A 60-Year-Old Woman with Pulmonary Nodules

WHAT IS YOUR DIAGNOSIS? A 60-year-old woman was admitted due to persistent right-sided vague chest pain since two months ago. She also complained of 5 kg weight loss and productive cough. On admission, she was stable and afebrile with mild crackles in both lungs without tachypnea or remarkable respiratory distress. She lived in a rural region in southwest of Iran and was being treated with combined fluticasone-salmeterol and ipratropium bromide due to chronic bronchitis since five years ago. Exposure to biomass fuels used for cooking and heating was a possible etiology for her chronic respiratory symptoms. She denied using systemic corticosteroids in recent months. Laboratory analysis revealed normal complete blood count, arterial blood gases, liver and renal function tests, serum lactate dehydrogenase and angiotensin converting enzyme levels. Human immunodeficiency virus antibody was negative and plasma immunoglobulin revealed no abnormality. Chest roentgenographic studies (Figure 1) revealed multiple nodules in both lung fields. Based on chest computed tomography (CT) findings and negative repeated sputum smears, the patient underwent CT-guided biopsy of lung nodules. Histopathological examination was unremarkable and the procedure was complicated by pneumothorax. Finally, bronchoscopy and bronchoalveolar lavage were performed. No abnormality was detected in the airways.