This 34 year old female presented for evaluation with 2 months of increasing shortness of breath, chest tightness and cough. There was minimal sputum production, but she is uncomfortable at night and had to sleep with 2 pillows. Wheezing had been present but she did not respond to steroids, albuterol or Symbicort. Her lab data was normal except for a positive mono test. She was not exposed to any aerosols. She is a non-smoking, non-drug using female with 2 children living in a rural enviroment.
The CT images are shown:
What are possible diagnoses and how would proceed at this time
July 24, 2008 at 2:28 pm |
Looks like septal thickening, ground glass, and nodules/masses predominently on the Right but with some nodules on the left, and more prominent in the base. Nodules seem to be associated with the pulmonary artery at times.
My Diff:
Lymphoma with lyphangitic involvement post-EBV
EBV associated Leiomyomatosis
Pulmonary Lymphomatoid Granulomatosis
Lymphagitic mets of another malignancy (breast, melanoma, or otherwise)
EBV associated fibrosing alveolitis
Leiomyosarcoma of the pulmonary artery
LAM (less likely)
Wegeners Granulomatosis (less likely)
Sarcoidosis
If she got a biopsy can we pull it for path conference?
July 24, 2008 at 2:37 pm |
There are some cases of SLE presenting with a positive monospot test. Her symptoms of SOB, and pleuritis without evidence of significant fibrosis or pleuritic disease on the CT could be suggestive of “shrinking lung syndrome.” The nodular infiltrates could be associated with thromboembolic phenomenon and it would be interesting to see what her serum antiphospholipid antibody levels are. The fact that a monospot was done leads me to think there were other symptoms prior to the ones she is having now…such as fatigue, low grade fevers, myalgias? Lymphoma is another possibility, but the lack of described B symptoms and normal “lab data,” without mention of physical exam findings for LAD suggests this is less likely. Her right breast has increased density on CT scan. This could be fat or possible breast cancer with mets to the lung. Workup would include complete breast exam, serologic evaluation for CTD, PFT’s, Echocardiogram, and possible biopsy of one of the peripheral lung nodules.