July 2014 Pulmonary Case of the Month: Where Did It Come From?

Colin B. Fitterer, MD

James M. Parish, MD

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 67 year old man presented with worsening cough and shortness of breath. He has a history of metastatic colon cancer first diagnosed in 2010. He was treated with radiation and chemotherapy (FOLFOX) but unfortunately developed new pulmonary nodules in October, 2013 which were metastatic colon cancer on biopsy. In February 2014 he developed a right parietal brain mass which was resected. Thoracic CT scan at that time showed progression of the pulmonary nodules. He has also noted a 30 pound weight loss over the past 6 months and an enlarging right supraclavicular lymph node.

PMH, FH, SH

In addition to the colon cancer, he has previous diagnoses of type 2 diabetes mellitus, hypertension, allergic rhinitis, and vitamin D deficiency. He is married and a recently retired railroad engineer. He has no history of tobacco use. There is a positive family history of lung cancer but no colon cancer.

Physical Examination

Vital Signs:  Temperature 36.8, pulse 98, respirations 18, blood pressure 144/70, SpO2 91% on 3 L via nasal cannula.

Pertinent findings include:

• A large firm and fixed right supraclavicular lymph node that is nonpainful on palpation.
• Diminished breath sounds across all right posterior lung fields with dullness to percussion. 
• Palpable liver edge is palpable approximately 2cm below the right costal margin.

Laboratory Analysis

Admission laboratory values include a hemoglobin of 11.1 g/dL but with a normal white blood cell count and platelet count. Electrolytes, blood urea nitrogen, creatinine, and liver enzymes were all within normal limits.  Serum chemistries are within normal limits.

Radiography

A chest x-ray (Figure 1A) and chest CT (Figure 1B) were performed.

Figure 1. Admission AP (Panel A) and representative image from the thoracic CT scan (Panel B).

Which of the following is the best interpretation of the radiographic findings? (Click on the correct answer to proceed to the next panel)

1. Large right pleural effusion
2. Right lung atelectasis
3. Right lung pneumonia
4. Right lung pulmonary edema
5. None of the above

Reference as: Fitterer CB, Parish JM. July 2014 pulmonary case of the month: where did it come from? Southwest J Pulm Crit Care. 2014;8(6):1-7. doi: http://dx.doi.org/10.13175/swjpcc080-14 PDF