December 4, 2024

20-year-old college student with prolonged productive cough and fatigue

By Med-Challenger · 2 minute read

A 20-year-old college student presents to you with productive cough and fatigue for the last 7 months. He was in his usual state of health before this school year, but he tells you that since he moved into a new apartment with a new roommate, he has been intermittently ill. He also reports an unintentional weight loss of 15 pounds in a 3-month period and loss of appetite.

His past medical history is negative. His past surgical history is significant for tonsillectomy and adenoidectomy at 9 years of age. He is not taking any medications and has no known allergies to medications. He has seasonal allergies to mold and ragweed for which he uses over-the-counter antihistamines as needed. He does not smoke but his roommate is a smoker. His roommate has a pet parakeet.

On examination, he is a thin man in no distress. Lung auscultation reveals crackles and wheezing. His temperature is 99.8°F.

Chest x-ray reveals a nonspecific diffuse interstitial pattern. Computed tomography reveals ground-glass opacities in the lower lobes. Pulmonary function studies reveal reduced forced vital and total lung capacities, with the preservation of airflow.

Lung biopsy reveals the following hematoxylin and eosin stain at 40× magnification (see figure):

image (34) Figure.

Which of the following is the most likely etiology of his symptoms?

his roommate’s pet parakeet
chronic obstructive asthma
asbestos in the apartment building
secondhand smoke from his roommate
mononucleosis

The correct answer is:

his roommate’s pet parakeet

Hypersensitivity pneumonia can be classified as acute (< 1 month), subacute (1 month to 1 year), or chronic (> 1 year). Lung biopsy is rarely necessary, particularly if the diagnosis can be concluded based on the patient’s history of exposure. Biopsy of the lung may show signs of chronic bronchiolitis, including lymphocytic infiltrate in the airway interstitium and multinucleated giant cells, which may contain calcified Schaumann bodies. These are nonspecific findings.

References:

Johannson, Kerri A., et al. "A diagnostic model for chronic hypersensitivity pneumonitis." Thorax (2016): thoraxjnl-2016.

Jose, Jaison, and Timothy J. Craig. "Hypersensitivity pneumonitis." Allergy and Asthma. Springer International Publishing, 2016. 311-331.

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