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Dr. Andrew Rynne
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Dr. Andrew Rynne

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Suggest treatment for shortness of breath and chest irritation

Answered by
Dr.
Dr. Kaushal Bhavsar

Pulmonologist

Practicing since :2008

Answered : 14549 Questions

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Posted on Wed, 22 Feb 2017 in Lung and Chest disorders
Question: Hello doctor,

I'm a non-smoking 22 y/o male who's been through a battery of medical tests trying to find out what's wrong with me, and trying to figure out whether it is lung CA and what type it is or not.

If you'll bear with me, I'd like to share what I've had done so far. I don't really know anyone in my age group who is knowledgeable about lung cancer, so I don't really have a reference point for what to expect on the road to diagnosis.

=====

Symptoms:
1) Shortness of breath on even mild exertion (1.5 months)
2) Cough with white phlegm, occasionally yellow. w/ chest irritation (1 month)
3) Finger Clubbing (2 months)
4) Firm, fixed supraclavicular + posterior cervical lymph nodes (3.5 months):
-Supraclavicular lymph node: noticed in August 2016, was palpable but not firm/fixed; firm-ness gradually noticeable in October 2016 onwards
-Posterior Cervical Lymph node #1 (on side, mid neck) = palpable and moveable until December 2016, rapidly became firm and fixed
-Posterior Cervical Lymph node #2 (rear neck, where shoulder meets neck) = felt firm/fixed since September 2016, can feel progressively worsening shoulder/neck pain near it's location
5) Persistent fatigue (4 months)
6) Odd sharp pains in shoulder, back, and arms (1.5 months)

=====

Radiological Exams:
[1] Chest CTs:
>(12/22/16) CT Chest With Contrast...URL Link -> [https://goo.gl/cYOC9f]

>(12/02/16) HRCT Chest WithOut Contrast...URL Link -> [https://goo.gl/e0X9Q7]

[2] Neck MRIs: Concerned about lymph node growth between Two Exam Dates especially in Left Supraclavicular region, Left Posterior Base of Neck general area. Please also comment on any other lymphadenopathy if spotted

>(12/22/16) MRI Neck With and Without Contrast...URL Link -> [https://goo.gl/ftsEfc]

>(11/05/16) MRI Neck With and Without Contrast...URL Link -> [https://goo.gl/yYDN3K]

=====

Blood Test Results:
Results (from 12/22/16):

(Please See Attached)

=====

History:

Late September 2016 -- First noticed "hardening" of left supraclavicular lymph node. Size is about 1cm.

October 2016 -- Got the node checked out, both primary doctor and ENT can't really palpate it so they didn't order biopsy. Said to wait on neck MRI. Meanwhile, paranoid me went on Dr. Google and found the infamous "Virchow" node and worried that it was a signal of stomach cancer. So we did a upper GI endoscopy, which came back clean.

Early November 2016 -- Neck MRI results came back, radiologist report doesn't mention any node enlargement, so doctors even more adamant to not biopsy. I got an Abdominal MRI and MRCP, which came back negative. Supraclavicular node still there.

Late November 2016 -- Suddenly developed shortness of breath on minor exertion. Noticed fingers were Clubbing. Didn't respond to inhalers, so got referred to pulmonologist. Did Chest X-Ray and HRCT, both came back clean. Full autoimmune disease panel also came back negative. Pulmonary Function Tests came back with reduced diffusion and Restrictive Lung function...unexplained by tests.

Only abnormal things were in the blood tests: D-Dimer, Inflammatory markers (CRP, ESR), and some Blood Cells (Monocytes, Basophils) were moderately elevated.

Late December 2016 -- Shortness of breath, Clubbing still present. Newly onset cough. Had repeat Pulmonary Function Tests, which showed worsening of lung function...still without determinate cause. Blood results still abnormal, gradually worse. Got repeat Chest CT with Contrast this time...had like 3 different radiologists read it. One of them found a "mild geographic ground glass opacification" on my left lung. No evidence of any lung "masses" though, according to the reports. I went to get a second opinion from a different pulmonologist, who said that the ground glass thing was a very subtle finding that was also very nonspecific.

January 2017 -- Clubbing is worse. Doctors can still barely palpate the lymph nodes. We did a Neck CT w/ Contrast that showed multiple visible but subcentimeter nodes. Also in the neck there was some "mild, ill-defined soft tissue stranding", which as you might have guessed, again is very non specific.

Present -- We decided to go for it and order an Ultrasound-guided Core Biopsy of any Neck Lymph Nodes that we could get. Getting that done next week, and that might give us some answers.

=====

Concerns:

With my symptoms and past tests ruling out benign causes, it seems that the only differential diagnosis possibility is Lung Cancer. Since only finding was "mild ground glass opacification" I am worried that there is a rare but metastatic Lung Cancer of some kind.

