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 Table of Contents  
Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 43-44

When doom is invincible and not easily perceptible: A case of diffuse nodular disease

1 Department of Neuromedicine, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
2 Department of Pulmonology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India

Date of Submission23-Feb-2022
Date of Decision27-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Debabrata Chakraborty
No. 64/4A/9, Beliaghata Main Road, Kolkata - 700 010, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jopcs.jopcs_3_22

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A 47-year-old -lady without known co-morbidity had presented with a one-month history of respiratory distress and headache. Someone incidentally started her with antitubercular drugs and steroids outside our hospital. Her routine CT scan of brain was unremarkable. She had a partial response to the same, but she presented to us with an increased headache after a month. We found her to have diffuse nodular pulmonary involvement with bilateral pleural effusion. The pleural fluid diagnostic evaluation revealed adenocarcinoma of the lung. The MRI of the brain revealed multiple nodular involvements consistent with the rare intracranial miliary metastasis. Our case underscores the importance of careful history taking and evaluation of patients with respiratory distress along with headaches (our patient lacked a classical history of miliary tuberculosis). We may overlook the silent brain metastasis on routine CT scans of the brain and cause an important delay in diagnostic evaluation and intervention in life-threatening diseases, like our case.

Keywords: Adenocarcinoma lung, diffuse nodular disease, miliary brain metastasis

How to cite this article:
Chakraborty D, Sengupta A, Chanda R, Sen S, Goenka S, Bhaumik S. When doom is invincible and not easily perceptible: A case of diffuse nodular disease. J Prim Care Spec 2022;3:43-4

How to cite this URL:
Chakraborty D, Sengupta A, Chanda R, Sen S, Goenka S, Bhaumik S. When doom is invincible and not easily perceptible: A case of diffuse nodular disease. J Prim Care Spec [serial online] 2022 [cited 2022 Dec 5];3:43-4. Available from: https://www.jpcsonline.org/text.asp?2022/3/2/43/345644

  Introduction Top

In clinical medicine, sometimes we face patients who do not present with a classical feature of a particular disease. However, on detail history and clinical examination clues emerge which guide us towards a definite diagnosis and we can cut short our differentials. We can then order specific investigations accordingly to reach the final diagnosis.

  Case Report Top

A 47-year-old female without known comorbidity had been at baseline till 1 month before her presentation to our institute. She had a progressive cough with scanty expectoration and complained of a new-onset holocranial dull aching headache. Within a few days of symptom onset, developed breathlessness requiring hospitalization. They started her with antitubercular drugs along with steroid in the local hospital. Her routine computed tomography (CT) scan of the brain was unremarkable. After an initial improvement, she had deterioration and transferred to our institute. At emergency room, she was alert, cooperative, and afebrile with stable vitals but required oxygen supplementation. She had decreased vesicular breath sounds bilaterally with occasional crackles. Her cardiac examination was normal. She had no neurodeficit or meningeal sign. We detected her to have diffuse bilateral lung involvement with nodular lesions and evidence of bilateral pleural effusion [Figure 1]. After stabilization with supportive care, we drained pleural fluid. It revealed total WBC of 600/cubic mm, lymphocytes of 90%, protein of 3.7 g/deciliter, and evidence of malignant cells consistent with adenocarcinoma. Her positron emission tomography CT scan of the whole body revealed brain lesions and magnetic resonance imaging (MRI) of the brain confirmed diffuse nodular involvement of the brain parenchyma [Figure 2]. A detailed cerebrospinal fluid study was unremarkable, including a comprehensive infection panel and GeneXpert for tuberculosis. Her headache resolved to some extent with antiedema measures. However, the family opted for alternative medicine and lost to follow-up.
Figure 1: Diffuse bilateral nodular lung involvement with pleural effusion.

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Figure 2: Multiple scattered heterogeneously enhancing intra-axial nodular parenchymal lesions of different sizes in the bilateral hemisphere, right caudate, and cerebellum.

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Our patient had granulomatous disease in the brain and lung. The list of etiological differentials for infectious granulomatous disease includes parasitic, bacterial, and fungal infections.[1] Importantly, central nervous system (CNS) metastasis may sometimes stimulate them.

Miliary tuberculosis (unlike our case) presents with fever, night sweats, and weight loss in almost all cases.[2] Patients may have hepatosplenomegaly, choroidal tubercles, and neurological and hematological disorders.[2]

Adenocarcinoma of the lung represents about 40% of all lung cancers and responsible for most miliary brain metastasis.[3] These lesions may be clinically silent because lack of mass effect.[4] Sometimes, calcifications in CT scan of the brain may be found as only clue to the CNS spread of the disease.[3]

Interesting and learning points in our case are as follows:

  1. Adenocarcinoma may present as diffuse nodular lesions in the brain and lung, though very rarely
  2. When miliary/nodular lung disease presents with respiratory distress at the onset, we should first consider possibilities other than tuberculosis
  3. Miliary brain metastasis may lodge silently and MRI of the brain with contrast is must in doubtful cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

da Rocha AJ, Maia AC Jr., Ferreira NP, do Amaral LL. Granulomatous diseases of the central nervous system. Top Magn Reson Imaging 2005;16:155-87.  Back to cited text no. 1
Mert A, Bilir M, Tabak F, Ozaras R, Ozturk R, Senturk H, et al. Miliary tuberculosis: Clinical manifestations, diagnosis and outcome in 38 adults. Respirology 2001;6:217-24.  Back to cited text no. 2
Inomata M, Hayashi R, Kambara K, Okazawa S, Imanishi S, Ichikawa T, et al. Miliary brain metastasis presenting with calcification in a patient with lung cancer: A case report. J Med Case Rep 2012;6:279.  Back to cited text no. 3
Bhushan C. “Miliary” metastatic tumors in the brain. Case report. J Neurosurg 1997;86:564-6.  Back to cited text no. 4


  [Figure 1], [Figure 2]


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