Common things are common, but not always the answer

Abstract

We reviewed a 76-year-old lady with a persisting left upper lobe opacity on subsequent chest radiographs. She complained of weight loss but denied constitutional upset. Bloods showed raised IgG subclass immunoglobulins. Computed tomography (CT) of the thorax demonstrated consolidation in the left upper lobe and small volume mediastinal adenopathy. Bronchoscopy was negative and CT-guided lung biopsy showed only inflammatory tissue. This was repeated with a similar result. As there was no evidence of malignancy, our patient was commenced on oral steroids and was discharged. Unfortunately, she re-presented 4 years later following an episode of acute dyspnoea. She underwent a further CT of the thorax and CT-guided biopsy in order to rule out malignancy. Storiform fibrosis was noted on histology and a diagnosis of IgG4-related lung disease was reached. IgG4-related lung disease had clearly not been considered as a differential diagnosis in this case. We pushed to rule out malignancy but did not explore alternative diagnoses. This highlights the need to consider other conditions or they will be missed!