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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.
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.
- What diagnosis is suggested by the raised plasma viscosity and monoclonal IgM band and how would you confirm this?
- What is the likely explanation for the lung mass?
- What treatment would you consider?