Chronic Shortness of Breath and Cough case study
“I have been experiencing shortness of breath on exertion and persist cough.”
History of Present Illness: The client, H.B is a 38yo white female presents. She visits the clinic after being admitted to the medical/surgical ward due to shortness of breath on exertion with a persistent cough five days ago. The client reports experiencing similar symptoms six months ago, necessitating a visit to her primary care physician’s (PCP) office. The PCP diagnosed H.B with acute bronchitis. Three medications, including bronchodilators, a short course oral steroid taper, and empiric antibiotics were prescribed to manage the client’s condition. However, the client reports that the treatment plan was ineffective in improving her symptoms. H.B adds that the presented symptoms have worsened gradually in the last six months. She reports losing approximately 20-pound (9 kg) over the last year intentionally. The client denies spelunking, camping, or hunting activities. She also denies coming into contact with sick persons.
Medications: Lisinopril 10 mg once daily taken to lower her blood pressure
Allergies: The client denies being allergic to food medicine, or environmental triggers. She reports being allergic to dust and cats during her childhood. Exposure to these triggers caused asthma exacerbation. However, the client denies experiencing any incident of asthma exacerbation since the age of 12 despite being exposed to dust and cats.
Past Medical History: Hypertension managed using Lisinopril 10 mg once daily
Past Surgical History: Cholecystectomy at 23 years
Sexual/Reproductive History: The client is sexually active. She is heterosexual with one sexual partner for the last 9 years. She uses an implant as a contraceptive. She denies any side effects associated with her contraceptive.
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Health Maintenance: The client visits her gynecologist every two years for cervical and vaginal examinations. The last visit was June 2021 and examination results were normal. The client also gets her eyes and dental checked regularly. She reports lastly visiting her optician and dentist for annual check-ups in August and October 2021, respectively. Eyes and dental examination results were normal. However, the client was prescribed glasses upon reporting experiencing pain when reading. The client also eats a balanced and healthy diet rich in fiber and low carbs. She takes adequate water (A minimum of 8 glasses daily). The client engages in physical activities, including morning runs and jogging in the evening. She goes to the gym over the weekends and during her off days. Consequently, she has lost about 9kgs in the last year. She reports remain healthy is her primary goal in life.
Immunization: H.B reports that all her childhood immunizations are up to date. She received a flu vaccine in March 2021. She was given a COVID-19 jab in September 2020.
Social History: The client reports being married for the last 9 years. She has three kids, two sons, and a daughter. She lives with her husband and their three children in the city. She likes visiting her parents in the neighboring city over the weekends and public holidays. Additionally, the client enjoys spending her free time with her children either within their compound or at the pack. While together they like swimming or riding bikes. She also enjoys spending quality time with her friends. She reports being a social drinker and takes 2 to 4 beers when she goes out with her friends over the weekend. The client reports smoking tobacco products for the last 20 years. Nonetheless, she quit smoking six months ago following the onset of the presented symptoms. She denies using other illicit drugs, including marijuana, heroin, and cocaine. H.B works in a cookie bakery. The client likes animals and pets, and she has two pet doves. One year ago the client traveled to Mexico for a one-week holiday with her husband and their three children.
Family History: The client is a second born in a family of four. All her siblings are alive. Their third and lastborn are healthy with no known health condition. However, their firstborn has a history of hypertension and Type 2 diabetes mellitus (T2DM). Her mother is alive at 70 years with obesity, T2DM, and high cholesterol. Her father is alive at 76 with hypertension and stroke. He has been bed-ridden for the last 2 years. Her maternal grandmother died of cardiac arrest at 88 years. Her maternal grandfather died of an infection of the respiratory system at 93 years. Her paternal grandfather and grandmother died at 86 and 81 years following a tragic car accident. The paternal grandfather had been diagnosed with prostate cancer and high blood pressure. Her paternal grandmother was healthy with no known chronic illness.
Review of System
General: The client reports intentional weight loss. She reports losing 9kgs over the last 12 months. She denies night sweats or fever.
