Multiple Pulmonary Nodules and Chest Pain

[mattie32]

My son had a Chest CT-Scan to follow-up on pulmonary nodules, recurrent symptoms of SOB and stabbing chest pain that radiates to his side and back. It is especially painful when he tries to takes a deep breath. The pain is not related to activity. He is a 50 year-old, white male, non-smoker. He is concerned about the results of the scans and what they indicate. The first scan was done over 5 years ago for the same symptoms. The scan showed: Enlarged mediastinal lymph nodes in the subcarinal, precarinal, paratracheal regions, measuring up to 1.5 cm in size. Bilateral hilar adenopathy, bilateral pulmonary nodules, which measure less than 1 cm in size. 2 cm lymph node present in the AP Window. No pleural effusions visualized. No pulmonary consolidations are noted. Small bilateral nodules are noted in the parenchymal, which measure less than 1 cm. They may or not be calcified.
The recent scan showed: There are multiple very small noncalcified bilateral pulmonary nodules, some are ill-defined. Examples are in the right upper lobe, left lower lobe and lingula. Other small nodules are noted bilaterally. There is some peripheral consolidation extending to pleural surface in left lower lobe with bronchiectasis, probably reflects some pleural and parenchymal scarring in the left lower lobe. Tiny bilateral noncalcified pulmonary nodules, most of which 4mm or less in diameter. There is nodular opacity in the right lung apex measuring up to 6mm in diameter. Degenerative changes in the thoracic spine. Follow-up scan in about 6 months could initiate follow-up. He was told there was nothing in the scans that would explain his recurrent symptoms of stabbing chest pain and shortness of breath. His symptoms were attributed to 14 year-old rib fractures. He was told to come back in 6 months for another scan and no other tests are necessary.

I am really concerned his chest pains are too severe to wait another 6 months for a diagnosis. Could you please tell me what his scans mean.

[David Tinkelman, M.D.]

Your description of the CT Scan nodules and adenopathy, present over a period of more than 5 years, suggests the diagnosis of what is called Pulmonary Sarcoidosis.   This is an inflammatory disease of unknown cause.  It can involve just the lungs and lymph nodes within the chest or can also involve almost any other organ in the body, most notably liver, brain, bone and heart.  It can involve the membranes that surround the lungs (the pleura) and can cause pleuritic pain that can be sharp.  In the majority of cases, however, sarcoid does not cause chest pain.  I mention this because there are numerous causes of chest pain in a 50 year old man and one should not assume that the underlying lung disease, be it sarcoid or another disease, is the cause of his pain.  His pain is unlikely to be caused by aged healed rib fractures.  Your son’s doctors should, by the way, be able to confirm the most likely diagnosis of his lung disease, be it sarcoid or other and proceed with treatment accordingly.

Sarcoid can be quiescent or progressive and can be associated with infection, for example with TB or with a fungus, the most common fungus being Aspergilla.

Sarcoid can not uncommonly result in shortness of breath but, like chest pain, it should not be assumed to be the cause, especially in the absence of abnormal pulmonary function tests, including blood gases.

You state that your son was told, “there was nothing in the scans that would explain his recurrent symptoms of stabbing chest pain and shortness of breath.”  

That statement is surprising, given the extensive disease you describe.  But, even if true, it behooves his doctors to investigate further to determine the actual cause of his chest pain and shortness of breath.  This will require not only further pulmonary function testing but testing of his heart, testing for infection superimposed on the chronic lung disease, and testing for recurrent blood clots to the lungs, among a number of possibilities.  Your son should not heed the advice to wait another six months for a repeat scan, without appropriate testing in the interim.  

Further evaluation should begin now, without further delay, and should be supervised by a lung specialist (pulmonologist).  Do not take no for an answer.

Good luck

[David Tinkelman, M.D.]

I hope my comments help to persuade them.

Good luck

[mattie32]

Thank you Dr. Tinkelman for your response, it was most helpful. It sounds like our concerns were justified and this may be serious. As unbelievable as it may sound my son was advised to rescan in six months and no other tests are necessary. Not only by his Internal Medicine doctor, but his Pulmonary doctor as well.

He specifically asked if he might possibly have lung disease or an infection and if there were any non-invasive tests they could do to find out. There is a strong family history of TB, so that is a concern. The doctors said the CT scan did not show either. Their recommendations were to rescan in six months to see if there are any changes and if there are they could do a biopsy. They do not know what the nodules represent and they cannot know until it is biopsied. What they do know is that the SOB, pain in his chest, side and back are from old rib fractures and not related to his lungs.  

Thank you again Dr. for the information provided. Hopefully, he will be able to convince both his doctors to follow-up on this before his next appointment six months from now.