Name:
A 72-Year-Old with Fever and Dyspnea
Description:
A 72-Year-Old with Fever and Dyspnea
Thumbnail URL:
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Duration:
T00H06M00S
Embed URL:
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Content URL:
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[music]
CATHY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Weiner, and we're coming to you from the Johns Hopkins School of Medicine. Here is today's question. Mrs. Woodstein, a 72-year-old woman has been complaining of low-grade fever and dyspnea for two weeks. She has a 10-year history of scleroderma with involvement of the digits and the esophagus. She also has a 30 pack year history of cigarette smoking but quit eight years ago. On chest radiograph, she has a nodular infiltrate in the right lower lobe.
CHARLIE: Positive emission tomography (PET) CT shows the right lower lobe lesion to be 3 centimeters in diameter with nodular infiltrative characteristics and an enhanced FDG uptake. Which of the following statements about Mrs. Woodstein is most accurate? So Cathy, what do you think of this patient's presentation so far?
CATHY: So, there are a couple of things to note about this patient. For one, she's elderly. We hear that she's 72 years old. No. 2, she has scleroderma. The manifestations of the disease affect her extremities and her esophagus, and she has a heavy smoking history. She's presenting today with low-grade fever and dyspnea which really gives a broad differential for what could possibly be going on. For one, she could be having an infection. She's potentially immunosuppressed from medications related to her scleroderma, and she's at risk for aspiration because of her esophageal dysfunction from her scleroderma.
CATHY: She could also be having primary lung disease associated with scleroderma, and she's definitely at risk for malignancy given her smoking history and her scleroderma history. Based on the 2013 U.S. Preventive Services Task Force recommendations alone, with her age being between 55 and 74 and having a greater than 30 pack year smoking history and a recent quit date, she really should have screening with low-dose CT scan because of her high risk for lung cancer based on that alone.
CHARLIE: And what about scleroderma? Does scleroderma increase her risk for malignancy also?
CATHY: It does. It increases risk for many cancers, including lung cancer, so the combination of the smoking and the scleroderma really puts her at high risk for malignancy.
CHARLIE: So, we are told that she has a 3 centimeter lesion both on chest x-ray and PET CT. What do you make of that?
CATHY: So, the nodular infiltrate on chest x-ray doesn't really help us that much-- there are infections that can present with a nodular infiltrate, and some examples of that would be fungal infection, nocardia infection, or atypical mycobacterial infections. In people who have underlying lung disease, sometimes bacterial infections can also present with nodular infiltrates. Malignancy can present like this, and then she can also have other noninfectious and nonmalignant causes of nodular infiltrates like Wegener's.
CHARLIE: So, let's review the listed answers for this question. So remember, the question asked, "Which of the following statements about Mrs. Woodstein is most accurate: a) additional diagnostic studies are indicated, b) the findings on PET CT make infection very likely, c) the findings on PET CT make infection very unlikely, d) the findings on PET CT make malignancy very likely, or e) the findings on PET CT make malignancy very unlikely? So, what do you make of the positive PET scan and what is FDG?
CATHY: So, FDG is a radiolabeled glucose analog, and it really can accumulate anywhere in the body that has high areas of metabolism. That gets picked up on PET scan and then that's what we see on the imaging findings that we have here described. PET scans can be useful in distinguishing benign versus malignant lesions. Benign lesions don't usually have high metabolic activity, and it can also be important in staging of known malignancies like lymphoma, where it's commonly used.
CATHY: However, there are some nonmalignant causes of positive PET scans. For example, anything that really causes inflammation, including autoimmune disease can cause PET positive scans, and then infections can also cause positive PET scans.
CHARLIE: So, the notion is that anything that has a large number of highly metabolic cells, such as a malignancy or white blood cells will accumulate the glucose and cause a PET positivity, right?
CATHY: That's right, and that's why in this case we really can't distinguish between infection versus malignancy, and she's at risk for both. So, we really need more information to help us determine whether or not this patient has an infection or a malignancy. The PET scan alone does not help us decide which one is more likely.
CHARLIE: So, in terms of this specific patient, what would you propose doing next?
CATHY: So, it depends a little bit more on her history. So, if she were having a productive cough, then I'd recommend getting a sample of sputum. You can do blood tests to look at fungal markers, and then you can also do a more invasive study like a bronchoscopy, which you can do a lavage to look for malignant cells or for evidence of infection, and then if there were something that were amenable to biopsy-- either percutaneously or via bronchoscopy-- then you could also do a biopsy.
CHARLIE: So, therefore the answer to this question is a) additional diagnostic studies are indicated, and in this specific case, it probably would be a bronchoscopy or a transthoracic needle aspiration unless she's producing sputum or has other source of potential infection or malignancy, correct?
CATHY: That's right.
CHARLIE: This case highlights the utility of PET CT in that while it is a very sensitive test, it actually in the right patient may not be terribly specific in distinguishing malignancy versus infection. I think that's the point we're trying to get across in this question.
CATHY: And if you want to read more about this, you can in Chapter 307 of Harrison's Internal Medicine: Diagnostic Procedures in Respiratory Disease. And the seminal paper on lung cancer screening that we mentioned as well is called Reduced Lung Cancer Mortality with Low-dose Computed Tomography Screening, and that's in The New England Journal of Medicine, 2011.
CHARLIE: Thank you. [music]