1. NYU Medical Grand Rounds Clinical Vignette Benjamin Seides, MD, MPH PGY-3 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 70 year-old African American man presents with positive purified protein derivative test on screening medical exam. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. In the early 1970s, the patient had been incarcerated for three years. Two years prior to presentation, the patient had a negative purified protein derivative test. Three months prior to presentation, the patient was arrested and detained by the New York City Department of Corrections at Rikers Island. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. As part of a routine pre-incarceration medical work-up, he was noted to have a positive purified protein derivative test with induration of 16mm. Review of systems was negative for cough, fevers, or chills, and a chest x-ray performed at Rikers Island was reportedly within normal limits. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: Hypertension diagnosed at Riker’s Island Left eye blindness secondary to cyst removal surgery Past Surgical History: Left eye cyst removal Social History: 100+ pack year smoking history, current tobacco user Heavy ethanol use in past, intranasal cocaine abuser Incarcerated for three months prior to presentation, but lived alone in apartment in Harlem prior to arrest Widower, three children Retired building superintendent U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Family History: Negative for cancer Allergies: No Known Drug Allergies Medications: Hydrochlorothiazide 25mg by mouth daily Aspirin 81mg by mouth daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination General: Well nourished, well developed male appearing stated age in no apparent distress Vital Signs: T:99.0 BP:119/74 HR:87 RR:14 O2 saturation: 95% on ambient air Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: Within Normal Limits Basic Metabolic panel: Within Normal Limits Hepatic panel: Within Normal Limits Prostatic Specific Antigen 1.14 ng/ml (0-4) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Latent mycobacterium tuberculosis infection Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Given the positive purified protein derivative test and that patient had been previously incarcerated, he was referred for high-resolution non-contrast chest computerized tomography imaging Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. High-Resolution Chest CT Scan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. High-Resolution Chest CT Scan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. High-Resolution Chest CT Scan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Based upon the radiographic findings, the patient was referred for computerized tomography-guided biopsy of the right middle lobe mass by interventional radiology The patient was able to undergo the procedure without complication Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Cytology positive for adenocarcinoma Immunostains pending Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Patient was referred to medical oncology, and is scheduled for staging imaging prior to initiation of further treatment. Patient was also referred for treatment of his latent tuberculosis infection prior to initiation of chemotherapy. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Bronchogenic adenocarcinoma secondary to heavy tobacco abuse, complicated by concomitant latent tuberculosis infection Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS