Intended for healthcare professionals

Endgames Case Review

A case of breathlessness

BMJ 2015; 351 doi: (Published 16 July 2015) Cite this as: BMJ 2015;351:h3515
  1. Rachelle Shafei, core medical trainee1,
  2. Rowena Goalby, trainee general practitioner 2,
  3. John Hutchinson, respiratory registrar3
  1. 1Department of Medicine, North Middlesex Hospital, London N18 1QX, UK
  2. 2Glasgow, UK
  3. 3Department of Respiratory Medicine, Nottingham University Hospitals Trust, Nottingham, UK
  1. Correspondence to: R Shafei r.shafei{at}

A 62 year old woman was referred to hospital by her general practitioner because of a few days history of progressive shortness of breath. She had associated fever but no cough or sputum production. Her medical history included rheumatoid arthritis, for which she had been taking methotrexate for the past 12 years.

On examination, she was visibly dyspnoeic, with low oxygen saturations. Her respiratory rate was 22 breaths/min, oxygen saturation was 90% on air, heart rate was 100 beats/min, blood pressure was 115/72 mm Hg, and her temperature was 37.4ºC. Chronic hand changes, consistent with rheumatoid arthritis, were noted. Bilateral widespread crackles were heard on auscultation of the chest.

Blood tests showed a white blood cell count of 8.8×109/L (reference range 4-10) and a C reactive protein of 1219 nmol/L (<47.6). Further blood tests, including antinuclear antibody (ANA) and extractable nuclear antigen (ENA), were negative. Chest radiography showed diffuse alveolar shadowing throughout both lungs, with possible background fibrotic changes (figure).

Chest radiograph showing diffuse alveolar shadowing throughout both lungs

She was treated with intravenous antibiotics for suspected severe community acquired pneumonia but continued to deteriorate and was transferred to the high dependency unit for closer monitoring and ventilatory support.

In view of the findings on chest radiography, she underwent a high resolution computed tomography scan of the chest. A working diagnosis of interstitial lung disease was made.


  • 1. What is the differential diagnosis at presentation?

  • 2. How would you treat this patient acutely?

  • 3. What would be your long term approach to management?

  • 4. What is the long term prognosis for this condition?


1. What is the differential diagnosis at presentation?


The differential diagnosis includes infection (including atypical organisms), pulmonary oedema, and interstitial lung disease (ILD), either secondary to rheumatoid arthritis or drug induced.


The differential diagnosis in a patient with subacute onset of …

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