A 71-year-old woman from Dominican Republic was admitted for dyspnea, fever, and nonproductive cough of one-day duration. Her medical history was significant for diabetes mellitus, systolic heart failure, gastric B-cell lymphoma treated with chemotherapy, and surgically treated basal cell carcinoma of forehead. She was a heavy smoker with 40 packs/year. She denied alcohol or illicit drug use. Family history was noncontributory. There were no sick contacts, recent traveling, or occupational exposures and no history of exposure to tuberculosis.
Initial examination showed an elderly woman on respiratory distress. Chest auscultation revealed bibasilar crackles and diffuse expiratory wheezing. There were no palpable lymphadenopathy, organomegaly, or skin lesions. The rest of exam was unremarkable. Significant laboratory findings included elevated Pro-BNP; there was no leukocytosis and renal and liver function was normal. A right sided thoracentesis was performed with pleural fluid analysis revealing transudative effusion with pleural/serum LDH ratio of 0.12 and pleural/serum protein ratio of 0.19.
Patient was treated for exacerbation of heart failure with diuretics and antibiotics were given for presumptive community acquired pneumonia with clinical improvement.
Chest-roentgenogram (CXR) on admission showed bilateral pleural effusion and infiltrates which rapidly improved suggesting a diagnosis of heart failure rather than pneumonic process (Figure 1). A chest computed tomography (CT) revealed a 15 mm spiculated nodule in the right upper lobe, a 10 mm nodule in the left upper lobe, chronic interstitial fibrosis, and a right paratracheal lymph node measuring 3.1 cm, unchanged from a prior chest CT performed three months prior (Figure 2).
Patient underwent flexible fiberoptic bronchoscopy (FFB) that revealed a small endobronchial lesion at the right upper lobe before the takeoff of anterior segmental bronchus. Endobronchial biopsy (EB) of the EBL as well as transbronchial biopsy (TBBx) of right upper nodule and EBUS-TBNA of the right paratracheal and subcarinal lymph nodes was performed. A 19'' gauge needle was used for the EBUS-TBNA with a total of four needle passes per lymph node. Twenty ml of purulent appearing fluid was aspirated from the right paratracheal lymph node (Figure 3). Aspirated EBUS fluid showed highly atypical squamous cells in necrotic background. The EB of right upper lobe endobronchial lesion and the core biopsy of material aspirated from 4R lymph node were consistent with squamous cell carcinoma (Figure 4). Cultures of blood, urine, lung tissue, and EBUS-TBNA aspirate were all negative for bacterial infections, fungal infections, and mycobacteria. Serology for mycoplasma and urine for legionella were all negative. Collagen vascular workup was negative as well. The patient received palliative chemotherapy.