Wednesday, November 15, 2006

Diagnostic dilemna

Ok, hopefully you can help me with this case. It's fairly long and complicated - not easy in this blog format but that's what we're stuck with. I presented this case before, but that was before some additional data.

He is a 45 year old with 6 months of a cough. This was found on a CT scan:


A biopsy was done. It showed interstitial inflammation. A previous biopsy had been obtained with similar non-specific findings. That one was read as "a mixed inflammatory infiltrate, greatest in the bronchial submucosa, with increased numbers of eosinophils. There are intraalveolar pigment/ hemosiderin laden macrophages and fresh blood; there is no vasculitis in this limited sample. Grocott stain is negative for fungus."

Also, a 2.1 x 1.3 cm hypoattenuating lesion was found within the tail of the
pancreas, nonspecific. This was biopsied by CT-guided and showed "The biopsy has stromal fibrosis, attenuation of the ducts/ acinar component and accentuation of the islets. In one level, there is a single granuloma My underline and the possibility of an underlying granulomatous inflammatory disease, such as a fungal infection or tuberculosis, accounting for both the lung and pancreatic lesions, cannot be excluded. Grocott stain is negative for fungus. Ziehl-Neelsen stain is negative for acid-fast bacteria. Immunostain is negative for mycobacteria. The present biopsy is not representative of a mass lesion."

He also was found to have adrenal insufficiency (cort-stim test) picked up when he presented to my clinic with hypotension, hyponatremia and hyperkalemia. (ACTH was 356). He also had a calcium of 10.9 but with normal PTH level (23).

Bronchial washings were negative for fungal. There was no growth of any micro subsequently.
A p-ANCA and c-ANCA were negative.

Any ideas on what's going on with this patient?

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

Baleeiro said...

Previous histo with adrenalitis and focal fibrosing mediastinitis?
Was there an ANA, ESR or any indication of autoimmune dz?

Arenberg said...

Back in the day...this woulda been TB.