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Sick Lungs From Sicca Syndrome
Pulmonary Manifestations of Systemic Disease SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Sick Lungs From Sicca Syndrome
INTRODUCTION: While many cases of acute hypoxic respiratory failure with bilateral pleural effusions are the result of decompensated heart failure, other uncommon causes should be explored. We present a case of an elderly female with suspicion of decompensated diastolic heart failure causing acute hypoxic respiratory failure. Further workup yielded a diagnosis of Sicca syndrome and mixed connective tissue disorder, which drastically responded to steroids. CASE PRESENTATION: An 85-year-old female presented to the ED with orthopnea, PND and cough. She also complained of small joint tenderness, dry mouth and dry eyes. Her PMH was significant for breast cancer s/p lumpectomy, diastolic CHF, paroxysmal atrial fibrillation, and DJD. She was recently admitted with an exudative pericardial effusion attributed to viral etiology and discharged home on appropriate medications. However, she returned to the ED 2 days later with tachypnea, hypoxia to 85% on room air with diminished breath sounds in lung bases. X-ray revealed bilateral pleural effusions and a residual pericardial effusion. Acute coronary syndrome was ruled out, with little relief from diuresis. Follow-up x-ray showed little improvement and echocardiogram revealed a minimal effusion. Diagnostic and therapeutic thoracentesis showed Pleural LDH/ Serum LDH was 0.72 and Pleural Protein/Serum Protein was 0.67. Cytology was negative for malignancy, TB and ADA were also negative. Breast and rectal exams revealed no masses. Full body CT revealed no discrete masses. Rheumatology panel showed elevated speckled pattern ANA of 250, but normal RF, C3, C4, anti-CCP, anti-histone antibody, Anti-Jo, Anti-Smith, AntidsDNA, SSA and SSB. Rheumatology was consulted; she was started on prednisone with improvement in her joint pain, SOB, and hypoxia. Follow up X-ray at discharge revealed stable decreased pleural effusions. DISCUSSION: Sjögren’s syndrome (SS) is an inflammatory disorder characterized by diminished lacrimal and salivary gland function. Onset of lung disease (LD) is 5-10 years after initial diagnosis of SS, however LD can often precede initial diagnosis 1-2. When it occurs, LD is more common in women, over the age of 60, manifesting as ILD, organizing PNA, LIP or UIP. Despite these presentations, there have been no reported cases of Sicca syndrome (dry eyes and dry mouth only) and mixed connective tissue disorders causing pleural disease1-2. CONCLUSIONS: Here the patient reported underlying joint tenderness, dry mouth, dry eyes, and significant kyphoscoliosis. Although numerous other etiologies of hypoxic respiratory failure are more common in the elderly, rheumatologic conditions need to be evaluated if no clear cause of an exudative pleural effusion is delineated. Reference #1: 1 Freemer MM, King TE Jr. Connective tissue disease. In: Interstitial Lung Disease, Hamilton, Ontario 2003. p.535. Reference #2: 70:354.
2
Strimlan, CV, Rosenow, EC, Divertie, MB, et al. Pulmonary manifestations of Sjögren’s syndrome. Chest 1976;
DISCLOSURE: The following authors have nothing to disclose: Komal Akhtar, Adam Zayac, David Lehmann No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1182
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
1075A
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Komal Akhtar MD* Adam Zayac MD; and David Lehmann MD SUNY Upstate Medical University, Syracuse, NY
Sick Lungs From Sicca Syndrome
INTRODUCTION: While many cases of acute hypoxic respiratory failure with bilateral pleural effusions are the result of decompensated heart failure, other uncommon causes should be explored. We present a case of an elderly female with suspicion of decompensated diastolic heart failure causing acute hypoxic respiratory failure. Further workup yielded a diagnosis of Sicca syndrome and mixed connective tissue disorder, which drastically responded to steroids. CASE PRESENTATION: An 85-year-old female presented to the ED with orthopnea, PND and cough. She also complained of small joint tenderness, dry mouth and dry eyes. Her PMH was significant for breast cancer s/p lumpectomy, diastolic CHF, paroxysmal atrial fibrillation, and DJD. She was recently admitted with an exudative pericardial effusion attributed to viral etiology and discharged home on appropriate medications. However, she returned to the ED 2 days later with tachypnea, hypoxia to 85% on room air with diminished breath sounds in lung bases. X-ray revealed bilateral pleural effusions and a residual pericardial effusion. Acute coronary syndrome was ruled out, with little relief from diuresis. Follow-up x-ray showed little improvement and echocardiogram revealed a minimal effusion. Diagnostic and therapeutic thoracentesis showed Pleural LDH/ Serum LDH was 0.72 and Pleural Protein/Serum Protein was 0.67. Cytology was negative for malignancy, TB and ADA were also negative. Breast and rectal exams revealed no masses. Full body CT revealed no discrete masses. Rheumatology panel showed elevated speckled pattern ANA of 250, but normal RF, C3, C4, anti-CCP, anti-histone antibody, Anti-Jo, Anti-Smith, AntidsDNA, SSA and SSB. Rheumatology was consulted; she was started on prednisone with improvement in her joint pain, SOB, and hypoxia. Follow up X-ray at discharge revealed stable decreased pleural effusions. DISCUSSION: Sjögren’s syndrome (SS) is an inflammatory disorder characterized by diminished lacrimal and salivary gland function. Onset of lung disease (LD) is 5-10 years after initial diagnosis of SS, however LD can often precede initial diagnosis 1-2. When it occurs, LD is more common in women, over the age of 60, manifesting as ILD, organizing PNA, LIP or UIP. Despite these presentations, there have been no reported cases of Sicca syndrome (dry eyes and dry mouth only) and mixed connective tissue disorders causing pleural disease1-2. CONCLUSIONS: Here the patient reported underlying joint tenderness, dry mouth, dry eyes, and significant kyphoscoliosis. Although numerous other etiologies of hypoxic respiratory failure are more common in the elderly, rheumatologic conditions need to be evaluated if no clear cause of an exudative pleural effusion is delineated. Reference #1: 1 Freemer MM, King TE Jr. Connective tissue disease. In: Interstitial Lung Disease, Hamilton, Ontario 2003. p.535. Reference #2: 70:354.
2
Strimlan, CV, Rosenow, EC, Divertie, MB, et al. Pulmonary manifestations of Sjögren’s syndrome. Chest 1976;
DISCLOSURE: The following authors have nothing to disclose: Komal Akhtar, Adam Zayac, David Lehmann No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1182
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
1075A
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Komal Akhtar MD* Adam Zayac MD; and David Lehmann MD SUNY Upstate Medical University, Syracuse, NY