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A4054 - Wheezing and the Assumption of Asthma in a Young Atopic Patient
Author Block: S. Barned1, O. M. Ahmedtaha1, A. Thomas2; 1Internal Medicine, Howard University Hospital, Washington, DC, United States, 2Division of Pulmonary and Critical Care Medicine, Howard University Hospital, Washington, DC, United States.
Introduction: Asthma is a chronic airway disease with a high prevalence in persons known to have atopy. However, all that wheezes is not asthma and appropriate investigations should be done to exclude other ominous causes of wheeze.
Case Presentation: 33 year old nonsmoker female presented to her Pulmonologist complaining of wheezing. Initially intermittent when exposed to noxious stimuli, wheezing became more constant and associated with dyspnea on strenuous exertion. Given her history of atopy, it was thought that she was developing adult onset Asthma and was sent for Allergy evaluation and given a trial of dual long acting beta antagonist/Corticosteroid inhaler. Pulmonary Function Testing showed mild restrictive defect with normal spirometry and no evidence of airway obstruction. Fractional exhaled nitric oxide was not indicative of significant airway inflammation, making asthma unlikely. Chest x-ray demonstrated consolidation within the left lower lobe which was noted on prior X-ray. Computed Tomography of chest with contrast showed a heterogeneous soft tissue mass in the left hilar/infrahilar region measuring approximately 1.8 x 2.2 x 3.5 cm causing narrowing of the left lower lobe bronchus. Bronchoscopy with endobronchial ultrasound showed a friable mass, later confirmed to be well differentiated adenocarcinoma. Tumor markers demonstrated an anaplastic lymphoma kinase (ALK) gene rearrangement and staging studies revealed metastasis to the pleura and mediastinal lymph nodes.
Treatment was started with Crizotinib and patient was noted to have resolution of wheezing within a few weeks of initiating treatment. There was complete resolution of obstructing left lower lobe mass and no progression of metastatic disease at follow-up.
Discussion: It is estimated that there will be approximately 225,000 new cases of Lung cancer resulting in almost 160,000 deaths in the year of 2017. While awareness has improved, it is still thought of as a smoker’s disease. 20% of patient’s diagnosed with Non small cell lung cancer have never smoked before. Of that number 2-8% will have an ALK rearrangement, 50% are young, never smokers, female or of East Asian descent. This patient met three of these criteria.
Conclusion: Our patient underscores the increasing atypical presentation of non small cell lung cancer in young black women including mimicking Asthma. It is imperative that physicians pursue a thorough investigation excluding other potential etiology including lung cancer in adults presenting with new onset wheezing. This will further help to reduce delay in diagnosis of more serious causes and initiation of appropriate therapy to halt progression.