Multiple Bilateral Pulmonary Nodules Research Articles

Epstein Barr Virus (EBV)‐Associated Diffuse Large B‐Cell Lymphoma (BCL) with Isolated Skin Involvement Associated with Combined Immunodeficiency and Multiple Opportunistic Infections

A 72‐year‐old man presented with nausea, vomiting, cough, dyspnea, weight loss and an ulcerated nodule on the right calf of four month's duration. CT revealed multiple bilateral pulmonary nodules. Skin biopsy demonstrated an angiodestructive infiltrate with neutrophils, CD4+ T‐lymphocytes, CD20+ large, atypical lymphocytes and histiocytes in the reticular dermis and subcutis. The atypical lymphocytes were positive for EBV by ISH. PCR demonstrated a clonal immunoglobulin gene rearrangement. Lung biopsy showed histoplasmosis without evidence of a lymphoproliferative disorder or EBV infection. Further investigation revealed a low CD8 count, IgM deficiency and candidal esophagitis. Treatment consisted of itraconazole and rituximab. The cutaneous findings in this patient resemble lymphomatoid granulomatosis (LyG), an angiocentric and angiodestructive lymphoproliferative disorder involving extra‐nodal sites. While LyG can involve multiple organs, it primarily affects the lungs. The infiltrate consists of large, atypical EBV‐positive B‐cells admixed with reactive T‐cells. Although our patient's skin pathology resembles LyG, we favor the broader diagnosis of EBV‐associated diffuse large BCL since he had an isolated skin lesion without evidence of lung or other systemic involvement. We will compare the clinical and histologic findings in our patient to cases of LyG from our institution to help classify this entity among other cutaneous lymphoproliferative disorders.

PULMONARY VASCULITIS

Case: A 26year old Caucasian female, never smoker, presented to an outside medical facility with right-sided pleuritic chest pain. She denied any other systemic complaints. She was not taking any medications. Chest radiograph followed by CT identified multiple bilateral ill-defined pulmonary nodules and infiltrates. Her past medical history was remarkable for a biopsy proven diagnosis of UC almost a year prior to this presentation. It was treated with sulfasalazine for initial six months and was in remission. Apart from a high sedimentation rate of 42 mm/hr & C-reactive protein of 28.2 mg/dl, her laboratory evaluation was normal including urine analysis, CBC, hypersensitivity panel, p-ANCA, c-ANCA, infectious etiology workup including PPD, fungal & HIV serologies & serologies for connective tissue diseases. CT guided biopsy of a nodule was suspicious for non-small cell carcinoma. Her cancer screening including mammogram, Pap smear, colonoscopy, EGD & CT scan of abdomen and pelvis were unremarkable. Thorascopic lung biopsy was done and she was referred to us. Her physical examination was normal. Repeat tests revealed positive p-ANCA & antibody to proteinase 3 at 154.7 EU/ml (NL <5) but negative antibody to myeloperoxidase & c-ANCA. Her initial colon biopsy was reviewed again at our institute and the diagnosis of UC was confirmed. Her pulmonary pathology showed necrotizing granulomatous vasculitis. She was started on tapering dose of corticosteroid. At three month follow- up, she remained asymptomatic and the pulmonary nodules had resolved on subsequent chest radiograph. Discussion: Extraintestinal manifestations of UC are common, however, pulmonary complications of UC are very rare. The etiology of pulmonary vasculitis is unknown and it appears to be unrelated to the underlying UC activity. Most of the patients described in seven case reports so far, presented with cough, pleuritic chest pain and dyspnea on exertion with evidence of bilateral infiltrates or nodular densities on chest radiograph. The significance of ANCA in the pathogenesis of the IBD remains unclear. Lung biopsy is essential to make the diagnosis. Conclusion: Pulmonary vasculitis is a rare complication of UC, but emphasizes the systemic nature of the disease. This case reiterates the fact that pulmonary manifestations of this entity can occur in the absence of overt bowel inflammation. Corticosteroid therapy appears to be the mainstay in the management of this condition.

