CHEST Guidelines-A-40-Year-Old-Woman-With-Multiple-Pulmonary-Nodule

A-40-Year-Old-Woman-With-Multiple-Pulmonary-Nodule

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A 40-year-old nonsmoking woman with a history of idiopathic thrombocytopenic purpura was evaluated for multiple pulmonary nodules after experiencing fatigue, lack of energy, and exertional dyspnea for two years. Initial imaging showed bilateral pulmonary nodules, which were confirmed by a CT scan revealing multiple nodular lesions in all lung lobes, with sizes varying between 1.1 and 2.0 cm. Despite multiple inconclusive biopsies, an open lung biopsy was considered, ultimately leading to a right video-assisted thoracoscopy, which identified pulmonary hyalinizing granuloma (PHG). This rare, benign condition involves slowly enlarging parenchymal nodules often associated with autoimmune phenomena or fibrotic processes like sclerosing mediastinitis.<br /><br />PHG is believed to stem from abnormal immune responses to previous infections, possibly leading to fibrogenic reactions to persistent antigens. Patients typically present with vague chest-related symptoms, and while imaging often mimics malignancy, a biopsy is required to confirm diagnosis. Although treatment protocols have not been established given its benign nature, corticosteroid trials have shown variable success in reducing nodule size in some cases.<br /><br />Radiologically, PHG is characterized by well-circumscribed nodules, which can be multi-lobar, bilateral, or even solitary. These nodules often exhibit a “feeding vessel sign” on imaging. Differential diagnoses include metastatic diseases, benign neoplasms, and granulomatous infections.<br /><br />The discussed patient with PHG was discharged in stable condition without specific treatment, with ongoing monitoring advised due to the potential associations with other fibrotic conditions. This case exemplifies the importance of considering PHG in differential diagnoses of multiple pulmonary nodules, particularly when autoimmune or extrapulmonary manifestations are present. Despite the challenges in establishing a diagnosis, the prognosis is typically excellent given the non-malignant nature of PHG.

Keywords

pulmonary hyalinizing granuloma

idiopathic thrombocytopenic purpura

pulmonary nodules

autoimmune phenomena

fibrotic processes

video-assisted thoracoscopy

immune response

corticosteroid treatment

differential diagnosis

benign condition