New onset of cough

Presenter: Jennifer DePry DO, Kurt Lu MD
Dermatology Program: University Hospitals Richmond Medical Center
Program Director: Jenifer Lloyd, DO
Submitted on: Feb 28, 2013

CHIEF COMPLAINT:  67 year-old Caucasian male with past medical history significant for multiple basal cell carcinomas who presents with new onset cough

CLINICAL HISTORY:

Signs and symptoms:  Dry cough for greater than one month

Previous Treatment:  Surgical excisions of multiple basal cell carcinomas including an aggressive one involving the underlying bone with perineural, and vascular invasion. This tumor required radiation and multiple surgeries, the last one in 2007, that resulted in sacrifice of the distal branches of cranial nerve VII, a parotidectomy as well as fat and nerve grafts.

Other information:  A CT of the chest showed pulmonary nodules in the left upper and right lower lobe.

 

CT of the chest showing left upper lobe nodule

 

CT of the chest showing right lower lobe nodule

PHYSICAL EXAM:

Examination revealed a pleasant, cooperative male with multiple scars on the right face consistent with repeated basal cell carcinoma resections. Additionally he had well healed scars involving the forehead, shoulders, back and chest. Regional adenopathy was absent.

LABORATORY TESTS:

CBC and CMP values in the last nine months were all within normal limits.

DERMATOHISTOPATHOLOGY:

Resection of the right lower lobe of the lung revealed invasive basal cell nests set in a fibrotic stroma with some central necrosis and individual necrotic cells positive for p63 and negative for TTF1. Additional immunohistochemical studies showed the tumor to be diffusely positive for p63 and diffusely strongly positive for BerEP4 supporting the diagnosis of metastasis from a basal cell carcinoma. Lymph node biopsies negative for malignancy.

 

H&E at 4X

 

BerEP4 staining

 

DIFFERENTIAL DIAGNOSIS:

1.   Pneumonia
2.   Bronchogenic carcinoma
3.   Metastasis from basal cell carcinoma
4.   Tuberculosis
5.   Lung abscess


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