CT Scan Questions/Concerns

[aggie_tx_gal]

Hi all, I have been perusing this site for a couple of weeks and thought I'd go ahead and join/ask a question since everyone seems SO helpful and welcoming here in this forum.

Mid-July, I started running a high fever.  I had no other symptoms besides the fever, no appetite and extreme fatigue - no shortness of breath, no cough, no respiratory issues.  The fever lasted 4 days, so I went to the doc.  They ran tests for flu, Covid, UTI, and did an abdominal CT.  My bloodwork was a little wonky (low WBC, liver enzymes elevated), but everything else was negative.  They told me I more than likely had Covid that wasn't showing up yet, and to check back if fever continued past 7-8 days.  (I have been vaccinated for Covid with 2 doses of Pfizer but this didn't seem to matter.) 

Fever continued, followed by a bad pain when I would breathe in my back below my rib cage.  I went back to the doc and they tested me for Covid again (negative), then started me on antibiotics for a possible kidney infection due to the location of the back pain (and pulled another urine culture).  They also did a chest x-ray at that time.  Pain in my back went away after a couple of days on this first antibiotic, but the fever continued and the urine culture came back negative for kidney infection.  My doctor messaged and said that they'd like to switch me to an antibiotic that was more for pneumonia as the radiologist saw something that could be pneumonia in my lungs.  When I got the results, this was the finding on the x-ray:  "Ill-defined focal parenchymal opacity in the lateral mid right lung is new.  Pneumonia vs. pulmonary nodule.  Correlation with Chest CT is recommended."

Fever continued for a few days more despite the new antibiotic for pneumonia, and I was getting weaker after 2 weeks of fever with increased pulse rate.  My doc sent me in for a chest CT-scan (and yet another Covid test - still negative.) 

These were the results on the CT Scan:

"Lungs:  No pneumothorax or pleural effusion. No focal consolidation suspicious for pneumonia.  Dependent atelectasis with additional areas of atelectasis/scarring. Pulmonary nodule in the superior posterolateral right lower lobe measures up to 1.8 cm in mean axial dimension.

Mediastinal adenopathy is present, with right paratracheal and hilar lymph nodes measuring up to 12 mm. No left hilar adenopathy. No supraclavicular adenopathy.

IMPRESSION: 18 mm pleural-abutting pulmonary nodule in the posterolateral right lower lobe, with mediastinal and right hilar adenopathy. Given clinical symptoms, this likely reflects a focal pneumonia with reactive adenopathy. However cannot exclude malignancy; follow-up radiographs are recommended 4-6 weeks after treatment."

Doc set up a follow up appointment with Pulmonology in 2 months and also gave me some prednisone.  My fever finally went away 2 days after the CT-Scan on the last day/dose of the antibiotics.  But I have never had a cough, nor did I cough anything up after the fever went away.  

If you've made it this far through my long-winded backstory, thank you.  Here are my questions/concerns:

1.  CT Scan results specifically said I had no focal pneumonia, but then on the impression said that the 1.8 cm pulmonary nodule was likely focal pneumonia due to my clinical symptoms (high fever).  This was confusing to me.  Can a pulmonary nodule be pneumonia?  I thought nodules were a solid mass, where pneumonia is more fluid?  I was just confused by why the radiologist specifically said there was nothing suspicious for pneumonia, but there's an 18 mm pulmonary nodule with affected lymph nodes that's likely pneumonia.  Any ideas?

2.  Is there any reason that I should be trying to escalate my follow up appointment (still about 7 weeks away)?  I'm a little anxious the more I study about the size of the pulmonary nodule they found, the affected lymph nodes, and the fact that I have never coughed anything up the entire time during and recovery after the pneumonia diagnosis.  I worry that my fever may have just been caused by a nasty virus, which may have uncovered something more sinister going on in my lungs. 

But I may also just be blowing this wayyyy out of proportion and the simple explanation is that I had a super bad case of non-symptomatic pneumonia that the 2nd round of antibiotics finally kicked and the pulmonary nodule and swollen lymph nodes will be gone on the follow up scan next month.  Do nodules go away?

I am 44 years old and a non-smoker (besides about one year in college where I made all sorts of bad decisions and luckily survived...and luckily social media hadn't been invented yet).  My maternal grandmother died from lung cancer at 60 (she was a smoker), and both my paternal grandparents survived lung cancer (grandma in 50s, grandpa in 60s).

Any help/advice is appreciated, and many thanks and prayers for those that have posted.

[Rower Michelle]

Hello and welcome.

While none of us are physicians, if you’ve been reading then you get our groove which is generally to eliminate the word “wait” from our vocabulary. 
The CT impression has a critical word on there “however when referring to potential malignancy.   That word alone is worthy of a more timely follow up, like your instincts are telling you. 
 

I spent an entire summer on multiple rounds of antibiotics, numerous specialists (including a pulmonologist at a reputable hospital system) all of whom missed my cancer diagnosis in 2018.  
 

