A 73-year-old woman with a history of type 2 diabetes mellitus treated with antidiabetic drugs, ischemic heart disease, arterial hypertension and paroxysmal atrial fibrillation treated with amiodarone, oral calcium antagonists and platelets.
She reported a 2-month history of cough, fever and dyspnea.
Complementary tests showed normocytic anemia, hypoxemia, high levels of acute phase reactants and brownish infiltrates in both hemithorax with right pleural effusion.
Multiple microbiological, serological, cytological and imaging studies were performed, which were negative or normal.
The diagnosis of bronchiolitis obliterans presumptive with organizing pneumonia (BONO) was established and treatment with prednisone 60 mg/day was initiated with disappearance of fever and improvement of acute respiratory symptoms, anemia and anemia.
The patient was admitted again one month later due to dyspnea at rest, edema and oliguria.
Examination revealed tachypnea, tachycardia without murmurs, global decrease in vesicular murmur with base crackles and edema in lower limbs.
Laboratory tests revealed 20,600 leukocytes/mm3, with 85% polymorphonuclear, LDH 537 U/L 214 0-normal CA/L 249 U/L albumin 2.3 g/dL, pO2.
Hemoglobin, platelets, glycemia, bilirubin, renal function, electrolytes, calcium handling antigen, CA 125 and determination of thyroid hormones were normal.
Chest X-ray and chest computed tomography (CT) showed bilateral pleural effusion and increased bilateral density in the pulmonary parenchyma, predominantly perihilar.
The mediastinum was normal and there were no signs of pulmonary embolism on CT angiography.
Transthoracic echocardiogram and abdominal CT were normal.
Seizures were performed bilaterally obtaining in both cases a pleural fluid with exudate characteristics, triglyceride concentration of 433 mg/dL and 163 mg/dL respectively, and presence of chylomicron
Cytological and microbiological studies of pleural fluid were negative.
Bronchoscopy with transbronchial biopsy showed bronchial mucosa due to proliferation of adenocarcinoma cells.
Cytologies and microbiological studies of bronchoaspirate and bronchoalveolar lavage were negative.
Steroid dose was increased and treatment was performed with bilateral thoracic drainage tube and parenteral nutrition.
The subsequent evolution was characterized by progressive respiratory failure leading to death of the patient.
Necropsy revealed disseminated carcinomatous lymphangitis with involvement of the lungs, liver, pericardium, pancreas and adrenal glands, secondary to adenocarcinoma of unknown primary.
