Critical pitfall: another cause of wheezing.

Description

An 87-year-old woman was referred to our hospital with progressive dyspnoea on effort over the previous 2 weeks. She had been treated for rheumatoid arthritis with oral prednisolone (5 mg/day) and tacrolimus (2 mg/day). At her first visit, vital signs and physical examination were normal except for slight rhonchi in anterior lung fields. Chest radiograph showed slight cardiomegaly, but no abnormal lesions were noted in either lung (figure 1A). Echocardiography demonstrated no evidence of congestive heart failure. She was thus diagnosed with cough variant asthma and/or asthma, and treated with inhaled budesonide (400 µg/day). However, 10 days later, she returned to our hospital because of increasing dyspnoea. She had tachypnoea (30 breaths/min), and intermittent wheezes emerged in both the cervical (online supplementary audio 1) and left tracheobronchial areas. Additionally, the left bronchovesicular sound (online supplementary audio 2) apparently decreased than that of right tracheobronchial area (online supplementary audio 3).

Figure 1

Chest radiograph taken at the first visit appeared normal except for slight cardiomegaly (A). Thoracic CT demonstrated that the mediastinal tumour compressed the left main bronchus, which partially invaded the bronchial lumen (B, C).

On the same day, thoracic CT revealed a mediastinal tumour (figure 1B,C) that compressed and/or partially invaded the left tracheal lumen, thereby generating the intermittent wheezes that radiated to the cervical area.

This case reminds us of the critical pitfalls for wheezing resembling asthma1 and the power of careful auscultation for appropriate diagnosis.2

General physicians should always be aware of the possibility of tracheal/bronchial stenosis due to malignant neoplasms whenever they encounter patients who wheeze.

Auscultation can be changeable over a short interval of time, but careful auscultation should be performed for appropriate diagnosis.

The intensity of tracheobronchial sound from bilateral lung fields should be compared in patients with respiratory symptoms.