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Mycobacterium Avium-Intercellulare Presenting as a Large Endobronchial Mass
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A1965 - Mycobacterium Avium-Intercellulare Presenting as a Large Endobronchial Mass
Author Block: R. M. Sidhom1, A. Beltran2; 1Internal Medicine, University of California, Irvine, Orange, CA, United States, 2Pulmonary and Critical Care, Long Beach Memorial Medical Center, Long Beach, CA, United States.
Introduction: Endobronchial lesions in patients with significant smoking history are almost always treated as neoplastic in origin. Infectious etiology is rarely considered in these cases, but can present similarly. Distinguishing the two can have significant impact upon the resources utilized and the emotional trauma imparted on our patients.
Case: A 52-year-old female with severe COPD and an 80 pack-year smoking history presented to the emergency department with 2 weeks of worsening cough, hemoptysis, night sweats, and 20-pound weight loss. She endorsed fever of 103 degrees fahrenheit and chest pain radiating to the right shoulder. Physical exam was notable for tachycardia to 132, respiratory rate of 24, and diminished breath sounds in the right upper airfield. Initial labs were significant for hemoglobin of 9.2 and lactate of 2.2. Initial chest radiograph revealed an opacification in the right upper lobe. Chest CT showed a soft tissue mass protruding into the proximal right main bronchus (1.8 x 1.6cm) as well as a spiculated mass w/ multiple calcifications in the right lung apex (7.0 x 5.1cm). A third mass was found in the left lower lobe (2.5cm x1.8cm). Given constitutional symptoms and multiple masses found on imaging, neoplastic work up was begun including MRI Brain, whole body bone scan, and plans for biopsy. CT guided biopsy was deemed too dangerous given assumed vascularity of mass, and endobronchial ultrasound guided biopsy and bronchoalveolar lavage produced non-diagnostic results. Cardiothoracic surgery performed direct mediastinoscopy with biopsy revealing non-caseating granulomatous disease. Cytology revealed no malignant cells. Two weeks later, endobronchial ablation was performed to clear the mass from the nearly obstructed airway. Acid-fast bacilli staining and cultures of the mass ultimately revealed Mycobacterium Avium-intracellulare Complex (MAC) in all samples. Patient was started on a regimen including Rifampin, Azithromycin, Ethambutol, and Amikacin and has been clinically stable. Repeat biopsies were taken, which again revealed no malignant cells.
Discussion: MAC infections are not known to readily present as endobronchial lesions. Pulmonary infections can masquerade as neoplasms and must be sought after aggressively when malignancy is not initially found. This patient had every sign and risk factor for a pulmonary malignancy, but extensive inquiry into this led to considerable waste of resources and stress for our patient. Understanding that infections can present similarly, and keeping an open mind to their possibility can help other patients in the future.
Author Block: R. M. Sidhom1, A. Beltran2; 1Internal Medicine, University of California, Irvine, Orange, CA, United States, 2Pulmonary and Critical Care, Long Beach Memorial Medical Center, Long Beach, CA, United States.
Introduction: Endobronchial lesions in patients with significant smoking history are almost always treated as neoplastic in origin. Infectious etiology is rarely considered in these cases, but can present similarly. Distinguishing the two can have significant impact upon the resources utilized and the emotional trauma imparted on our patients.
Case: A 52-year-old female with severe COPD and an 80 pack-year smoking history presented to the emergency department with 2 weeks of worsening cough, hemoptysis, night sweats, and 20-pound weight loss. She endorsed fever of 103 degrees fahrenheit and chest pain radiating to the right shoulder. Physical exam was notable for tachycardia to 132, respiratory rate of 24, and diminished breath sounds in the right upper airfield. Initial labs were significant for hemoglobin of 9.2 and lactate of 2.2. Initial chest radiograph revealed an opacification in the right upper lobe. Chest CT showed a soft tissue mass protruding into the proximal right main bronchus (1.8 x 1.6cm) as well as a spiculated mass w/ multiple calcifications in the right lung apex (7.0 x 5.1cm). A third mass was found in the left lower lobe (2.5cm x1.8cm). Given constitutional symptoms and multiple masses found on imaging, neoplastic work up was begun including MRI Brain, whole body bone scan, and plans for biopsy. CT guided biopsy was deemed too dangerous given assumed vascularity of mass, and endobronchial ultrasound guided biopsy and bronchoalveolar lavage produced non-diagnostic results. Cardiothoracic surgery performed direct mediastinoscopy with biopsy revealing non-caseating granulomatous disease. Cytology revealed no malignant cells. Two weeks later, endobronchial ablation was performed to clear the mass from the nearly obstructed airway. Acid-fast bacilli staining and cultures of the mass ultimately revealed Mycobacterium Avium-intracellulare Complex (MAC) in all samples. Patient was started on a regimen including Rifampin, Azithromycin, Ethambutol, and Amikacin and has been clinically stable. Repeat biopsies were taken, which again revealed no malignant cells.
Discussion: MAC infections are not known to readily present as endobronchial lesions. Pulmonary infections can masquerade as neoplasms and must be sought after aggressively when malignancy is not initially found. This patient had every sign and risk factor for a pulmonary malignancy, but extensive inquiry into this led to considerable waste of resources and stress for our patient. Understanding that infections can present similarly, and keeping an open mind to their possibility can help other patients in the future.
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