Pulmonary infiltrates

This is a 68 y/o man with a very remote TOB Hx (quit >20 years ago) who had an interesting initial presentation of persistent neck adenopathy since 1995. He had had many non-diagnostic biopsies over the years and was treated for toxo. He finally had an excisional Bx of an 8x6 cm neck node and was found to have Hodgkin's. He had mediastinal adenopathy at the time (7/05) and has received 3 cycles of ABVD. He was set up for another cycle in early December but presented to the hospital with worsening dyspnea, cough (non-productive) and fatigue and was found to be hypoxemic. He is not neutropenic but is quite hypoxic and I have posted his CxR and CT chest below.
What is your DDx and what would you do next?

Abnormal CT scan

This is an 83 y/o man sent to us by our CT surgeons. Two months ago he had a tracheo-bronchitis treated by his PCP. A CxR showed a subtle abnormality on his L lung and that was better seen on a CT scan. He is now assymptomatic but has a persistent abnormality on his L lung on a repeat CT scan (see below, this was done roughly 6 weeks after the first one).
He is a former smoker (quit in 1967) with no other remarkable exposures.
Exam is fairly normal.
PFTs showed mild COPD (FEV1~70% with normal TLC, increased RV and DLCO ~60%).
The surgeons thought we might want to see him before cutting anything out.
What would you do next?

Levalbuterol

Our hospital has a very high usage of levalbuterol as opposed to racemic albuterol (most of it actually not motivated by pulmonary). It is often prescribed in higher frequency than the q8 hour use. Pharmacy has been trying to rein this in because of cost differences.
There is a lot of data available (some conflicting) and most of it sponsored by Sepracor (such as Truitt's paper on Chest 2003).
What is your opinion on the use and have you noticed similar patterns with levalbuterol?

Follow up to lung mass

This is the man with the large LUL mass and the hot spot on the sacrum seen on PET. The main question was what to do and how to finish his staging. Our CT surgeon offered to do a mediastinoscopy for further staging (of a IIIA vs IIIB) to help decide on whether he would be operable. He had tumor invasion of the mediastinum itself (T4) with positive N2 nodes (IIIB). We are performing a MRI of the pelvis today to better define that hot spot (his PSA is high too) and a MRI of his head. Since he is not operable we feel inclined to further image but not biopsy the sacral lesion at this point. What do you think?

Bronchs and coag's

This comes up fairly often in patients with AFib, mechanical heart valves and liver disease who need bronch's. What is your comfortable cutoff for PT-INR and or platelets when doing a bronchoscopy? Is there any good data on safety and cutoff levels?

Ethical question

69 yo male with PMH of hypertension, CAD and DM2 presented to his PCP with fatigue and "falling asleep anywhere." After testing him for anemia, renal disease and thyroid disease, he decided to get a sleep study. The sleep study was grossly positive with an AHI (RDI) of 67 that occurred with both REM and NREM sleep. During the split night portion of the study, his AHI was reduced to 12 with CPAP of 11 cm H20.

He saw me after the study. When asked, he claimed to fall asleep reading the newspaper in the morning on the weekends, watching TV at night and had, on 2 occassions, fallen asleep while driving. He pulled over, napped for 10 minutes and started to drive again. There were no accidents and he needs to drive each day to get to work. He is constantly sleepy while driving and usually drives with the windows down in 20 degree temperatures to keep himself awake.

From our office, we arranged for CPAP to be delivered to his house the day of his appointment.

Would you ask him not to drive? If so, for how long?
Would you report this to the state (this is not required in the state of Michigan).

Lung mass

This is a man in his 60's with no previous lung or heart disease. He presented to the ER with atypical R-sided CP, had an abnormal CxR and had the following CT:

I saw him in our office, he has an occasional cough and normal PFTs.
I did a bronch which showed no endobronchial lesions but confirmed a NSCLCa (squamous).
His PET scan showed obvious uptake by the mass and an ipsilateral node.

It also showed some increased uptake in the sacrum:

The sacral area is anterior and not approachable by CT-guided Bx... What would you do next? With the PET but no tissue confirmation from the sacrum would you consider him a stage IV? Would you try and get a surgical Bx from the sacrum?

PET and SUV

new comment in unusual configuration cxr. I had a long discussion with the radiologist in nuclear medicine. He essentially refused to tell me the SUV value on a PET scan, saying that there was so much overlap that it was useless. He was not (yet) able to cite any references to back this up but will hopefully be getting back to me on this. Judging by some of the comments here, I gather some of you rely on this value when making decisions regarding the "hotness" of a lesion. While we are awaiting the radiologist's reply, is anyone aware of studies debunking/invalidating the utility of the SUV value?

Follow up to abnormal CT scan

This is the young guy with the mediastinal adenopathy. I did request a PET scan and there was no abnormal uptake anywhere. Mike L raised a good point on that discussion about PET-negative slow growing lymphomas. With these results, what would you do next?

rEmerson Biguns

19 year old woman who is 26 weeks pregnant presented with 2 weeks of progressive shortness of breath, which was worse lying down and better sitting up and leaning forward. + wheezing. No fever/chills/sweats. No weight loss. No cough/sputum production.

No past medical history/social history/family history of significance.

The exam was notable only for inspiratory and expriatory wheezing.

Abnormal CT scan

This is a 44 y/o man referred to our office because of an abnormal CT scan of the chest. He had fallen of a horse and had a CT scan of his thoracic spine and the mediastinal findings were incidental. He has NO respiratory symptoms. He is a smoker (1-1.5 pack/day x ~30years) and has normal PFTs. I have outlined the abnormality on the first cut so you may follow along. No other parenchymal abnormalities were noted.

