The Insidious Onset of Dyspnea and Right Lung Collapse in a 35-Year-Old Man* Syed F. Hussain, FRCP, FRCPE; Nawal Salahuddin, MBBS, FCCP; Aslam Khan, MBBS; Shafia S. J. Memon; Saulat H. Fatimi, MD; and Rashida Ahmed, FCPS (CHEST 2005; 127:1844 –1847) A 35-year-old man presented with 4-month history of cough, chest pain, and shortness of breath. There was no history of fever, hemoptysis, night sweats, weight loss, environmental/drug exposure, or foreign travel. He was a nonsmoker with no previous medical illness. Chest radiographic findings were reported as normal. He was treated with two courses of antibiotics and a cough suppressant. Over the next 2 months, his cough persisted and his weight de- creased by 2 kg. A repeat chest radiograph showed partial collapse of right lower lobe. He was unable to produce sputum, and was started on empiric qua- druple antituberculosis therapy. Just over 1 month later, central chest pain with worsening dyspnea developed. The chest radiograph now showed a complete collapse of the right lung. He was referred for further evaluation and management. Physical Examination On hospital admission, the patient was breathless at rest, with a respiratory rate of 28 breaths/min and pulse oxygen saturation of 82% on room air. He had a regular pulse of 102 beats/min, BP of 130/70 mm Hg, and body temperature of 37°C. He was of average build with no evidence of a multisystem disease, clubbing, or lymphadenopathy. Chest exam- ination revealed tracheal shift to the right accompa- nied with reduced chest expansion, dull percussion note, and absent breath sounds on the right side. Findings of a left-sided chest examination were normal. Laboratory and Radiographic Findings Hemoglobin was 16.2 g/dL with hematocrit of 48.7%, mild leukocytosis of 12.5  10 3 /L with neu- trophilia of 76%, and normal platelet count of 307  10 3 /L. Serum BUN, creatinine, electrolytes, coagulation, and albumin results were normal. Liver function test results were normal, except an elevated -glutamyltranspeptidase of 117 U/L. Arterial blood gases on oxygen (10 L/min by face mask) revealed pH 7.45; Paco 2 , 39 mm Hg; Pao 2 , 83 mm Hg; HCO 3 , 27.6, base excess, + 4.0; and oxygen satura- tion of 96.7%. A chest radiograph showed homoge- nous opacification of right hemithorax with right- sided mediastinal shift suggestive of right lung collapse (Fig 1). A CT scan of the chest revealed a mass lesion completely occluding the right main bronchus protruding above the carina, causing com- plete collapse of the right lung (Fig 2). There was no mediastinal lymphadenopathy. The left lung, liver, and adrenals were normal. Hospital Course The patient was suspected to have a carcinoid tumor. In view of severe symptoms and hypoxia, patient was scheduled for urgent bronchoscopy with a view to resectional surgery if feasible. After induc- tion of general anesthesia, a flexible fiberoptic bron- choscope was introduced. The trachea was normal. The right mainstem bronchus was completely oc- cluded with a smooth polypoid lesion that was protruding 1 cm above the carina but was not *From the Sections of Pulmonary Medicine (Drs. Hussain, Salahuddin, and Khan, and Ms. Memon) and Cardiothoracic Surgery (Dr. Fatimi), and Department of Pathology and Micro- biology (Dr. Ahmed), The Aga Khan University Hospital, Kara- chi, Pakistan. Manuscript received February 13, 2004; revision accepted June 8, 2004. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Syed F. Hussain, FRCP, FRCPE, Head of Pulmonary Section and Associate Professor, Section of Pulmonary Medicine, The Aga Khan University Hospital, Stadium Rd, PO Box 3500, Karachi 74800, Pakistan; e-mail: fayyaz.hussain@ aku.edu pulmonary and critical care pearls 1844 Pulmonary and Critical Care Pearls Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/22025/ on 06/21/2017