diagnostic dilemna_15

Diagnostic dilemna

Ok, hopefully you can help me with this case. It's fairly long and

complicated - not easy in this blog format but that's what we're stuck

with. I presented this case before, but that was before some

additional data.

He is a 45 year old with 6 months of a cough. This was found on a CT

scan:

A biopsy was done. It showed interstitial inflammation. A previous

biopsy had been obtained with similar non-specific findings. That one

was read as "a mixed inflammatory infiltrate, greatest in the

bronchial submucosa, with increased numbers of eosinophils. There are

intraalveolar pigment/ hemosiderin laden macrophages and fresh blood;

there is no vasculitis in this limited sample. Grocott stain is

negative for fungus."

Also, a 2.1 x 1.3 cm hypoattenuating lesion was found within the tail

of the

pancreas, nonspecific. This was biopsied by CT-guided and showed "The

biopsy has stromal fibrosis, attenuation of the ducts/ acinar

component and accentuation of the islets. In one level, there is a

single granuloma My underline and the possibility of an underlying

granulomatous inflammatory disease, such as a fungal infection or

tuberculosis, accounting for both the lung and pancreatic lesions,

cannot be excluded. Grocott stain is negative for fungus.

Ziehl-Neelsen stain is negative for acid-fast bacteria. Immunostain is

negative for mycobacteria. The present biopsy is not representative of

a mass lesion."

He also was found to have adrenal insufficiency (cort-stim test)

picked up when he presented to my clinic with hypotension,

hyponatremia and hyperkalemia. (ACTH was 356). He also had a calcium

of 10.9 but with normal PTH level (23).

Bronchial washings were negative for fungal. There was no growth of