CASE PRESENTATION: An 80-year-old-woman was referred for evaluation of chest pain that appeared after providing care at home for her sick husband, which included helping him to get up and move about. The pain was initially triggered by lifting heavy objects but then became constant, without exacerbating or relieving factors. The pain was located in the left hemithorax and was not associated with shortness of breath or cough. Because the patient did not feel any better after a month, her general practitioner ordered a radiograph, which revealed a suspicious pulmonary nodule in the left upper lobe. She was a lifelong nonsmoker and denied any drug abuse. She had not been professionally exposed to lung carcinogens. She had a medical history of type 2 diabetes, ischemic cardiomyopathy, and renal artery stenosis. Her father died of lung cancer. She resided in Lille, France, and did not report any recent travel. CHEST 2020; 157(3):e85-e89
Physical Examination FindingsThe patient was normotensive and afebrile. Vital signs included BP of 147/95 mm Hg, heart rate at 99 beats/ min, and 99% oxygen saturation in ambient air. Pulmonary examination revealed clear breath sounds and no sign of respiratory distress. She had a regular cardiac rhythm with no additional heart sounds noted. The rest of the physical examination was unremarkable.
Diagnostic StudiesCBC count and metabolic panel were unremarkable. Fungal serologic tests and QuantiFERON-TB Gold returned negative. A CT scan confirmed the presence of a spiculated mass in the left upper lobe, measuring 22 脗 15 mm without adjacent adenopathy (Fig 1). On PET scan, the lesion had a peak standard uptake value of 8.2 for 18-fluoro-deoxyglucose (Fig 1). No other focus was detected. Bronchoscopic examination was normal, and cytologic analysis did not identify any cancer cells. After a multidisciplinary meeting, the patient underwent therapeutic video-assisted thoracoscopic lobectomy. Examination of the fresh surgical specimen showed the presence of a solid, brown, poorly limited mass. Pathologic examination of the lesion showed lymphoplasmacytic infiltration with kappa light chain restriction and numerous eosinophilic intracytoplasmic inclusions with sharp contours (Fig 2). Molecular analysis of the lesion revealed a kappa light chain gene rearrangement. Electron microscopy (Fig 2) and mass spectrometry later confirmed the diagnosis.
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