A CURIOUS CASE OF GRANULOMATOUS INFLAMMATION OF THE LUNG

Abstract

SESSION TITLE: Medical Student/Resident Tobacco Cessation and Prevention Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Young patients may have a multitude of causes for incidental lung lesions. Granulomatous lung lesions are frequently associated with infections, less common causes such as toxin mediated and vasculitis should be ruled out. We present the case of a patient who presented with granulomatous nodules due to water pipe smoking (WPS). CASE PRESENTATION: 21 year-old female presented with chest pain and dyspnea. She reported a 3-year history of tobacco use in the form of WPS and a remote history of vaping. Chest x-ray revealed a right middle lobe infiltrate concerning for pneumonia which was treated with antibiotics. CT chest further characterized the lesion as a 4 cm mass with additional clusters of irregular sub-centimetre nodules with subcarinal and mediastinal lymphadenopathy (Fig 1). Bronchoscopy showed large endobronchial lesions and histology showed necrotizing granulomas with negative stains and cultures for fungal or tuberculosis or evidence of malignancy. lymph node biopsy tissue samples demonstrated necrotizing granulomas. The patient was subsequently discharged from the hospital for outpatient management with a brief course of corticosteroids and was lost to follow up thereafter. DISCUSSION: Our patient who presented with an incidental lung lesion on her radiographs was found to have granulomatous lung nodules on histology. Workup remained negative for common causes such as Fungal infections, Tuberculosis or malignancy and she was eventually presumed to have WPS induced granulomatous lung disease given her prolonged and recent exposure. WPS as a trend has been silently picking up among certain young adult populations in the West with some studies indicating usage rates as high as 46.4% among college students. Contents in water pipe smoke such as ultrafine particulate matter (PM), carcinogenic particles and heavy metals have been implicated in a host of lung pathologies ranging from emphysema to infections and even lung cancers. Granulomatous inflammation however remains an infrequent complication and the mechanism underlying this pathology has yet to be elucidated. Such a finding has only been reported once before by Dyal et al who described the case of a young female with bilateral granulomatous secondary to WPS who was treated successfully with steroids, suggesting a component of underlying inflammation. CONCLUSIONS: Detailed and updated review could help strengthen evidence for the truly disastrous effects of WPS on long term health of our young adults, and potentially support litigation for the ban on sale and use of these products, as was accomplished recently in case of E-cigarettes or vaping. Reference #1: American Lung Association. Hookah smoking: a growing threat to public health [accessed 2016 Apr 9] Reference #2: Shafagoj Y.A., Mohammad F.I. Levels of maximum endexpiratory carbon-monoxide and certain cardio vascular parameters following hubble-bubble smoking. Saudi. Med. J. 2002;23:953958 Reference #3: Dyal H, Singhvi A, Patel R, et al. 2014. A case of Eosinophilic pneumonia following recent onset of hookah smoking. Chest 146:406A DISCLOSURES: No relevant relationships by Sanjay Dogra, source=Web Response No relevant relationships by Sandeep Kumar, source=Web Response No relevant relationships by Shaiva Meka, source=Web Response No relevant relationships by Syed Mustafa, source=Web Response No relevant relationships by Ehsun Naeem, source=Web Response