Already under treatment for panic disorder, a man returning from Iraq battles recalcitrant cough.
Mr. Z is a 26-year-old Caucasian soldier serving in the U.S. Army. After completing a tour of duty in Iraq, he remained a member of the inactive ready reserve and was ordered to report for duty in August 2005. During his required physical exam, he informed the clinicians that he was under treatment for panic disorder and taking mirtazapine 15 mg nightly. He reported no other medical conditions or symptoms.
Evaluation
One month later, he reported for sick call at one of the troop medical clinics with the chief complaint of nausea and upper respiratory symptoms. He denied fever, nasal discharge, sore throat, and shortness of breath but did report a nonproductive cough, headache, and myalgia. Vital signs were normal, as was his physical exam. He was diagnosed with anxiety and told to return if there were any further problems.
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A few weeks later, he returned with upper respiratory symptoms. His chief complaint was headache and productive cough with clear sputum that was worse in the evening. He denied chest pain, shortness of breath, pain with inspiration, and fever. Past medical history was positive for anxiety as well as self-reported respiratory symptoms. Vital signs were normal, and oxygen saturation was 97%. Because he was a heavy smoker, a chest x-ray was ordered to rule out infiltrate. A complete blood count (CBC) was also ordered. He was treated empirically for bronchitis with azithromycin.
At his follow-up appointment, the soldier continued to complain of a clear productive cough. He reported new symptoms of nasal congestion and the sensation that his throat and neck were swollen, but he denied pain or wheezing. Physical exam revealed mild erythema of the pharynx. Examination of the nasal mucosa, oral cavity, and neck showed no abnormalities. Auscultation of the lungs revealed inspiratory wheezing at the base on the right. Exaggerated use of accessory muscles was not observed with inspiration. Breath sounds were normal, and examination was negative for rales and crackles. His cardiovascular system was normal.
Lab results
Chest x-rays revealed bilateral scattered granulomas with minimal pleural thickening at the apices. In consideration of these findings, a chest CT was ordered. CBC was normal. A throat culture ordered during a previous visit was negative. The soldier was given a decongestant and scheduled for a follow-up appointment two days later.
Two days later, the soldier’s vital signs were stable, there were no additional complaints, and he reported no change in the way he felt. Since there was no improvement of symptoms, the patient was placed on sulfamethoxazole/trimethoprim (Septra DS).
Results of the chest CT were negative for axillary, mediastinal, and hilar adenopathy. However, there was extensive calcification involving the mediastinum and bilateral hila. Scattered calcified granulomas were also noted in the lung parenchyma. Cystic scarring was noted bilaterally at the lung apices. In the anterior segment of the left upper lobe, there were opacified segments of small branching bronchioles, or tree-in-bud opacity. Also noted in the left lower lobe was a larger area of what appeared to be a tree-in-bud opacity. The CT was negative for pleural effusion and bronchiectasis. There was an incidental finding of multiple calcifications within the spleen. On the recommendation of a radiologist, a high-resolution CT scan was ordered.
The differential diagnosis included histoplasmosis (active vs. inactive), sarcoidosis, TB (active infection vs. old infection), bronchiolitis obliterans with organized pneumonia (BOOP), pulmonary interstitial emphysema, viral infection, chronic obstructive pulmonary disease, and nodule.
Apart from his tour in Iraq, Mr. Z had not recently traveled outside the United States. He denied exposure to others with similar complaints or exposure to others with TB (a negative purified protein derivative test just one month before eliminated the possibility of TB). Moreover, the area in which Mr. Z had grown up was not endemic for histoplasmosis, but he did report that he had worked in a potting soil factory during 2003, which would heighten the suspicion for that disease. No baseline chest x-rays were available for comparison.
Diagnosis
The high-resolution CT recommended by the radiologist demonstrated a few scattered granulomas in both lungs and extensive mediastinal lymph-node granulomatous calcifications without significant lymphadenopathy. Also noted were a few linear and several groups of scattered small nodular branching-type densities of the peripheral and central lung fields and in both apices (greater in the left lung). There was associated bronchiolitis with terminal bronchial thickening noted in scattered areas. No evidence of adenopathy or of cavitary or pleural disease was observed. Findings indicated the possibility of BOOP or infectious pathologies, such as changes of calcified granulomatous disease with activated process (e.g., histoplasmosis or TB). An interesting incidental finding was the structural anomaly of a left superior vena cava without a right superior vena cava.
In November, two months after undergoing his initial examination, the patient still had the productive cough. Moreover, he reported new complaints of right-sided chest pain (rated 5 on a scale of 10). At this visit, he once again denied shortness of breath or fever. He was still taking the antibiotics and reported no constitutional symptoms. Lungs were clear to auscultation and negative for wheezing. Of note was an oxygen saturation of 95%.
The patient was referred to the department of internal medicine. His physical exam, metabolic profile, CBC, blood gases, and angiotension-converting enzyme levels were all normal. The next day, his CT images were reviewed by the radiologist and a pulmonologist. The soldier was diagnosed with a common viral or bacterial infection. Clinically, he did not have signs of TB, and his symptoms were improving. He was prescribed OTC saline nasal spray and oxymetazoline (Afrin) and told to return in two weeks. If the patient’s symptoms continued to improve, observation would be considered with a repeat CT in six to eight weeks.
Discussion
Mr. Z’s initial reports of nausea and respiratory symptoms were secondary to his anxiety disorder. Subsequent respiratory complaints appear to have evolved into a viral infection, with anxiety remaining as a comorbid condition. Mr. Z was also a heavy smoker, which certainly contributed to the cough and low oxygen saturation. It is possible that Mr. Z had a past histoplasmosis or TB infection (the incidental findings with the spleen could have been due to either). He was discharged from the military and did not keep his scheduled follow-up appointments. Additionally, he did not heed recommendations to repeat labs and high-resolution CT.
