Kant’s thought retains its relevance even when clinical reasoning is the subject of analysis | Rassegna di Patologia dell'Apparato Respiratorio

Abstract

60-YEAR-OLD MALE, NEVER SMOKER
FARMER WITH MODERATE EXPOSURE TO BIRDS AND HAY 
FAMILIAL CLINICAL HISTORY: not relevant 
PAST MEDICAL HISTORY: allergic rhino-sinusitis, paroxysmal atrial fibrillation
PHARMACOLOGICAL THERAPY: apixaban
CLINICAL ONSET: exertional dyspnoea and low grade fever

Due to the progressive worsening of symptoms, the patient was admitted to a pulmonology department. 
Chest CT and bronchoalveolar lavage (neutrophils 70% - eosinophils 20%) were interpreted as possibly consistent with the 

Diagnosis of Eosinophilic Pneumonia.

After one month of corticosteroid therapy, both low-grade fever and dyspnea resolved and a follow-up chest CT was reported as negative. Consequently, corticosteroid treatment was discontinuated.
One month after discharge, the patient was again admitted for respiratory failure. CT scan showed bilateral ground glass attenuation mainly in peribronchovascular fashion (Fig.1). A bronchoalveolar lavage (BAL) was performed again, revealing 80% macrophages, 8% lymphocytes and 12% neutrophils. On suspicion of a recurrence of eosinophilic pneumonia, corticosteroid therapy was restarted.

Despite corticosteroid therapy, the patient showed progressive clinical worsening and after a few weeks was admitted to our unit for progressive respiratory failure.
Upon admission, additional blood investigations, including arterial blood gas analysis were carried out. Laboratory tests (Tab.I) revealed a mild neutrophilia, associated with an increase in inflammatory markers and positivity for beta-D-glucan.
The arterial blood gas analysis (Tab. I) performed on room air shows severe type 1 respiratory failure, improving with oxygen at high flows through nasal cannulae (HFNC).