53 years old female, with 15 pack year (half pack a day for 30 years) smoking history, presented to urgent care with dry cough and dyspnea on exertion. Two weeks prior to the presentation, she started to have dry cough associated with mild sore throat and rhinorrhea. Two days prior to the presentation, the patient developed mild gradual onset dyspnea on exertion, which prompted her to go to urgent care. A Chest X ray was done and showed diffuse pulmonary micronodules (Fig. 1). Subsequently, the patient was transferred to our institute for further evaluation for possible TB. She denied fever, night sweats, anorexia or weight loss, and her vital signs were in normal range. She did not require any oxygen supplementation. Patient was well appearing and breathing comfortably in ambient air. Chest auscultation revealed minimal bilateral expiratory wheezing. No rash, lymphadenopathy or abdominal organomegaly was appreciated.
The patient does not have chronic medical conditions and takes no daily medications. She reported that she moved into an old house 2 months ago and did not notice any molds in her house. She lives with two cats. She smokes half a pack per day for 30 years and denies alcohol or illicit substance use. She works in a pastry store. She lives in New England area and denied any recent domestic or international travel. Last long-distance travel was more than 20 years ago. She went to England and Barbados.
On further inquiry, the patient had varicella in her 30s when she was postpartum, which she contracted from her elementary-school-aged daughter. Neither of them were hospitalized.
CT pulmonary angiogram showed numerous, diffuse, subcentimeter, pulmonary nodules throughout the lungs, many of which demonstrate calcification with an associated calcified mediastinal lymph node (Fig. 2). Patient's CBC with differential, basic chemistry profile, liver functional test, inflammation markers including ESR and CRP were all within normal limits. Respiratory pathogen panel was negative. Urine and serum histoplasma antigens were negative. Coccidoides antibody was negative. Patient was not able to produce sputum even with induction, hence AFB culture with smear was not performed. TB QuantiFERON was negative. VZV IgM was negative, but IgG was positive. HIV was non-reactive. CT of abdomen and pelvis showed no intraabdominal abnormalities.
A multidisciplinary discussion was held between internal medicine, pulmonary medicine, infectious disease as well as radiology. Given patient was overall well appearing, no B symptoms, fever or hypoxia, no travel history to endemic mycoses area or occupation exposure history, as well as pan-negative lab data including non-reactive fungal, TB and HIV serology. Pt was presumptively diagnosed with healed chronic granulomatous lung infection. Given she had history of varicella 20 years ago and her VZV IgG was positive, we believe her lung lesions are most likely secondary to healed VZV lung infection. After careful weighing risk and benefit, no further invasive testing such as bronchoscopy or lung biopsy was recommended.
We believe patient's respiratory symptoms, including cough and shortness of breath, were related to obstructive lung disease rather than pulmonary nodules. She was treated empirically with prednisone and albuterol/ipratropium nebulizer with significant improvement and discharged with a 5-day course of prednisone.
The patient followed up with primary care physician one month after discharge and was feeling well. Her lung nodules do not require further follow-up imaging. One year after discharge, patient self-reported feeling well in a follow up phone call by one of the authors.
CT chest showed numerous, diffuse, subcentimeter, pulmonary nodules throughout the lungs (indicated by arrows), many of which demonstrate calcification.