Thursday, July 26, 2007

Steroid responsive adenopathy?

65-year-old woman presented initially for evaluation of shortness of breath. A CT thorax revealed some patchy airspace opacification RUL (see below) . She underwent bronchoscopic evaluation and it demonstrated some interstitial inflammation with hyperplastic type 2 pneumoctyes. No granulomas seen. No fungal or AFB elements on BAL. A cell count was not sent.
She was begun on a course of steroids 40mg and felt her breathing improved significantly while on them, but once she stopped them, her shortness of breath recurred. Her cough has also recurred, though it's mostly non-productive. A CT was repeated 5 monts later and is shown below.

Question: What ILD had adenopathy and is steroid responsive? The only 2 I can think of are sarcoid and berrylliosis, but the interstial inflammation would be inconsistent with that. Any thoughts out there?

Tuesday, July 24, 2007

A man with weakness and a some minor CT abnormalities

From Doug:

53 yo man with an 80 pack yr smoking hx and history of Etoh abuse was admitted
with a 5 week hx of progressive ataxia, diplopia, dysarthria,
and dysphagia. Initially w/u revealed unremarkable MRI brain, and a CT
C/A/P showing prevascular lymph nodes with some calcifications and left hilar borderline enlarged lymph nodes, and a renal cyst not further characterized on that study.

DDx included subacute cerebellar degeneration and progressive supranuclear palsy.
Multiple CSF and serum labs were pending at time of discharge

He was readmitted a week later for progressive dysphagia for liquids in addition to solids, worsening gait s/p falls, and continued dysarthria and diplopia. IV IgG was given empirically without improvement. Repeat LP and additional infectious
serologies were negative. A dedicated renal CT was done to further characterize the indeterminate lesion on the previous CT, showing only a
simple cyst.

What would you do next? <<<>>>

Addendum added after case presented:

These are the EBUS images from the bronch including and the core biopsy from the TBNA. The answer was that these little lymph nodes were small cell carcinoma. The special stain is a cytokeratin stain of the malignant cells.