A 40-year-old, moderately obese man presents with a persistent
productive cough. The cough has been present for several weeks, but recently
the man noted that his sputum has assumed a greenish color. Further questioning
elicits a history of productive cough , usually in the winter months, over the
past several years. He has smoked two packs of cigarettes per day since he was
16 years old. On examination, the man is febrile (100° F), and coarse rhonchi
and wheezes can be appreciated bilaterally. Which of the following is the most
likely diagnosis?
A. Bronchogenic carcinoma
B. Chronic bronchitis with superimposed infection
C. Cystic fibrosis
D. Emphysema
E. Pulmonary tuberculosis
B. Chronic bronchitis with superimposed infection
C. Cystic fibrosis
D. Emphysema
E. Pulmonary tuberculosis
Answer is B-The diagnosis of chronic bronchitis requires the presence of chronic productive cough over at least 3 months of the year for 2 successive years. The symptoms in this patient (green productive sputum, fever) suggest that he has an acute infection superimposed on chronic bronchitis (history of cigarette smoking, history of excessive mucus production over many years). Histologically, the mucus-producing glands in the bronchi would show hyperplasia and hypertrophy and extend to a greater depth in the bronchial wall, resulting in a higher Reid index (ratio of thickness of mucus gland to thickness of bronchial wall).
ReplyDeleteAlthough the patient is a smoker and is at increased risk for bronchogenic carcinoma (choice A), this is unlikely to be the cause of his symptoms. Hemoptysis and weight loss might also be present if he had cancer.
Cystic fibrosis (choice C) presents earlier in life and may be associated with severe production of mucus, especially if bronchiectasis supervenes. The age of the patient and the relative late onset of disease preclude this diagnosis.
This patient may also have emphysema (choice D), as chronic bronchitis and emphysema are often coexistent. However, although pure emphysema might cause dyspnea, it would not be associated with a fever or a productive cough.
Pulmonary tuberculosis (choice E) would typically present with a history of hemoptysis rather than abundant green sputum. Weight loss, night anorexia, malaise, and weakness may also be present.