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HEENT:
Head: The client denies head trauma or headaches. Denies hair color or texture change. Eyes: The client denies visual loss, blurred vision, eye redness, eye drainage, or eye irritation. She reports using glasses while reading.
Ears: The client denies hearing difficulty, ear pain, vertigo, hearing loss, or drainage from the ears.
Nose: She denies nasal drainage, difficulty with smell, or epistaxis.
Throat: She denies dry mouth, hoarseness, sore throat, or snoring. Denies pain in the mouth, teeth pain, or tongue. She denies mouth ulcers, difficulty with smell, or chewing and swallowing difficulties. She denies gum ulcers or bleeding gums. The client denies any dental problems.
Neck: She denies shoulder or neck swelling. Denies neck stiffness.
Respiratory: The client reports shortness of breath on exertion and cough. She reports childhood asthma. However, has not experienced asthma exacerbations since the age of 12. She denies wheezing, hemoptysis, or sputum production.
Cardiovascular/Peripheral Vascular: She denies chest pain, palpitations, or chest tightness.
Gastrointestinal: The client denies vomiting, nausea, constipation, diarrhea, or abdominal pain.
Genitourinary: Denies pain with urination or increased frequency.
Musculoskeletal: Denies muscular changes. Denies muscle stiffness or back pain. Denies decreased movement or difficulty in climbing stairs.
Neurological: Denies neural sensation changes. Denies dizziness, headache, weakness, or numbness.
Endo: Denies change in appetite. Denies cold or hot intolerance.
Psychiatric: Denies anxiety, insomnia, or suicidal thoughts.
Skin/hair/nails: Denies pigmentation or brittle nails.
OBJECTIVE DATA
Physical Exam:
Vitals: T, 97.8 F; RR 22; heart rate 88; bp 130/88; Weight, 176 lbs Height 5 “6” BMI score 28. 4
General: The client, H.B is a well-nourished, pleasant, and well-developed female. Her hair is well maintained. She was dressed in a hospital uniform and lying on a stretcher. She is accompanied by her husband and healthcare provider from the surgical ward where she has been admitted for five days. The client seems agitated and in mild distress probably due to her health condition. She is conversing freely with a clear voice and a normal tone. Nonetheless, respiratory distress is making the client stop conversation mid-sentence. She is attentive and maintains eye contact throughout the clinical interview. She seems eager to know more about her health condition. H. B is alert and oriented to place, person, time, and situation. She has a strong thought process with remote and current memories. Her effect and judgment
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are good, and she is future-oriented. She denies suicidal thoughts or ideations.
HEENT:
Head: No deformities to the scalp. No scars on the head or evidence of trauma. No lesions or tenderness. Long and evenly distributed brown hair.
Eyes: Equally round and sensitive to light pupils. Non-injected and accommodation at 3mm bilaterally. No drainage from both eyes.
Ears: External ears are well-developed. No drainage on the external auditory canals. Symmetrical auricles.
Nose: No external lesions noted. No nasal drainage. Pink and moist nasal turbinates. No maxillary or frontal sinus tenderness.
Throat: No mouth, gum, or lip ulcers. No bleeding gums. The client has a well-developed and visible hard palate. No visible tonsils. No erythema. No throat drainage.
Neck: Highly-flexible neck, demonstrating a full range of motion of the shoulders and the neck. The trachea is midline. No tonsillar or thyromegaly. Tender posterior cervical node. On auscultation, no carotid bruits were heard.
Breast: No nipple discharge or masses.
Respiratory: The client has mild wheezing and diffuse rales. She is tachypneic.
Cardiovascular: Normal S1 and S2 with regular rate and rhythm. Murmurs, gallops, or rubs are absent.
Gastrointestinal: Bowel sounds are audible in all four quadrants. No pulsatile mass or bruits.
MSK: Normal back curvature. No deformities or tenderness.
Neuro: Her bilateral hand grip is strong and equal.
Psych: Seems anxious and agitated
Skin: Warm and dry skin. No spots or pigmentation. Appropriate elasticity and turgor.
Initial Evaluation
Laboratory Studies:
Full blood count: This test was conducted at the emergency department to assess variations in the client’s blood composition. The results indicated pancytopenia with a hemoglobin level of 8.3 g per liter, a platelet count of 74,000 per mm3; ALT 112, and an AST 90.
