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A 37-year-old Man with Dyspnea and Pulmonary Nodules

Authors
Karen Flores Rosario MD1, Yasmeen M. Butt MD2, Chad Newton MD3
1 Department of Internal Medicine, University of Texas - Southwestern
2 Department of Pathology, Division of Thoracic Pathology, University of Texas - Southwestern
3 Department of Internal Medicine, Division of Pulmonary Medicine, University of Texas - Southwestern


Case

A previously healthy 37-year-old man presented to the emergency department with one month of worsening dyspnea on exertion and intermittent pleuritic chest pain. He had not experienced fevers, chills, cough, night sweats, anorexia, or hemoptysis. He took no medications. He smoked 1-2 cigarettes/day for the last 20 years. He was a construction worker and cut natural stone for swimming pools. He lived on a ranch with exposures to dogs, cats, birds, and horses. On physical exam, he had normal vital signs, heart rhythm and rate were regular, and lungs were clear to auscultation bilaterally. Joint and skin exam were unremarkable.

Infectious workup was unremarkable. Spirometry revealed low-normal lung volumes and diffusion capacity and no response to bronchodilators. Autoimmune workup revealed non-specific positive findings consisting of the following: Antinuclear Antibody 1:2560, speckled pattern, Rheumatoid Factor 27, Anti-Ro/SSA>8, Anti-La/SSB >8, Angiotensin Converting Enzyme 84.

Computed tomography angiography (CTA) of the chest is shown below.

Images A & B

CTA

Initial bronchoscopy and bronchoalveolar lavage (BAL) of the right middle lobe revealed a hazy colorless fluid with 1315 nucleated cells, 125 red blood cells, and macrophages with hemosiderin or ingested material. Given inconclusive findings of BAL, a video-assisted thoracoscopy (VATS) wedge biopsy of the right upper and lower lung lobes was performed.

Image C

VATS

Question

What would you do next?

A. Advise smoking cessation and treat with oral steroids.
B. Advise smoking cessation and avoidance of silica exposure.
C. Initiate bronchodilators.
D. Perform whole lung alveolar lavage.

Answer