The Descartes’ lesson: the doubt as part of the clinical reasoning
Abstract
- 39 year-old male, caucasian, non smoker, living in a subtropical island.
- low level exposure to molds.
- familial clinical history: not relevant.
- past medical history: not relevant.
- clinical onset: exertional dyspnea persisting for six months.
The patient was admitted to the local hospital where CT scan, bronchoalveolar lavage (BAL) and transbronchial lung cryobiopsy were performed.
Even though the analysis performed on the BAL fluid, collected during the bronchoscopy, stated lymphocytosis (CD4+T cell), a final diagnosis of Lipidic Pneumonia was made and treatment with high dose steroids (prednisone 50 mg/die) was started.
The patient experienced a recurrence of symptoms - including dyspnea, fever, and recently, oral mucosal blisters - during steroid tapering, despite repeated high doses of steroids and attempts at tapering.
He sought a second opinion while on high-dose steroids.
Upon admission in our Department, the CT scan of the thorax was nearly normal.
Laboratory tests revealed mild anemia (Hb=12.7 g/dL, MCV=90.7 fl), normal C-reactive protein, negative autoimmunity (including myositis autoantibodies and ANCA), negative Bence-Jones proteins and monoclonal components in urine and serum.
Precipitins for molds and avian proteins were also negative.
Pulmonary function tests showed normal lung volumes but a reduced DlCO (Tab. I).
CT scan and cryosamples carried out during the first admission to the Hospital were revised.
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Questo lavoro è fornito con la licenza Creative Commons Attribuzione - Non commerciale - Non opere derivate 4.0 Internazionale.
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© Associazione Italiana Pneumologi Ospedalieri – Italian Thoracic Society (AIPO – ITS) , 2025
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