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