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Cavitating Lung Lesion in a 59 year- old man.

Reviewed By Critical Care Assembly

Submitted by

Maryum Merchant, M.D.

Fellow, Pulmonary/Critical Care Medicine

Division of Pulmonary and Critical Care Medicine

Cedars Sinai Medical Center

Los Angeles, CA

David Gum-Tong Ng, M.D.

Attending Physician

Division of Pulmonary and Critical Care Medicine

Cedars Sinai Medical Center

Los Angeles, CA

Sara Ghandehari, M.D.

Director, Outpatient Pulmonary Rehabilitation

Assistant Director, Lung Transplant Program, Assistant Professor of Medicine, Cedars Sinai Medical Center

Women's Guild Lung Institute, Division of Pulmonary and Critical Care Medicine, Cedars Sinai Medical Center

Los Angeles, CA

Submit your comments to the author(s).

History

A 59 year- old man with recent lumbar decompression surgery was admitted at a local community hospital with cough and a cavitary right lung mass on chest imaging. His work-up included a CT guided biopsy of the lung mass which demonstrated suspicious cells concerning for malignancy. Prior to a follow-up appointment with his pulmonologist, he presented to our hospital with subjective fevers, chills, back pain and increased drainage from his lumbar wound. His review of systems was positive for occasional dry non-productive cough, improved from his previous admission. He denied shortness of breath at rest, dyspnea with exertion, wheezing, hemoptysis or chest pain.

His past medical history was remarkable for history of lumbar stenosis with multiple back surgeries, hypertension and diabetes.

His medications prior to admission included lisinopril and gabapentin.

He was a lifelong non- smoker and worked as a water well driller.

Physical Exam

The patient appeared comfortable and was in no acute distress. He was afebrile and other vital signs were unremarkable. The cardiac exam demonstrated regular rate and rhythm, a normal S1 and S2, and no murmur, gallop or rub. Breath sounds were equal bilaterally with no adventitious sounds. The abdomen was soft and without organomegaly. The patient’s extremities were without clubbing or edema. Mild swelling was noted along the incision site at the back and it felt hard, warm and tender to touch.

Lab

A chest CT scan was repeated this admission which revealed a 2 cm cavitary mass in the right mid lung with a thick wall and spiculations extending to the pleural surface.

july-2013

An abdominal and pelvic CT scan was unremarkable.

Hospital course:

Patient recovered well from his postoperative lumbar wound infection with antibiotics. His microbiology specimens (blood and sputum cultures and serology for Mycoplasma, Legionella, viruses, fungi) were negative.

Because of the concern for malignancy, a video-assisted thoracoscopic (VATS) wedge resection was performed. The resected nodule on gross inspection was found to be a 2.6 x 1.7 x 0.8 cm  firm intraparenchymal nodule with a gray-tan solid cut surface and central 0.5 x 0.4 x 0.3 cm cavity space. Microscopic examination revealed intrabronchiolar aggreg ates of fibroblastic tissue and mononuclear cells invading alveolar spaces, as well as presence of multinucleated giant cells with no evidence of organisms on acid fast or Gie msa staining.

Question 1

What is the diagnosis?

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