![]() Given the large number of biopsies with no evidence of recurrence, this is somewhat less likely. However, the diagnosis of a sarcoid-like reaction to tumor antigens released from a recurrence cannot be completely ruled out (see below). While clubbing is rare in sarcoid, given these findings and the perilymphatic distribution, sarcoidosis is the most likely diagnosis. Pathology instead revealed granulomatous lymphadenitis in the lymph node samples and multiple non-necrotizing granulomas in the trans-bronchial samples. Also, little septal thickening and no effusions were seen. However, no malignant cells were seen in the mediastinoscopy samples or the trans-bronchial biopsy samples. Given the patient’s history of cancer, recurrence was high on the differential and needed to be thoroughly evaluated. In our case, the nodules were in a perilymphatic pattern. Other, less common diseases such as lymphocytic interstitial pnuemonitis and Langerhans’ histiocytosis can present this way as well. Hypersensitivity pneumonitis and respiratory bronchiolitis are the most common diseases that present as ground-glass centrilobular nodules (2). This appearance usually fits with an infection such as Mycobacterium avium complex, Mycobacterium tuberculosis, fungal, or other bacterial infection. Tree-in-bud refers to branches that can come off the nodules, giving them this appearance (4). The differential of this category is broader than the other two, and breaking it down further into nodules with a “tree-in-bud” appearance versus those with a more “ground-glass” appearance can be helpful. These nodules are found around the centrilobular bronchioles and their pulmonary artery branches, hence the label centrilobular nodules (3). The third category involves nodules that do not touch the pleura and are not along the fissures. Importantly, lymphangitic carcinomatosis occasionally fits a perilymphatic distribution, but it is usually associated with lymphadenopathy, pleural effusions, and septal thickening. Silicosis and coal-workers’ pneumoconiosis can also appear in this distribution. Sarcoidosis can also occur in the lymphatics of the bronchovascular bundle. Sarcoidosis is the classic disease that fits this distribution. These regions are where the lymphatics are extensive, and this pattern is termed a perilymphatic distribution (2). Nodular disease can also be found clustered around the fissures, along the interlobular septae, and along the pleura. Miliary infections, such as tuberculosis, Mycobacterium avium complex, or fungal disease can also cause this pattern, but are usually seen in a centrilobular distribution (see below). Metastatic disease, such as carcinomatosis, is the most common cause of random nodules. Although diffuse, these nodules may show a predominance in the lung bases due to the higher perfusion there (2). Diseases that are spread via a hematogenous route commonly cause a random distribution of nodules. Randomly distributed nodules are by definition diffuse in nature with no obvious pattern. The three most commonly used distributions are: random, centrilobular, and perilymphatic. However, in order to develop a useful differential diagnosis, characterizing nodular disease by its relationship to secondary lobar anatomy is the most useful (1). Multinodular lung parenchymal disease can be characterized by lobar distribution and by diffuse versus focal disease. A repeat mammogram and breast ultrasound were both negative. The patient denied any cough, weight loss, night sweats, fevers, or occupational or travel-related exposures. In addition, a positron emission tomography (PET) scan revealed uptake in several mediastinal lymph nodes with a standard uptake value of 8. A chest CT confirmed bilateral hilar and mediastinal lymphadenopathy as well as perilymphatic nodules less than a centimeter in diameter throughout the lungs. Just prior to the visit a chest radiograph revealed hilar and mediastinal lymphadenopathy. ![]() However, over the last two years she had increasing dyspnea on exertion and was able to walk only 1 mile. She was followed closely over the next two years and had no evidence of recurrence.īefore developing breast cancer, the patient was physically active, walking 3 to 4 miles daily. She was treated with surgery, radiation, and chemotherapy that included doxirubicin, cyclophosphamide,paclitaxel, and gemcitabine. One of twenty-nine axillary lymph nodes were positive for tumor, which was estrogen receptor positive. Three years ago, she was diagnosed with breast cancer. A 59-year old white woman presented to the clinic for evaluation of dyspnea and an abnormal chest computed tomography (CT). ![]()
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