Autor :Garro, MarÃa Manuela1, ChurÃn, Lisandro1, Quadrelli, Silvia1
1 Pulmonology Service, Sanatorio Güemes. City of Buenos Aires, Argentina.
https://doi.org/10.56538/ramr.DYEC1676
Correspondencia : MarÃa Manuela Garro; E-mail: manuelagarro0@gmail.com
ABSTRACT
Lung nodules can vary in nature:
solid, ground glass, granulomatous or non-granuloÂmatous, cavitary
or non-cavitary. They are a common finding in chest
imaging when the patient comes to the consultation. According to their
characteristics and the patient’s history (medical history, physical
examination, and laboratory results), they guide us towards different
etiologies: infectious, autoimmune, or oncological. However, many times it is a
great clinical challenge.
We present the case of a young
patient with no previous medical history who came to the consultation with a
cough of 3 months of evolution. The chest CT showed left mediastinal
mass displacing the trachea and bilateral cavitary
lung nodules. After rulÂing out more probable etiologies based on frequency for
the patient’s age and clinical manifestation, the diagnosis was: classic
nodular sclerosing Hodgkin lymphoma with extranodal involvement. A very rare
disease, and in our case, with an atypical form of presentation.
Key words: Lung nodules, Etiological study, Hodgkin lymphoma
RESUMEN
Los nódulos pulmonares pueden ser variados:
sólidos, en vidrio esmerilado; granuloÂmatosos o no granulomatosos; cavitados o no cavitado. Son un
hallazgo frecuente en las imágenes de tórax cuando el paciente
llega a la consulta. Según sus características y en concordancia
con los antecedentes del paciente (historia clínica, exámen
físico y resultados de laboratorio) nos orienta a las distintas
etiologías: infeccioso, autoinmune u oncológico. Sin embargo,
muchas veces es un gran desafío clínico.
Se presenta el caso de una paciente joven sin
antecedentes que consulta por tos de 3 meses de evolución. En TC de
tórax se evidencia masa mediastinal izquierda
que desplaza tráquea y nódulos pulmonares bilaterales cavitados. Luego de descartarse etiologías
más probables por frecuencia para su edad y forma de
manifestación clínica, se arriba al diagnóstico de Linfoma
de Hodgkin clásico Esclero
Nodular con compromiso extranodal. Enfermedad poco
frecuente y en nuestro caso, modo de presentación atípica.
Palabras claves: Nódulos pulmonares, Estudio etiológico, Linfoma de Hodgki
Received: 10/05/2021
Accepted: 01/24/2021
INTRODUCTION
Lung nodules are a common finding
in chest imagÂing when the patient comes to the consultation. Basing on their
morphological characteristics, size, distribution, and in line with the
patient’s clinical condition, they usually guide us to conÂsider the most
likely cause, and with the help of supplementary studies, we can confirm or
discard the diagnostic hypothesis.
The objective of this case is to
review the study of lung nodules and their causes; in this particular clinical
report due to the atypical manifestation of a rare disease.
CASE REPORT
25-year-old female
patient with no relevant medical history (neither personal nor family). The patient presents with persistent cough with occasional whitish
expectoration; subsequently she starts to have dyspnea mMRC
2, isolated fever episodes and multiple consultations at the on-call service,
where she is indicated bronchodilator treatment. One month before consultation
she started having night sweating, and 24 hours before consultation at the
on-call service she showed hemoptoic expectoration.
The patient claims she didn’t lose weight.
She enters the emergency service
in a normotensive state, 97% room-air pulse oximetry,
no fever, good general condition. Good ventilatory
mechanics, bilateral rhonchus and laryngeal rumor. She had palpable axillary
and supraÂclavicular nodes.
Blood tests: HCT (hematocrit) (%)
27%, Hb (hemogÂlobin): 8.6 g/dl, Leukocytes: 18.600,
Neutrophils: 83%. Lymphocytes: 9%, Platelets: 401.000, RIN: 1.52, LDH (lactate
dehydrogenase): 314 U/L, CRP: C Reactive protein (polymerase chain reaction):
164 mg/L, GSR (globular sediÂmentation rate) 140 mm/H. HIV (human
immunodeficiency virus): non-reactive.
Chest CT without endovenous contrast (Fig. 1 & 2): at the level of the sternoclavicular articulation, mass on the left side
displacing the trachea towards contralateral, appears to infiltrate tracheal
wall with reduction of luÂmen of at least 50%. Mediastinal
nodes increased in size at the retrocaval-pretracheal,
paratracheal, perihilliary
and subcarinal levels, without reaching the adenomegalic range. Multiple node-like bilateral images
with increased attenuation in the pulmonary parenchyma, of various sizes, with
diameter greater than 10 mm, some of them cavitary,
associated with perilesional ground glass opacity.
