Perplexing case of lung mass perfectly mimicking a malignancy

Abstract

A 35-year-old man, a known asthmatic and with a history of smoking presented with a history of recurrent episodes of mild haemoptysis. On examination, there was decreased intensity of breath sounds on the right infraclavicular area. The chest X-ray and CT chest showed a mass in right upper lobe with nodules in the other lobe. The VAT showed large heavily vascularised mass with surface laden with multiple nodules. The wedge resection of the mass was taken and sent for histopathology examination. The biopsy result showed picture suggestive of connective tissue disease associated follicular bronchiolitis. The patient did not have any signs or symptoms of connective tissue disease. However he was positive for Rheumatoid factor, ANA, anti-RO, anti-CCP antibodies. He was started on steroids and azathioprine. After 6 months of treatment, the size of the mass and nodules reduced by 50% and ESR was reduced to 5 from 75.

Keywords: bronchiolitis; connective tissue disease; interstitial lung disease; rheumatoid arthritis.

Figure 1

(A) The chest X-ray showed right upper lobe mass with golden S sign suggestive of right upper lobe volume loss . (B) The right lower lobe also showed centrilobular nodularity, interlobular septal thickening and tree-in bud appearance .(C,D) The CT chest showed right upper lobe occupied by soft tissue like structure with minute hyper-dense focus of calcification (reverse S sign).

Figure 2

Compared with CT chest (A,B) at the start of treatment, the repeat CT chest (C,D) showed almost 50% reduction in the size of the largest mass and reduced size of the other nodules after 6 months of treatment with steroids suggesting partial clinical and radiological response.

Figure 3

(A) The biopsy showed necrotising granulomas that are relatively well circumscribed and characterised by peripheral palisaded histiocytes which is typical of rheumatoid nodules . (B,C,D) Lymphoid follicles characterise the follicular bronchiolitis with well-developed germinal centres exquisitely localised to peribronchiolar interstitium where it is accompanied by peribronchial metaplasia .