PROSTATIC SARCOMA WITH RAPID TUMOR PROGRESSION AFTER NERVE SPARING RADICAL CYSTOPROSTATECTOMY

Prostate sarcomas are rare but aggressive neoplasms presenting unique therapeutic challenges. We report a case of prostate sarcoma, and discuss disease control and preservation of quality of life. CASE REPORT A 51-year-old healthy male with normal prostate specific antigen was referred to our institution for evaluation of an asymmetrically enlarged nodular prostate and progressive obstructive voiding symptoms. Transrectal ultrasound revealed a multilocular cystic mass replacing the left side of the prostate (fig. 1, A). Pathological examination of the biopsy cores and subsequent chips from transurethral resection of the prostate for acute urinary retention revealed an indeterminate subtype of prostatic sarcoma. Further diagnostic evaluation included pelvic magnetic resonance imaging which demonstrated a complex multilocular solid mass of the left peripheral prostatic lobe displacing the seminal vesicles but without evidence of local invasion (fig. 1, B). Computerized tomography of the chest, abdomen, pelvis and brain, bone scan and fluorodeoxyglucose whole body tumor scan revealed no evidence of metastatic disease. The patient subsequently elected to undergo radical cystoprostatectomy with unilateral sparing of the neurovascular bundle and continent urinary diversion. Pathological examination of the cystoprostatectomy specimen revealed 5 5.5 cm. high grade prostatic sarcoma with focal chondroid differentiation arising from the left prostatic lobe. All surgical margins were negative. The patient presented with bloody urethral discharge 2 months postoperatively. Urethroscopy and biopsy revealed recurrent sarcoma at the level of the external urethral sphincter. Repeat computerized tomography further demonstrated interval development of multiple bilateral pulmonary nodules. The patient was subsequently started on systemic chemotherapy with dacarbazine, ifosfamide, doxorubicin and mesna. DISCUSSION

POSITRON EMISSION TOMOGRAPHY DETECTION OF METASTATIC PENILE SQUAMOUS CELL CARCINOMA

A 58-year-old white man presented elsewhere with small white lesions on the glans of the penis in 1992. History included circumcision at age 16 years and multiple sequential rigid dilations for urethral stricture. Balanitis xerotica obliterans was diagnosed and treatment was local. The area became sore 5 years later and a biopsy revealed squamous cell carcinoma. The patient underwent Mohs’ procedure and was disease-free for the next 15 months when a recurrent lesion, just ventral to the meatus, was positive for squamous cell carcinoma. No palpable inguinal adenopathy was identified and a chest x-ray was negative for metastatic disease. The patient was referred to us and we recommended partial penectomy. In 1998 he underwent a wide wedge resection of the glans penis, meatus and distal urethra with plastic reconstruction of the distal penile shaft to accommodate a new meatus. Pathological examination confirmed invasive, well differentiated, keratinizing squamous cell carcinoma. All surgical margins were free of tumor. A firm mass in the left groin was palpated 2 years later. Computerized tomography (CT) of the pelvis identified a 3.5 3 2.5 cm. heterogeneous left inguinal mass consistent with nodal spread of penile carcinoma. No intravenous contrast material was given due to iodine allergy. Left superficial and deep inguinal lymph node dissection revealed metastatic keratinizing squamous cell carcinoma in 2 of 12 superficial lymph nodes. The largest positive node was 3 cm. and showed extracapsular invasion. All resected deep nodes were negative. The postoperative course was complicated by an increased drainage from the Jackson-Pratt drain, increased wound swelling and wound separation requiring daily packing and home nursing care. The patient noticed a small single nodule on the left anterior upper thigh 2 months after discharge from the hospital. Abdominal and pelvic CT without intravenous contrast material revealed multiple surgical clips and ill defined soft tissue at the left groin surgical site (fig. 1, A). Inferiorly in the left groin, there was a 4.5 3 4.5 cm. fluid attenuation lesion (fig. 1, B). It was difficult to discern between recurrent disease versus postoperative changes. CT of the chest showed multiple bilateral pulmonary nodules suspicious for metastatic disease. It is noteworthy that no hilar adenopathy was visualized. Whole body positron emission tomography after the intravenous injection of 11.39 mCi. F-18 fluorodeoxyglucose demonstrated multiple foci of increased fluorodeoxyglucose activity in the left groin, left upper thigh, left iliac chain and right groin (fig. 2). One of the abnormal areas of fluorodeoxyglucose activity in the left groin had central decreased uptake, which corresponded to the fluid collection on CT (fig. 2). In addition, there were punctuate foci of abnormal increased fluorodeoxyglucose uptake in the chest. A single focus was seen in the left upper lobe, which corresponded to a nodule on CT. Foci of increased activity were noted in both hila suspicious for metastatic disease, although no lymphadenopathy was visualized on CT.

