Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration. As part of a preoperative evaluation for hip surgery, a routine chest x-ray was obtained as below. Click on the thumbnails below for full size images:
A prior film done six months previously showed similar but less impressive findings. Upon review, the patient denied any pulmonary symptoms or significant history of smoking. There was no history of pets, occupational exposures, recent travel or illicit drug abuse. His only medication was oxcodone.
Chest computed tomography showed the following:
What procedure would you recommend and what is your preprocedure diagnosis?
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2 comments on “Mystery Quiz #2”
This 77 yo male essentially presents asymptomatically, though his use of oxycodone may suppress a pulmonary symptom, i.e. cough. The absence of fever or constitutional symptoms argues against infection, though does not rule it out obviously. He has patchy opacities on his CXR, going back at least six months, which also suggests a very indolent course.
His CT Scan demonstrates multiblobular groundglass; especially in the RML and lingular. I do not otherwise see significant pulmonary disease, he has preserved lung architecture. The DDx include of interstitual lung disease includes: pulmonary edema and hemorrhage, interstitial pneumonias (UIP, DIP, LIP, and acute), hypersensitivity pneumonia, atypical infectious pneumonias such as Pneumocystis carinii, mycoplasma, or CMV pneumonia, and cryptogenic organizing pneumonia.
Given these the indolent chronicity of these abnormalities: very abnormal CT Scan in an elderly presumably immunocompetent man, I think the diagnosis coubd be BOOP. I would recommend a VATS or open lung biopsy.
lipoid pneumonitis. for your nerves.
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