Mark Crislip, MD


September 30, 2011

Clinical Presentation

An infectious diseases consult is received for a 56-year-old man who had an unexpected pathology finding following lung cancer surgery.

History and Physical Examination

History. The patient is a 56-year-old man whose right upper lobe (RUL) was removed because of concerns about lung cancer. His pulmonary symptoms began 2 months prior to surgery, with a chronic nonproductive cough. He saw his primary care provider and was given a course of a macrolide and inhalers with no resolution of his symptoms. During the second month of his illness, he began to experience increasing fatigue, mild dyspnea on exertion, a 10-lb weight loss, and constant pain in his right upper chest.

One week prior to admission, hemoptysis developed, producing a teaspoon of bright red blood each time the patient had a coughing spell. A CT of his chest revealed a RUL mass that was invading into the chest wall. An outpatient bronchoscopy for bronchoalveolar lavage revealed many white blood cells (WBCs), no organisms, and many atypical cells. He was scheduled for lung resection because of the concern about lung cancer.

  • Medical history: type 2 diabetes, hypertension, gastroesophageal reflux disease (GERD)

  • Medications: oral hypoglycemic agent, proton pump inhibitor

  • Allergies: none

  • Habits: never smoked or drank alcohol. Parents were smokers

  • Pets: dog and cat


  • Diet: regular

  • Travel: extensive. He is an engineer in the Army Corp of Engineers specializing in flood control. He has traveled throughout the Mississippi River Valley and the Southwest inspecting dams. On his most recent trip, 3 months previously, he went to Louisiana, where he was inspecting the Old River Control Structure. This inspection required crawling through the riverside forests at the base of the dams.

  • Social: married

  • Immunizations: up to date

  • Sports/water exposure: Mississippi River water. No hot tubs. Waded and swam in many Central American rivers and lakes

  • Infectious disease exposure: no ill contacts. He has had 2 tooth crowns placed in the last 4 months

Physical examination. On physical examination, the following were noted:

  • Vital signs: temperature: 99.1o F; pulse: 110 beats/minute; respirations: 16 breaths/minute; blood pressure: 143/87 mm Hg

  • General: somewhat ill appearing

  • Head, eyes, ears, nose, throat: normal;

  • Lungs: clear; chest tube in right chest

  • Heart: normal

  • Abdomen: normal

  • Extremities: normal

  • Skin: normal

  • Genitourinary: normal

Diagnostic Evaluation

Laboratory results. The following results were obtained:

  • WBC: 8.9 x 103/mm3

  • Hemoglobin: 10.8 g/dL

  • Differential: normal

  • Hemoglobin A1c and glucose: normal

  • Bilirubin: normal

  • Transaminases: normal

  • Urinalysis: normal


  • Chest radiograph: round mass in the RUL

  • CT: RUL solid mass invading into chest wall with hilar adenopathy


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.