A 37-year-old, single, Caucasian woman presented to the emergency department with a 3-month history of experiencing progressive shortness of breath that was associated with bilateral lung infiltrates. She was examined in several clinics and was treated with several courses of different oral antibiotics; however, her condition did not improve, and her shortness of breath progressively worsened over time. She reported a history of low-grade fever, a dry cough, fatigue, and the loss of appetite. Furthermore, she did not have a history of skin lesions, joint pains, or any symptoms that suggested connective tissue diseases. Additionally, her past history revealed that she had been suffering from severe depression for which she was taking oral antidepressants. Upon presentation, she was found to be on daily doses of two SSRI medications. She was prescribed paroxetine 50 mg to be taken once daily, which she was taking for the last 1 year, and owing to a misunderstanding, she was also prescribed escitalopram 10 mg to be taken once daily. As a result, she was taking both medications together for at least the last 6 months.
A physical examination disclosed that the young lady was suffering from moderate respiratory distress and peripheral cyanosis and that her oxygen saturation, measured by pulse oximetry, was 84% in the room air. During chest auscultation, she exhibited fine bilateral basal crepitations, but she did not exhibit wheezing. Furthermore, she did not present finger clubbing, skin abnormalities, or palpable lymphadenopathy. The examination of her cardiovascular system was unremarkable, and an abdominal examination did not reveal palpable organomegaly. The musculoskeletal and central nervous system examinations also did not reveal any abnormalities.
Furthermore, her initial investigations revealed a normal complete blood count (CBC), and her renal and liver function tests were normal as well. Her arterial blood gases showed type I respiratory failure with a partial pressure of oxygen (PO2) of 54 mmHg and a normal pH. The electrocardiogram (ECG) displayed sinus tachycardia with a heart rate of 125 per minute. A chest X-ray captured on presentation revealed a bilateral interstitial pattern with prominent hila that is suggestive of enlarged hilar adenopathy without pleural reactions.
She was initially admitted for a chest infection; however, her condition did not improve with IV antibiotics. The results of a further work-up were consistent with those associated with a diagnosis of interstitial lung disease (ILD). A high-resolution computed tomography (HRCT) scan of her chest confirmed a bilateral micronodular interstitial pattern with hilar adenopathy (Figure 1).
Consequently, she required fibro-optic bronchoscopy and a transbronchial lung biopsy. The biopsy revealed a noncaseating granuloma (Figure 2).
However, the results of all the microbiological examinations, including those of the polymerase chain reaction (PCR) tests, were negative for Mycobacterium tuberculosis. Further, the results of all the autoimmune screening tests were also negative. Following a complete discussion, during a chest department team meeting, she was diagnosed with sarcoidosis.
Subsequently, she was started on IV methylprednisolone 60 mg BD, and due to her history of severe depression, she was orally administered escitalopram 10 mg once daily as well. Nevertheless, her respiratory status continued to deteriorate, and her oxygen requirement increased. Her condition worsened over the next few days, and she was eventually intubated and shifted to ICU for mechanical ventilation. At this stage, due to the lack of an adequate response to systemic steroids, she underwent a full re-evaluation, including another bronchoscopy (without a biopsy), by ICU team, which did not generate any new findings. Following this, broad-spectrum antibiotic coverage was added to her treatment plan for a possible nosocomial infection. However, a full septic screen failed to show any positive outcomes. A quick literature review disclosed that there is a possible correlation between granulomatous lung diseases and antidepressants. For this reason, escitalopram was discontinued in the ICU, and the methylprednisolone dose was increased to 100 mg BD. After a few days, she started to exhibit progressive signs of improvement in her respiratory status, and she was weaned off mechanical ventilation within 12 days.
She was then shifted to the general ward where she continued to demonstrate remarkable improvement in her condition. She was subsequently examined by the psychiatry department, and it was decided that she should avoid taking SSRIs while being treated for her depression. As a result, she was started on amitriptyline orally, the IV steroids were replaced with oral prednisolone 50 mg OD, and all the antibiotics were discounted. Consequently, she continued to show progressive improvement in the general ward, and she was able to walk without an oxygen supply; furthermore, her oxygen saturation approached 90% in the room air. Within 10 days, she was discharged from the hospital. Her doses of oral steroids were kept the same, and she was given an appointment for a follow-up at the chest clinic after a month.
During her follow-up, it was observed that she continued to show progressive improvement with normal oxygen saturation and good exercise tolerance. Her oral steroid doses were gradually reduced to prednisolone 15 mg once daily to be taken over 6 months. Unfortunately, 8 months following her discharge, she presented with a deterioration in her respiratory status during her regular follow-up appointment. She reported experiencing an increase in breathlessness and was found to have a reduction in her oxygen saturation that decreased to 88% in the room air. On further clarification, it was uncovered that she had started taking oral escitalopram 10 mg once daily again. She received a prescription for this medication from a private psychiatry clinic that was not aware of her previous history. A chest X-ray captured at this stage revealed a worsening of the interstitial pattern that was consistent with a flare-up of sarcoidosis. Consequently, she was advised to discontinue the use of escitalopram, and the dosage of oral prednisolone was again increased to 50 mg once daily; as a result, she did not require readmission. An examination during a follow-up visit after 2 weeks revealed good improvement clinically and radiologically. She was again advised to avoid all SSRI medications; however, she was not satisfied with the effect of amitriptyline in controlling her depression.
Following this visit, she requested a full written report as she was moving to another city, and she did not attend anymore of her follow-ups.