Case Challenge #14

History of Present Illness

A 46 year old female presents to clinic for followup of chronic cough (10 years duration). She was first evaluated 4 years ago with dry cough, diarrhea, and weight loss. She denies dyspnea, wheezing, sputum, or fevers. No travel or smoking history. No birds or occupational exposures. Seen by ENT, allergy, GI, speech therapy; she has had 24h ambulatory ph monitoring (no reflux found); laryngoscopy (no vocal cord dysfunction), skin testing for allergens (negative). She has been treated with BID Nexium, nasal steroids, inhaled steroids, systemic steroids, bronchodilators, leukotriene antagonists, and ipratropium with no change in cough. No rashes, joint pain, dysphagia, skin change, hair changes, fevers, chills, malaise or other symptoms.

Physical Exam

  • T 98.5 HR 85   BP 111/72   RR 14   100% room air BMI 23
  • Gen: well appearing, mild coughing, no distress. Otherwise, exam is normal.
  • Pertinent negatives: no oral ulcers, no cardiac murmurs or rubs, clear lungs, no wheezes, normal effort, symmetric diaphragmatic excursion, no HSM, no skin rashes, no joint swelling or effusion, no nailbed changes, no sinus tenderness, normal tympanic membranes, no lymphadenopathy.

Pulmonary Function Test

  • FVC: 1.73 (45%) || FEV1: 1.22 (39%) || Ratio: 70 || TLC   2.47 (46%) || VC: 1.73 (45%) || RV: 1.28 (71%) || DLCO: 11.6 (53%) || Pt started coughing with albuterol; BD response not assessed

CT Scan (only visible on the website)

Biopsy

Screen Shot 2015-04-29 at 5.34.47 PM

Question

D-dimer Primer

You know that the d-dimer does not always suggest VTE, but WHAT ELSE COULD IT BE?!

Non-pathological conditions associated with elevated D-dimer titers include:

  • Age (healthy elderly people)
  • Cigarette smoking
  • Functional impairment
  • Post-operatively
  • Pregnancy
  • Race (e.g. African Americans)

Pathological conditions associated with elevated D-dimer titers include:

  • Acute coronary syndromes
  • Acute upper gastrointestinal haemorrhage
  • Aortic dissection
  • Arterial or venous thromboembolism
  • Atrial fibrillation
  • Consumptive coagulopathy – DIC, VICC
  • Infection
  • Malignancy
  • Pre-eclampsia
  • Sickle cell disease
  • Stroke
  • Superficial thrombophlebitis
  • Trauma
To learn more about the d-dimer, check out yesterday’s quiz from JAMA. D-dimer PE quiz