Case 3--Nodules, Cysts, and Interstitial Lung Disease

Clinical summary: A 76-year-old woman was referred to the Chest Clinic in 5/98 for evaluation of mild dyspnea and an interstitial pattern on a chest radiograph. She reported very slight dyspnea on exertion: on level ground she had virtually unlimited walking capacity, but she became short of breath after walking up 2 flights of stairs. She also reported polyuria and polydipsia and was found to have diabetes mellitus. On physical examination, fine bibasilar crackles were heard. The remainder of the physical examination was normal. There was a past medical history of idiopathic thrombocytopenic purpura treated by splenectomy in 1986.

A chest x-ray shows bilateral, increased reticular markings in the lungs most prominent at the bases, peripherally. A small nodule (arrow) in the left upper lobe was suspicious for malignancy. No previous films were available.

An 8 mm, irregular, somewhat spiculated nodule is present in the apical posterior segment of the left upper lobe. Note the peripheral reticular changes anteriorly in both lungs.

A prone HRCT of the lower lobes shows peripheral, reticular changes with frank honeycombing seen as palisading (layered) cysts, most marked at the periphery of the anterolateral left lower lobe.

In 11/98, she underwent a wedge resection of the LUL nodule. Since that time she has had only minimal symptoms. She still experiences occasional dyspnea, but only when walking great distances or when walking up more than one flight of stairs. She currently receives no treatment. Her diabetes is well-controlled on oral agents, and she remains otherwise well.

Clinical summary Case 3 continued

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