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Presentation of Case
Dr. Amulya Nagarur: A 64-year-old man was evaluated in the emergency department of this hospital because of dyspnea, wheezing, headaches, cough, and night sweats.
Approximately 6 years before this presentation, the patient had received a diagnosis of fibromyalgia, which had been made by a rheumatologist at another hospital. Two years before this presentation, the patient had had a sudden onset of pain on the right side of the lower back and buttock, with hypoesthesia and weakness in the right leg. Magnetic resonance imaging (MRI) revealed lumbosacral disk protrusion at L5–S1, with moderate-to-severe foraminal encroachment on the right side. Needle electromyography revealed evidence of L5 radiculopathy on the right side. Neurosurgery consultants recommended physical therapy, and two glucocorticoid injections were administered, which improved symptoms. However, 2 months later, electromyography revealed persistent active L5 radiculopathy on the right side that had not improved since the previous study had been obtained.
Approximately 1.5 years before this presentation, the patient’s rheumatologist reported that the patient had a persistent right foot drop and persistent tenderness of the paraspinal muscles. In addition, a diagnosis of carpal tunnel syndrome was made on the basis of the gradual onset of bilateral hand and wrist discomfort and hand paresthesias.
Approximately 5 months before this presentation, the patient noted the onset of a cough that produced thin yellow sputum. During the next month, exertional dyspnea, chest tightness, and wheezing developed. Six weeks later (9 weeks before this presentation), the patient was evaluated by his primary care physician at another hospital. On examination, rhonchi and wheezing were noted; the remainder of the examination was reportedly normal. Laboratory test results are shown in Table 1. A chest radiograph was reportedly normal. A diagnosis of bronchitis was made, and an albuterol inhaler and azithromycin were prescribed. The patient was referred to an allergist, because there were concerns about allergic bronchitis.
On evaluation by the allergist, epicutaneous and intradermal skin tests revealed no reaction to pollens, molds (including aspergillus), or dust mites. Pulmonary-function testing revealed a forced expiratory volume in 1 second (FEV1) of 2.51 liters (77% of the predicted value), a forced vital capacity (FVC) of 3.03 liters (70% of the predicted value), and a ratio of FEV1 to FVC of...