A 59-year-old female presents to her primary care doctor with a chief complaint of progressive shortness of breath and nonproductive cough. She denies chest pain, palpitations, or wheezing. Her PMH is notable only for right-sided inflammatory breast cancer, diagnosed 1 year prior to presentation and treated with doxorubicin/cyclophosphamide/paclitaxel followed by x-ray telescope (XRT) and mastectomy. At rest, her room air saturation is 95% and other vital signs are normal. Chest CT is negative for pulmonary embolus but notable for patchy consolidation and ground glass opacities in the right lung as well as traction bronchiectasis. Her WBC is normal and sputum gram stain shows no organisms.
What is the most appropriate treatment?
A. Ceftriaxone and azithromycinCorrect Answer: C
This patient with a PMH of inflammatory breast cancer and recent (<1 year) radiation to the chest is likely presenting with radiation-induced pneumonitis. Inflammatory breast cancer is a rare but aggressive form of breast cancer that classically presents with a finding of “peau d’orange”— warm, thickened, firm skin over the affected breast. Treatment, as in this case, is multimodal with neoadjuvant chemo, surgery, and radiation. Patients who undergo thoracic radiation are at risk for radiation pneumonitis, which can present weeks to months after therapy. Radiation pneumonitis is thought to result from radiation-induced injury to type II penumocytes and endothelial cells. It typically presents with shortness of breath and dry cough. Chest CT findings include patchy consolidation, fibrotic changes, and ground glass that does not respect lobar borders. Newer radiation techniques make the classic radiographic finding of a portal line marking the boundary of the radiation field less likely. The mainstay of treatment of high-dose prednisone. Ceftriaxone and azithromycin would be appropriate treatment for CAP but the subacute onset, negative gram stain, and lack of other infectious signs and symptoms make that diagnosis less likely here. Similarly, vancomycin and cefepime would not be the most appropriate therapy. Obstructive lung disease (asthma and COPD) can present with dyspnea and would be appropriately treated with bronchodilators such as albuterol, but there are no physical examination findings or history to support that diagnosis here.
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