1) The second Chest CT with Contrast showed "mild ground glass opacification", but "no mass". Furthermore, this finding was NOT present in the first Chest CT, so it must have appeared in a few weeks. I have attached the radiologist's report. Could this still be a presentation of bronchogenic CA?

2) We ruled out every autoimmune disease and interstitial lung disease, since those had blood tests in addition to the imaging. Whereas lung cancer would only have imaging to rely on...so isn't that the only remaining condition that we are less certain of ruling out?

3) The blood tests are concerning to me. Why are the basophils/monocytes, D-Dimer, and inflammatory markers elevated? They have been progressively increasing in past few months, not going down

4) Neck MRI findings included: "mild, ill-defined soft tissue stranding in left neck". Can you please explain what that means and whether it is concerning or not?

5) The lymph nodes being investigated are the supraclavicular and posterior cervical at the base of the neck. If they are indeed malignant, aren't these particular nodes most likely to point towards an abdominal or lung cancer? ...of which we've ruled out abdominal causes, leaving only lungs?

6) Are there any other tests we can do to determine the cause?

7) The shortness of breath is very concerning to me. I cannot breathe properly and my inhaled Breo Ellipta medicine does not seem to help either. What options are there to improve my breathing?

The shortness of breath is the most concerning, and in conjunction with worsening PFTs and Clubbing, I am worried about malignant process.

Lab Reports:
(Please refer to attached files): CBC, Inflammatory Markers, CMP, Urinalysis, Protime INR, Pulmonary Function Tests on (Dec.02, 2016) and (Dec. 22, 2016)
doctor
Answered by Dr. Kaushal Bhavsar 8 hours later
Brief Answer:
No need to worry for lung cancer.

Detailed Answer:
Thanks for your question on Healthcare Magic.
I can understand your concern.
I have gone through the reports you have attached.

Answer to your 1st question.

Some degree of interobserver variations in reporting of CT scan is common. So sone degree of ground glass opacity is not worrisome.

Answer to your 2nd question.

No, I don't think about lung cancer in your case. Possibility of some infection or inflammation is more likely.

Answer to your 3rd question.

On the basis of blood reports only I think about infection or inflammatory process.

Answer to your 4rth question.

No need to worry for this as this is insignificant.

Answer to your 5th question.

Most common cause for enlarged lymphnodes is infection. So enlarged lymphnode does not always suggest malignancy. And neck nodes are more commonly Enlarged in neck cancers like thyroid, ENT cancers.

Answer to your 6th question.

Yes, you should get done bronchoscopy and XXXXXXX (bronchoalveolar lavage) for infection. Also get done PCT (procalcitonin) to rule out bacterial infection.

Answer to your 7th question.

No need to worry much for shortness of breath as your PFT values are not much deteriorating, they are almost same.

Hope I have solved your query. I will be happy to help you further. Wish you good health. Thanks.


Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Kaushal Bhavsar 22 minutes later
Thank you for responding doctor. I have a few more follow-up questions, if you don't mind. Sorry if it seems excessive, I'm just trying to cover all bases here

(i) Just to be safe, would you mind looking through the links/URLs to the imaging exams I have provided (unless you already have)? What is your interpretation of findings based on your observer perspective?

(ii) I am getting Arterial Blood Gas on room air this week. Will that give us any new information?

(iii) What could be causing the nail clubbing?

(iv) As for bronchoscopy procedure, I am unsure about doing it for a few reasons. First, is that I am concerned about complications of collapsed lung or additional infection. Second, I am not sure how my pulmonary physician can justify a bronchoscopy Order with a relatively nonspecific CT finding.

(v) Any additional less-invasive tests than bronchoscopy/BAL we can do quickly to get clues on diagnosis?

(vi) I know you mentioned that PFTs are roughly the same. But DLCO seems a bit low in both cases, and below LLN on more recent PFT. Why could this be happening and is it a reversible/improvable process?

(vii) What is the possible differential dx if (a) infection? and if (b) inflammation? Is ILD still possible?

(viii) As in (vii)...possible treatments. If infection, treatment is antibiotics, right? If inflammation, what are the options? Is any lung damage sustained from infection/inflammatory process reversible or is the treatment only to prevent further deterioration?

Thank you very much, doctor!
doctor
Answered by Dr. Kaushal Bhavsar 17 minutes later
Brief Answer:
Send me the image of your Clubbing fingers.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
No worries, I am here to solve your doubts only.
For Clubbing, it would be of great help if you can send me pictures of your Clubbing fingers.
And sorry to say but I can not open these links provided by you.
Can you please take screenshots and send them as attachments?
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar 1 hour later
Ok doctor, I have uploaded the picture of my fingers and I have tried my best to provide as much of the CT scan images of the GGO region as possible. Both of these should be available underneath the attachments/reports section.

