Abstract
Introduction: Lung transplantation can be lifesaving in patients with rapidly progressive interstitial lung disease (RP-ILD). We present a case of incidentally diagnosed metastatic adenocarcinoma in a lung transplant candidate with RP-ILD. Case Report: A 37-year-old woman with a remote history of melanoma in situ, obstructive sleep apnea, asthma, and gastroesophageal reflux disease presented to an outside institution with chronic cough, severe dyspnea, and digital clubbing. The patient had a 15-pack-year smoking history and frequent contact with birds as a child. She was diagnosed with non-specific interstitial pneumonia, presumably due to chronic hypersensitivity pneumonitis, and started on mycophenolate mofetil and prednisone. One year later, the patient was hospitalized for acute hypoxic respiratory failure. Given progressive symptoms, she was referred to our institution for transplant evaluation. On presentation, the patient required 8 L of oxygen via nasal cannula; her exam was notable for bilateral crackles and grade 3 clubbing. Computed tomography showed progressive diffuse centrilobular ground-glass opacities with areas of consolidation, traction bronchiectasis, and subpleural cystic changes, and incidentally noted indeterminate T11 hypoattenuating lesion with a compression fracture. Due to the patient's rapidly deteriorating pulmonary function, she was listed for lung transplant. Twenty days later, the patient was admitted with a severe respiratory exacerbation requiring high-flow oxygen. She also reported back pain and tenderness in the lower thoracic spine. Magnetic resonance imaging done after hospital admission showed enhancing T8 body and T12 pedicle lesions along with a pathologic T11 compression fracture. Biopsy of the T11-T12 lesion showed metastatic adenocarcinoma invading soft tissue and bone; cells were immunoreactive for cytokeratin20 (CDX2) and negative for TTF-1, suggesting gastrointestinal or pancreatobiliary origin. Further diagnostic studies were not obtained due to limited functional status. The patient was delisted and discharged home with hospice; she died two months later. Discussion: In patients with RP-ILD who experience a sudden decline in functional status, concurrent disease processes may be overlooked due to the severity of lung disease. Incidental findings on pretransplant screening should be thoroughly explored.