An unusual mimicker of asthma in an active duty army physician: Common variable immunodeficiency presenting as granulomatous lymphocytic interstitial lung disease

Active duty service members are frequently diagnosed with asthma after referral to pulmonary for undifferentiated cough and dyspnea. Occasionally, patients have symptoms despite optimal therapy necessitating evaluation for asthma mimickers. We present a 48 year-old active duty physician who initially presented in 2007 with dyspnea and cough. Despite the absence of variable obstruction on spirometry, a clinical diagnosis of asthma was made. The patient's symptoms were temporized with inhaled corticosteroids and bronchodilators, titrated to his symptoms, until eventual therapeutic failure resulted in re-referral to pulmonary. Chest computed tomography (CT) showed ground-glass nodules and patchy airspace opacities with evidence of thoracic lymphadenopathy. A positron emission tomography CT (PET CT) showed diffuse adenopathy throughout his thorax and abdomen with high avidity for fluorodeoxyglucose (FGD)-18. This prompted a comprehensive pathologic and serologic evaluation that unveiled a diagnosis of granulomatous-lymphocytic interstitial lung disease (GLILD) secondary to common variable immunodeficiency (CVID). Once the diagnosis was made, the patient was treated with intravenous immunoglobulin resulting in clinical improvement. Given the patient's time-to-diagnosis and response to IVIG monotherapy, this case serves as a unique presentation of a rare pathophysiologic entity which should be considered in refractory cough and dyspnea with radiographic abnormalities.