By "not able to open these links", do you mean the link is not working or opening the links is not permitted? Because if the link isn't working, I'm sure we could find an another way.

But...if links aren't permitted, how can I best share all the study images with you? They are large files and only a few will fit as direct attachments.

doctor
Answered by Dr. Kaushal Bhavsar 28 hours later
Brief Answer:
I am unable to open the links.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
Sorry for late reply as I was busy yesterday.
I can have gone through the images you have provided.
By looking at your fingers, I don't think you are having visible Clubbing. So no need to worry too much for this.
And sorry to say but I am unable to open the links provided by you.
And no need to worry for ground glass opacities as they are also nonsignificant.
Have you tried oral steroids?

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar 10 hours later
Ok doctor, thanks for the response.
No, I have not used oral steroids yet. We should wait for a correct diagnosis before starting course of those oral steroids, right?

Also, would you mind answering the several numbered (i), (ii), etc. follow-up questions from a few posts earlier?

Thank you!
doctor
Answered by Dr. Kaushal Bhavsar 22 hours later
Brief Answer:
Yes, you are right.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
Yes, you are right. We should first reach the diagnosis and then start steroids.
And which question s are you talking about?
I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar 51 minutes later
(i) What could be causing the nail clubbing?

(ii) Any additional less-invasive tests than bronchoscopy/BAL we can do quickly to get clues on diagnosis?

(iii) I know you mentioned that PFTs are roughly the same. But DLCO seems a bit low in both cases, and below LLN on more recent PFT. Why could this be happening and is it a reversible/improvable process?

(iv) What is the possible differential dx if (a) infection? and if (b) inflammation? Is ILD still possible?

(v) As in (iv)...possible treatments. If infection, treatment is antibiotics, right? If inflammation, what are the options? Is any lung damage sustained from infection/inflammatory process reversible or is the treatment only to prevent further deterioration?
doctor
Answered by Dr. Kaushal Bhavsar 2 days later
Brief Answer:
Sorry for late reply as I was very busy.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
First of all extremely very sorry for late reply as I was very busy.

Answer to your 1st question.

I don't think you are having nail Clubbing. Mostly you have noticed your nails after your symptoms and you started believing that it is Clubbing. Do you have any before after kind of picture of your nails?

Answer to your 2nd question.

You can get done induced sputum examination for culture and microscopy. Induced sputum means sputum after giving mucolytic any expectorant drugs. I don't know whether doctors in your part of world are practising this or not.

Answer to your 3rd question.

With normal hemoglobin and normal CT scan, no need to worry for this little lesser DLCO value. Since PFT is effort dependent test, this kind of variations are acceptable.

Answer to your 4rth question.

No need to worry for ILD. Possibility of viral or atypical bacterial or fungal (rare) is more. Inflammation due to any inhaled agent like chemicals, dust, smoke, gas etc is also a possibility.

Answer to your 5th question.

If it is atypical bacterial infection then azithromycin is the drug of choice. It is viral infection then acyclovir or valcyclovir are the options. It is inflammation then oral steroids are the treatment of choice. Usually all these are reversible with early treatment but it this stays long (1-2 years) then possibility of irreversible lung damage is high.

Hope I have solved your query. I will be happy to help you further. Wish you good health. Again sorry for late reply. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar 2 days later
Thank you for the response doctor.


I have attached a more recent CBC test from this month.

It seems like hemoglobin and mch and mchc are worse compared to previous test (even though technically still within reference range).

(A) Does the trend in hemoglobin, mch, mchc, etc. indicate anything worrisome?

Also, I have attached a report of Stress Echocardiogram.

(B) Could you please review Stress echo and see if any of those point towards vascular issues with Lungs like Pulmonary Artery Hypertension etc?

doctor
Answered by Dr. Kaushal Bhavsar 4 hours later
Brief Answer:
No need to worry for pulmonary artery hypertension.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
I have gone through the new reports you have attached.
No need to worry for pulmonary artery hypertension and no need to worry for hemoglobin and other values as all are normal values.
Hope I have solved your query. I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Kaushal Bhavsar 18 hours later
Hi doctor,

Thank you for your response.

As for the clubbing, I definitely did not have it prior to October 2016. From October to November 2016, I had gradual loss of usual angle between nail and nail bed. Then from December to now, nails have been rounding out as well.

I am in the United States. My pulmonary doctors have never mentioned induced sputum examination, so I'm not sure if we even have that test here. Is it dangerous/complications? If not, then I will be sure to ask about it, since it's noninvasive.

a) Based on this, why has clubbing started with such a sudden onset? Also, does that explain strange pains I am having near fingertips/joints?

b) Is there anything I can do to alleviate the shortness of breath?

c) How reliable is pulse oximetry in showing oxygen saturation? How well does it correlate to arterial blood gas analysis? Up to what point is the correlation reliable?

