CASE
A 54-year-old male presented with moderate dyspnea at rest that had been worsening for 3 weeks. He had a dry cough but no hemoptysis, chest pain, orthopnea, or palpitations. Low-grade fevers were relieved with acetaminophen. To address episodes of hypotension, he had stopped taking atenolol (Tenormin), but his systolic BPs remained between 90 and 99 mm Hg. He denied lower-extremity edema, changes in bowel habits, or signs of GI bleeding.
History In December 2007, the patient had stage IV, nodular, lymphocytepredominant Hodgkin's disease with bulky lymphadenopathy in the right axilla and chest wall and neoplastic involvement of the T12 vertebral body. In May 2008, he completed six cycles of chemotherapy with ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine), during which he experienced hematologic toxicities, including moderate anemia. Mild dyspnea began 2 weeks after the chemotherapy ended. Pulmonary function tests (PFTs) and a multigated acquisition scan showed no obstructive/restrictive lung disease. Ejection fraction (EF) was 61%. He also had hypertension, hyperlipidemia, chronic back pain, and psoriasis. He had quit smoking 25 years ago after a 5- pack-year smoking history and reported no occupational exposures.
Physical examination The patient appeared pale and dyspneic but alert and oriented. He was afebrile. His BP was 109/70 mm Hg; heart rate, 120 beats per minute; respiration rate, 22 breaths per minute. Oxygen (O2) saturation at rest was 87% on room air and 93% with 2 L of O2 via nasal cannula. The neck was supple and without jugular venous distention. Fullness of the right axilla was noted, but there was no palpable lymphadenopathy. The patient had mild sinus tachycardia; no murmurs, rubs, or gallops were heard. Auscultation of the lungs revealed inspiratory bibasilar crackles and scattered expiratory wheezing. Air movement was decreased in both lung fields, which were resonant to percussion. No egophony was heard. Abdomen was soft, nontender, and nondistended. Extremities were without edema, cyanosis, clubbing, or palpable cords. Psoriasis was seen on the elbows. No neurologic deficits were found. The patient underwent CT pulmonary angiography (see Figure 1).
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