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Peter Michael M.D.
Peter Michael M.D., Doctor
Category: Health
Satisfied Customers: 37
Experience:  Licensed Physician, 4 years. Radiologist, focused interest in educating people in imaging studies
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I had some twinges of pain in my left breast and went to my

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I had some twinges of pain in my left breast and went to my pcp-prescribed a mammogram and a chest x-ray. The mammogram was clear, chest x-ray showed an infiltrate on the left upper lobe of lung. CT scan showed same, but was not clear. Pet scan followed - hot spot showed carcinoma that has metastisized-abdominal wall/rib/mediatinum (diagnosed with cancer by radiologist-both pulmonologists said he should not have done this). Pulmonologist did bronchoscopy-showed NO malignancy but also neg for bact, fung & TB. Tests showed very focal inflamed granuloma filled with mucoid fluid-non caseating/no necrosis. Blood tests showed same neg results (bac & fungal), normal CBC, no rhem. arth or lyme disease)and kidney & liver function norm. I have been fevered lately (some night sweats) & nauseous (vomited once) and still experience chest/back/leg joint pain, but not like it was when this began in late September (appears to be getting better). O2 level blood 100%, normal blood pressure. I am 31 years old, had slight cough with brown/green sputum (never blood) for years (diagnosed with asthma in 2000) but this cough/sputum stopped when I quit smoking(over a month ago) after 14 years (pack a day). I've seen two pulmonologists-still no answer. Follow-up ct scan in 5 days to see if granuloma is still present. Before this, I had not been ill(other than a cold here and there)since I had walking pneumonia in 1999. Please help...before 9/26/08, I thought I was incredible healthy (normal pap smear in 7/08)!
Have you had a TB test performed?

Have you had blood work performed?

Any other findings on the CT scan besides the infiltrate in the left upper lobe?
Customer: replied 7 years ago.
Dr. Michael, yes, I was tested for TB. In fact, the biopsy sample was cultured for TB, Fungus and Bacteria. Plus, I did have bloodwork done...several times. The first set of bloodwork was before the bronchoscopy---CBC- NORMAL. Second was for the following tests, all NEGATIVE: rheumatoid factor (ANCA), Histoplasma (urine), Coccidioides antibody, Blastomyces antibody, Anachoice screen w/ refl to Titer. The third set of bloodwork was for CBC again (STILL normal), urinalysis normal, kidney function normal, liver funcion normal, blood glucose level-91. Vital statistics are good--temp 98.1, pulse 106 (reg) , respirations-14 (unlabored), b.p.110/70, Pulse Ox 100%. To reiterate, I am 31, in good physical shape (5;5", 130lbs.), and I have no history of lung cancer in my family. I also have NO drug history and have maybe 3 alcoholic beverages a yearThe ct scan report performed on 10/2/08 reads as follows, 'An irregularly shaped stellate opacity is present in the left upper lobe. It measures approx. 1.8 x 1.7 cm. While the patient is fairly young for a lung tumor, because of the morphology of this opacity, I would strongly recommend a PET scan for further evaluation. No other pulmonary opacity is seen. No chest wall mass is identified. No enlarged lymph nodes are seen in the mediastinum. There is no pleural effusion. No definite hepatic mass is seen on this noncontrast study. No adrenal mass is identified.' The PET scan on 10/7/08 (read by same radiologist as CT scan) states, 'Left upper lobe catcinoma with mediastinal metastases and probable left lateral abdominal wall/left lateral rib metastasis.' Bronchoscopy 10/16/08: specimen bronchoalveolar lavage specimen...'negative for malignant cells. There is no evidence of a malignant process. There is also no evidence of an active inflammatory process.' Surgical pathology report states, 'non necrotizing well formed granulomas are present. Background pigmented macrophages and lobular spaces compatible with findings of smokers lungs. No carcinoma is identified. Areas of granulomatous inflammation had been cut through and could not be fully evaluated on special stains. Clinical correlation suggested regarding the sampling, as it is possible this could represent non specific reactive changes adjacent to an unsampled mass.' Diagnosis states, 'lung, upper left lobe, transbronchial biopsy: very focal non necrotizing granulomatous inflammation. Background changes of smokers lung.' I have been smoke free since this all began and I do breathe better--no wheezing, coughing or sputum.**Sorry for the long answer, but I seem to be a medical mystery. Please advise as best you can. Thanks so much! Lesley
Thank you for the additional information. You sure have an extensive medical history.

The only additional diagnosis I can think of that may produce non-caseating granulomatous disease is sarcoidosis. This disease can be elusive, but definitely should be considered. It is usually diagnosed with blood 'ACE' levels, and additionally there is a skin test available for this diagnosis. 'ACE' stands for acetylcholinesterase, and is abnormally elevated in sarcoid.

Additionally, granulomas can create "false positive" results on PET scans, so with the pathology report confirming a granulomatous reaction, I would not be overly concerned that it is cancer.

I would also consult a rheumatologist. Rheumatoid arthritis can present with lung nodules, but not all cases of rheumatoid have positive rheumatoid factor in blood tests. It should be diagnosed clinically, and not from a single lab result.

Hope this helps. All the best.
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