Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 56-year-old African American male (AAM) with a past medical history (PMH) of COPD, alcohol abuse, and smoking is admitted to the hospital with a chief complaint of shortness of breath (SOB) for 2 months. SOB is so severe that he is not able to prepare his dinner. He also reports a 18-kg weight loss during the last 6 months. The patient is legally blind but he says that he has seen blood in his sputum. PPD was negative 2 years ago and he has a 60 pck-yrs h/o smoking.
He was admitted to the hospitals 2 months ago for a weight loss work-up. A CT of the abdomen showed a 1.5 cm-pancreatic mass which did not look cancerous on ERCP. He had evidence of chronic pancreatitis. A CXR was reported as COPD changes.
Thin male in NAD.
Chest: Markedly decreased air entry on the right, with an area of dullness.
CVS: Clear S1S2.
Abdomen: Soft, NT, ND.
Extremities: no c/c/e.
What is the most likely diagnosis?
Is it a pleural effusion? This is less likely with audible air entry and normal percussion tone at the base.
Infiltrate vs. lung mass?
Pneumonia or TB?
Lung cancer? But how did it grow so fast? The CXR was reportedly only with COPD changes only 2 months ago.
What will be the next step in the diagnostic workup?
Let's start with a CXR.
PA CXR, close-up view (left); lateral CXR, close-up view(right) (click to enlarge the images).
Dow you see anything else than COPD changes on the CXR?
The film is overpenetrated but you can see a perihilar mass on the right. It is even clearer on the lateral film.
The CXR report (click to enlarge the image).
The labwork showed a mild hyponatremia (sodium 129 mEq/L ), a hemoglobin (Hgb) of 15 mg/dL, and a corrected calcium level of 10.4 mg/dL.
Laboratory results (click to enlarge the image).
What do you think is the most likely diagnosis now?
Is it SIADH?
The uric acid level is typically low in SIADH because of dilution and increased excretion of uric acid due to ADH.
The CT chest showed a mass in the right lung:
Lung cancer on CT of the chest (click to enlarge the images).
CT report (click to enlarge the image).
What is the next step?
Bronchoscopy and biopsy.
The biopsy showed a squamous cell lung cancer. The patient was not a surgical candidate due to the advanced stage of the tumor. SIADH was not confirmed by the follow-up laboratory results.
Sir Richard Doll Dies at 92; Linked Smoking to Illnesses - NYTimes, 7/2005.