Clinical-pathologic conference in general thoracic surgery: disseminated nocardiosis presenting as Pancoast syndrome

Abstract

Clinical Summary A 61-year-old woman presented with a left upper lobe lung lesion and clinical evidence of T1 neuropraxia. Her history included carcinoma of the ovary treated with surgical resection and adjuvant chemotherapy with paclitaxel (Taxol) 10 months before presentation. She had a 20 pack-year history of smoking, ceasing 10 years before, and was hospitalized as a child with pneumonia. She had taken only hormone replacement therapy before the diagnosis of the ovarian carcinoma. She had become unwell in January 2001, with generalized lethargy, an intermittent cough, and a reduction in exercise tolerance from several kilometers to several hundred meters. Left shoulder pain extending down her arm preceded the development of some mild weakness of her left thenar eminence. She had had several upper respiratory illnesses in December but had no fevers or sweats, hemoptysis, change in voice, weight loss, or other neurologic symptoms. Chest radiography revealed a mass in the superior pulmonary sulcus (Figure 1), which, on computed tomographic (CT) scanning, was shown to arise from the apex of the left lung and extend into the chest wall (Figure 2). This is highly suggestive of invasive carcinoma. Two percutaneous biopsy specimens were nondiagnostic, showing no malignant cells, occasional granulomata, and no organisms. single photon emission computed tomography (SPECT) scanning showed soft tissue inflammation in the left supraclavicular fossa, with involvement of the first rib. The features were considered nonspecific. Anterior mediastinotomy failed to reveal any evidence of metastatic tumor, and the patient was transferred to our institution for definitive surgical intervention. Registrar, Department of Cardiothoracic Surgery, the Department of Pathology, and the Cardiothoracic Unit, The Alfred, Melbourne, Australia.