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A young man with two large lung masses.

(CHEST 1999; 116:814 ‐ 818) A 37-year-old white man was referred to the Cleveland Clinic Foundation for evaluation of two lung masses noted on chest radiograph and confirmed on CT scan of the chest. He complained of chest pain for 3 months before presentation. It was localized in the left axillary region and later also in the right upper chest, more on inspiration, and was not related to posture or exertion. It was initially attributed to muscle pull caused by heavy exertion on his job, and partially relieved by therapy with ibuprofen for a few days. He returned to the physician for progressive nonproductive severe cough during 2 months. He was found to have weight loss of 5.5 kg during 3 months. He denied fever, dyspnea, exercise limitation, night sweats, fatigue, sinusitis, skin rash, or joint pains. He did not have pets, recent travel, or exposure to tuberculosis (TB). His only significant past medical history was a remote fall causing left-sided rib fractures and accidental dental trauma by his infant’s head 6 months before presentation. He had a 40-pack-year smoking history and consumed up to a 12-pack of beer daily for 5 years. He worked underground installing cables. He was a young man of average build in no apparent distress, with normal vital signs and lung examination, and no chest tenderness. No physical abnormality was detected except the two loose upper incisor teeth with mild tenderness over the surrounding gum. There was no erythema or discharge from the gum. His WBC count was increased to 17 3 10 3 /mL and his erythrocyte sedimentation rate was 24 mm/h. The findings from the rest of the laboratory examination, including hemoglobin, platelet count, serum chemistry, coagulation profile, room air arterial blood gases, and urine analysis, were normal. Results of antinuclear antibody, cytoplasmic and perinuclear antineutrophilic cytoplasmic antibodies (by enzyme immunoassay and fluorescence tests), fungal serologies (for aspergillosis, histoplasmosis, blastomycosis, and coccidioidomycosis), and tuberculin skin test (with positive anergy panel) also were normal or negative. Chest radiograph (Figs 1 and 2) and CT scan (Fig 3) are shown. Flexible bronchoscopy did not reveal endobronchial abnormality, and BAL was negative for routine bacterial Gram’s stain and cultures, acid-fast bacilli, nocardia, and legionella. Cytology of bronchial washing and brushing specimens was negative for malignancy. Histopathologic study of tissue from the left lung lesion obtained by transbronchial biopsy was nondiagnostic. Later, the histopathologic examination of the tissue obtained from wedge resection by thoracotomy was typical of the final diagnosis.