A 71-year-old man who had received a diagnosis of emphysema 12 years ago was referred by his primary care physician to the pulmonary clinic. His symptoms were well controlled until a few months ago, when he complained of mild shortness of breath on physical activity. However, the shortness of breath worsened and became a significant limiting factor. He also had a persistent dry cough.
The results of the patient's recent cardiac workup were unremarkable. He was treated with a 2-week course of oral corticosteroids and antibiotics empirically just before this visit. These measures did not provide significant relief. His regular medications included inhaled tiotropium; aspirin, 81 mg/d; and atorvastatin, 20 mg/d.
On physical examination, the patient was afebrile and in no respiratory distress. There was no cyanosis or jugular venous distention nor were there palpable masses or lymphadenopathy in the neck. Lung sounds were vesicular but were somewhat diminished bilaterally. The patient's heart sounds and findings from an abdominal examination and examination of his extremities were unremarkable.
A radiograph of the chest was significant for hyperinflated lung fields but did not show any parenchymal abnormalities. Blood work revealed mild neutrophilic leukocytosis. Bronchoscopy was performed to rule out any upper airway obstruction (Figure). Examination of bronchoalveolar lavage fluid did not reveal any pathogens.
What is the likely diagnosis?
Answer on next page.
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