What do you see?

The patient is a 59-year-old female with history of hepatitis C, currently on dual therapy with pegylated interferon and ribavirin for last 2 months presented with complaint of cough.
PAST MEDICAL HISTORY:
1. Hepatitis C, liver cirrhosis.
2. Childhood asthma.
3. History of positive PPD more than 10 years ago, which was positive, at
that time with negative chest x-ray.

stage iiia?

Would this PET scan be enough to convince you that this is IIIa or would you have the surgeon go after that node for staging purposes?
A corollary: if that node is negative, would he be a surgical candidate (assuming lung function etc. not issue)

post thoracotomy pain

One more post today. How do you best deal with post-thoracotomy pain. I admit I see it fairly often as well.

Patient writes in a recent comment

I have acute persistent pain in my right breast and along the six inch incision at the base of my breast. I have tried gabapentin, Lyrica, and Topimate. I am on my third round of corticosteroid injections into the intercostals. I am reluctant to use narcotics, but if the steroids do not work, I am at a loss. I cannot move my right arm without pain. Any suggestions would be greatly appreciated.

ABPA without steroids

A reader writes:

I am 48 years old female, and lived with asthma for the last 25 years. I am not under great control. I have had blood work done recently, and found out I have severe allergies. I have an IgE of 1700, my aspergillus allergen is 2.05 ku/l. I recently had a chest ct which showed nonspecific infiltrates with ground glass appearance. A sinus ct showed acute maxillary sinusitis. my physician says she is not sure of a diagnosis of ABPA, and is hesitant to treat me with steroids. In the past year I have been diagnosed with avascular necrosis of both hips, and my right knee as well as severe cataracts in both eyes. I was told probably from the use of steroids to treat my asthma. My concern is I never feel great, and why is this so hard to diagnose, and if I have ABPA what will ahappen if it goes untreated.

What types of steroid-sparing therapies do you use for ABPA (or asthma)?

Acute ILD

This 77 year old man has had a bit of honeycombing at the bases since at least 2004. Radiographically c/w UIP. Biopsies not done and he has been stable for years (and FVC normal at 84% predicted).
In February he developed worsenign cough and SOB. He was admitted and was hypoxic with the CT shown below. A cath was done showing normal wedge, normal CO/CI.
A BAL showed only 184 cells half of which were macrophages. A TBBX was not done because he's on coumadin for afib and we didn't think it would add much to determining the diagnosis.
SH, desk job all his life. In January, routine maintenance change of the humidifier pipes in his furnace. This may be a red herring but throwing it out there. No one else in household sick.



Was going to send him for open lung/VATs, but what do you think are possible etiologies?
I also repeated autoimmune chemistries that had been negative in 2004.

lesion in a 45 year old woman

A 45 y/o woman presented with atypical chest pain that led to a ct showing the following:


Although a benign lesion/resolving pneumonia were possibilities, I was concerned about bronchoalveolar carcinoma in this young non-smoker. A bronch was done - BAL cytology and tbbx were negative. We were in the right area (posterior segment RUL) and Fluoro did support this, but the biopsies came back as unremarkable pulmonary parenchyma.

What would you do next? Some options would be follow with serial CT's - q 3 months, open lung, repeat bronch, or another course.

What's your line?

A resident put in a left subclavian line and maybe went a little too far. An xray shows that it went into the right atrium and into the IVC and up to the IVC filter. When it was removed (with help from vascular), the filter had migrated up 2 vertebrae... Click image to enlarge. It is a bit dark.

Fibrosis

A submission from a reader: "34 year old, non-smoking African American female presenting with a recurring (for three years now), chronic (lasts for several weeks up to a few months) dry, non productive cough. No other symptoms (though the attached CT report says wheezing). No response to a variety of drug treatments over the years, including steroid shot, Levaquin, OTC Mucinex, OTC Claritin, Tussionex, Nasacort, OTC Prilosec, 6-day regimen of Metrol (4mg), Advair and Albuterol. First pulmonologist (who performed no diagnostic tests) diagnosed asthma and allergies. Nothing indicated on chest x-ray. Internal medicine doctor ordered CT scan (report attached). Second pulmonologist said subpleural cysts exist, which he indicated exist with UIP patients, but he said this was not UIP. Also said it's not tuberculosis or sarcoidosis. Prescribed 20 mg of Prednisone twice a day to get rid of cough, said we will proceed once cough is gone. Said a lung biopsy or thoracic biopsy may be in order.

CT reading:
Helical CT images through the chest were obtained following
intravenous contrast administration.

Within both lungs and involving both the upper and lower lung zones,
there are areas of subpleural macrocystic change with some
associated subpleural interstitial thickening. There are no
particular areas of ground-glass opacity associated with these
findings. No significant nodularity is seen. The central and midlung
zones are spared. No pleural fluid or lymphadenopathy is seen. These
findings can be seen in patients with usual interstitial pneumonia
(UIP) although this would be somewhat atypical in a patient of this
age group. Does the patient have a smoking history? Other
interstitial lung disease in its early stages may give a similar
appearance.