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Assembly

Too Much of a Good Thing

Authors
Spoorthi Davala1, Elizabeth Gibb1, Fatima Neemuchwala1, Kelly Tuveson1, Kensho Iwanaga1, Gywnne Church1, Ngoc Ly1
UCSF Benioff Children's Hospital Oakland, Oakland, CA, United States


Case

A 12-year-old female presented to the ED with four days of acute worsening of chronic cough and dyspnea. Upon presentation, saturations were 80% on RA and she was placed on 5LPM nasal cannula. Exam was notable for diminished breath sounds bilaterally, otherwise no crackles or wheezes. Chest x-ray showed bilateral diffuse opacification. Respiratory viral panel was positive for non-novel coronavirus 229E. She was initially admitted to the general wards, but overnight required escalation of respiratory support to 25L heated high-flow nasal canula and was transferred to ICU.

Infectious disease and Pulmonary were consulted. Further history revealed that the family lived in the Central Valley in California until she was 8 years old and she had an intermittent dry cough, improving with short acting beta agonist (SABA) as needed. Her cough resolved after moving to the Bay Area. Four months prior to presentation, she visited the Central Valley when her cough returned and did not improve with inhaled SABA and steroids.

Chest CT
Figure 1. Chest CT was obtained.
Bronchoalveolar lavage
Figure 2. Bronchoalveolar lavage was performed and showed

On the physical exam, the chest wall was symmetric, without deformity. No tenderness was appreciated upon palpation of the chest wall. The patient did not exhibit signs of respiratory distress; and normal heartbeat and breath sounds were heard upon auscultation. The patient denied chest pain, and shortness of breath.

Laboratory evaluation was unremarkable, but serology revealed that the patient was positive for Influenza type A.


Question

What is the most likely etiology of these findings?

A. Coccidioides
B. Mycobacterial Infection
C. Bronchiolitis Obliterans
D. Pulmonary Alveolar Proteinosis
E. Hypersensitivity Pneumonitis

Answer