SPIROMETRY: FEV1/FVC (forced
expiraÂtory volume in the first second/forced vital capaciÂty): 0.38 - FEV1:
34% (1.20 L) - FVC: 75% (3.14 L) Flow-volume curve: the expiratory phase shows
curve flatÂtening compatible with intrathoracic
collapse; inspiratory phase remains unaltered.
Interpreted as
tracheal stenosis associated with cavitary lung
nodules under study.
For this situation, we suggest
three diagnosis-related groups: First: infectious, and due to the prevalence
and form of presentation, Tuberculosis, without discarding other common
bacterial microorganisms. Secondly: autoimÂmune, granulomatous vasculitis with polyangiitis.
Thirdly: primary or metastatic cancer.
Within the first 24 hours after
the patient had been admitted, a bronchoscopy was performed, showing stenosis
at the distal third of the trachea by extrinsic compression of left lateral
wall infiltrating the entire trachea in a 2 cm path. We performed mechanical
resection, dilation, and biopsy and placed a silicone tracheal stent.
Supplementary tests were done
according to diagÂnostic suspicions. Sputum culture for common germs,
mycological test, and BAAR (acid-alcohol-resistant baÂcillus): all negative.
Blood test: negative. Koch culture: negative. Immunologic tests: FAN, Anti DNA,
PR3 and MPO: negative.
Anatomopathological results of tracheal mucosa: classic nodular sclerosing
Hodgkin lymphoma, with extranodal involvement (stage
IV).
DISCUSSION
The finding of multiple lung
nodules, some cavitary, and mediastinal
nodes, in young woman without known clinical personal or familiar hisÂtory
makes us think of an infectious cause in the first instance (1-2):
bacterial, such as StaphyloÂcoccus aureus, Nocardia, Haemophylus influenÂzae; fungal, such as Aspergillus;
and mycobacteria such as Mycobacterium tuberculosis. However, due to the
absence of isolates from sputum and blood cultures, and the chronicity of the
patient’s clinical symptoms, this etiologic suspicion is less probable.
Among the autoimmune causes (1-3-4),
the granulomatosis with polyangiitis,
necrotizing vasculitis, of very low incidence
(5-10/millions of inhabitants) is presented with pulmonary involveÂment in more
than 90% of the cases. It is shown in the chest CT with bilateral cavitary nodules in 50% of the cases. In advanced stages of
the disease, the subglottic involvement of the trachea can ocÂcur, generating
stenosis. The antineutrophil cytoÂplasmic antibodies
(ANCAs) with cytoplasmatic pattern tend to be
elevated in 90% of the cases.
Oncologic causes (2):
the presence of multiple solid nodular images, some cavitary,
of various sizes suggests metastatic lesions. In the particular case of our
patient, thyroid, breast and germ cell cancer or lymphoma are the most probable
types. Those types of cancer have low prevalence, but if the infectious cause
is discarded, the probabilities of a non-infectious cause increase, among them
the neoplastic cause.
Thyroid cancer (5)
accounts for 1-2% of all types of cancer; in 50% of the cases, they show
distant metastasis at the moment of the diagnosis and the lung is the involved
organ in 50% of the cases. Malignant breast and germ cell tumors (2)
also tend to metastasize to the lungs.
With regard to the Hodgkin
lymphoma (6-7-8), it accounts for 0.5% of malignant neoplasms in adults,
with an incidence of 2.5 cases every 100,000 inhabitants. The nodular sclerosing form is the most common sub-type, accounting for
2/3 of all the classic variants of lymphoma, with a high survival rate when
diagnosed in early stages of the disease. It is mostly presented with intrathoracic involveÂment, mainly the superior
mediastinum, due to the presence of adenopathies that
sometimes generate compression of mediastinal organs,
thus causing dyspnea, dysphagia or dysphonia, depending on the organ that is
involved: the trachea, esophagus or recurrent laryngeal nerve. Lung involvement
in lymphoma usually appears throughout the course of the disease and represents
failure of response to the oncospecific treatment. As
regards the involvement of the pulmonary parenchyma, it is usually manifested
through three radiological patÂterns: unique consolidative mass that many times
makes us suspect of an infectious process; due to contiguity from hilar lymph node involvement, or pulmonary nodules. The
exception is the presence of cavitary nodules
described in less than 1% of the cases post-chemotherapy. At the time of the
diagnosis, it is unusual and has been observed in patients younger than 30
years. In those cases, it is extremely important to discard other diseases that
also show this type of pulmonary lesions, basing on the patient’s inquiry and
physical examination.
It is a rare disease of atypical
presentation that makes us think and discard multiple differential diagnoses.
Conflict of interest
The authors declare that there is
no conflict of interest.
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