A 53-year-old male smoker, unemployed with no occupational exposure, is admitted with progressive shoness of breath. He has been unwell for some time and has received multiple courses of antibiotics for “bronchitis.” During the prior 4 mo, he has not had any medical follow-up. On exam, he is afebrile but looks ill. Lung exams reveal diffuse rhonchi and crackles with no localizing signs. ABGs on room air show PaO2 of 68 mm Hg with mild compensated respiratory alkalosis. Sputum for AFB is negative. CXR is shown.Associated with this diagnosis is
Correct Answer: Clubbing
Description: This x-ray shows a bilateral generalized nodular pattern in all lung fields. There is an area of a masslike confluence in the left upper zone. The superior mediastinum appears widened primarily on the left side with a prominent right paratracheal node. Cardiophrenic and costophrenic angles are clear. This x-ray is consistent with left upper lobe mass with metastatic disease. This clinical scenario is consistent with metastatic carcinoma. The presence of a confluent density in the left upper lobe suggests the metastases probably arose from a lung primary malignancy. Diffuse pulmonary nodular metastases usually arise from a nonlung primary (70%). Clubbing is the most likely associated finding. Hypocalcemia is unlikely. Hypercalcemia is most commonly caused by bony metastases, especially with small cell carcinoma and adenocarcinoma. It is seen in squamous cell carcinoma as a result of humoral mediators with PTH-like activity. However, squamous cell carcinoma of the lung is a very infrequent cause of widespread pulmonary metastasis. Sputum for AFB would most likely be positive in this radiographic setting. Eosinophilia and increased IgE levels may be seen in the pulmonary infiltrates with eosinophilia syndrome, but there is no indication or history of fleeting infiltrates to suppo that diagnosis here.
Category:
Radiology
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