Respiratory Therapist/Second opinion
QUESTION: Hi Stephanie,
Six months ago I moved to Phoenix, AZ from the Midwest and have had nothing but lung problems since I moved here. (Probably due to the dust and pollution.)
Anyway, after experiencing shortness of breath, night sweats, fatigue, and lung soreness, my doctor ordered an x-ray which was abnormal. She was concerned so she sent me to get a cat scan a few weeks later. My doctor thought I may have Valley Fever or TB but my blood work came up negative. The only thing that is a fact is that I have lymphadenopathy which shows up on the x-rays. But doctors are not sure what is causing it.
She cannot diagnose me and is sending me to a pulmonologist and maybe to get a lung biopsy too.
I am a healthy, middle aged, fit person. Non smoker, non drinker, health conscious.
Here are the results of my Cat Scan:
Lungs: Multiple bilateral upper lobe suprahilar subcentimeter nodular airspace opacities in a peribronchovascular distribution.
Right lower lobe pleural-based 5mm nodule, posterior. Nodular thickening within the minor fissure.
Calcified left lower lobe granuloma. No consolidation, effusion or pneumothorax.
Lymph Nodes: Bilateral hilar and mediastinal adenopathy. A few of these lymph nodes demonstrate internal speckled calcification
Impression: Multiple perihilar pulmonary nodules. Bilateral hilar and mediastinal lymphadenopathy. Some of these lymph nodes are calcified.
Considerations include sarcoidosis, glaucomatous /fungal etiologies, less likely lymphoma and metastatic disease. Transbronchial biopsy may be considered for further evaluation.
ANSWER: Hi Todd,
Granulomas are small masses of immune / inflammatory cells at sites of infection or inflammation that essentially envelope the offending agent in an effort to get rid of it. Sometimes, over time, these will go away on their own and sometimes they will become calcified. Calcification seems to indicate that they occurred in the past. Often people have no idea they have granulomas until they have an x-ray or cat scan because often there are no symptoms and these are generally not considered a problem.
In your case, you have symptoms, and you have the hallmark for sarcoidosis which is bilateral hilar lymphadenopathy. This basically means that your lymph nodes on both sides of the hilum, which is the root of the lung where blood and lymph vessels, nerves, etc. enter and leave the lungs, are enlarged. Swollen lymph nodes are usually associated with injury or infection in or near the particular area they serve.
Sarcoidosis is considered to be the most common non-infectious cause of granulomas although no specific causal agent(s) have yet been clearly identified but it is not caused by smoking (in fact is inversely associated). On the other hand, fifty percent of granulomas have a fungal or mycobacterial origin so these must be ruled out before a diagnosis of sacoidosis can be confirmed, usually definitively by biopsy but, and by ruling out any other suspects. Your results for TB and valley fever were negative ruling out these particular mycobacterium and fungal suspects. Valley fever is produced by a fungus in soil, that may be inhaled with dust, and not uncommon in Pheonix and the southwest U.S. Histoplasmosis is another fungal agent, found in bird droppings, and the most common initiator of granulomas especially in eastern and central U.S. There may or may not be others your doctor will want to exclude, this usually depends on the situation and your occupational, medical and personal history. Sometimes effects may be produced many years after an exposure to certain agents or may recur with symptoms even though the initial event was asymptomatic. Also, some features of sarcoidosis on CT or x-ray are also similar to some other conditions such as some metastases or cancers so these must also be considered.
It appears that your doctor is following what seems to be the most likely path according to the CT results and your symptoms. But you have a broader perspective and if you are not comfortable with the situation you might want to see a specialist that has more experience in this area. Perhaps, since a pulmonologist consult has been suggested by your doctor you could find one with the appropriate expertise who can also give you a valuable second opinion and either affirm your doctor's preliminary diagnosis and course of action or offer some more appropriate alternative accordingly.
I hope that you feel better soon and that you will experience a full and uncomplicated recovery.
---------- FOLLOW-UP ----------
QUESTION: Hi Stephanie,
Wow that was awesome. Thanks for information.
Histoplasmosis runs in our family. I grew up on a farm in Midwest (Illinois) and played basketball in haybarns and went inside chicken coops a lot when I was young. My sister is losing her eye sight due to histoplasmosis as well as my mother.
I was diagnosed with having "old granulamtaous disease" 20 years ago because it showed up on x-rays as having calcifications in both lung fields.
Its ironic, I never had any symptoms in the Midwest, however, 6 months after moving to Arizona I woke up wheezing and feeling like I had bronchitis. The problem is it never went away completely and I am exhausted so much that its hard to hold a full time job.
I lived In Las Vegas for a year and developed Epstein Barr virus there and has lung issues there too. Maybe the desert is bad for my lungs with the dust and pollution.
Since I never had lung problems in the Midwest I am moving move back there and hopefully this Sarcoidosis(or whatever it is) will go into remission.
I have been out of the loop for the last week so I just wanted to say you're welcome and I hope you are feeling better.
Also, I am very sorry to hear about the vision problems of your mother and sister due to histoplasmosis. Although vision effects appear to be rare, it seems even mild cases of histoplasmosis can lead to visual problems years later so it is important for anyone who has had it to be checked if even slight changes in vision occur (according to the National Eye Institute).
I hope that you have already had or have planned follow-up. If so great, you can stop reading here. In case you had not planned to follow-up I wanted to encourage you to, so I wrote a little more. I could not tell from your reply whether you were planning to move back without follow-up and hope for the best.
Follow-up is as important as initiation on the path of due diligence so do not be discouraged by the seeming complexity and time involved in the process. Remember, your CT scan did not provide a definitive diagnosis, it provided information about structural changes in your lungs that are suggestive of certain abnormal conditions or processes, according to interpretaton, but that require further testing for accurate determination. And this determination is necessary to know whether specific interventions are required or not. You do not want to assume no treatment is necessary if a condition is present that requires timely and specific treatment, nor do you want to be treated for something that may not need to be treated. That is why your doctor wants an evaluation by a pulmonologist, who is more likely to be able to assess the situation definitively. This is a good opportunity to learn all you can about your lung health and get any questions answered and concerns addressed. So foster effective two-way communication between yourself and your doctor(s) and be sure to get any testing procedures and results, diagnois, prognosis, therapeutics, implications etc. explained thoroughly, in a personal context, and to your satisfaction, so you can take an informed and interactive role in your healthcare now and in the future.
Hopefully the experience will provide you with peace of mind, symptom relief, and a path to better long-term health.