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A pulmonary mass and hyperviscosity
  1. J A Corlessa,
  2. D J Allsupb,
  3. T J Deebleb,
  4. J C Delaneya
  1. aArrowe Park Hospital, Arrowe Park Road, Wirral, Merseyside L49 9AB, UK: Department of Respiratory Medicine, bDepartment of Haematology
  1. Dr Corless, c/o Dr Delaney's secretary (email: johncorless{at}hotmail.com)

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Answers on p 587.

A 69 year old woman was referred to hospital because of a persistent dry cough and dyspnoea. She has never smoked and was taking captopril for hypertension and thyroxine for hypothyroidism. At age 20 she developed pulmonary tuberculosis which was treated with a left artificial pneumothorax. A few years later during the course of investigation into infertility she was found to have tuberculous endometriosis and salpingitis. This was treated with streptomycin injections and isoniazid.

A large mass measuring 10 cm × 9 cm was seen on chest radiography (see figs 1 and 2). Computed tomography of the thorax demonstrated a solid, partially calcified 10 cm mass situated posteriorly in the left upper lobe. In addition there was loss of volume and concentric pleural thickening in the left hemithorax, probably as a result of the previous artificial pneumothorax. No metastases were evident. At bronchoscopy irregular mucosa was noted in the left upper lobe bronchus. A biopsy specimen of this showed abnormal lymphoid tissue. Staining of sputum for acid-alcohol fast bacilli and subsequent mycobacterial cultures were negative.

Figure 1

Chest radiograph, posteroanterior view.

Figure 2

Chest radiograph, lateral view.

In the meantime the patient had developed marked hypertension, spontaneous bruising, and epistaxis. Fundal haemorrhages were present. Blood tests revealed a plasma viscosity of 5.3 mpa/s (normal range 1.5–1.72), haemoglobin 114 g/l, white cell count 3.9 × 109/l, platelets 230 × 109/l, globulin of 81 g/l, and an IgM monoclonal band of 42 g/l. Renal function was normal.

Questions

(1)
What diagnosis is suggested by the raised plasma viscosity and monoclonal IgM band and how would you confirm this?
(2)
What is the likely explanation for the lung mass?
(3)
What treatment would you consider?

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