1. The patient is now agreeable to biopsy. What is the cause of the mass 1. Lung cancer 2. Lung abcess 3. Metastatic renal cell cancer 4. Coccidiomycosis 5. Pseudotumor A Middle-Aged Man with a History of Renal Cell Carcinoma A 61 yo male was first seen in March, 2008 because of a lung mass. He was admitted in the for congestive heart failure. PMH includes:  Right renal cell carcinoma found incidentally in 2006 with subsequent right nephrectomy,  Obesity,  Type 2 diabetes mellitus,  Two previous myocardial infarctions,  Hypertension,  Obstructive sleep apnea  135 pack-year history of smoking.

2. Physical Examination Afebrile Obese Bilateral rales 2+ pitting pretibial edema.

3. Laboratory Sputum cultures for bacteria, fungi and tuberculosis were negative. Arterial blood gases were PaO2 82, PaCO2 25 and pH 7.44. Spirometry revealed FVC 2.36 l (43% predicted), FEV1 1.81 l (42% predicted) and FEV1/FVC 77%.

4. Chest X-ray and CT Scan PET scan showed a low uptake not consistent with lung cancer. What would you do?

5. Course Biopsy was recommended but the patient refused and he was treated with 10 days of oral doxycycline. A repeat CT scan was done 3 months later

6. Diagnosis? The patient is now agreeable to biopsy. How would you biopsy? What is the cause of the mass? 1. Lung cancer 2. Lung abcess 3. Metastatic renal cell cancer 4. Coccidiomycosis 5. Pseudotumor

7. Lung Abcess

11. Lung Abcess 4/6/2009

12. Subsequent Course He did well until January, 2010 Readmitted with shortness of breath and chest tightness. EKG showed atrial flutter with fast ventricular response-treated with esmolol. Spiral CT done for PE but none found EKG and serial troponins negative for myocardial infarction.

13. CT January 21, 2010

14. Hospital Course Treated with cephipime, piperacillin/tazobactam, and vancomycin later moxifloxacin when cultures negative. Developed hemoptysis. Bronchscpopy negative for blood or source. Developed respiratory failure and was intubated.

15. CXR 1/24/2010

16. Further Course Chest tube inserted with 450 cc of serosanginous fluid. Developed massive hemoptysis. Despite tamponade balloon hemoptysis continued. Family withdrew support and patient died on 1/28/2010.