CASE

PRESENTATION
Jose Henao, M.D.
02/09/2022
CASE PRESENTATION
 CC: Chest pain
 HPI: 34 yr Caucasian male with PMHx of bipolar disorder and type 2 diabetes presented
complaining of chest pain
 Chest pain was pleuritic for 1 day
 DOE, SOB, fever, night sweats, weight loss (80 pounds), fatigue, abdominal pain, nausea,
constipation and intermittent episodes of hematochezia and extremity “pains” for 6-8 months
 Pruritic rash on his right leg 1 week ago now resolved
LABORATORY
LABORATORY
LABORATORY
MICRO
 Blood cultures negative
 COVID-19 PCR negative
IMAGING
 CXR
 Chest CTA
 LE Venous Doppler: several wall thickening in both popliteal artery and vein consistent with
localized vasculitis, no clot.
 Sinuses CT: no evidence for acute or chronic sinusitis
CT PE PROTOCOL 3/22/2021
DISPOSITION
 Transferred to University of Louisville: no records available
 Rheumatology was consulted : planning to do muscle biopsy and EMG
PREVIOUS WORKUP
 CT chest 1/4/2021 low lung volumes and hiatal hernia
 CT head 1/4/2021 shows no acute intracranial abnormality‘s
 CT abdomen and pelvis 1/4/2021 demonstrates nonspecific retroperitoneal inflammation and
edema with numerous small  reactive lymph nodes, splenomegaly without  focal lesion, mild
right and minimal left renal collecting system prominence, small pericardial effusion

 PET SCAN 1/6/2021 mild FDG Avid right level 3 lymph node and left infra clavicular lymph
nodes; 2 intensively avid left and right upper pulmonary lesions, multiple FDG avid and
predominantly upper lobes nodules, right lower paratracheal lymph node as well as several
intensively FDG avid left internal mammary lymph nodes. Numerous sub centimeter and
intensity FDG avid retroperitoneal lymph node in the periaortic and aortocaval spaces,  Intense
FDG activity diffusely throughout  the retroperitoneum from the level of the renal arteries to
aortic bifurcation, insensitively avid right external iliac lymph nodes largest measuring 1.4x0.7
cm, osseous structures.
PREVIOUS WORKUP
 Scrotal sonogram 1/4/2021: Normal

 1/8/2021
Biopsy 10 R lymph node: Alveolar macrophages, negative for malignancy 
Biopsy of left upper lobe lung mass: Bronchial cells, lymphocytes, macrophages and
epithelial Histiocytes, suggestive of granulomatous inflammation and negative for
malignancy. Methenamine silver stain was negative for fungus, negative for pneumocystis.
PREVIOUS WORKUP
 CT chest at Greenview Hospital 3/8/2021: compared to outside study from 4/24/2020
demonstrated similar abnormalities in both lungs with comment that masslike abnormality
with air bronchogram extend from posterior right hilum into the posterior right upper lobe and
interlobular fissure but no longer extends to the pleural surface, overall size similar, and that
there are additional small patchy nodular foci, calcified granuloma LLL and left hilum and
masslike abnormality in the medial left lung apex.
 CT guided lung biopsy at Greenview: dense fibroinflammatory tissue with lymphocytes
plasma cells and a few PMNs with areas of bronchovascular hyperplasia, no significant atypia
or infiltrative pattern, no granulomas or necrosis.
 Flow cytometry, tumor markers for germ cell tumors ( beta HCG, AFP ), LDH : normal
 Bone morrow biopsy 6/14/2021: negative
ADMISSION 8/7/2021
 CC: Syncope
 HPI: 34 yr Caucasian male with PMHx of bipolar disorder and type 2 diabetes presents with
syncope.
 Syncope 1 week ago while sitting
MEDICATIONS
 Atorvastatin
 Insulin Detemir
 Lithium
 Fenofibrate
 Metformin
 Lubiprostone
 LABORATORY
LABORATORY
 LABORATORY
LABORATORY
 LABS
LABORATORY
IMAGING
 Head CT: negative
 CXR
 Chest CTA
 Modified barium swallow
 Panorex
CHEST CTA
CT SURGERY CONSULTED FOR VATS
LUNG TISSUE
MAYO CLINIC
CLEVELAND CLINIC
PLAN
 Prednisone 40mg/day per pulm
 Bactrim DS for PCP prophylaxis
 Ceftriaxone 2g IV daily for 2-4 weeks
ADMISSION AT NORTON 9/2021
 Histo Ag urine, Histo complement fixation <1:8, Histo complement fixation, Crypto AG neg,
blasto Ab, Cocci IgG and IgM, Aspergillus Ab and Fungitell negative.
 ANA screen, MPO IgG, Proteinase 3 IgG, DS DNA, SSA, SSB, Jo-1 IgG, CCP negative
 9/24: Skeletal muscle gastrocnemius biopsy: neuropathic process with denervation atrophy
ADMISSION 10/18/2021
 CC: suicidal ideation
 Steroids stopped at Norton on hospitalization on 9/16/2021, never followed up with
pulmonology
 Started back on steroids
DDX
 IGG4
 Associated with type 1 autoimmune pancreatitis
 IgG4- related sclerosis cholangitis
 Major salivary gland enlargement or sclerosing sialadenitis (IgG4 related Mikulicz disease
when presented with combination of lacrimal;, parotid , and submandibular gland
enlargement)
 Orbital disease (Proptosis)
 Retroperitoneal fibrosis (with chronic periaortitis and often affects ureters, leading to
hydronephrosis and renal injury)