Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 73-year-old man with a history of lung and bladder cancer presented to the emergency department complaining of 17 days of profound dyspnea on exertion, hoarseness, expiratory wheezes, and cough that was productive of scant white sputum. He denied having fever, hemoptysis, or chest pain. His symptoms started just after being discharged from another hospital where he had presented with urosepsis. His lung cancer was resected surgically more than 10 years ago, with no evidence of recurrence. He did not have a history of exposure to Mycobacterium tuberculosis. His baseline exercise tolerance was normal without any respiratory complaints.Physical examination revealed a thin man who had mildly labored breathing and who was not hypoxic. Monophonic wheezes were noted in the upper lung fields and over the trachea with a prolonged expiratory phase. Chest radiographs showed an elevated right hemidiaphragm consistent with his prior lung surgery, but no infiltrate. Plain film radiographs of the neck showed no narrowing or obstruction of the trachea. Ventilation-perfusion scanning was performed to look for pulmonary emboli. Ventilation scanning revealed severely decreased ventilation to the right lung (Figure 1), as well as marked retention of tracer material in the right lung at 5 minutes. A computed tomographic scan of the chest showed narrowing of the bronchus intermedius (Figure 2).What is the diagnosis?