Oxford Case Histories in Respiratory Medicine OXFORD CASE HISTORIES Series Editors Peter Rothwell and Sarah Pendlebury Published: Neurological Case Histories (Sarah Pendlebury and Peter Rothwell) Oxford Case Histories in Gastroenterology and Hepatology (Alissa Walsh, Otto Buchel, Jane Collier, and Simon Travis) O xford Case Histories in Respiratory Medicine (John Stradling, Andrew Stanton, Najib Rahman, Annabel Nickol, and Helen Davies) Forthcoming: Oxford Case Histories in Cardiology (Colin Forfar, Javed Ehtisham and Rajkumar Rajendram) O xford Case Histories in Nephrology (Chris Pugh, Chris O’Callaghan, Aron Chakera, Richard Cornall and David Mole) O xford Case Histories in Rheumatology (Joel David, Anne Miller, Anushka Soni and Lyn Williamson) Oxford Case Histories in Stroke and TIA (Sarah Pendlebury and Peter Rothwell) Oxford Case Histories in Respiratory Medicine John Stradling Professor of Respiratory Medicine, Oxford University, Consultant Physician, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford Andrew Stanton Specialist Registrar in Respiratory Medicine Oxford Centre for Respiratory Medicine Churchill Hospital, Oxford Najib Rahman Specialist Registrar and MRC Training Fellow Oxford Centre for Respiratory Medicine Churchill Hospital, Oxford Annabel Nickol Clinical Lecturer in Respiratory Medicine Oxford Centre for Respiratory Medicine Churchill Hospital, Oxford Helen Davies Specialist Registrar in Respiratory Medicine Oxford Centre for Respiratory Medicine Churchill Hospital, Oxford 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. 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Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Data available Typeset in Minion by Cepha Imaging Private Ltd., Bangalore, India Printed in Great Britain on acid-free paper through The MPG Group ISBN 978-0-19-955637-3 (Pbk.) 10 9 8 7 6 5 4 3 2 1 O xford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-preg- nant adult who is not breast-feeding. A note from the series editors Case histories have always had an important role in medical education, but most published material has been directed at undergraduates or residents. The Oxford Case Histories series aims to provide more complex case-based learn- ing for clinicians in specialist training and consultants, with a view to aiding preparation for entry and exit-level specialty examinations or revalidation. Each case book follows the same format with approximately 50 cases, each comprising a brief clinical history and investigations, followed by questions on differential diagnosis and management, and detailed answers with discussion. All cases are peer-reviewed by Oxford consultants in the relevant specialty. At the end of each book, cases are listed by mode of presentation, aetiology and diagnosis. We are grateful to our colleagues in the various medical specialties for their enthusiasm and hard work in making the series possible. Sarah Pendlebury and Peter Rothwell Quotes on the first book in the series – “Neurological Case Histories” “I recommend this excellent volume highly ....... this book will enlighten and entertain consultants, and all readers will learn something.” Lancet Neurology 2007; 6: 951 “This short and well-written text is …. designed to enhance the reader’s diag- nostic ability and clinical understanding …. A well documented and practical book” European Journal of Neurology 2007; 14: e19 This page intentionally left blank Introduction Postgraduate medical education has changed considerably over the last 30 years. There is greater emphasis on structured learning, but apprenticeship time has decreased. Thus specialist registrars may reach the end of their t raining without having seen cases of either rare diseases, rare presentations of c ommon diseases or unusual problems in association with common diseases. Most phy- sicians learn from cases they have seen. This collection of cases is a second-best alternative, providing vignettes that hopefully will come to mind when a similar case is encountered in the future. The cases are not meant to comprehensively cover the ‘syllabus’ of a specialist registrar in respiratory medicine, but are selected for their interest, or to eluci- date points that the authors feel are important but may be under-appreciated. The style of presentation thus inevitably varies depending on the type of message and some of the problems discussed have no right answer, ours may well be disputed! W e hope the question-and-answer format will keep the reader on their toes and make reading through the cases more fun. This page intentionally left blank Acknowledgements M any people have given their time to read through these cases and correct errors or improve clarity. We are very grateful for their input; in particular Rachel Benamore has provided considerable help with the radiology, and Rolf Smith read through all the cases to provide us with invaluable help. These are the individuals who reviewed one or more cases for us: Lesley Bennett, Malcolm Benson, Di Bilton, Steve Chapman, Sonya Craig, Ling-Pei Ho, Rob Davies, Colin Forfar, Maxine Hardinge, Robin Howard, Gary Lee, Raashid Luqmani, Lorna McWilliam, Grace Robinson, Rana Sayeed, Claire Shovlin, Catherine Swales, Catherine Thomas, Chris Winearls, and John Wrightson. Needless to say any errors remain our responsibility.