Cough Cough

A 37 year old lady presents with mild dyspnea and an intermittent, non-productive cough for 3 months. There was no history of wheezing, nocturnal aggravation of the cough, orthopnea, or paroxysmal nocturnal dyspnea.

While there is no history of fever, or loss of weight, she does complain of feeling lethargic since the onset of symptoms. She also noticed a transient, painful erythematous rash over her shins for the last six months.

Her medical and surgical histories are unremarkable. She does not smoke, and has no family history of lung disease.

Select Relevant Investigations
Complete Blood Count

Performed

WBC/DC: 5,000/mm3 (4,600-11,000)
N: 68% L: 25%
Hb: 10.2 g/dL (11-18)
Platelets: 300,000/mm3 (150,000-400,000)
Blood film: Normochromic normocytic anemia.
Chest X-Ray

Performed

The chest X-ray reveals bilateral hilar lymphadenopathy with diffuse reticulonodular shadowing.
Serum ACE levels

Performed

Serum Angiotensin-Converting Enzyme (ACE) levels: 202 U/l (normal: 9 - 67)
Transbronchial biopsy

Performed

The biopsy reveals multiple granulomas consisting of epithelioid cells with Langhans type giant cells in the center and a scanty rim of lymphocytes. There is no evidence of caseation.
Stains for Acid-Fast Bacilli (AFB) and fungi are negative.

Select Relevant Management
Antibiotics
Steroids
Methotrexate
Beta Agonists