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ACCP-SEEK Board Review Question of the Month |

Woman With Dry Cough and Dyspnea on Exertion Has Clubbing, Conjunctival Injection, and Diffuse Crackles*

Susan M. Harding, MD, FCCP
Author and Funding Information

*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.

Correspondence to: Susan M. Harding, MD, FCCP, 2714 Old Trace, Birmingham, AL 35243-2030; e-mail: sharding@uab.edu



Chest. 2003;123(3):935-936. doi:10.1378/chest.123.3.935
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A 36-year-old woman presents with dry cough and dyspnea on exertion, which have progressed over the past 2 years. She is dyspneic after climbing two flights of stairs. This surprises her because she was able to run an 8-min mile 2 years ago. She does not have wheezing, fever, chills, weight loss, skin rash, or joint pain, but she does have conjunctival injection. She is a life-long nonsmoker and has no pets. She does not have any history of asbestos exposure and works as a diamond polisher for a large-volume diamond buyer. Physical examination shows mild clubbing, conjunctival injection, and dry crackles bilaterally in the lower third of the lung fields. She does not have hepatosplenomegaly or a skin rash. Her chest radiograph is shown in Figure 1 . Pulmonary function tests show FVC of 2.67 L (60% of predicted), FEV1 of 2.35 L (63% of predicted), and oxygen saturation by pulse oximetry of 93% at rest and 87% after walking 300 feet in 3 min. Bronchoscopy with BAL and transbronchial lung biopsy are performed. A few hours later, the pathologist calls to report bizarre-appearing, multinucleated giant cells with a cell within a cell, or a “cannibalistic” appearance in the BAL specimen (Fig 2 ). Which of the following diseases is most likely?

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