Rather than worry, advocate for yourself for an earlier appointment.   That peace of mind is priceless.  Never mind if the medical community doesn’t think it’s convenient for them.  You will feel so much better when you get seen sooner.   
 

Hopefully this is a big nothing-burger….

Go for it,

Michelle

[Judy M2]

I agree with Michelle, push it. I too was misdiagnosed for several months because I didn't have risk factors. 

[LouT]

Aggie

I throw my hat in with Michelle. While a nodule could have resulted from pneumonia (60% of nodules are benign) it is worth getting confirmation sooner rather than later.  Your pulmonologist may do a pet scan but,at 18mm the most definitive test will be a biopsy. Please follow-up with your doctor now rather than wait.  If it is benign then you lose nothing and have peace of mind. But if not then you catch the problem earlier which is always a good thing. Please update us when you learn something. 

Lou 

[Tom Galli]

Aggie,

Welcome here.

Here is my go to resource explaining pulmonary nodules and why they happen. Two important points in from this source: 95% of  nodules are not cancer and a respiratory infection is a very common cause of nodules and enlarged lymph nodes. Your question: do nodules go away? Yes, mine do. In fact, I have phantom nodules that show up on one scan and hide on the next.

Two more points: the 1.8 cm nodule is too small for a reliable result on a PET scan (here is information about PET scans, select the right arrow titled position emission tomography (PET)). And, to Lou's point, the only way to diagnose lung cancer is with a tissue sample biopsy and a 1.8 cm nodule is a small target, difficult to hit with a needle biopsy. You could press for a surgical biopsy, but a surgical wedge resection or a surgical lobectomy is a lot of mayhem for a small, possibly benign, nodule and two inflamed lymph nodes.

You've told us of your very brief smoking history. Troy Texas is not known to present a radon gas risk, so if you've lived in Troy all your life, radon should be off the table as a risk factor. But if you went to college or lived in a Rocky Mountain State, Michigan or the North East, you might have been exposed to radon gas. However, and unfortunately, even folks with low risk factors get lung cancer. Michelle's point on peace of mind is well made. Better to urge your doctors to rule out lung cancer than to wait. If what you have turns out to be lung cancer, it is very treatable by a number of very effective methods. If one waits and the disease spreads, then treatment becomes much more difficult.

Your radiologist is suggesting 4 to 6 weeks for a repeat CT scan. I'd push for 4. 

Stay the course.

Tom

 

 

[aggie_tx_gal]

Thanks everyone for your kind responses.  I did reach out to my primary care doctor, and he scheduled a follow up chest x-ray for a week from today.  My assumption is if the nodule is still showing on the x-ray after pneumonia treatment, I will have more ammunition to get the pulmonology follow up escalated to sooner.  The nodule was evident on the two x-rays that were done before my CT-Scan.  

Tom, I was born in Oklahoma but have lived in Texas since the age of 2.  I do not believe I have had exposure to radon gas.  My career does entail being around a lot of agriculture chemicals though.  Thanks for the links.  I'm glad to hear that the size of my nodule is small and that yours have come and gone.  The very first search I did online took me to a site that said 80% of pulmonary nodules over 10mm are malignant (see here), so that got my head spinning since mine was sized at 18mm. The internet can be a dangerous place...  I'd much rather focus on 95% of nodules being benign.   

Fingers crossed that the nodule is gone on next week's x-ray.  I will keep you posted.  Thanks again to everyone - you definitely calmed down my nerves.

[Rower Michelle]

That’s good to hear- you’ve quickly figured out Dr Google is not our friend.  Keep us posted…. So glad you have a PCP in your court.  

[aggie_tx_gal]

Just wanted to give you guys an update as I said.  I started having flank pain again, so my primary care doc moved up my follow up scan.  The scan still showed the nodule, so he called pulmonology and they got me right in.  The pulmonologist was awesome and thorough.  He said the CT-Scan shows the nodule right in the bottom edge of my lung and shows inflammation in the lining, which in turn has caused inflammation between my ribs (thus the crazy flank pain.)  I have a CT-guided needle biopsy of the area set up for next Tuesday.  Pretty much all of my right and middle chest lymph nodes are very enlarged so he was concerned for lymphoma (and I learned we have a LOT of lymph nodes around our lungs!)  He also said we could do a scope to biopsy my inflamed lymph nodes instead, but felt going directly into the nodule would be a better approach.  I do worry about lymphoma given my low WBC count on one of my recent CBC tests and high C-reactive protein (but that worry is coming from post-appointment Dr. Google so I'm trying not to put too much stock into it.)    

Doc said even though there is a chance of lymphoma/cancer that needs to be investigated, we both believe this is more than likely a fungal issue due to the fact that my husband and I have been remodeling and working on cleaning up an old farm and farmhouse that we bought last year.  Plus I'm around agriculture a lot in my business.  I could have breathed in something from the disruptions in the soil or construction that caused the nodule/inflammation.  He's ordered fungal cultures from the biopsy as well and said they could take up to 6 weeks to grow.  He said I'd find out sooner if the biopsy showed anything more sinister.  He also ordered a lot more bloodwork including antigens for different fungi, a fungal profile, TB, another CBC (which I already got back and everything was normal including WBC - yay!), LDH, Urinalysis, & CMP.

