Pulmonary and Critical Care Pearls

A 49-Year-Old Woman With Hepatitis, Confusion, and Abnormal Chest Radiograph Findings

Physical Examination

On admission, she was tachycardic and confused, but in no acute distress and with no focal neurologic deficit. Dry mucous membranes were noted. There was no cervical, supraclavicular, axillary, or inguinal lymphadenopathy. Lungs were clear to auscultation, and cardiac examination revealed no abnormalities. The abdomen was soft and nontender with no organomegaly. No clubbing, edema, or skin lesions were noted.

Laboratory data

WBC count was 4.6 × 10⁴/μL; with 77% neutrophils; hemoglobin, 12.0 g/dL; platelet count, 92/μL; international normalized ratio, 0.93. Serum electrolytes were as follows: sodium, 129 mmol/L; potassium, 3.8 mmol/L; chloride 98, mmol/L; bicarbonate, 23 mmol/L; BUN, 36 mg/dL; creatinine, 1.9 mg/dL; total calcium, 12.4 mg/dL; glucose, 78 mg/dL; total protein, 5.7 g/dL; albumin, 2.4 g/dL; total bilirubin, 0.2 mg/dL; alkaline phosphatase, 100 U/L; aspartate aminotransferase, 23 U/L; and alanine

Hospital Course

The admission chest radiograph showed a normal cardiac silhouette, no mediastinal lymphadenopathy, and bilateral interstitial markings (Fig 1). A previous radiograph obtained 9 months earlier was clear. The patient was treated initially with hydration followed by the addition of low-dose furosemide. Her confusion and abdominal symptoms rapidly improved as her calcium levels declined. Pulmonary function tests showed normal spirometry (FEV₁, 2.40 L, and 85% of predicted; and FVC, 3.13 L, and 90%

Clinical Pearls

• 1.

  IFA immunotherapy skews the immune system toward a Th1 response and can cause Th1-mediated toxicities.

• 2.

  Sarcoidosis is a common Th1-mediated complication of IFA treatment, particularly in the context of chronic hepatitis C infection.

• 3.

  IFA immunotherapy stimulates IFG, which drives excess production of 1,25(OH₂)D₃by macrophages, and can precipitate clinically important hypercalcemia.