Case 38-2014

Dr. Leigh H. Simmons: An 87-year-old man with multiple chronic medical problems was seen in an outpatient clinic of this hospital because of sore throat and fatigue. The patient had been in his usual health until several weeks before presentation, when hoarseness, sore throat, and increasing fatigue developed. At the urging of his family, he was seen by his physician in an outpatient clinic of this hospital. He reported hoarseness, increasing facial puffiness, and periorbital swelling, with no chest pain, dyspnea, or new joint pains or muscle aches. The patient had hypertension, hyperlipidemia, and chronic kidney disease. Two months earlier, the creatinine level was 2.22 mg per deciliter (196 μmol per liter; reference range, 0.60 to 1.50 mg per deciliter [53 to 133 μmol per liter]), which was stable, as compared with values obtained the previous year. He also had hypothyroidism, with a normal thyrotropin level 8 months earlier (3.38 μU per milliliter [reference range, 0.40 to 5.00]), as well as gastroesophageal reflux disease, esophageal motility disorder, an abdominal aortic aneurysm, chronic back pain, depression related to the death of his wife several years before, and recurrent urinary tract infections. In the past, he had had pneumonia and had undergone angioplasty of the right renal artery (10 years earlier), a cholecystectomy, a lobectomy of the right middle lobe due to a spiculated nodule that was found to be benign, photoselective vaporization of the prostate due to obstructive benign prostatic hypertrophy (2 months before this presentation), and wrist surgery. Medications included atenolol, vitamin D3, a fluticasone propionate and salmeterol inhaler, aspirin, citalopram, a fluticasone nasal spray, atorvastatin, omeprazole, and levothyroxine. Lisinopril had caused a cough, and zolpidem tartrate had caused nightmares. The patient was retired and lived alone. He could independently perform activities of daily living, and he managed his own medications. His three children lived nearby and were in frequent contact with him, but he came to most medical appointments unaccompanied. He was under the regular care of an internist, a nephrologist, a cardiologist, and a urologist. Immunizations were up to date. He had stopped smoking many years earlier and did not drink alcohol. His father had died of liver cancer, and a son had sarcoidosis; his two other children were healthy. On examination, the patient was pleasant, smiling, and in no distress; he spoke From the Departments of Medicine (C.A.I.), Internal Medicine (L.H.S.), Radi‐ ology (F.J.F.), and Pathology (A.S.D.), Massachusetts General Hospital, and the Departments of Medicine (C.A.I.), Inter‐ nal Medicine (L.H.S.), Radiology (F.J.F.), and Pathology (A.S.D.), Harvard Medical School — both in Boston.