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multiple nodular densities both lungs

i am a medical student and my groupmates and I were given a case of a 69/F, single with a chief complaint of cough.

6months PTA he had nonproducitve intermittent cough with on-off low grade fever, night sweats and anorexia. She was diagnosed with pneumonia. She was given meds and was compliant but no improvement of symptoms nor on her x-ray findings. She was given another set of unrecalled meds no relief again.

1 month PTA, increase anorexia, weight loss of 11 kg over 6 months, epigastric pain (gnawing), decreased frequency of bowel movement (no change in character).

2 weeks PTA same symptoms, recurrence of cough (increased frequency) noted weakness, Chest x-ray done, ampiclox given for 7 days, cough decreased frequency and intensity (with bouts of excacerbation) repeat x-ray: increase in nodules. Avised for admission and started on anti-Koch's regimen.

ROS: no chestpains no palpitations no bladder changes no paralysis

PMH: (+) Hypertension past 2-=30 years, on metoprolol 50 mg OD
          (-)  diabetes/cardiac problem
          (+) surgery TAHBSO and thyroidectomy - the year when they were done was not mentioned in the case that was given to us, our professors said some details were ommitted and modified

Personal and Social history: unremarkable

The admmitting P.E is as follows:
Not in respiratory distress; BP = 130/80, Hr = 84, RR = 18, Temp = 37.4
Pink conjunctivae, anicteric sclera.
(-) tonsillopharyngeal congestion, (-) cervical lymphadenopathy, equal chest expansion, (-) retractions, (+) rales, bibasilar distinct heart sounds, regular rate and rhythm, no murmurs
(-) fluid wave/abdominal tenderness
(-) bipedal edema
Rectal exam: good sphincter tone, rectal vault not collapsed, (-) mass tenderness.

Assessment was Pulmonary Tuberculosis Class IV, T/C colonic growth vs. Functional constipation (with probable mets); hypertensive cardiovascular disease, not in failure.

The following meds were started:
• Mycostatin 5 cc oral solution TID
• Vitamin K 1 amp BID
• Paracetamol for fever every four hours
• Arachnil 1 amp every 4 hours
• Codipront 2 tsp OD
• Piperacillin 2.25 gms IV q 6 hours
• Losec 2 mg OD
• Myrin 2 tabs BID
• Metoprolol 50 mg BID
• Captopril 25 mg SL for BP > 160/100.

June 12, 2003 – Fluconazole 200 mg IV OD and Tazolin IV were started.

CT images: multiple nodular densities on both lungs, largest are seen at the right upper and left lower lobes, size range of 0.5 to 5 cm.
• The masses have fluid density with one of the nodules having a pocket of air within. No calcifications.
• A 1.0 cm cavitary lesion is also present at the left upper lobe.
• There are enlarged lymph nodes at the right perihilar area.
• Pulmonary parenchyma infiltrates are likewise seen at the lower lobes. No pleural effusion present.
• The aortic walls are calcified but with no evidence of aneurysm or dissection.
• The heart is enlarged with left ventricular configuration. No pericardial effusion.
• There are degenerative changes in the osseous structures but no lytic changes seen.
• Additional cuts of the upper abdomen do not reveal any lesions in the liver or adrenal glands.
Impression 1. Bibasal pneumonia
2. Multiple pulmonary nodules with fluid density  and some with cavitation/ air within and right hilar lymphadenopathy
Considerations are:
a. Disseminated fungal/TB infection  
b. Necrotizing metastasis

June 13, 2003 – Continued giving Fluconazole 200 mg IV OD  and Tazolin IV was shifted to Meropenem 1 gm IV every 8 hours and Nexium was started.

June 14, 2003 –
 UTZ: dry tap.
 Patient continued to be awake, tachypneic and tachycardic. Oxygen was administered at 95% saturation at 10 1pm via face mask.  
 Nexium was shifted to Losec 20 mg tablet once a day.
 Despite these measures, desaturation worsened and when labored abdominal breathing was note, patient was intubated and cathetherized.
 Assessment was Sepsis secondary to bronchopneumonia in immunocompromised host T/C colonic carcinoma with pulmonary metastasis; hypertensive cardiovascular disease, not in failure.

Ultrasound:  There is a small pocket of air upper hemithorax, accounting to about 30 cc. No fluid aspirated.

CXR: No significant changes in the size of the right upper lobe nodular density.
 The left upper lobe nodular density (1.0cm cavitary lesion) is obscured by new pneumonic left upper lobe haziness in this study.
 The perihilar vascular markings are also thickened, suggestive of pulmonary congestion.
 A semi rounded right lower lobe mass is better seen in this study.
 There is a regression of the reticular infiltrates in both lower lobes.
 There is almost complete opacification of both lung fields, as seen in the film taken few hours later.
 Probably due to progression of pulmonary congestion and edema.
 The heart is not enlarged.

June 15, 2003 – CXR:
 Significant clearing of the pulmonary congestion and/ or edema.
 Reticular infiltrates are seen in both lower lobes again.
 The right upper lobe nodule is again well seen at this study with no significant changes.
 The heart is not enlarged in the last study.
 The rest of previous chest findings are the same.
June 16, 2003  
• Patient was coded but was revived.
• Impression then was acute respiratory failure secondary to sepsis secondary to pneumonia (high risk); hypoxic encephalopathy S/P CP arrest; T/C colonic CA.
• She remained comatose, tachypneic and tachycardic until her demise 3 days later when ventilator support was removed upon consultation with family.
• ECG: Sinus tachycardia, Low voltage QRS complexes.

June 17, 2003 CXR:
• Minimal increase in the sizes of the nodular densities in both upper fields. There are reticular densities in the right lower lung fields with confluence on the left, probably due to the pneumonia.
• These, in retrospect  were present previously, unchanged in status.
• Heart is top normal in size. Aorta is atheromatous.
• Diaphragm, sulci and bony thorax are unremarkable.

June 18 and 19, 2003 – BP = 120-130/80, HR = of 128-136, RR = 32-38, temperature = 36.4 – 37.6 ˚C Died

we were thinking of a possible pulmonary metastases secondary to cervical cancer that recurred after the surgery with opportunistic infections such as pneumonia and/or TB. Are the radiographic findings consistent with our diagnosis? can you help us diagnose the patient and also with his immediate and underlying cause of death? our professors said we should think outside the box since this will be presented in a clinico-pathologic conference. thank you very much!
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This is not the doctor/answer forum, but I'll bite!  I correctly diagnosed TB before I got to that part.  I am thinking a septic pulmonary emboli as the diagnosis.  It's not CHF as the heart size is normal and the pulmonary congestion had cleared.  Let me know what they say!
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what was the update of the diagnosis of this patient you have presented????
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