Initial Exam 6 /29:
45yo F, 5 wks ago, persistent dry cough, no sputum or blood, chest congestion, vague chest discomfort & dyspnea. Never smoked, no fever, chills or sweats. Resp 16 unlabored. Pharynx clear, no neck masses or vein distention, No neck or supraclavicular adenopathy, Lungs sound very clear. No consolidation or effusion. Abdomen - benign. No edema or calf tenderness on extremities. No rashes. No CVA tenderness. Meds: Prozac, Abilify, Neurontin, Klonopin, Wellbutrin, Phytoestrogen Past Med: hysterectomy, ovarectomy w/benign cyst, benign cyst removed from left breast, cholecystectomy in 20’s - 30’s, depression, squamous cell carcinoma in situ completely excised R forearm 5/21/07 Tests:CBC wbc 8500, H/H 15.2/45.3, platelets 306,000. X-ray & CT- bilateral extensive diffuse pulmonary nodular infiltrates appx. .5 to 1 cm, Some pleural based others entirely within lung parenchyma. CT density was lipoid. Bronchoscopy w/ trans biopsy, feature suggestive of lipogranulomas w/associated foreign body giant cell reaction, surrounding interstitial fibrosis. No evidence of neoplastic process. Negative for malignancy. AFB & PAS stains - negative for acid-fast bacilli & fungal elements at 4 wks. Gram stain: small aggregates of both gram positive cocci & gram positive rods. Tissue culture had moderate & protected micro brush had light growths of Actinomyces odontolyticus at 1,600 CFU/ml. Pen-VK 500mg was started. Empirically started 40-mg Prednisone, & tapered off 1 mo. Felt 30 - 40 % better & improved clinically. Negative for Niemann-Pick Type B. Pulmonary Function Test – Spirometry: Mild restriction in the forced vital capacity without obstruction. Lung Volumes: Mild restriction Diffusion Capacity: Normal diffusion capacity. Ox 93% rest 87% walking. Bilateral Screening Mammogram – normal. Mod. Barium & Barium swallows – normal. Open Lung Biopsy planned for 9/24.
Well-defined nodules as small as 1 to 2 mm in diameter, can be detected on high resolution CT (HRCT) scan in patients with a variety of diseases. These are usually interstitial in origin and can be benign or malignant, infectious or inflammatory without infection, called granulomatous. The pattern of the nodules can suggest one or another of these but an accurate diagnosis requires lung biopsy. The choice that you and your doctors have made to proceed with an open lung biopsy is absolutely the correct decision. Anything short of that is speculation. The presence of lipid material is seldom diagnostic but pulmonary Actinomycosis can assume many forms and the apparent response to therapy is impressive, but a "slight growth" could simply be a contaminant.
The open lung biopsy tissue should be cultured for fungi, tuberculosis (TB) and fungi.
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