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Incidental Pulmonary Nodule in a 75-Year-Old Man

Case Editor - Judd Flesch

Reviewed By Clinical Problems Assembly

Submitted by

Leanne K. Strack, DO

Clinical Instructor and Pulmonary/Critical Care Fellow

The Ohio State University

Columbus, Ohio

Charles L. Hitchcock, MD, PhD

Associate Professor of Medicine, Clinical

Department of Pathology

The Ohio State University

Columbus, Ohio

Karen Wood, MD

Assistant Professor of Medicine

Pulmonary/Critical Care Medicine

The Ohio State University

Columbus, Ohio

Submit your comments to the author(s).

History

A 75-year-old man is referred to an outpatient pulmonary clinic for evaluation of an abnormal chest radiograph. The chest radiograph was performed as part of routine examination by his cardiologist. He has a history of coronary artery disease, high cholesterol and hypertension. He was placed on amiodarone after coronary artery bypass grafting 12 years ago. His other medications include clopidogrel, atenolol, rosuvastatin, colesevelam and aspirin. He denies a personal or family history of malignancy. He works as a mechanical engineer and denies exposure to asbestos, but gives a recent history of exposure to polyurethane and lacquers. He is a life-long nonsmoker and denies exposure to second-hand smoke. He denies symptoms of hemoptysis, weight loss, fatigue or shortness of breath.

Physical Exam

The patient is 67 inches tall and weighs 140 pounds. He is in no acute distress and his oxygen saturation is 98% on room air. His chest examination does not reveal any bony abnormalities and his lungs are clear to auscultation bilaterally. His remaining cardiac, abdominal, extremity and neurologic examinations are unremarkable.

Lab

A chest CT scan reveals a 1.6 cm by 2.7 cm irregularly shaped soft tissue density nodule or focus of consolidation in the posterior basal segment of the left lower lobe. A fusion positron emission tomography (PET)/CT scan of the chest demonstrates a standardized uptake value (SUV) of 5.5 for the left lower lobe lesion and no associated lymphadenopathy or increased uptake elsewhere. A CT-guided biopsy was performed and demonstrates organizing pneumonia, alveolar septal thickening due to lymphoplasmacytic infiltrate, and poorly defined granulomas with no evidence of organisms on acid fast bacilli (AFB) and giesma (GMS) staining.

Because of the concern for malignancy, a video-assisted thoracoscopic (VATS) wedge resection was performed. The pathology is pictured below.

Figures


Figure 1: a) Low magnification of hematoxylin and eosin (H&E) stain of pathologic specimen; b) Higher magnification of H&E stain of pathologic specimen; c) High magnification of H&E stain of pathologic specimen; d) High magnification of GMS stain of pathologic specimen. The biopsy contains a prominent fibrotic nodule containing numerous microabscesses with brown pigmented, moniliform elements within giant cells and within granules characterized by a prominent Spledore-Hoeppli phenomenon.

Question 1

What is the most likely diagnosis?

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