Saturday, 24 November 2012

A 34-year-old woman, a recent immigrant from Eastern Europe, is seen with complaints of vague chest discomfort after an upper respiratory tract infection.

A 34-year-old woman, a recent immigrant from Eastern Europe, is seen with complaints of vague chest discomfort after an upper respiratory tract infection. She is not a smoker and gives a history of BCG vaccination when she was an infant. Physical examination is normal. PPD is 10-mm induration and induced sputum for acid-fast bacilli is negative. CXR is shown below:





















What is the most likely diagnosis?
a. Granuloma
b. Scar carcinoma
c. Coccidioidomycosis
d. Hamartoma

What is the next step in the management of this patient?
a. MRI of the chest
b. Fiberoptic bronchoscopy
c. Comparison of previous chest radiograph, if available, and repeat chest radiograph in 3 mo
d. Treatment with four-drug anti-TB chemotherapy

This chest x-ray shows a normal heart size. No pleural or mediastinal disease is noted. Cardiophrenic and costophrenic angles are clear. A dense, rounded solitary pulmonary nodule is noted in the right lung.

The answers are 2-a, 3-c. With a history of a positive PPD in a young immigrant and the presence of a calcified peripheral SPN, the likely diagnosis is tuberculous granuloma. Comparison with a previous x-ray to confirm stability of the lesion would prevent the need for further diagnostic tests. An MRI of the chest would not add definitive information, and bronchoscopy for a peripherally located calcified lesion would be of low yield. Since this lesion probably represents latent, old, healed granulomatous focus, treatment with four antituberculosis drugs is not warranted unless evidence of active disease is seen.

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