How would you (or would you) work up this lesion?

Interesting configuration of a lung lesion.

73-year-old female with mild COPD, former smoker. Found to have a left upper lobe nodule on x-ray:
A CT scan was performed, confirming a 3 cm vertically oriented cylindrical lesion.

Do you agree that this is an unusual configuration for a malignancy? Could it be a mucous plug? Well, how about the fact that this is the PET scan results:

Update on previous lung cancer

There were no comments on this case but I would still like to hear your suggestions since it is an ongoing case and I don't have a final answer yet. This is the 61 y/o man with the previous IIB NSCLCa now with abnormal hilum and RML bronchus with path changes of radiation but no obvious malignancy. As it is getting close to the holidays, he came to the office yesterday for the bronch results and we agreed to watch him closely with a repeat CT in 3 months and no other invasive procedures. What would you do?

Update on lung mass

This is the 54 y/o man with >85p/y of TOB and the PET+ lung mass. We felt that with his pre-test likelihood of malignancy, surgery was his best option. He underwent a LULobectomy with partial resection of ribs as the mass was adherent to them (no bone involvement on the PET-CT) and the frozen was "consistent" with adenoCa. The final path was a granulomatous inflammatory mass with fungal agents consistent with blasto and no cancer.

Update on abnormal CxR and hypoxemia

This is the 58-year-old white male with the ICD, and pulmonary infiltrates. Good pick up on the Amio (I thought about just listin "antiarrhythmics" but that seemed unfair). We followed along the same ideas posted: gentle diuresis, continued BiPAP and then a bronch. He had alveolar spaces filled with foamy macs full of phospholipid complexes. Amio was discontinued and he was placed on steroids. He went to a SNF and eventually came off O2. His PFTs normalized and his CxR cleared up.

Update on ongoing cases

We have three cases from this week and one question/comment going on and still need to hear from our readers. Try and leave comments/suggestions and we will be posting the conclusions to the lung mass cases tomorrow.

Previous lung cancer

This is a 61 y/o man who was seen in our office last year. He had significant obesity and OSA and was found to have a RUL mass. He underwent resection of a IIB (T2N1M0) NSCLCa (squamous), followed by xRt and chemoTx. His course since then has been remarkable for a fall and a hip Fx but no respiratory problems.
He came back to his PCP this past month with a new cough and R chest tightness. His CT showed some loss of volume and more soft tissue swelling in the hilar area (see below):

Incidentally he had this huge gallstone (cool pic):

I bronch'ed him and he had narrowing and scarring of the residual RML bronchus with normal RLL and a healthy looking RUL stump. EndoBBx, brushings and lavages were remarkable for radiation changes and atypia but no neoplasm. Would you do a PET, a more invasive sampling (e.g. Mediastinoscopy) or just follow him after some ABTx since he has already had maximal therapy to the area and would have limited options with recurrent Ca?

Lung mass

This is a 54 y/o man with a 2-pack day TOB habit who had been referred to us for atypical chest pain. He complained of intermittent chest tightness and had had a negative cardiac w/up (normal SPECT-stress, normal EF, etc.). We identified a mild to moderate obstructive ventilatory deffect (normal FVC and FEV1 that fluctuated between high 50s to 70%) and started him on bronchodilators and continued to counsel him about smoking. He had a CxR with a RUL bulla and some L apical scarring. In the course of his follow-up however, we performed a repeat CxR which revealed a new LUL lesion:

He had some cough at the time so he was given a course of ABTx and followed closely and there was no improvement in the lesion after 4 weeks. A CT scan was obtained and revealed a soft tissue mass associated with some scarring:

A bronch was done and was non-diagnostic and the mass remained unchanged on CxR.
A PET-CT was then performed and revealed intense uptake on the area (SUV ~5.7 about 6 weeks after he had completed the course of ABTx) :

What would you do next?

Abnormal CxR and hypoxemia

We were consulted on this pleasant 58-year-old white male with known coronary artery disease. He was last admitted 3 months ago with a inferior lateral wall myocardial infarction. He is status post angioplasty. He has a history of chronic obstructive pulmonary disease. He had been doing fairly well andhad gone back to work as an electrician however, over the last five days he developed increasing lethargy, chills and felt feverish with a dry nonproductive cough and worsening dyspnea.
PMHx: Ventricular tachycardia, S/P AICD/PM. CAD, S/P inferior lateral myocardial infarction and previous EF~45%. He is status post stenting of the OM/circumflex. Chronic obstructive pulmonary disease. Dyslipidemia.
Current meds: Lovenox, Albuterol and Atrovent, Levofloxacin, Aspirin and Amiodarone.
FHx: Noncontributory
SHx: Heavy cigarette smoker, he quit 3 months ago. He has been drinking several beers daily. He works as an electrician. He lives alone and his wife died last year.
ROS non-contributory.
On exam he was tachypneic to 36 with an O2Sat of 90% on BiPAP with 100% FiO2. BP and HR were stable. His lungs had very faint crackles and no wheezing or ronchi.
ABG was: 7.43/CO2: 37/ O2: 58 on 100% FM.
His CxR and CT are posted below.
What would you do next?

ICS in COPD

This is a quick question. How often do you add inhaled steroids in the care of your COPD patients? I am more curious about people's anecdotal and personal opinions rather than data (FEV1< 30%, response to PO steroid trial, etc.).