Assembly

Slow Winds in a Dark and Starry Night

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Authors
Andres Herrera-Camino MD1,2, Ferdinand Coste DO2, Mai He MD PhD3, Jennifer Duncan MD1

1 Division of Pediatric Critical Care Medicine, Washington University in St. Louis
2 Division of Pediatric Pulmonary Medicine, Washington University in St. Louis
3 Division of Pediatric Pathology, Washington University in St. Louis


Case

Intro

An 11-year-old female presented to the pediatric intensive care unit (PICU) for evaluation and management of hypoxemia. Two months prior to admission the patient was evaluated for an acute respiratory illness associated with a submandibular mass. The initial chest x-ray (CXR) showed diffuse pulmonary nodules and an infectious work-up was negative. Her respiratory symptoms resolved; however, her submandibular mass persisted. She was scheduled for an MRI of the neck on the day of admission and was noted to have significant hypoxemia. She was ultimately transferred to the PICU for oxygen therapy. CXR on PICU admission demonstrated the following:

Figure 1: Chest Radiograph
Chest Radiograph

The patient underwent an extensive evaluation for the disseminated pulmonary nodules seen on the CXR (Fig 1), including a Chest CT scan (Fig 2):

Figure 2: Chest CT scan
Chest CT Scan

Prior to admission, the patient had undergone an ultrasound examination of the submandibular mass which was suggestive of a vascular soft tissue mass. Due to concern for bleeding, a biopsy of this site was deferred and the decision was made to perform an open lung biopsy which revealed the following (Fig 3):

Figure 3: Histopathology
histopathology
histopathology

Question

What is the diagnosis?

A. Miliary Tuberculosis
B. Fungal infection
C. Hypersensitivity pneumonitis
D. Sarcoidosis
E. Disseminated malignancy

Answer