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NYU Medical Grand Rounds
Clinical Vignette
Benjamin Seides, MD, MPH
PGY-3
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 70 year-old African American man presents
with positive purified protein derivative test
on screening medical exam.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
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
Working Diagnosis
• Latent mycobacterium tuberculosis infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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
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
Clinical Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• Cytology positive for adenocarcinoma
• Immunostains pending
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Bronchogenic adenocarcinoma secondary
to heavy tobacco abuse, complicated by
concomitant latent tuberculosis infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS