November 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 67-year-old man developed a right neck mass and underwent a right radical neck dissection. It was initially thought to be a high-grade sarcomatoid cancer, but after review was determined to be metastatic melanoma.

Past Medical History, Social History and Family History

He had no significant past medical or family history. He was a nonsmoker.

Physical Examination

His initial physical examination showed a right neck mass but was otherwise unremarkable. No abnormal skin lesions were identified.

PET/CT Scan

A positron emission tomography/computed tomography (PET/CT) scan showed increase uptake in the neck (Figure 1A) but his chest showed no increased uptake (Figure 1B).

Figure 1. Panel A: PET/CT scan showing increased tracer uptake in the right neck (arrow). Panel B: No abnormal tracer uptake is seen within the chest.

Which of the following is/are true? (Click on the correct answer to proceed to the second of four pages)

1. Bronchoscopy should be performed to search for bronchial melanoma
2. Radiation and oncology consultation should be obtained
3. The pathologic diagnosis is likely wrong since no primary melanoma can be identified
4. 1 and 3
5. All of the above

 Cite as: Wesselius LJ. November 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;15(5):181-7. doi: https://doi.org/10.13175/swjpcc117-17 PDF 

October 2015 Pulmonary Case of the Month: I've Heard of Katy Perry

Kathryn E. Williams, MB

Maxwell L. Smith, MD

Philip J. Lyng, MD

Laszlo T. Vaszar, MD

 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 45-year-old man with a history of dyslipidemia and a family history of early coronary artery disease (CAD) underwent coronary artery calcium scoring CT. He was a non-smoker and asymptomatic.

Past Medical History

In addition to his hyperlipidemia he has a history of obesity and impaired fasting glucose.

Physical Examination

His physical examination was unremarkable.

Radiography

The thoracic CT was interpreted as a low risk for CAD but there were incidental findings (Figure 1).

Figure 1. Panels A-C: Representative views from the thoracic CT scan in lung windows. Lower panel: video of thoracic CT in lung windows.

What incidental finding is not shown on thoracic CT scan. (Click on the correct answer to proceed to the second of six panels).

1. Honeycombing
2. Multiple small pulmonary nodules
3. Patchy ground glass opacities
4. Slightly enlarged mediastinal lymph nodes

Cite as: Williams KE, Smith ML, Lyng PJ, Vaszar LT. October 2015 pulmonary case of the month: I've heard of Katy Perry. Southwest J Pulm Crit Care. 2015;11(4):126-35. doi: http://dx.doi.org/10.13175/swjpcc123-15 PDF

November 2013 Pulmonary Case of the Month: Dalmatian Lungs

Lewis J. Wesselius, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 36 year old woman was referred to the pulmonary clinic at Mayo Clinic Arizona. In early May 2013 she developed headache and blurred vision. She was referred to a neuroopthalmologist who diagnosed a 6th cranial nerve palsy. She had a brain MRI and lumbar puncture (LP). Both were reported as normal. She was treated with corticosteroids and improved.

She was tapered off prednisone in late May and developed discomfort in her left ear with hearing loss and tinnitus.  Some left facial asymmetry was noted.

She was treated with intra-tympanic steroid injections as well as oral steroids with some improvement. Her last dose of corticosteroids was 3 weeks prior to being seen.

At the beginning of August she developed speech and swallowing difficulties and was neurologically diagnosed with palsies in 4th, 6th, 8th, 9th, 10th and 11th cranial nerves. Other symptoms included photophobia and a non-productive cough. Two additional LPs were reported to be normal.

PMH, SH, FH

She had cervical cancer with a cone biopsy 2006 and right arthroscopic shoulder surgery. She is a nonsmoker who is a field engineer for a medical device company. She travels throughout the US extensively. There is no significant family history.

Medications

• Zolpidem 
• Vitamin B and D
• Herbal remedy immunotox

Physical Examination

On neurologic exam she had blurred vision with left gaze and facial asymmetry.

Otherwise, the physical exam was unremarkable.

Laboratory

Her complete blood count (CBC) and erythrocyte sedimentation rate (ESR) were within normal limits.

At this point which of the following are diagnostic tests that should be ordered?

1. Anti-neutrophil cytoplasmic antibody (ANCA)
2. Coccidiomycosis serology
3. Lyme disease serology
4. Serum angiotensin converting enzyme (ACE)
5. All of the above

Reference as: Wesselius LJ. November 2013 pulmonary case of the month: dalmatian lungs. Southwest J Pulm Crit Care. 2013;7(5):271-8. doi: http://dx.doi.org/10.13175/swjpcc130-13 PDF