Blood cultures: Results were negative for gram staining or bacterial growth.
Chest X-ray
Impression: Mild interstitial pneumonitis
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ASSESSMENT
Primary Diagnosis: Acute Pulmonary Histoplasmosis
Based on the patient’s medical history, presented clinical manifestation, physical examination results, and diagnostic test results, the client’s primary diagnosis is acute pulmonary histoplasmosis.
Etiology and Clinical Manifestations
The etiology of histoplasmosis is complicated, making its diagnosis challenging. Pulmonary histoplasmosis is caused by the presence of microconidia of Histoplasma spp. fungus into the lungs (Baker et al., 2020). The mycelial phase is less harmful while in the environment at normal temperature. However, it converts into budding yeast cells upon being exposed to high temperatures over 37 C in the host’s lungs. These changes cause an infection, affecting the lung and the entire respiratory system. In most cases, the fungus is transmitted from the soil to a person’s lungs through inhalation, causing infection. Cases of human-to-human transmission are also common. A person can contract the disease upon coming into contact with an infected individual, chronically harboring yeast-forming colonies. Following initial inoculation, the colonies are viable for years; hence can cause infections. Individuals may have a reactivated infection upon traveling from endemic to non-endemic regions. The infection might occur months to years later following long-term viability.
These infections can be asymptomatic or life-threatening conditions. The severity of the infection significantly depends on the fungal inoculum size or the host’s immunological status (Staffolani et al., 2018). Organic matter enriched with bat or bird supports the growth of Histoplasma spp. Therefore, coming into contact with bat-feces-rich caves raises the risk of infection. Similarly, the inoculation rate is relatively high among pet owners. In this case, H.B traveled outside of Nebraska accompanied by her family members within the last year. Additionally, she keeps two birds as pets. Traveling outside the city and keeping birds increased the risk of contracting this infection.
Acute pulmonary histoplasmosis’ symptoms begin to manifest between 3 to17 days after coming into contact with the fungus. Clinically silent manifestations with ill impacts are common among immunocompetent individuals (Staffolani et al., 2018). The acute stage of this infection is mainly characterized by nonspecific respiratory symptoms such as flu and cough. Upon visiting the clinic, the client reports shortness of breath with exertion and cough, which have persisted for the last six months. Thus, acute pulmonary histoplasmosis qualifies as her primary diagnosis.
Differential Diagnosis
Differential diagnosis should be conducted to rule out other conditions with similar symptoms. The potential diagnosis for this client is discussed below from the most to the least likely diagnosis.
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Aspiration Pneumonitis and Pneumonia
Aspiration pneumonia is another potential diagnosis for this client. It is an infection of the lungs, which occurs after inhaling other particles, including food, saliva, liquid, or vomit among other foreign objects (Mandell & Niederman, 2019). The inhaled chemicals burn the airways and lungs, causing acute inflammation that leads to lung injuries (Mandell & Niederman, 2019). This condition is characterized by shortness of breath (dyspnea), coughing up blood or pus, wheezing, bad breath, chest pain, or extreme tiredness. Symptoms of aspiration pneumonia manifest shortly after inhaling a foreign object. In some people, symptoms manifest within 2 hours after inhaling a foreign particle (Mandell & Niederman, 2019). The client reports shortness of breath on exertion and cough, qualifying for this diagnosis. However, aspiration pneumonia is ruled out since the client’s cough is not accompanied by blood or pus. Additionally, the client denies other significant symptoms, including wheezing, bad breath, chest pain, and extreme tiredness.
Viral Pneumonia
The second differential diagnosis for this client is viral pneumonia, which is mainly caused by influenza, SARS-CoV-2, and respiratory syncytial virus (RSV) (Hu et al., 2021). These viruses also cause colds and the flu. Viral pneumonia represents one-third of total pneumonia cases. In the early stages, viral pneumonia is characterized by influenza symptoms, including dry cough, fever, headache, weakness, and muscle pain (Hu et al., 2021). These symptoms worsen within a day or two. At a late stage, individuals experience increasing cough, muscle pain, and shortness of breath. The client might have viral pneumonia since she reported shortness of breath and cough. Nonetheless, viral pneumonia is ruled out since the client’s condition has persisted over the last six months.
