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A Case Report of Dyspnea With Pulmonary Nodules FREE TO VIEW

Johnathan Grant*, DO; Wil VanderRoest, DO
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Botsford Hospital, Canton, MI

Chest. 2012;142(4_MeetingAbstracts):964A. doi:10.1378/chest.1357451
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SESSION TYPE: Miscellaneous Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: A 63 year old white male presented to our hospital emergency room on February 15, 2011 with progressive dyspnea on exertion since January 2011 after having a splenectomy due to a previous diagnosis of myelodysplastic syndrome in October 2010.

CASE PRESENTATION: . Initial lab tests, chest x-ray and CT Scans were done with the plan for bronchoscopy with BAL, protected brushing, transbronchial biopsy and biopsy with EBUS and EUS.The biopsy results from the RUL, RML, and RLL all came back showing noncaseating granulomas. Due to the patient’s respiratory status, he was started on methylprednisolone IV and then tapered over several days. After one week the patient was on oral prednisone 60mg daily, when he experienced increasing shortness of breath and new infiltrates on chest x-ray. The BAL of LLL also started growing histoplasma in culture.With the concern that this was Disseminated Histoplasmosis vs. Miliary Sarcoidosis; we looked back at the pathology of the spleen, where urine histoplasma antigen and serum antigen were negative. Stains of the spleen were negative for any organism, but no cultures were done.. The decision was made to treat the patient as both.

DISCUSSION: This case is one example of the growing body of literature where patients have sarcoidosis and/or fungal infection. Usually when treatment for the fungal infection is complete and the patient has continued respiratory symptoms, the diagnosis of exclusion is now sarcoidosis. When this type of case appears the repeat bronchoscopy proves the diagnosis.. With cases like this, it can be difficult to know which condition preceded the first or predisposed to the other. Whichever view is correct the medical team must consider all the possibilities in order to treat the patient appropriately.

CONCLUSIONS: In August 2011 on follow up in our office, our patient had continued weakness but dyspnea had resolved. Our plan was to wean the patient off prednisone over the next 4-6 weeks as tolerated, and continue voriconazole for the histoplasmosis infection. Pending how the patient is doing in the future, we would like to repeat the bronchoscopy.

1) Ma Y, Gal M, Koss M. The Pathology of Pulmonary Sarcoidosis:Update. Seminars in Diagnostic Pathology 2007;24:150-161.

2) Gal A, Koss M. The Pathology of Sarcoidosis. Current Opinion in Pulmonary Medicine 2002;8:445-451Assi M, Sandid M, Baddour L et al. Systemic Histoplasmosis: a 15 year retrospective institutional review of 111 patients. Medicine 2007;86(3):162-169.

3) Assi M, Sandid M, Baddour L et al. Systemic Histoplasmosis: a 15 year retrospective institutional review of 111 patients. Medicine 2007;86(3):162-169.

DISCLOSURE: The following authors have nothing to disclose: Johnathan Grant, Wil VanderRoest

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Botsford Hospital, Canton, MI




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