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Innumerable pulmonary nodules

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Early detection is critical with this aggressive disease. However, the patient’s financial status prompted her to delay medical care.



A 56-year-old woman with a history of a thyroid goiter following a partial thyroidectomy presented to the emergency department with shortness of breath, progressive weakness, and fatigue. She also reported a poor appetite and unintentional weight loss of approximately 40 lbs over the past 2 months but had not sought medical care. She denied having a cough, chest pain, hemoptysis, hematemesis, fevers, chills, or night sweats.

Soft-tissue densities in bilateral lungs on x-ray

Physical examination revealed a cachectic woman with tachycardia and tachypnea, along with diffuse coarse rales throughout both lungs. The patient’s initial heart rate was 101 beats/min; respiratory rate, 25 breaths/min; and oxygen saturation, 74% on room air. The results of a complete blood count and comprehensive metabolic panel were within normal limits. A chest radiograph was performed, showing innumerable subcentimeter- and ­pericentimeter-sized soft-tissue densities in both lungs (FIGURE 1). Computed tomography (CT) of the chest was subsequently obtained to better characterize the nodules (FIGURES 2A and 2B). The CT revealed innumerable noncalcified pulmonary nodules as well as multiple hilar masses suggestive of malignancy; however, infectious etiologies could not be ruled out.

CT revealed hilar mass and offered a better glimpse of the nodules

As the patient was visiting from a tuberculosis-endemic area, she was empirically started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy for treatment of Mycobacterium tuberculosis infection. Subsequently, polymerase chain reaction (PCR) testing and acid-fast bacillus sputum smear came back negative for M tuberculosis and RIPE therapy was stopped. Bacterial culture and fungal screens for Pneumocystis jirovecii, Coccidioides, Cryptococcus, and Histoplasma capsulatum were negative.



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