Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I |

An Unusual Cause of Cough FREE TO VIEW

Theresa Yang, MD; Janine Vintch, MD
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Harbor-UCLA Medical Center, Torrance, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1086A. doi:10.1016/j.chest.2016.08.1193
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: When a patient presents with a chronic cough complaint, a chest radiograph can be helpful in elucidating the diagnosis. In this case, reticulonodular opacities were found with a differential diagnosis that is quite broad and includes infection, malignancy, and vasculitides.

CASE PRESENTATION: A 28 year old man with a 10 pack-year smoking history, hypertension, and sickle trait presented with four months of dry cough and two months of night sweats. One month prior to this admission he had gone to an Emergency Department with worsening cough and had a chest radiograph which showed bilateral diffuse reticulonodular opacities and hilar fullness. He was treated for bronchitis with minimal improvement. A CT chest was subsequently ordered which demonstrated innumerable diffuse bilateral pulmonary nodules with solid and cavitary features along with mediastinal and hilar lymphadenopathy. A large left renal mass was also noted. Lab results were notable for hemoglobin of 9.6 and urinalysis with 2 RBCs. A dedicated CT of the abdomen showed a 9cm left renal mass with liver hypodensities. The patient underwent UTS-guided biopsy of the renal mass and pathology revealed renal medullary carcinoma (RMC). He was started on sunitinib with improvement in his anemia.

DISCUSSION: RMC is a rare disease that predominantly affects young patients with sickle cell trait with a prevalence of 1 in 20,000. Men are preferentially affected in a 2:1 ratio and the median age at diagnosis is 22. It is hypothesized that areas of vaso-occlusion and chronic ischemic changes leads to damage in the renal medulla, explaining the increased pathogenesis in patients with sickle trait. Symptoms at presentation are usually flank pain, abdominal pain and hematuria, and respiratory symptoms only accounted for 9% of cases in a review. Metastasis is common on presentation with common sites including lymph nodes, liver, lung, and adrenal glands. Tumors are detected using ultrasound, CT and MRI. A variety of cytotoxic chemotherapy as well as targeted therapy is currently used. There is no standardized treatment for RMC, and radiation and chemotherapy have not proven to significantly improve outcomes. Prognosis is poor with 95% mortality from disease progression and a median survival time of 1 year after diagnosis.

CONCLUSIONS: RMC is a rare and aggressive cancer that is linked to sickle cell trait. Our patient is a 28 year old African American man with sickle trait, which fits the phenotype of patients who are affected by this disease. However, his presentation was unusual as he did not have any hematuria or abdominal pain, instead presenting with cough and night sweats.

Reference #1: Alvarez O et al. Pediatr Blood Cancer. 2015 Oct;62(10):1694-9

Reference #2: Shetty A et al. Ochsner J. 2014 Summer;14(2):270-275

DISCLOSURE: The following authors have nothing to disclose: Theresa Yang, Janine Vintch

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