Monday, October 10, 2005

Multiple pulmonary nodules

This is a 58-year-old woman who has carried the diagnosis of asthma for 5 to 7 years. She has been on Advair for that time. She presented with cough and wheezing. She has one ER visit per year. Her other symptoms are well controlled. No cough. No chest pain. Positive fatigue. No fever. No chills. No night sweats. The patient had an episodes of hemoptysis last year (coughed up bright red blood one-fourth of a cup at a time and the episode resolved spontaneously. The patient has had no hemoptysis since then The only workup was chest x-ray.

PAST MEDICAL HISTORY: Allergic rhinitis and Asthma.

OCCUPATION: Distribution clerk at a post office for 21 years. No occupational exposures.

SOCIAL HISTORY: No tobacco. The patient has always lived in Michigan. No TB
exposure. No alcohol. No illicit drug use.

PHYSICAL EXAMINATION: Height 5 feet 7 inches, weight 230 pounds, blood pressure 152/73, pulse 91, and respirations 16. General: No acute distress. No cervical lymphadenopathy. Lungs: Clear to auscultation. No clubbing. Intact radial pulses
bilaterally.Abdomen: benign. No c/c/e

PFT's FEV1 1.84 (64%) FVC 2.42 (65%) ratio 76 (97%) TLC 3.61 (66%) Diffusion 72%

Review of chest CT revealed multiple pulmonary nodules; two representative slices are shown here:



DDx and other tests?

14 comments - CLICK HERE to read & add your own!:

Baleeiro said...

She has a mixed defect with a BMI of 36.
Does she a have many other nodules? Any skin rashes?
How about a CBC with diff and IgE for starters?

Baleeiro said...

Basically she either has straightforward asthma and now has a new infectious/inflammatory process or another condtion has been labeled as asthma all along.
I don't see any bronchiectasis in the cuts shown but she could have ABPM. Sarcoid could tie in the nodules and obstruction. She is a non-smoker so Lung Ca is low on my list but she could have metastatic Dz (e.g. medullary thyroid, etc.).
I get a sense that the nodules are not associated with an acute wrsening of her clinical course and since she has not had a previous CT, they have probably been there for a while so they may be related to the underlying condition that has been treated as asthma. Maybe she has HP in response to the moldy paperwork in the post office...

Jeff H said...

I agree with Carlos. One mimic of asthma would be Churg Strauss with some vasculitis leading to prior hemoptysis and some focal areas of ground glass nodules now. ABPA/ABPM is possible, and cancer is unlikely.

Mike L said...

Maybe it is the resolution on my monitor, but there appear to be small nodules in addition to the larger ones.
I would put malignancy somewhat higher on my list than previously mentioned. She is in her late 50's, so she is at risk for colon cancer (especially distal colon/rectal cancer metastasizing to the lung in the abscence of liver mets), lymphoma, breast cancer and renal cancer.
Has she had her screening studies (mammography, pap/pelvic, colonscopy)?
Other things that can do this are AVM's.
Oh, and I would place a PPD. If this blog has taught me one thing, TB shows up in all kinds of unexpected places.

Jennings said...

I can't access the computer until tomorrow to answer some of your specific questions. I will say that the decision was made to do a core needle bx of one of the bigger nodules (mendez was correct regarding multple nodules some smaller than others). That showed "necrotizing granuloma".
Any additional thought now? I'll fill in the rest tomorrow when I get back to the computer.

DKeena said...

I like the DDx thus far. The necrotizing granulomas moves TB, atypical mycobacterium and fungus up on the list. Churg Strauss and Wegeners can give you necrotizing granulomas also, and might be hard to diagnose on a core Bx. Any renal Dz, U/A, ANCA, fungal serologies, PPD?

Jennings said...

Her percent eosinophils was 2%. They did not send off an IgE though. It is true, as you guessed, that there was no bronchiectasis on the rest of the CT cuts.

Her histoplasmin Ab was positive (H band); blasto, coccidio and aspergillin Ab was negative.
The sputum had "rare mold, identification to follow" but there was also some candida and oral flora in another sample, so interpret with caution.
No HP panel was sent.
Hmm...I just noticed that they did not bronch the patient, so I can't give you a cell count.

As for wegeners, C-ANCA was negative.
As for Churg Strauss, P-ANCA was also negative.

I do not know about her screening tests; no GI symptoms at least, for what that's worth.

Jennings said...

PPD was negative.

Jennings said...

sed rate 25 and Creatinine 0.7.
U/A no blood protein, WBC's.

Arenberg said...

I am currently seeing a patient who must be twins with the patient under discussion here. I got a surgical lung biopsy on my patient, and saw some granulomatous inflammaiton with some central necrosis, but cultures were negative and stains were similarly negative. There was no vasculitis or any features of Wegener's.

Ten months later, I saw her in clinc. She was doing fine, but I repeated her ANCA and this time it was positive >1:320, p-ANCA. I am going to start her on prednisone, but not CTX for now, and add methotrexate as a steroid sparing drug.

Jennings said...

Hmm..interesting. Do you think the positive histo Ab in this patient is a red herring?

Arenberg said...

I missed the histo Ab,but the serology, as you know, is not diagnostic of active disease. ONe solution would be to repeat the ANCA in 6 months or sooner if symtoms worsen. I would not necessarily treat even if I did belive this was histo. This too could be followed, but I'd really like to see one of those nodules under the microscope (surgically speaking). I believe M-bands are more indicative of active disease than H-bands, but it has been a while since I read this.

Mike L said...

Doug-
Why methotrexate when there is an article using azathioprine in patients with stable WG after 4 months of CTX and prednisone?
Jayne et al. NEJM, Jul 2003; 349: 36

Arenberg said...

Good question Mike. I am not anxious to treat my particular patient with CTX because of the very mild presentation. I think that MTX is a good remission inducing agent, and there are some studies to support this...e.g. Gary Hoffman's article, Arthritis Rheum. 1992. 35(11). Then the same group, same journal a few years later...1995 38(5).

More recently there was a randomized European trial comapring MTX and CTX for induction of remission...

De Groot et al. Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis & Rheumatism 2005; 52:2461-2469

This one is available online at

http://www3.interscience.wiley.com/cgi-bin/abstract/110575111/ABSTRACT