Endgames Picture Quiz

A very breathless woman

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5935 (Published 27 October 2011) Cite this as: BMJ 2011;343:d5935
  1. Catriona Maybury, senior house officer,
  2. Alex Horsley, senior clinical fellow,
  3. Robert Lord, senior house officer,
  4. Rowland Bright-Thomas, consultant
  1. 1Manchester Adult Cystic Fibrosis Centre. University Hospital South Manchester, Manchester M23 9LT, UK
  1. Correspondence to: C Maybury catriona.maybury{at}gmail.com

A 37 year old woman was referred to the chest clinic by her general practitioner because of increasing shortness of breath over the previous few months and a chronic productive cough. She had no rhinitis or sinusitis. She gave a history of recurrent chest infections since early adulthood.

Other medical history of note included three episodes of pancreatitis, and as a baby she had a prolonged hospital admission with gastroenteritis and failure to thrive.

She lived with her son and worked as a kitchen assistant. She smoked 20 cigarettes a day and rarely drank alcohol. Her brother also had recurrent pancreatitis. She took no drugs.

On examination she was thin (body mass index 17). Her respiratory rate was 24 breaths/min, saturations were 95% on room air, and her blood pressure was 90/60 mm Hg. Respiratory examination showed clubbed fingers. Crackles were auscultated on the left with diminished breath sounds at the left base.

Blood tests showed haemoglobin 87 g/L (115-155), mean cell volume 85 fL (80-100), white cell count 16.3×109/L (4.5-11), platelets 765×109/L (130-400), and C reactive protein 857 nmol/L (0.76-28.5). On spirometry, her forced expiratory volume in one second was 0.9 L (38% of predicted) and forced vital capacity was 1.2 L. Her sputum was sent for microbiology and cultured Staphylococcus aureus and Haemophilus influenzae.

Chest radiography (fig 1) and high resolution computed tomography (fig 2) of the chest were performed.

Fig 1 Chest radiograph

Fig 2 High resolution computed tomogram of the chest


  • 1 What are the radiological changes seen?

  • 2 What is the most likely diagnosis and what are the differentials?

  • 3 What investigations would you carry out to confirm the diagnosis?

  • 4 How should this patient be managed?


1 What are the radiological changes seen?

Short answer

The chest radiograph and high resolution computed tomogram show abnormalities consistent …

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