Chlamydial Pneumonia
Lastly, the client is diagnosed with chlamydial pneumonia, which is caused by C. pneumoniae that also causes bronchitis and lung infection. The risk of developing laryngitis is relatively high among individuals with pneumonia caused by C. pneumoniae and those with pneumonia caused by other types of bacterial pneumonia. This condition is characterized by various clinical manifestations, including shortness of breath, coughing, chest pain due to coughing, stuffy or runny nose, low-grade fever, fatigue, hoarseness, headache, or sore throat.
Slowly worsening cough that can last for weeks or months. Symptoms take around 3 to 4 weeks before manifesting following exposure to bacteria. Individuals might experience these symptoms for several weeks. The client qualifies for this diagnosis since she reported shortness of breath with exertion and cough. However, chlamydial pneumonia is ruled out since the client only experiences shortness of breath on exertion. Additionally, the client denies other significant symptoms, including a stuffy or runny nose, low-grade fever, fatigue, hoarseness, headache, and sore throat.
Confirmatory Evaluation
Further evaluation was conducted to confirm the client’s diagnosis.
A CT of the chest: Results indicated a diffuse centrilobular micronodular pattern with no focal consolidation.
Diagnostic bronchoscopy of the lungs: Was conducted to detect rare or atypical infections and the results would be used to rule out the likelihood of malignancy. A fluid with a muddy and cloudy appearance was detected. Cytology indicated Histoplasma capsulatum. No bleeding.
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TREATMENT PLAN
In asymptomatic patients, pulmonary histoplasmosis is self-resolving and no treatment is needed. Nonetheless, treatment is needed in moderate to severely symptomatic cases. In this case, the client should be prescribed itraconazole 200 mg orally twice daily for 6 to 12 weeks, depending on the client’s response. Itraconazole 200 mg was preferred due to its effectiveness in preventing and treating fungal infections (Pappas et al., 2018). A chest x-ray should be conducted regularly to assess the client’s response to the treatment regimen. Additionally, the client should be observed in the future for recurrence following the diagnosis. The client will continue with itraconazole 200 mg orally twice daily if the medication is effective in improving the client’s symptoms and is well-tolerated. However, the client should be administered amphotericin B for at least 2 weeks and a maximum of 1 year if symptoms worsen after using itraconazole 200 mg orally twice daily.
References
Baker, J., Kosmidis, C., Rozaliyani, A., Wahyuningsih, R., & Denning, D. W. (2020, May). Chronic pulmonary Histoplasmosis—A scoping literature review. In Open forum infectious diseases (Vol. 7, No. 5, p. ofaa119). US: Oxford University Press.
https://doi.org/10.1186/s12879-018-3476-z
Hu, Z., Lin, J., Chen, J., Cai, T., Xia, L., Liu, Y., … & He, Z. (2021). Overview of viral pneumonia associated with influenza virus, respiratory syncytial virus, and coronavirus, and therapeutics based on natural products of medicinal plants. Frontiers in Pharmacology, 12, 1380. Doi: 10.3389/fphar.2021.630834
Mandell, L. A., & Niederman, M. S. (2019). Aspiration pneumonia. New England Journal of Medicine, 380(7), 651-663. DOI: 10.1056/NEJMra1714562
Pappas, P. G., Kauffman, C. A., Andes, D. R., Clancy, C. J., Marr, K. A., Ostrosky-Zeichner, L., … & Sobel, J. D. (2018). Clinical practice guideline for the management of candidiasis: 2018 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 62(4), e1-e50. https://doi.org/10.1093/cid/civ933
Staffolani, S., Buonfrate, D., Angheben, A., Gobbi, F., Giorli, G., Guerriero, M., … & Barchiesi, F. (2018). Acute histoplasmosis in immunocompetent travelers: a systematic review of literature. BMC infectious diseases, 18(1), 1-14.
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