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Lung Nodules

I am a 58 year old female non smoker who has had several inhalation exposures-most recently a 6 week hay fire in 2009 on our ranch that has birds with a diagnosis of chemical pneumonitis, NY hot zone for 6 weeks 9/11, and brief IRFNA exposure and oil fire smoke during 1st gulf war 1991.  They picked up a tiny 1mm lung nodule 2009 while I was sick for 6 months, and monitored it with 2 stable CT's.  #3 was just done at a different facility after a very quick progressing viral? pneumonia with bilat atelectasis lower lobes.  It showed mild scarring and multiple scattered nodules measuring up to 7mm, with one being a 3.9mm groundglass nodule in the lingula.  I do have a history of in situ breast CA with mastectomies in 1984.  I am negative for TB & histoplasmosis, coccidiomycosis isn't back yet. Arterial blood gas was abnormal in PH= 7.46H, O2 sat= 99.1%H, and COHb%=1.9%H..  Pulm Funct results were confusing in that they showed restrictive and it seemed also obstructive if I understood them correctly.  Does the explanation of different "superior CT" explain changes.  Should I feel comfortable waiting 3-6 months for repeat scan?  Do the results make sense to you?
4 Responses
242587 tn?1355424110
MEDICAL PROFESSIONAL
Yours is a rather complex history, with multiple exposures, any of which, singly or in combination, could be the cause of the CT Scan abnormalities and abnormal pulmonary function tests (PFT’s).  The initial insult to your lung tissue, exposure to red-fuming nitric acid (RFNA - The rocket propellant red fuming nitric acid  sometimes combined with hydrogen fluoride) during the First Gulf War, clinically resolved but could conceivably have left some residual lung damage.  That you remained seemingly healthy for more than 18 years suggests that this exposure is not a major factor contributing to your current illness. The same could be said for your 6 week exposure in the 9/11 “hot zone” in 2001, in both instances an acute inflammation of the lungs without clinically significant lung damage.

The history strongly suggests your current problem relates to the six week hay fire in 2009 that resulted in a six month illness.  This, almost certainly, is the cause of the scattered nodules, the scarring , the “viral pneumonia” and the atelectasis, as well as the cause of the obstructive and restrictive changes, apparent on the PFT’s.  “Exposures, such as the one you experienced can lead to progressive loss of lung function; a condition called Bronchiolitis Obliterans.

Your ABG’s are actually normal and that is good news, but the apparent progression of a disease process on your CT Scans in association with measurable PFT abnormalities is alarming, in that both may be indicative of a progressive lung disease process.  The apparent progression of lesions on the most recent “superior” CT scan might be attributable to the superiority/sensitivity of  this scan, but that should not be the working assumption.  

Your doctors should assume that the apparent progression is actual progression and,  based on that premise you should not wait 3-6 months for another CT Scan on the “superior” machine.  You should request consultation with physicians actively engaged in the diagnosis, treatment and research on Interstitial Lung Disease (ILD) and you should do this without delay.  Two such medical centers are:  1) National Jewish Health in Denver, Colorado, the program under the direction of Dr. Kevin Brown, 2) the University of California in San Francisco, Dr. Talmadge King or, 3) the ILD Clinic at the University of Iowa Medical Center in Iowa City.  One of your doctors should be able to assist you with a referral.

Do not delay.

Good luck
Avatar universal
Thankyou Dr Tinkleman for your thoughtful input and time.  After I recieved it, I requested my medical records and found a few differences and wanted to make sure I hadn't led you astray with misinformation.  If you have time, would you glance at my records and see if you still suggest ILD referral?  If you do- please give me guidance on whether I should go for SF and stay near sea level while visiting my daughter here in CA.,, or go for Denver and my ranch at 7,000ft. elevation in Northern NM- 5 hours from Denver.   All other labs were WNL or neg, including histo, cocci, crypto,TB, ANA.

05/  /2009- CT Thorax with contrast=5mm images Findings=No mediastinal adenopathy.  Small hiatal hernia.  Tiny left hepatic cyst. Clear central airways.  Stable peripheral subcentimeter nodule superior segment RLL.  No new nodules identified.

