A 44 years old, Saudi male, married, ex-smoker for 4 years, with a smoking index of 10 packs/year. He has Type 2 diabetes for 10 years and takes basal insulin, metformin and sitagliptin. He has dyslipidemia on statins and vitamin D deficiency.
He had a productive cough for 2 weeks with large quantities of odorless yellow sputum, with intermittent pain in the left shoulder for 3 days. He denied fever, dyspnea, hemoptysis, or diarrhea. He denied any history of choking or dental caries.
The general examination was unremarkable. Local chest examination was positive for dullness in the left upper chest with fine inspiratory rales.
Chest x-ray showed opacity in the left hilum and para-hilar area (Fig. 1a). CT chest without contrast showed a soft tissue mass in the left upper lobe (lingual) with central necrosis (Fig. 2a, b).
Since he is diabetic and pulmonary tuberculosis is relatively common in our area, he was admitted to a negative pressure isolation room until tuberculosis can be confirmed or ruled out.
He was treated with intravenous amoxicillin and clavulanic acid as a case of pulmonary abscess and further investigations were performed. Sputum for acid fast bacilli 3 samples by stain and polymerase chain reaction were negative for tuberculosis as well as sputum Grams stain and culture were negative. The situation improved at first, as the chest pain subsided and the sputum became less and whiter. He was discharged after 3 days on oral co-amoxclave and ordered to follow up in the clinic after 10 days.
After a week he came for follow-up, complaining only of hemoptysis, a small amount of bloody sputum, with no other symptoms. Subsequent chest radiograph revealed persistent opacity of the left upper lobe and CT thorax showed 2.2 x 2.5 cm subpleural cavitary nodules in the left upper lobe/lingula associated with an adjacent area of patchy languor, minimal interlobular septal thickening, and tree-in-bud nodules (Fig. 2c, d).
He underwent a CT guided lung biopsy to diagnose the etiology, possibly lung cancer, and the procedure was performed as a day case under local anesthesia without complications (Fig. 2e)
A diagnosis of inflammatory myofibroblastic tumor of the lung was rendered based on histopathology evaluation and a panel of immunohistochemistry stains (Fig. 3a-e).
Sections of the tumor sampled in the core biopsy revealed spindle cells in a background of abundant mixed inflammatory infiltrate rich in plasma cells, lymphocytes, and few eosinophils. The spindle cells are arranged in fascicles. The immunohistochemistry stains revealed that the spindle cells were positive for Actin. They are negative for pankeratin, S100, CD68 and Alk1. The plasma cells in the background are proven to be polyclonal using Kappa and Lambda immunohistochemistry staining.
A follow-up CT thorax with contrast was performed to assess the size of the mass, other lung areas, and the mediastinum preoperatively (Fig. 2-f).
A multidisciplinary team of pulmonology, oncology, thoracic surgery, and radiology was consulted and the decision was made to perform a surgical resection with a safety margin and rapid incision. A limited left thoracotomy was performed and a wedge resection with safety margin was performed. The resected lung lesion was confirmed by histopathological and immunohistochemical examinations as IMT of the lung.