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Pulmonary puzzle
Bilateral pulmonary nodules in a patient with extensive autoimmune disease
  1. Sachin Patel1,
  2. Wael Nasser1,
  3. Rumi Khan1,
  4. Luis Herrera2,3
  1. 1 Pulmonary/Critical Care & Sleep Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
  2. 2 Thoracic Surgery, Orlando Regional Medical Center, Orlando, Florida, USA
  3. 3 Department of Thoracic Surgery, UF Health Cancer Center—Orlando Health, Orlando, Florida, USA
  1. Correspondence to Dr Sachin Patel, Pulmonary/Critical Care & Sleep Medicine, Orlando Regional Medical Center, Orlando, FL 32806, USA; sachin.patel{at}

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Clinical presentation

A 64-year-old woman presented to our hospital complaining of generalised fatigue and history of mechanical fall with rib fractures while in Africa. Chest X-ray (CXR) incidentally discovered multiple bilateral pulmonary nodules. She has a history of rheumatoid arthritis on methotrexate, Hashimoto’s thyroiditis, Sjögren’s syndrome (SS) and psoriatic arthritis on immunotherapy. She denied symptoms of cough, chest pain, dyspnoea, weight loss, night sweats, fever or haemoptysis. She denied smoking, alcohol consumption, illicit drug use and environmental exposures. She had a family history of lymphoma in sister but no personal/family history of arteriovenous malformations, hamartomas or vasculitis. CXR conducted 3 years prior showed no lesions. She was up-to-date with breast screening but refused colonoscopy. Physical exam was unremarkable.

On arrival to USA, chest CT confirmed bilateral nodules with lower lung predominance (figure 1) and positron emission tomography scan demonstrated hypermetabolic activity of the nodules. Lab work—blood count, metabolic profile, urinalysis, immunoglobulins, HIV, serum/urine protein electrophoresis and …

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  • Contributors SP, the principal author, made substantial contributions to study conception and design, acquisition, analysis and interpretation of data, and drafting and final revision of the manuscript. WN, the second author, made contributions by reviewing imaging, sources and references, helping to acquire patient consent and reviewing drafts for multiple revisions for flow, organisation and tone. RK, the third author, made significant contributions to drafting and final revision of the manuscript for important intellectual content. LH, the fourth author, made contributions by revising the initial manuscript drafts and making final revisions on word selection and grammar.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer All of the authors certify our affiliations and have no disclosures to report. We all certify that our affiliations with, or financial involvement with any organisation, or entity with a financial interest in, or financial conflict with the subject matter, or materials discussed in the manuscript are completely disclosed.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.