A 70 year old European coal miner comes to you with joint pain and trouble breathing. You notice his hands:
On CXR, you find multiple peripheral basilar nodules. He is PPD and HIV negative. You rule out the most common etiology of multiple pulmonary nodules (which you learned for Boards): metastatic solid organ malignancy, Non-Hodgkin's lymphoma, Kaposi sarcoma, multiple bacterial abscesses, septic emboli, fungi (histoplasmosis, coccidioidomycosis, aspergillosis, cryptococcus), flukes (Paragnomius westermani), Wegener's granulomatosis, and AV malformation. Histology of one of those nodules would show the following:
Interesting. You note the central necrosis. This is an odd association between two diseases, one reflecting the joint pain and one reflecting the pulmonary nodules.
Challenge: What is this syndrome called?
Both images shown under fair use.
Case idea and title contributed by Alex Penn.