-I have attached the Chest CT and Neck CT/MRI scans as a repository of .zip files. These .zip files contain plain images exported from the scan. Please review and comment on the findings I have mentioned that we have discussed.

Here is the Google Drive link to the Chest and Neck scans ==> https://drive.google.com/open?id=0B8VVRuIADGiaS3k0dVdaQUxRTVE

d) How large would you estimate the dimensions of the left supraclavicular and posterior cervical nodes are? Are there any strange/suspicious patterns maybe hinting at malignancy? Are they large enough to obtain a FNAC or core biopsy on?

e) Ground glass opacity is also seen in bronchioalveolar carcinoma, right? I know I sound paranoid, but is that condition possible w/ my presentation?

Sorry to bother you with so many questions, but my symptom presentation and test findings are so strange that I'm trying to get some sort of idea of what's going on. I am in a strange limbo where we have done nearly all the non-invasive tests, but don't have enough justification to do invasive tests. So we don't have any definitive answers from prior tests and no real way to perform new tests for answers.
doctor
Answered by Dr. Kaushal Bhavsar 3 days later
Brief Answer:
No, induced sputum is not dangerous.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
Sorry for late reply.

Answer to your 1st question.

No, induced sputum is not dangerous. It is not having any complications.

Answer to your 2nd question.

In my opinion, you are not having Clubbing.

Answer to your 3rd question.

Pulse oximetry is usually accurate except hypotension and extreme tachycardia. Pulse oximetry denotes only oxygen saturation in blood while arterial blood gas (ABG) analysis denotes more information like partial pressure of oxygen, carbon dioxide, bicarbonate, sodium, potassium etc. If you compare pulse oximetry and ABG, ABG is more accurate but It invasive test and costly also.

Answer to your 4th question.

I am not able to open the link so these questions are not possible to answer.

Answer to your 5th question.

Yes, ground glass opacities can be seen in bronchoalveolar carcinoma. But it is not common. Consolidation is more common in it.

Hope I have solved your query. I will be happy to help you further. Wish you good health. Thanks. Again sorry for late reply.

Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Kaushal Bhavsar 29 minutes later
Hi doctor,

Thank you for your response.

By unable to open the links, do you mean you are not permitted to or the links are not working?

If link is not working, please try: https://goo.gl/m0gEWj
If that too isn't working, please refer to CT_Chest_GGO.pdf file I have uploaded in attachments section previously.

First of all for the pulse oximetry. Sometimes I have had fast heartrate, like about 110 bpm. It usually varies between 80 to 115 bpm depending on time. And pulse oximetry usually shows between 97-99% saturation for me.

--Would this heartrate reduce the accuracy of pulse oximetry? Assuming it doesn't, is the given O2 saturation adequate and likely to correlate well with ABG?

===


--What ground glass opacity features are seen in bronchoalveolar carcinoma? Are any of those visible in my scan?

--What do you mean by consolidation? Do you mean like a mixed-solid/GGO region? Or a solid mass elsewhere in the lungs?

According to a PubMed study, I had seen on malignant vs. benign GGOs: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000/

They had concluded that: "In conclusion, an fGGO nodule with lobulation, a well-defined but coarse interface and pleural indentation gives a greater than average likelihood of being malignant."

--I have heard that malignant GGOs tend to have those ^above^ certain characteristics. Does mine appear to have any of those?
doctor
Answered by Dr. Kaushal Bhavsar 16 hours later
Brief Answer:
Yes, your oxygen saturation is normal. No need to worry for this.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
'not able to open 'means there is some error flashing everytime I try to open these links.
And for heart rate upto 110 bpm, pulse oximetry is accurate. For heart rate more than 170 bpm, pulse oximetry can give false interpretation.
Yes, your pulse oximetry reading an ABG are correlated.
No need to worry for this.
Please let me know
1. Are you single?
2. Do you have stressful life?

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar 12 hours later
Thank you for your response doctor.

I have attached a document titled "Radiology_Links.pdf" which contains studies and their corresponding DICOM viewer and/or pure JPEG links.

Please try that out and let me know if you can access the links.

In response to your questions,
1. Yes I am single
2. I have a busy life, but it is not very stressful, except for worries about health issues
doctor
Answered by Dr. Kaushal Bhavsar 2 days later
Brief Answer:
Yes, I have seen the images.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
Sorry for late reply.
I have seen the images.
No need to worry cancer.
And consolidation means air sonogram, infiltration. It is more commonly seen in pneumonia.
No need to worry for Bronchoalveolar Carcinoma (BAC).
In my opinion, you should also consult psychiatrist to rule out any psychiatric pathology.
Hope I have solved your query. I will be happy to help you further. Wish you good health. Thanks. Sorry again for late reply.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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