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Case based discussions
Pancytopaenia and breathlessness: Hickam’s Dictum prevails!
  1. Andrew W Creamer1,
  2. Rachel Protheroe2,
  3. Harsha Gunawardena3,
  4. Shaney L Barratt4
  1. 1 Respiratory Medicine Department, Southmead Hospital, Bristol, UK
  2. 2 Bone Marrow Transplantation, Bristol Haematology and Oncology Centre, Bristol, UK
  3. 3 Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
  4. 4 Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
  1. Correspondence to Dr Andrew W Creamer, Respiratory Department, Southmead Hospital, Bristol BS10 5NB, UK; andrewcreamer{at}nhs.net

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Dr Andrew W Creamer (AWC), Respiratory Registrar: A 70-year-old retired teacher was referred to the respiratory clinic with a 12-month history of progressive exertional dyspnoea and dry cough. He denied haemoptysis, constitutional symptoms or diurnal variation. He took omeprazole, amlodipine and ezetimibe for a long-standing history of dyspepsia, hypertension and hypercholesterolaemia. He was an ex-smoker with a 30 pack-year history.

He reported monophasic colour change in his fingers in the cold, but denied any other connective tissue disease (CTD) symptoms. He denied any significant environmental exposures such as organic dusts or moulds.

His vital signs were normal. There was evidence of mechanic’s hands (a hyperkeratotic eruption with fissuring and cracking on the palmar and radial aspects of the fingers, strongly associated with idiopathic inflammatory myopathies) but no other features of CTD or clubbing. Bibasal fine inspiratory crepitations were audible on chest auscultation. Cardiovascular examination was normal.

Initial investigations revealed pancytopenia (figure 1) with unremarkable liver and renal function, prompting referral to local haematology services for further assessment.

Figure 1

Baseline blood tests at presentation. Abnormal values are highlighted in bold. Pancytopenia was evident, in the context of normal B12, folate and ferritin.

Lung function testing revealed a restrictive pattern with significantly reduced gas transfer (figure 2), while 6 min walk test demonstrated baseline saturations of 95% on air dropping to 77% on exertion, achieving 260 m (48% of theoretical distance).

Figure 2

Lung function tests at baseline and 4-month follow-up. Spirometry demonstrated a restrictive pattern with reduction in gas transfer factor. KCO, carbon monoxide transfer coefficient; TLCO, transfer factor for carbon monoxide.

Chest X-ray showed prominent interstitial lung markings in the mid and lower zones (figure 3). High-resolution CT thorax (HRCT) demonstrated centrilobular emphysema throughout the lungs and a basally predominant interstitial process with features suggestive of non-specific interstitial pneumonia (NSIP) (figure …

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