A 25-yr-old female was admitted to hospital due to fatigue and dyspnoea for a duration of 3 months. Difficulty in breathing occurred during physical activity and in stressful situations, but also sometimes during bed rest, and was associated with the feeling of palpitations. The patient smoked 30 cigarettes?day -1 (total 8 pack-yrs) and took no medication. The patient9s personal and family history was uneventful. There was no recent history of travelling. She worked as a clerk and noticed no change in symptoms at work or over the weekends.The patient was overweight (body mass index 31.5 kg?m -2 ) and had a normal body temperature on clinical examination. Her blood pressure was 120/80 mmHg, heart rate 76 beats?min . No crackles were heard during auscultation. The blood tests showed no abnormalities, specifically no anaemia nor inflammatory signs. A chest radiograph and ECG were performed, and showed normal results. Pulmonary function tests demonstrated normal static and dynamic lung volumes, but a mild reduction in diffusing capacity (70% predicted). A computed tomography (CT) of the chest was performed because of the smoking history and the reduced diffusion capacity ( fig. 1).Serological tests for HIV and systemic vasculitic diseases were negative. The tuberculin test showed no reaction. Metastatic disease of the lung was suspected and a search for a primary tumour was commenced. Skin and retina showed no suspicious lesions regarding melanoma. A gynaecological examination, including mammography and ultrasound of the breasts, showed normal results, as well as ultrasounds of the thyroid and abdomen.The patient, who was afraid of having a malignant tumour, asked for a second opinion and was admitted to the authors9 clinic. The differential diagnoses included metastases, infectious, inflammatory or granulomatous lung diseases. Due to the lack of diagnosis from noninvasive diagnostic procedures, bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was discussed prior to video-assisted thoracoscopy. However, the patient requested a straightforward approach with the highest chance of diagnosis and, therefore, a video-assisted thoracoscopic wedge resection with histopathological examination of a subpleural nodule of the right lower lobe was performed (figs 2-4).
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