NYU Medical Grand Rounds Clinical Vignette

Benjamin Seides, MD, MPH

PGY-3

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 70 year-old African American man presents with positive purified protein derivative test on screening medical exam.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•In the early 1970s, the patient had been incarcerated for three years.

•Two years prior to presentation, the patient had a negative purified protein derivative test.

•Three months prior to presentation, the patient was arrested and detained by the New York City Department of Corrections at Rikers Island.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•As part of a routine pre-incarceration medical work-up, he was noted to have a positive purified protein derivative test with induration of 16mm.

•Review of systems was negative for cough, fevers, or chills, and a chest x-ray performed at Rikers Island was reportedly within normal limits.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:•Hypertension diagnosed at Riker’s Island•Left eye blindness secondary to cyst removal surgery

•Past Surgical History:•Left eye cyst removal

•Social History:•100+ pack year smoking history, current tobacco user•Heavy ethanol use in past, intranasal cocaine abuser•Incarcerated for three months prior to presentation, but lived alone in apartment in Harlem prior to arrest•Widower, three children•Retired building superintendent

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Family History:•Negative for cancer

•Allergies: •No Known Drug Allergies

•Medications:•Hydrochlorothiazide 25mg by mouth daily•Aspirin 81mg by mouth daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: Well nourished, well developed male appearing stated age in no apparent distress

•Vital Signs: T:99.0 BP:119/74 HR:87 RR:14

O2 saturation: 95% on ambient air

Remainder of physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC: Within Normal Limits

•Basic Metabolic panel: Within Normal Limits

•Hepatic panel: Within Normal Limits

•Prostatic Specific Antigen 1.14 ng/ml (0-4)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Latent mycobacterium tuberculosis infection

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Given the positive purified protein derivative test and that patient had been previously incarcerated, he was referred for high-resolution non-contrast chest computerized tomography imaging

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

High-Resolution Chest CT Scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

High-Resolution Chest CT Scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

High-Resolution Chest CT Scan

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Based upon the radiographic findings, the patient was referred for computerized tomography-guided biopsy of the right middle lobe mass by interventional radiology

• The patient was able to undergo the procedure without complication

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Cytology positive for adenocarcinoma

• Immunostains pending

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient was referred to medical oncology, and is scheduled for staging imaging prior to initiation of further treatment.

• Patient was also referred for treatment of his latent tuberculosis infection prior to initiation of chemotherapy.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Bronchogenic adenocarcinoma secondary to heavy tobacco abuse, complicated by concomitant latent tuberculosis infection

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS