Abstract Introduction Lung adenocarcinoma can present as a variety of radiological findings, from ground glass nodules to large solid masses. They can also present atypically, mimicking other pathologies. We describe a case of lung adenocarcinoma presenting as bilateral, fluctuating pulmonary infiltrates. Case A 61-year-old female with remote history of colon cancer was treated for community acquired pneumonia with initial imaging showing a dense right lower lobe (RLL) infiltrate with patchy ground-glass infiltrates spreading to the right middle (RML) and left lower lobes. Three months later, she developed a right lower extremity deep vein thrombosis and started apixaban. Despite anticoagulation, she developed an acute pulmonary embolism with corresponding imaging showing dense RLL consolidation and extensive ground-glass opacities bilaterally. She was again empirically treated for pneumonia. One week later, she was admitted with worsening hypoxia and imaging showing severe multifocal consolidations in the RML and RLL. Antibiotics were broadened and infectious and rheumatologic workups were unremarkable. On day 6, bronchoalveolar lavage and transbronchial biopsy were performed in the RML. Infectious workup and cytology returned negative. On day 7, anisocoria prompted head imaging, which showed multifocal infarcts and intraparenchymal hemorrhage. Imaging of the abdomen and pelvis did not show any evidence of malignancy. High dose steroids were started and slowly tapered with slight improvement in respiratory status. Her transbronchial biopsy resulted on day 18 with TTF-1 positive adenocarcinoma. Cell free DNA testing from the blood showed EGFR (+) consistent with lung primary. Carboplatin and pemetrexed were started with slow clinical improvement. On day 34, she became unresponsive and died after transitioning to comfort care. Discussion Lung adenocarcinoma represents 50% of lung cancers with risk factors including tobacco use, family history, environmental exposures. It is also the most prevalent lung cancer in non-smokers, particularly women. It has varying radiologic presentations, from ground-glass nodules to solid mass lesions. Our patient had multifocal patchy ground-glass and consolidative opacities that initially pointed toward infectious or rheumatologic etiologies. The differential was broadened to include malignancy, which required a tissue biopsy given the low sensitivity of bronchoalveolar lavage for adenocarcinoma. Clinicians should maintain a high index of suspicion for malignancy in this situation as this diagnosis may be missed, delaying treatment. Conclusion We report a case of lung adenocarcinoma that presented atypically with bilateral pulmonary groundglass opacities and consolidations. While uncommon, lung cancer must be considered in patients with these non-resolving radiologic findings and negative infectious and autoimmune workup. This abstract is funded by: None
Shyu et al. (Fri,) studied this question.