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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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