity pneumonitis. Given the patient''s ongoing daily cigarette smoking, the differential would include the spectrum of respiratory bronchiolitis/desquamative interstitial pneumonia (RB/DIP). Atypical infection remains a possibility. Answer Diagnosis: RB/DIP
Diagnosis
RB/DIP
The soft tissue windows demonstrate bilateral hilar and central intralobar adenopathy. Several lymph nodes are partially calcified. Differential considerations most likely of sarcoidosis or other granulomatous insult. Despite worsening symptomatolgy, the patient has thus far declined smoking cessation, bronchoscopy, broncho-alveolar lavage, and lymph node tissue sampling by endobronchial ultrasound."
Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.