Case of the Week: August 11-August 18, 2020

47 year old female presents as an out-patient to her primary care provider with SOB, GERD, obstructive sleep apnea, and type 2 DM.

Current everyday cigarette smoker.

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Case Details

Her provider orders a CT chest; representative images below. What is your diagnosis?

The lung window images demonstrate pronounced mosaic attenuation on inspiration. This persisted on expiratory phase imaging (not shown). This suggests underlying small airways disease and air-trapping. The most likely consideration would be hypersensitivity pneumonitis. Given the patient''s ongoing daily cigarette smoking, the differential would include the spectrum of respiratory bronchiolitis/desquamative interstitial pneumonia (RB/DIP). Atypical infection remains a possibility.

Answer

Diagnosis: RB/DIP

The soft tissue windows demonstrate bilateral hilar and central intralobar adenopathy. Several lymph nodes are partially calcified.  Differential considerations most likely of sarcoidosis or other granulomatous insult. Despite worsening symptomatolgy, the patient has thus far declined smoking cessation, bronchoscopy, broncho-alveolar lavage, and lymph node tissue sampling by endobronchial ultrasound."

Correct answers by users

Radiology Medicine/Pulmonary
VCU Resident
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    VCU Department of Thoracic Imaging Virginia Commonwealth University VCU Medical Center