Monday February 25th 2019


A 50-year-old man had progressive exertional dyspnea and chest tightness for 3 months. He noted two or three previous discrete self-limited episodes characterized by malaise, subjective fever, and myalgias, each lasting 24 to 72 h, the first of which predated his pulmonary symptoms by 1 week. His medical history was noncontributory, he took no medications, never smoked, used no illicit substances, and had no significant risk factors for HIV infection. He drank one to two glasses of wine on weekends buy prednisone. He had always been extremely active and regularly completed a demanding mountain bicycling course until pulmonary limitations developed. He had worked as a dentist for 23 years, performing routine examinations and procedures and producing oral appliances with dimethacrylates, but there was no history of exposure to beryllium. He wore a paper ear-loop mask when fabricating appliances and working with patients. His symptoms were not clearly associated with work, and there was no change on the weekends. He lived with his wife in the same house for 16 years. The structure was 65 years old, and had been renovated before they moved in. Minor remodeling, involving removal of some drywall and subsequent plastering, was performed around the time his symptoms began. He intermittently used his outdoor hot tub, which filtered through an adjacent swimming pool, but not for several weeks before symptom onset. He kept no pets.

Physical examination was unremarkable. The chest examination was normal. In addition, there were no obvious skin or ocular lesions, organomegaly, or other features suggestive of sarcoidosis. His pulmonary function testing showed mild obstruction (FEV1/ FVC = 0.67, FEV1 = 80% of predicted) and impaired diffusing capacity (62% of predicted). High-resolution CT of the lungs showed small, bilateral, diffuse, centrilobular, ground-glass nodules and extensive mosaic attenuation consistent with air trapping on expiratory images, all thought to be most consistent with hypersensitivity pneumonitis. Of note, there was no adenopathy, no large nodules or consolidation, and no peri-bronchovascular or pleural thickening or nodularity. A CBC count with differential leukocyte count, serum creatinine, and liver enzymes and ECG were normal. An HIV test was negative. Canadian health pharmacy

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