Acute-onset dyspnea and substernal chest pain radiating to the back developed in a 46-year-old African-American woman while she was watching television. There was no cough, fever, or chills. She had been admitted to the hospital 3 months earlier with a similar presentation; a spontaneous, left basal pneumothorax was found and was treated with tube thoracostomy.
Six years before that, she had been first told she had emphysema and was treated with inhaled bronchodilators; she stopped smoking (smoking history, 13 pack-years). A review of prior chest radiographs demonstrated that emphysema involving predominantly the upper lobes had been present 13 years prior (smoking history at that time, 5 pack-years). Her medical history was remarkable for two episodes of suspected pneumonia in her early thirties, hypertension, hyperlipidemia, and diffuse idiopathic skeletal hyperostosis. She worked as a data processor in a health institution; had never been exposed to fumes, dusts, asbestos, or silica; denied any drug use; and had no family history of lung disease. A careful review of systems revealed occasional arthralgias, mainly involving the hips, elbows, and the thoracic spine. There was no history of urticaria, ocular disease, or joint laxity.