CASE PRESENTATION A 64-year-old man presented for consideration for lung transplant. He had a history of previous tobacco use, OSA on CPAP therapy, and gastroesophageal reflux disease. He worked as a design engineer. The patient had a 4-year history of dyspnea on exertion, followed with periodic CT scan of the chest. Nine months prior to his evaluation for lung transplant, the patient developed worsening of dyspnea, dry cough, poor appetite, and weight loss. At times, the cough was violent and associated with chest pressure. He was prescribed systemic corticosteroids and antibiotics without improvement. Four months later, the patient noted sudden onset of severe chest pain and worsening dyspnea. A CT scan of the chest demonstrated extensive pneumomediastinum in addition to changes consistent with pulmonary fibrosis. An esophagogram showed thickening of the distal esophagus, but no signs of perforation. He was prescribed supplemental oxygen and advised to stop the use of CPAP. The patient sought a second opinion. A CT scan of the chest showed improvement of the pneumomediastinum and extensive fibrotic lung disease. Pulmonary function tests (PFTs) were consistent with a restrictive pattern, decreased diffusing capacity (Dlco), and a preserved residual volume over total lung capacity ratio. The patient was prescribed systemic corticosteroids with no improvement of his symptoms. Repeat PFTs showed further decline of Dlco, and he was referred for lung transplant evaluation.

中文翻译：

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一名患有快速进行性呼吸衰竭和纵隔气肿的 64 岁男性

病例介绍 一名 64 岁男性考虑进行肺移植。他有吸烟史、CPAP 治疗 OSA 和胃食管反流病史。他是一名设计工程师。患者有 4 年劳累性呼吸困难病史，随后定期进行胸部 CT 扫描。在接受肺移植评估前 9 个月，患者出现呼吸困难、干咳、食欲不振和体重减轻的恶化。有时，咳嗽剧烈并伴有胸部压力。他被开了全身皮质类固醇和抗生素，但没有改善。四个月后，患者突然出现剧烈胸痛和呼吸困难加重。除了与肺纤维化一致的变化外，胸部 CT 扫描还显示广泛的纵隔气肿。食管造影显示远端食管增厚，但没有穿孔迹象。他被规定补充氧气并建议停止使用 CPAP。患者寻求第二意见。胸部 CT 扫描显示纵隔气肿和广泛纤维化肺病有所改善。肺功能测试 (PFT) 与限制性模式、弥散量 (Dlco) 降低和残余容积与总肺活量之比保持一致。该患者被开具全身性皮质类固醇，但其症状没有改善。重复 PFT 显示 DLCO 进一步下降，他被转诊进行肺移植评估。胸部 CT 扫描显示纵隔气肿和广泛的纤维化肺病有所改善。肺功能测试 (PFT) 与限制性模式、弥散量 (Dlco) 降低和残余容积与总肺活量之比保持一致。该患者被开具全身性皮质类固醇，但其症状没有改善。重复 PFT 显示 DLCO 进一步下降，他被转诊进行肺移植评估。胸部 CT 扫描显示纵隔气肿和广泛纤维化肺病有所改善。肺功能测试 (PFT) 与限制性模式、弥散量 (Dlco) 降低和残余容积与总肺活量之比保持一致。该患者被开具全身性皮质类固醇，但其症状没有改善。重复 PFT 显示 DLCO 进一步下降，他被转诊进行肺移植评估。