What's Your Diagnosis?
What Caused This Man’s Chronic Cough and Discolored Nails?
Gena Han, DO1 • Timothy Leisching, MD1,2
1Pulmonology Department, Beth Israel Lahey Health, Burlington, Massachusetts
2Chief Medical Officer, Lahey Hospital & Medical Center, Burlington, Massachusetts
Han G, Leisching T. What caused this man’s chronic cough and discolored nails? Consultant. 2021;61(11):e19-e21. doi:10.25270/con.2021.04.00012
Received November 19, 2020. Accepted December 28, 2020. Published online April 21, 2021.
The authors report no relevant financial relationships.
Gena Han, DO, Beth Israel Lahey Health, Attn: Pulmonary and Critical Care, 41 Mall Road, Burlington, MA 01805 (Gena.Han@Lahey.org)
A 66-year-old man was referred to our clinic for evaluation of cough, fevers, and rigors that had progressed over 10 days. His sputum was purulent but without hemoptysis. His medical history was significant only for a similar episode of pneumonia, which was resolved with antibiotics 1 year earlier.
A physical examination revealed crackles auscultated in the chest over the right middle lobe anteriorly, trace bilateral lower extremity shin lymphedema, and yellow-discolored nails (Figure). A chest radiograph demonstrated focal consolidation consistent with pneumonia of the right middle lobe.
Figure. The patient’s discolored, brittle nails.
As the current infiltrate was the patient’s second such episode, a computed tomography (CT) scan of the chest was performed, results of which demonstrated multifocal consolidation and scattered ground glass opacities without pleural effusions. The patient was given azithromycin, 250 mg, daily.
Two months later, the patient presented with persistent cough. At that time, the cough had been present for 6 weeks and was characterized as dry. The patient also had rhinorrhea with postnasal drip, night sweats, and weight loss of 8 lbs. A chest examination demonstrated clear lung fields. Otherwise, the physical examination had been unchanged since his first presentation.
A repeat CT chest scan demonstrated resolution of the previously noted multifocal consolidations, but the scattered ground glass opacities were unchanged. In addition, bronchiectasis was evident.
The chronic cough coupled with persistent ground glass opacities seen on chest CT scans prompted a bronchoscopy. Bronchoalveolar lavage samples demonstrated a cell count differential with 81% neutrophils and negative cultures, including a negative acid-fast bacillus stain and culture.
Transbronchial biopsies showed focal perivascular chronic inflammation without evidence of malignancy. The patient was started on scheduled guaifenesin and fluticasone nasal spray, and he was shown how to use a flutter valve.
At a follow-up visit several months later, the chronic cough had continued with the interval development of significant sinus drainage, as well as a small right pleural effusion.
Answer and discussion on next page.