Tuesday, November 08, 2005

COPD and weight loss.

From Carlos, who is on vacation:
This is a 60 y/o man with a 50 p/y Hx of smoking sent to us because of worsening DOE, cough productive of scant amounts of thick sputum and weight loss. No hemoptysis, no CP.

PMHx: Mild HTN.

SHx: 50 p/y TOB. Quit in 2003.

On exam, thin male in NAD. Distant BS B/L with rare R upper crackles. S1/S2 RRR, benign abdomen.

His Spiro revealed an FEV1 of 1.1 L (27% of his predicted) and he had the following CxR and CT scan findings:

update(after 1st 2 comments):
He was started on aggressive bronchodilator therapy, given ABTx and steroids and returned with symptomatic improvement. His FEV1 increased to 2.17L (53%) and he felt better. However, he still had some weight loss (6 lbs.) and a persistent infiltrate after 4 weeks. I did a bronch which revealed only chronic bronchitis and no other Dx.

A PET-CT was done and it revealed marked FDG uptake to the RUL (average SVU of 13 with max SVU of 21) and nowhere else. What would you do next?

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

Arenberg said...

This looks like bad emphysema with densely consolidated upper lobe. Obviously lung cancer is on the radar in any smoker, but this looks more like airspace disease , and I will presume that Carlos is not sending in cases of pneumococcal pneumonia while on vacation. If he is, then I would advise him to get a life, but that's not important now.

I would be worried about TB in anyone with this history, and the films certainly are compatible with that, as they are with a number of other infections (fungus, gram negatives etc.,). There is significant RUL volume loss suggesting that there is some chronicity to this process, so I would be worried enough about TB that I might send sputum, and empirically treat with four drugs until I knew what this was. However, I guess the practical thing to do is treat for CAP, send sputum ASAP, and strongly consider empiric TB therapy if he doesn't get way better on coverage for CAP.

I will assume that there is no endobronchial mass too, as those cuts are not on this CT.

Baleeiro said...

Greetings from Brazil.
I actually left this case ready so I wouldn´t have to type much. I had the same concerns as Doug that this looks like CAP but Lung Ca is always a concern. I didn´t put all the CT cuts but some of the more posterior and lower process (rather than all the scarred up lung) looked a bit like soft tissue density.

Jennings said...

Well, despite the positive PET, I would agree with Doug that TB is still quite high on the list. However, I assume you BAL'd the RUL without any AFB? A PPD is tempting, but wuldn't help to evaluate for active TB, and latent TB with a scar shouldn't be PET positive.
I realize that carcinoma can never realy be ruled out, but the shape looks funky - not mass-like (the air space part could be seconary infection so this can't be used to r/o underlying cancer).
I might get a split-lung perfusion or something similar and if operable, might bite the bullet and resect.
(disclaimer: the way the email was set up, I did not look at the answer; parts 1 and 2 are separated by enough space in the email that it was easy not to cheat) :)

Jennings said...

From Carlos: with a positive PET, improved PFTs in a smoker with ongoing weight loss we went ahead with surgical resection. He did very well post-op and the lesion was an inflammatory mass with no clear etiology but some Actyno-like filaments on path (though not on Cxs). He remains on bronchodilators, has gained 13 lbs from his weight nadir and other than thoracotomy site discomfort has no other complaints.