FCRCR 2B SBA CVS
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"This 41-year-old woman developed acute left-sided chest pain. She has had gradually increasing shortness of breath and a dry cough over the last 8 months, and has a 25-pack-year history of cigarette smoking. Her posteroanterior chest radiograph is presented. Which one of the following is the MOST likely diagnosis?
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A. Tuberculosis
B. Metastatic disease
C. Lymphangioleiomyomatosis
D. Langerhans cell histiocytosis
E. Sarcoidosis
Findings: Chest x-ray shows a left-sided pneumothorax and diffuse irregular nodular opacities.
A. Mycobacterium tuberculosis may present innumerable discrete miliary nodules, know as military tuberculosis. The chest radiograph shows innumerable 2 to 3 mm nodules, symmetrically distributed throughout both lungs. This form of tuberculosis is not associated with pneumothorax.
B. Metastatic disease may present with multiple pulmonary nodules, usually larger in size. However, the occurrence of pneumothorax is very unusual, although it may uncommonly occur with some metastases, such as sarcomas. The absence of a history of known malignancy also argues against this diagnosis in this patient.
C. Lymphangioleiomyomatosis (LAM) is an obstructive pulmonary disease characterized by diffuse pulmonary cysts. Patients with LAM are female and of child-bearing age. Early chest radiographic findings include subtle, fine, reticular opacities. Later findings are discrete cysts. Spontaneous pneumothorax is the presenting event in more than half of patients. The older age of the test patient and the irregular nodular opacities make LAM not the most likely diagnosis.
D. Langerhan's cell histiocytosis is a smoking-related lung disease in adults. Chest radiographs typically demonstrate a symmetric, reticulonodular pattern, less commonly a solely nodular pattern, with upper and mid-lung predominance. The nodules are usually irregular. The disease may progress to cystic lung disease. Spontaneous pneumothorax is common, occurring in up to 25% of affected patients. The clinical and radiographic findings in this patient are characteristic of Langerhans cell histiocytosis.
E. Most patients clinically present with sarcoidosis between 20 and 40 years of age. Lymph node enlargement is the most common intrathoracic manifestation of sarcoidosis, occurring in about 80% of patients. The classic pattern is bilateral hilar and right paratracheal lymph node enlargement. Parenchymal disease is seen in about half of patients. Reticulonodular opacities are the most common pattern, and exhibit an upper lung predilection, along the bronchovascular bundles. While sarcoidosis may be associated with spontaneous pneumothorax, this is rare, and the absence of nodal enlargement makes sarcoidosis not the best choice.
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