Wednesday, October 04, 2006

Dyspnea and a LUL mass

Here's a case from Arenberg:

This is 69-year-old lady with coronary artery disease, diastolic congestive heart failure, and dyspnea on exertion. She came to see me because her cardiologist said she has been experiencing increased dyspnea out of proportion to her normal symptoms for ~3 months. Other than a pacemaker over her left chest, her plain chest x-rays were normal

and her pulmonary function tests were mildly restrictive (FVC ~69%), actually improved from her last testing ~ 4 years prior.

I got a VQ scan that was normal, but only on her second visit (when I actually asked) did I learn that she has had 2 birds as house pets for the last 3 years. She further revealed that she has felt unwell going back about 2-1/2 years. One of the birds was in fact sick, and during this time, she fed the bird from mouth to mouth. Yes, I am serious. She was DEAD SET against getting rid of the birds, so I got a CT scan in anticipation of doing a bronch, to prove she had HP.

The CT showed very subtle changes of ground glass, and was actually read as no evidence of ILD, but surprise surprise, she now had a LUL mass that was not seen on the CXR taken 2 months earlier. The radiologist thought it was likely to be inflammatory. What would you do?

I have more images, and some cool pictures to follow, but I’ll hold onto them until people have a chance to comment.

"...good evidence for chronic HP in the form of a patchy chronic
bronchiolitis that includes occasional multinucleated giant cells of the
sort commonly seen in that condition"

Comments from our pathologist.

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

Jennings said...

Was/is she a smoker? Were there any enlarged mediastinal nodes? These 2 factors would as you know be not typical in HP. What features on CT made the radiologist think it was inflammatory? I would think you would want to make sure it was "just inflammatory" because maybe she has HP AND cancer that was picked up incidentally on the CT....

Jeff H said...

I'd be worried that that the mass was "hidden" on the previous xrays by it's location and, possibly, the pacemaker positioning. I don't know that we can assume that this is "inflammatory." I'd work this up as a suspected malignancy.

Arenberg said...

A long time ago, she smoked a litttle bit, but less than 10 pk-years. There were no enlarged lymph nodes.

She had a non-diagnostic bronch, both for HP, and for cancer, and a PET scan showed uptake only in the LUL mass.

To make matters worse, she has BAD sleep apnea, pulmonary hypertension, and is on coumadin for paroxysmal atrial fibrillation.

The discussion in our tumor board resulted in agreement that we could not determine that this mass was new within 2 months because of the pacer, and therfore could have been more consistent with a mas that was there for a while.

She underwent a thoracotomy, and the pathology was poorly differentialted large cell carcinoma.

I asked our pathologist to section some of the normal lung, and did not tell him why, because I didn't want to bias him. I got an e-mail back from him the next day showing me the pictures that I will send today, they showed a classic pattern of HP.

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