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Use of Endobronchial Ultrasound to Diagnose an Incidental Lung Nodule

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Luca Paoletti, MD

Fellow, Pulmonary/Critical Care Medicine

Division of Pulmonary and Critical Care Medicine

Medical University of South Carolina

Charleston, SC

P. Zachary Svigals, MD

P. Zachary Svigals, MD

Department of Internal Medicine

Medical University of South Carolina

Charleston, SC

J. Terrill Huggins, MD

Assistant Professor

Department of Medicine

Medical University of South Carolina

Charleston, SC

Nicholas J. Pastis, MD, FCCP

Assistant Professor

Department of Medicine

Medical University of South Carolina

Charleston, SC

Medical University of South Carolina

Medical University of South Carolina

Department of Medicine

Medical University of South Carolina

Charleston, SC

Submit your comments to the author(s).

History

A 71 year old non-smoking African American man presented to an outpatient clinic for evaluation of an incidentally discovered lung nodule on a computed tomography (CT) scan of the chest.  One week prior, the patient presented to the Emergency Department (ED) complaining of lightheadedness, generalized malaise, and dyspnea on exertion.  He was able to walk approximately 50 yards until he had to rest to catch his breath.  He also complained of a persistent dry non-productive cough, chronic rhinorrhea with white discharge, and a five pound unintentional weight loss over two months.  The patient denied shortness of breath at rest, wheezing, hemoptysis, and chest pain.  In the Emergency Department a computed tomography angiogram (CTA) of the chest was performed due to the suspicion of pulmonary embolus. While the CTA was negative for pulmonary embolus, a 1.4 cm soft tissue nodule was visualized in the superior segment of the right lower lobe (Figure 1) along with lower lobe bronchiectasis. The patient has had no prior imaging.

In the Emergency Department, he was diagnosed with a viral infection and volume depletion, he was given intravenous fluids and subsequently felt significantly better.  Outpatient follow up was arranged for his lung nodule the following week.

His past medical history was significant for type 2 diabetes mellitus controlled with oral medications, gastroesophageal reflux disease, erectile dysfunction, and hypercholesterolemia.  He denied prior surgeries.  His medications included glucophage, glipizide, tadalafil and dexlansoprazole. He had no allergies and was a lifelong nonsmoker.  His family history was unremarkable.

Physical Exam

Vital signs were within normal limits with an oxygen saturation of 100% on room air.  Head and neck exam revealed no palpable lymphadenopathy or jugular venous distension.  Lungs were resonant on percussion and clear to auscultation bilaterally.  The cardiovascular exam revealed a regular rate and rhythm with normal S1 and S2 and no murmurs.  The abdomen was soft and non-tender without hepatomegaly.  Extremities revealed no clubbing, cyanosis or edema.

Lab

White blood count 8.5K/mm3, hemoglobin 12.0g/dL, hematocrit 37% platelet count of 220K/mm3. Sodium 134mmol/L, potassium 4.7mmol/L, chloride 102mmol/L, bicarbonate 22mmol/L, urea nitrogen 45mg/dL, creatinine 1.4mg/dL, calcium 9.1mg/dL. Brain Natriuretic Peptide (BNP) <10pg/mL.

Pulmonary function test two weeks prior showed an forced vital capacity (FVC) of 4.78L (118% of predicted), forced expiratory volume in 1 second (FEV1) of 3.92L (127% of predicted), FEV1/FVC ratio of 0.82, total lung capacity (TLC) of 6.91L (99% of predicted), residual volume (RV) of 2.0L (74% of predicted), and an unadjusted diffusing capacity of carbon monoxide (DLCO) of 18.2 (ml/min/mmHg) (82% of predicted).

A flexible bronchoscopy was performed and a polypoid lesion was found occluding the orifice to the superior segment of the right lower lobe (Figure 2).  A radial endobronchial ultrasound probe was used to further aid in the diagnosis of the lesion and it showed multiple echogenic foci of calcification (Figure 3).  In order to diagnose the lesion and to restore patency of the airway an electrocautery snare was used to remove the lesion.

Figures




Question 1

What is the most likely diagnosis?

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