Multiple Lung Nodules that have Pathologists & Surgeon stumped...

[tlee59]

I've been fatigued for several months (symptoms at work also include headaches, nausea and dizziness)... on Jan 31st I had a CT done after an x-ray came back 'suspicious for nodules'.  The CT found over 80 nodules (only 3 showed any calcification).  Since I had an abdominal CT done last August for another issue and no nodules were seen in the lower lungs, my Pulmonologist. was concerned and arranged a surgical consult.  I had a VATS lung biopsy done on the 14 of February.  Although there is no cancer present (some good news!), the pathologists are stumped.  At this point they are eliminating different things instead of focusing on what it is.  Late last week some of the tissue samples were sent to the Armed Forces Pathology Lab in MD.  Along with cancer the list of what they have excluded includes an old or current infection.  I have uterine fibroids, they thought it may have had something to do with those, it does not appear that there is a connection.  It does not have the appearance of normal granulomas.  Although the symptoms at work are much worse (my company moved into a new office in October, my symptoms started late November) my surgeon said the tissue around the nodules is very normal and healthy looking, he said environmental causes would normally show irritation and so that is unlikely.  Do you have any ideas for more research?  Thanks for your help!

[National Jewish Health]

It appears that the diagnosis will not be forthcoming, from the pathology findings alone, even as reviewed by the Armed Forces Pathology Lab (AFPL).  There are myriad causes of multiple nodules:  infectious, such as tuberculosis (TB); fungi; bacterial, such as Nocardia; embolic, such as a blood clot or tumor emboli originating in the heart; hypersensitivity diseases, such as hypersensitivity pneumonitis (HP); auto-immune diseases, such as Wegener's Granulomatosis; and tumors, benign and malignant.

Apparently the last of these tumors have been ruled out but not necessarily old or current infection.  That would require cultures for bacteria, fungi and TB.

The temporal relationship between your company's move into a new office in October and the onset of symptoms in November cannot be ignored, even allowing that the two may not be related.  However if they are, then everything must be cultured including your sputum, any lung biopsy tissue that was preserved, and the heating and cooling systems in your office.  The finding of multiple nodules with inter-nodular normal lung tissue would argue against infection, such as Legionella or fungi, but not necessarily against Mycobacterium tuberculosis (TB) or nontuberculous mycobacterial infection.  The same could be said for HP, called extrinsic allergic alveolitis, but such strange presentations sometimes do occur, albeit rarely.

The key action, at this time, is to look carefully at the relation between your disease and your work environment and this investigation may benefit from consultation with an industrial hygienist.  Were another employee to develop similar signs and symptoms that too would strongly suggest an environmental cause.

Good luck.

Please give us a follow-up to let us know how you are doing.

[tlee59]

.  Thank you for your response.  I received a call from my surgeon yesterday afternoon, the samples came back positive for both histoplasmosis and silicosis (I have an appointment this afternoon with my Pulmonologist).  From what the surgeon said these are new, active conditions and they will want to treat the histoplasmosis with an anti-fungal med.  I hope to learn more about the timing of both of these.  I'm even more curious about the work connection with the histoplasmosis now.  I live in the Tampa Bay area of Florida - not an area usually connected with this.  However, in the journal I've kept from the beginning of this shows that the first week in December the building management company cleaned all the plants (an atrium type set-up with a three story opening in the center, I am located on the third floor).  It was shortly after that I began getting sick.  Also, I have Beau's lines on more than half of my nails that tie into the same time line.

As for the Silicosis, I have no idea where I would have been exposed to that.  I have never been in an occupation (or hobby) that is connected with Silica dust.  

Are you aware of any connection between histoplasmosis and silicosis?  How can I locate an environmental hygienist?

Again, thank you for your time and advice.