A 46-year-old man comes to an urgent care center with fever and productive cough for the past 2 days. He had a "bad pneumonia" 2 years ago that required hospitalization and intravenous antibiotics. Since then he has had almost daily cough with "thick, yellow" sputum and 5-6 episodes of a "respiratory infection" with fevers, sputum production, and occasional hemoptysis. The episodes have responded well to oral antibiotic therapy. The patient reports no chills, night sweats, weight loss, diarrhea, or swollen glands. He has no other medical problems and does not use tobacco.
His temperature is 38.0 C (100.4 F). On auscultation, crackles are heard at the right lung base.
Which of the following is the most likely diagnosis?

Question

A 46-year-old man comes to an urgent care center with fever and productive cough for the past 2 days.  He had a "bad pneumonia" 2 years ago that required hospitalization and intravenous antibiotics.  Since then he has had almost daily cough with "thick, yellow" sputum and 5-6 episodes of a "respiratory infection" with fevers, sputum production, and occasional hemoptysis.  The episodes have responded well to oral antibiotic therapy.  The patient reports no chills, night sweats, weight loss, diarrhea, or swollen glands.  He has no other medical problems and does not use tobacco.
His temperature is 38.0 C (100.4 F).  On auscultation, crackles are heard at the right lung base.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9866_20c2_853d_791e19344ab5_MD0002_00 This patient's presentation, with daily cough, mucopurulent sputum, and repeated infections with hemoptysis after an episode of pneumonia, suggests bronchiectasis. Bronchiectasis results when damage occurs to the bronchial walls from inflammation or infection, setting up a cycle of future infections and further airway damage. Etiologies include airway obstruction (eg, lung cancer, foreign bodies), infections (eg, viral, tuberculosis), and genetic diseases (eg, cystic fibrosis [CF], α-1 antitrypsin deficiency). Smoking has not been shown to cause bronchiectasis. Diagnosis is confirmed with CT scan. Additional workup focuses on identifying treatable etiologies, including measurement of immunoglobulin levels, genetic analysis for CF, and sputum culture for bacteria (including mycobacteria) and fungi. CT scan (Choice B) CF presents in adulthood in just over 5% of cases. However, late presentations are more likely to start with nonpulmonary findings such as diabetes mellitus, infertility, and gastrointestinal symptoms. An adult presentation of isolated lung disease without other associated symptoms is less common. (Choice C) Desquamative interstitial pneumonia is an idiopathic inflammatory lung condition most commonly associated with smoking (>90%). Patients usually present in their 30s and 40s. The most common symptoms are dyspnea on exertion and chronic cough with or without sputum. (Choice D) Although patients with small-cell lung cancer can experience episodes of post-obstructive pneumonia, it is seen almost entirely in those with a history of smoking. In addition, this patient has had symptoms for 2 years and has no signs of malignancy such as weight loss. (Choice E) Tuberculosis (TB) also presents with chronic cough but is most frequently accompanied by chronic fever and weight loss; this patient has neither. TB may predispose patients to bronchiectasis, but this patient's presentation is not consistent with active TB infection. Educational objective: Bronchiectasis results when damage occurs to the bronchial walls, setting up a cycle of future infections and further airway damage. The most common symptoms are daily productive cough, mucopurulent sputum, dyspnea, fatigue, and hemoptysis. Diagnosis is confirmed with CT scan. __________ References: Bronchiectasis--diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22211147) Airway disease: similarities and differences between asthma, COPD and bronchiectasis. (http://www.ncbi.nlm.nih.gov/pubmed/23184213)

A 46-Year-Old Man Comes to an Urgent Care Center with Fever