CHEST Guidelines-A-70-Year-Old-Man-With-Large-Cervical-and-Mediasti

A-70-Year-Old-Man-With-Large-Cervical-and-Mediasti

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The case report presents a 70-year-old man with enlarged mediastinal and cervical lymphadenopathies, who had experienced atypical chest pain and generalized weakness for two weeks. Despite normal basic laboratory findings and pulmonary function tests, imaging revealed enlarged lymph nodes with calcifications in the paratracheal, subcarinal, and right hilar regions. His medical history included hypertension and onychomycosis.<br /><br />Initial differential diagnosis included several conditions such as sarcoidosis, tuberculosis, cancers, lymphoma, and infections. Biopsies of lung parenchyma and bronchial wall showed only mild inflammation with no malignancy. Further biopsy analysis revealed the presence of amyloid deposits, specifically presenting as Congo-red positive and exhibiting apple-green birefringence under polarized light. Further examinations confirmed the diagnosis of primary amyloidosis localized to pulmonary lymph nodes without systemic involvement, as there was no evidence of systemic amyloidosis from serum, urine analyses, or bone marrow biopsy.<br /><br />Amyloidosis includes the extracellular deposition of fibrillar proteins. The two main types discussed are AL (amyloid light chain) amyloidosis, often associated with systemic involvement, and AA (secondary) amyloidosis related to chronic inflammatory conditions. Localized pulmonary amyloidosis can present as diffuse interstitial, nodular, or lymphadenopathic forms with varying prognoses and management strategies. Common symptoms include shortness of breath and cough, occurring due to airway obstruction by amyloid deposits.<br /><br />Radiologic examinations are often nonspecific but may show nodular and interstitial changes with potential calcifications. Diagnostic challenges necessitate biopsy for definitive diagnosis. Treatment varies and includes observation for the nodular form to systemic therapy for diffuse involvement. In this case, the treatment for localized lymph node amyloidosis was conservative, and the patient responded well to dexamethasone. He was simultaneously treated for latent tuberculosis. Overall, this case emphasizes the diagnostic complexity associated with pulmonary amyloidosis and highlights the importance of histopathological examination for definitive diagnosis.

Keywords

mediastinal lymphadenopathy

cervical lymphadenopathy

amyloidosis

pulmonary lymph nodes

differential diagnosis

biopsy

Congo-red positive

localized amyloidosis

dexamethasone treatment

latent tuberculosis