A 55-year-old white woman presented with a two- month history of increasing dyspnea and dry cough. The week prior to admission, the patient noted the onset of pleuritic chest pain without associated fever, chills, sputum production or hemoptysis. She had no significant occupational exposures, travel or smoking history. Five months prior to admission, the patient had noted mild “arthritic” pain in her right hip which had resolved entirely with aspirin therapy, which she had since discontinued.
Physical examination revealed a thin white woman in mild respiratory distress. The blood pressure was 140/80 mm Hg without paradox; pulse rate, 90/min; respiratory rate, 26/min; and temperature, 37.5°C. Bilateral dry inspiratory crackles were heard at the bases. Results of cardiac and abdominal examinations were normal. The extremities showed no cyanosis, clubbing or edema. The neurologic exam was entirely normal.
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A chest roentgenogram on admission showed multiple bilateral pleural-based densities as well as an increase in interstitial markings without cardiomegaly (Fig 1). Computed tomography of the chest revealed bilateral, pleural-based, wedge-shaped densities especially prominent in the lower lung fields (Fig 2). The electrolyte levels were normal. The С ВС revealed a hematocrit of 39.4 percent, platelets of 260,000 and white blood cell count of 7,900/cu mm with a normal differential. Arterial blood gas determination with the patient breathing room air revealed a pH of 7.43, PaC02 of 33 mm Hg and Pa02 of 70 mm Hg. A 5 TU PPD test was negative with positive controls. The erythrocyte sedimentation rate was 89 mm/h. Gram- stain evaluation of the sputum was unrevealing. An open lung biopsy was performed.