This case involves a 75-year-old male patient who had dyspnoea for one month prior to admission. He had a medical history of chronic obstructive pulmonary disease, diabetes mellitus, hepatitis B, and gastric polyps. He had a smoking history (45 pack-years) and was allergic to mackerel. He was diagnosed with autoimmune pancreatitis by his previous doctor and began 5.0 mg of oral prednisolone daily when he was 67 years old; his prednisolone dosage was decreased to 2.5 mg daily one year ago. He visited our hospital eight months prior due to cough and sputum. He was diagnosed with asthma and chronic obstructive pulmonary disease overlap because of obstructive ventilatory disturbance and reversibility by short-acting β2 agonists by spirometry. His symptoms had been improved by treatment with inhaled vilanterol trifenatate/fluticasone furoate and oral montelukast sodium. But gradually, dyspnoea developed.
Examination
His vital signs were normal, and physical examinations revealed no abnormalities. Laboratory findings were as follows: white blood cell count 11,220/μl, with 76.5% polymorphic nuclear leukocytes and 5.5% eosinophils; C-reactive protein 0.29 mg/dl; haemoglobin A1c 6.5%; serum IgG level 3556 mg/dl, including 1310 mg/dl of IgG4; and serum immunoglobulin E level 3968 U/ml. An interferon-gamma release assay showed a negative result (T-SOPT; panel A-nil 0 spot, panel B-nail -1 spot, positive control 551 spots, and negative control 2 spots). Chest radiography and a chest computed tomography (CT) scan showed a moderate amount of left pleural effusion. Additionally, CT revealed peripheral consolidation with interlobular septal thickening in mainly the bilateral upper lobe, emphysema, and swelling of the mediastinal lymph nodes.
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