Nocardiosis pulmonar como causa de imagen radiológica en “suelta de globos”

Lung nocardiosis is a rare disease affecting patients with lymphoreticular neoplasm, immunodeficiency or chronic obstructive pulmonary disease; it can also affect patients who have received transplants. We report a case of lung nocardiosis in which radiographic presentation was acute, with a pattern of multiple bilateral pulmonary nodules ("cannonballs"), requiring us to rule out metastatic disease to arrive at a diagnosis. The patient responded slowly to antibiotic treatment until full resolution.

Lymphocytic interstitial pneumonitis in a patient with systemic lupus erythematosus

A 34-year-old woman with stable systemic lupus erythematosus (SLE) treated with low-dose prednisone and hydroxychloroquine developed multiple bilateral pulmonary nodules. Open lung biopsy documented lymphocytic interstitial pneumonitis (LIP). LIP should be considered in the differential diagnosis of nodular pulmonary lesions in patients with SLE.

Pulmonary nodules due to Corynebacterium ulcerans

A 53 year old male with symptoms of coughing for 6 months presented with bilateral multiple pulmonary nodules suggestive of metastatic disease. By surgical resection 4 out of 6 nodules were removed. Histopathological examination showed granulomatous necrotizing inflammation with growth of Corynebacterium ulcerans, which did not produce diphtheria toxin. The patient was treated with penicillin for 1 week. Follow-up for 2 yrs showed no sign of recurrence.

Detection of Pulmonary Metastases in a Patient with Synovial Cell Sarcoma Using ln-111 Labeled Monoclonal Antibody 19-24

A 35-year-old man was diagnosed in 1984 as having a synovial cell sarcoma of his right wrist without evidence of metastatic spread. The patient underwent regional hyperthermic chemoperfusion, wide-field excision, post-operative radiation therapy and systemic adjuvant chemotherapy. In 1986 and in 1987, because of new lesions found on chest radiographs, the patient underwent bilateral staging thoracotomies with resection of pulmonary metastases, followed by chemotherapy and radiotherapy. Later in 1987, a chest radiograph showed a large left hilar mass and multiple bilateral pulmonary nodules. Computerized tomography of the chest demonstrated a left hilar mass and two nodules in the right lower lung, raising the possibility of recurrent pulmonary metastatic cancer. As a diagnostic procedure, In-111 labeled monoclonal antibody (Mab) 19-24, produced against a human malignant fibrous histiocytoma, was infused intravenously, and 48-hour images revealed focal areas of increased uptake corresponding to the lesions seen on CT. At surgery, the lesions were confirmed to be synovial cell sarcoma. Imaging with Mabs specific for sarcoma may be particularly useful in sarcoma patients in whom there is clinical uncertainty regarding the nature of pulmonary lesions. In this case, the Mab was useful in distinguishing tumor deposits from postsurgical scarring and helped to guide subsequent surgery and treatment.

Intravascular Bronchoalveolar Tumor

We report the case of a young woman presenting productive cough and arthralgia in the left ankle. Chest radiography revealed multiple bilateral pulmonary nodules and abdominal echography and computerized axial tomography demonstrated various hepatic nodules. Definitive diagnosis of an intravascular bronchoalveolar tumor was reached by an open pulmonary biopsy. Liver involvement was confirmed by laparoscopy and biopsy.

Pulmonary hyalinizing granuloma

A patient with pulmonary hyalinizing granuloma (PHG) is presented. PHG is a rare disease with very specific histological characteristics. Roentgenograms display multiple bilateral pulmonary nodules which may be cavitated. Evidence exists that the nodules are the result of an exaggerated chronic immune response. The course of the disease is generally favourable. PHG should be considered in patients showing multiple bilateral pulmonary nodules.

The radiology of lymphomatoid granulomatosis in the lung

This paper describes the salient clinical and radiological features of two patients with lymphomatoid granulomatosis of the lungs. We have, in addition, reviewed the previously documented 22 cases in which radiographs were published along with their case histories. The commonest radiographic appearance, that of bilateral multiple pulmonary nodules, should not be mistaken for multiple metastases.