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Bilateral Peripheral Cystic Lesions in a Patient with Progressive Dyspnea

Arvind Nishtala, MD, MPH; Peggy Bui, MD, MBA; Richard Wang, MD; Leslie Sheu, MD 

June 2, 2017

A 71-year-old male presented with 6 months of a progressive productive cough, dyspnea, night sweats, and a 20-pound unintentional weight loss. His medical history was significant for hypertension, hyperlipidemia, atrial fibrillation, and depression. He was a 35 pack-year current smoker, with remote alcohol use, but no illicit drug abuse. He was a retired construction worker who volunteered as a water truck driver for forest fires in Northern California. Previously, he worked in a uranium mine and a cyanide plant. He did not have any animal exposures. He took rosuvastatin, sotalol, and lisinopril but no over-the-counter supplements. Colon and prostate cancer screening were negative, and he had not been screened for lung cancer.

Vital signs were significant for an oxygen saturation of 89-93% on room air. Respiratory exam was notable for tachypnea, bibasilar coarse crackles with a musical quality of pops and whistles on both inspiratory and expiratory phases. There was no supraclavicular, axillary, or inguinal lymphadenopathy. A basic chemistry panel was normal. Complete blood count was notable for leukocytosis of 14.1 x109/L (absolute neutrophil count 10.1 x109/L and otherwise normal differential). A comprehensive infectious and autoimmune workup, including blood cultures, respiratory viral panel, acid fast bacilli smear and cultures, HIV, Beta D-glucan, galactomannan, coccidioides antibody, blastomycosis antibody, histoplasmosis antigen, rheumatoid factor, anti-CCP, p-ANCA, c-ANCA, and ACE, was negative. 

Pulmonary functions tests showed a mixed restrictive and obstructive pattern with significant reversal with bronchodilators. A transthoracic echocardiogram was normal. Chest CT (See Figure 1) revealed bilateral peripheral cystic lesions with surrounding consolidation and ground glass opacities, without evidence of hilar or mediastinal lymphadenopathy. Bronchoalveolar lavage revealed lymphocyte-predominant fluid with negative cytology and cultures.

He was treated empirically for pneumonia with amoxicillin-clavulanate and oral prednisone, without improvement. 





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Author Information:

Arvind Nishtala is a second-year internal medicine resident at University of California San Francisco.

Peggy Bui is a third-year internal medicine resident at University of California San Francisco.

Richard Wang is a second-year pulmonary fellow at University of California San Francisco.

Leslie Sheu is an attending physician in General Internal Medicine at University of California San Francisco.