Dysphagia, chest pain, and refractory asthma in a 42-year-old woman.

A 42-year-old woman who had a diagnosis of asthma since childhood that was refractory to corticosteroid therapy complained of chest discomfort, progressive dyspnea on exertion, and chronic cough, all gradually worsening in severity over the past several years. Her chest pain was described as a constant band-like pressure encircling the chest wall, and was exacerbated by cold weather, exertion, supine position, and forced expiration. The chest pain occasionally radiated to the throat and left shoulder. Both the chest pain and dyspnea were partially relieved by inhaled -agonist, nitroglycerin, and/or rest. In addition, she complained of intermittent dysphagia for solids and liquids. Her medications included a short-acting 2-agonist, inhaled corticosteroids, and intermittent oral corticosteroids. Results of her physical examination were within normal limits, except for mild Cushingnoid features. Routine laboratory blood studies were unremarkable. A chest radiograph is shown in Figure 1. Findings on ECG, cardiac enzymes during a severe episode of chest pain, two-dimensional echocardiogram, cardiac catheterization, and a 24-h ambulatory pH probe were all within normal limits. Spirometry showed a FVC of 3.67 L (102% of predicted), FEV1 of 2.96 L (99% of predicted), and FEV1/FVC ratio of 81%. The flow-volume loop showed flattening of the expiratory segment (Fig 2).