A 42-year-old nonsmoking Saudi man with a history of type 1 diabetes was referred to our institution for investigation of a chronic cough and mild exertional dyspnea. He denied a history of hemoptysis, weight loss, night sweats, or change in appetite. A physical examination revealed a temperature of 37.0 C, respiratory rate of 20 breaths/min, heart rate of 70 beats/min, blood pressure of 110/70 mmHg and oxygen saturation of 96% on room air. A chest examination was entirely normal. There was no lymphadenopathy. The rest of examination was unremarkable. A complete blood count, liver function test, erythrocyte sedimentation rate and C-reactive protein were within normal limits.
The chest-X-ray was unremarkable. The Computed Tomography (CT) scan revealed a lobulated round nodule in the left upper lobe adjacent to the bronchus, measuring 1.8 x 1.6 cm with an absence of significant lymph nodes (Figure 1). Flexible bronchoscopy revealed a swollen endobronchial lesion at the apical posterior segment of left upper lobe of the lung (Figure 2). Cytology and brushing were negative for malignant cells. Acid fast bacilli and MT-PCR were positive and later, the Mycobacterium tuberculosis culture was also positive. Multiple biopsies were taken from the endobronchial lesion and histopathology was consistent with the diagnosis of squamous papilloma (Figure 3). There was no evidence of dysplasia, malignancy, or granuloma in all biopsies taken from the endobronchial lesion. HPV in situ hybridization was negative. The patient completed a 6-month course of anti-TB treatment. A follow-up CT chest redemonstrated the same lobulated round nodule in the left upper lobe, almost stable from the previous study (Figure 4). Repeated flexible bronchoscopy showed the same findings. Multiple transbronchial biopsies were consistent with the diagnosis of well-differentiated squamous cell carcinoma (Figure 5). The patient had a left upper lobectomy and biopsies of the mediastinal lymph nodes did not reveal any malignancy or granulomas (T3N0M0). The patient was treated with 6 cycles of chemotherapy and he was considered cured. He underwent a surveillance program with no evidence of recurrence after three years of follow-up.