tag:blogger.com,1999:blog-12660458.post112853207589770265..comments2023-09-01T10:33:09.297-04:00Comments on Pulmonary Roundtable: Diffuse Masses/NodulesUnknownnoreply@blogger.comBlogger8125tag:blogger.com,1999:blog-12660458.post-1128619694209647812005-10-06T13:28:00.000-04:002005-10-06T13:28:00.000-04:00She was initially started on Voriconazole and Bact...She was initially started on Voriconazole and Bactrim, but these were discontinued when the cultures remained negative. Following her CT-guided biopsy, she was discharged home. A repeat CXR done 3 days later showed enlargement of the nodules. <BR/><BR/>5 days after her CT guided biopsy, a VATS was done, with wedge resection of two of these nodules.<BR/><BR/>Path: numerous large B-cells (+ for EBV staining) diagnostic of PTLD/large B-cell lymphoma.Jeff Hhttps://www.blogger.com/profile/01209432708535732499noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128615496791151692005-10-06T12:18:00.000-04:002005-10-06T12:18:00.000-04:00I think I'd have a lower threshold to start antifu...I think I'd have a lower threshold to start antifungals and ABTx. She has been sick for a while and is likely to get worse before she gets better... especially if she has fungi in there.Baleeirohttps://www.blogger.com/profile/03993066135160692535noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128607896365382822005-10-06T10:11:00.000-04:002005-10-06T10:11:00.000-04:00That was our thinking. The short list consisted o...That was our thinking. The short list consisted of Nocardia versus post-transplant lymphoproliferative disorder and/or lymphoma, with less likelihood of endemic fungi or aspergillus. We were also concerned about the possibility of metastatic disease (possibly arising from one of her native kidneys).<BR/><BR/>All cultures from both the bronch and from the CT guided core remained both smear and culture-negative.<BR/><BR/>A CT scan of the abdomen and pelvis showed no evidence of masses or lymphadenopathy.<BR/><BR/>So, the question now is: would you initiate (or would you have initiated) any empiric therapy prior to any of the biopsies or now while arranging for a VATS? If so, what would you start?<BR/><BR/>I will post the follow-up after giving some time for final comments.Jeff Hhttps://www.blogger.com/profile/01209432708535732499noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128607831616274262005-10-06T10:10:00.000-04:002005-10-06T10:10:00.000-04:00I agree that sarcomas may fit the bill in someone ...I agree that sarcomas may fit the bill in someone on immunossup. for such a long time.Baleeirohttps://www.blogger.com/profile/03993066135160692535noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128605122134851722005-10-06T09:25:00.000-04:002005-10-06T09:25:00.000-04:00Nocardia can present this way - either by direct i...Nocardia can present this way - either by direct inhalation or hematogenously.Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128604482450096822005-10-06T09:14:00.000-04:002005-10-06T09:14:00.000-04:00Those are very impressive. Being on immunossuppre...Those are very impressive. Being on immunossuppression this long not only puts her at risk for infectious complications such as Aspergillus (even if she is not neutropenic) and TB but also for malignancies (though they seem to have grown awfully fast) such as lymphomas and solid organ tumors (some sarcomas can appear to grow fairly fast). <BR/>I'd ask the CT surgeons to try and get a VATS Bx of one of those.<BR/>Do we know which regimens she had been on in the past? PPD status?Baleeirohttps://www.blogger.com/profile/03993066135160692535noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128542893001824172005-10-05T16:08:00.000-04:002005-10-05T16:08:00.000-04:00Bronchoscopy was non-diagnostic. All serologies w...Bronchoscopy was non-diagnostic. All serologies were negative. All labs were normal. A CT guided biopsy was non-diagnostic (all ghost-cells and necrotic tissue). <BR/><BR/>What, if any, infections and/or neoplasms might be likely?Jeff Hhttps://www.blogger.com/profile/01209432708535732499noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1128540375667669612005-10-05T15:26:00.000-04:002005-10-05T15:26:00.000-04:00watch it, bubba.Anyway, I do agree that infectious...watch it, bubba.<BR/>Anyway, I do agree that infectious seems to be the most likely; lack of symptomatology is unusual, but then it would be unusual for almost anything on the differential. Also, her immunocommpromised state means she is susceptible to infections. On that note, I might think that an autoimmune etiology is less likely because she is immunocompromised. Cancer, via hematogenous spread is less likely given the rapidity, and it doesn't look like the more rapid cancers like small cell.Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.com