02/04/2010-CT Thorax with contrast-Impression: No significant interval change.  Tiny 3mm peripheral nodule superior segment RLL.

06/11/2010-ER -dry cough, slightly hoarse voice, lungs RR 18-20, nml WOB, exp wheeze audible when speaking, coarse bilat, with prolonged E:I, exp wheezes in all fields.PF

in ED on arrival is:225, after 2 Duonebs= 275, but subject much better. labs are non-specific  =   WBC=12.4H , lymphs=18L., eGFR=>60,
06/11/2010-CXR= Findings=There are strandy opacities involving both lung bases.  A focal nodular opacity is seen at the left lung base adjacent to the descending aorta. cardiomediastinal silhouette is nml.
1. Bibasilar opacities, atelectasis versus early consolidation.
2. Focal nodular opacity at the left lung base, possibly due to atelectasis or confluence of vessels,

06/18/2010-PFT=Abnormal- FVC;2.43, FEV1=1.92, RATIO=76%, tlc=70%, dlco=80%. There is mild restrictive ventilatory defect with normal DLCO.  ABG's= pH7.46H, o2 sat=99.1H, COHB%=1.9H, shows mild respiratory alkalosis and elevation on carboxyhemaglobin, suggestive of active smoking.(I'm non-smoker).  There is normal A-a gradient. No BDR.

7/14/2010-WBC= 3.6L (have been normally low for last 8-10 years ), Lymps 45, eGFR>60,  UA=cloudy with many AMcrystals, rare mucus, rare bacteria, RBC/HPF=0-2.  Blood NE# 1.5L

7/17/20-CT Thorax w/o contrast=Small hiatal hernia. Coronary arteries- moderate atherosclerotic calcification. Aorta:moderate atherosclerotic calcification. Lungs-Mild scarring at the lung apices. 3.9mm groundglass nodule in the lingula. 4.7mm nodule LLL. 6mm nodule RML.  6mm subpleural nodule RLL.  6.6mm nodule in the superior segment of the RLL.  No nodules found to explain the opacity seen on the chest x-ray in the medial LL lung zone. Recommend followup CT scan at 6-12 months if lowrisk- 3-6 months if high risk. Airways: patent- no endobronchial mass.

07/23/2010-Pulm=Per CT- Chest negative, with PFT's showing a mild restricitive physiology with normal DLCO, ABG showing respiratory alkalosis with elevated carboxyHb (consistent with active tobacco or other smoke exposure)  
DDX=1. reactive airway disease related to allergen, weather, tobacco smoke.2. recurrent GERD related symptoms causing reactive airways disease. 3. Infectious etiologies (cocci, crypto)  4. The possibility of other parenchymal diseases like hypersensitivity pneumonitis, drug reaction, NSIP, and flare of possible ILD are low but not absent. Increase PPI to BID dosing doubled.  Check exercise oximetry.

08/11/2010-Serum RFelisa: 51.9H IU (norm 0.0 - 19.0)
Avatar universal
I just had repeaat PFT's and ABG's done today.  So far all theyt told me was my o2 sat was 99- which is great, but I think she said my carboxyhemaglobin was 112% (the tech seemed concerned and left to go check with the doc).  It doesn' seem to be in the same format as the earlier result- but I am guessing it isn't an improvement. The VA pulmonologist appt in next Feb, they cancelled my rheumatology follow up, and they cancelled the exercise oximetry test.  They said I don't need them, but they are sending me for a GI consult eventually.  I guess I had a mixture of stalling, wishful thinking and trying to not be a drama queen, and hoping the VA would come through.  I really generally think they do an outstanding job for most things.  Assuming you still think it is appropriate, I am definately feeling like a second opinion is reasonable.
Avatar universal
ABG results 09/09/10-HGB-14.2, HCT-43.7, FIO2-21%, PH, 7.45, PCO2 34L, PO2- 112H, Base excess- 0.1, HCO3 23.0, O2 Sat 99.9H, COHB% 2.4H, Methb% 0.5, O2 CNT. 19.5  Not sure if anyone will be able to explain what this means and how it translates to my shortness of breath with exertion. Thanks

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