I'll follow up again after my biopsy next week.  Thanks again for your advice.  Hope all are well.

[Rower Michelle]

Thanks for the update, a needle biopsy is the fastest way to get the initial diagnostics, typically within three to five days.  Believe me we all know what the waiting period is like. It’s awful.  I remember going out of chocolate milkshakes every day.    Try and find something enjoyable to do to ease the anxiety of waiting.  Keep us posted!  Nice to hear from you.  
Michelle

[LouT]

Great update!  I'll be sending out good vibes for your results. And next time I'm nervous I'm going over to Michelle's for chocolate milk shakes (my favorite). 

Lou

[aggie_tx_gal]

Haha!  @LouT and @Rower Michelle, I think everyone on here definitely deserves milkshakes!!   Thanks for the good vibes!

[aggie_tx_gal]

Hi everyone, my CT needle biopsy was Tuesday so I'm in the "waiting for results" stage...  Michelle, I took your advice and made my husband take me for a very sinful tasting Whataburger Dr. Pepper shake after the biopsy (it's Texas's version of a chocolate milkshake but with added endorphins, rainbows and all things happy.)  

I have gotten several results from bloodwork from last week and initial biopsy smears back on MyChart that are starting to worry me a little.  I have thought this was a fungal thing, but the antigen blood tests for histoplasmosis, coccidioidomycosis (which doc thought was most likely), and cryptococcal came back negative.  I also got the quick results from a gram stain and fungal stain from the biopsy of the nodule and they were both negative for microorganisms and fungus.  So my thought that my growth was a fungus from our farm house remodel doesn't seem to be panning out.  I also had a high LDH count in my blood tests.  Liver enzymes and proteins have stayed elevated as well.  If this wasn't an acute fungal/bacterial infection, then I'm worried about what it could be given all the hilar and mediastinal lymph node enlargement and the pleural pain.  I'm trying to stay positive, especially since I'm inferring all this based on my non-medical degree researched interpretations of the test results that have been sent to me via automated process.  My husband says he wishes they would wait and just send everything together all at once with my diagnosis.  He may shut off our internet.......  

I'll keep you posted.  For those that have had them, how long does it usually take to get a pathology report after a needle biopsy?

[LexieCat]

Trying to figure things out on your own based on a few lab results is an exercise in futility. I try not to look at most test results (e.g., CT scan reports) till my doctor can interpret them for me. It's too easy to get carried away trying to read the tea leaves. Others here want their test results immediately. Different strokes...

Anyway, there are multitudes of conditions that could cause the lab results you mention. Let the docs earn their money and figure it out. Your biopsy results should be back soon.

[Tom Galli]

Aggie,

I agree with Lexie. Do not engage in futility exercises. There is more than enough drama in our disease already.

Let's wait till the biopsy results are in. Till then...

Stay the course.

Tom

[Rower Michelle]

Hi, Just catching up on your post yesterday.  For me it took 48 hours (literally to the minute) to get the biopsy results.  That was back in 2018, today, it might take a little longer “due to covid” a phrase we are all sick and tired of hearing.  

The Epoch system is the computer program running MyChart which delivers results for immediate release so you will likely see the biopsy results before your doctor does.   This is definitely the worst part, the waiting.  I had a milkshake every day while waiting…..

Hang on and yes do turn off the internet.   

[aggie_tx_gal]

Hey y'all, I just got the pathology report and the results are benign!  "Benign pulmonary parenchyma with necrotizing granulomatous inflammation...GMS stains, performed on the blocks 1A and 1B, are positive for yeast form fungi, morphologically compatible with Histoplasma species."

Shortly before I received that, I received the Fungal Profile-Serum blood test results that were done a couple of weeks ago.  They showed high levels of Blastomyces Antibody, Histoplasma Yeast and Histoplasma Mycelia.  

Things I've learned:  Histoplasmosis can cause pulmonary nodules with hilar and mediastinal adenopathy that mimic malignancy.  Fungal smears and fungal antigen tests can all be negative but the biopsy can still show a fungal infection source.  Don't immediately rule out a benign cause of pulmonary nodule/englarged lymph nodes based on trying to google test results.  In fact, stay off the internet all together except to discuss favorite milkshake flavors with @Rower Michelle.  

Thank you all again for the good vibes and words of wisdom.  I know so many of you and your loved ones are fighting the good fight with such grace and overcoming  obstacle after obstacle.  You all gave me hope that no matter the diagnosis, there are countless stories of survival, faith, good humor, and kicking cancer's a$$.  You all are my heroes.

[Rower Michelle]

Very happy you found us, it’s an important story as many people find themselves here in search of information.   This thread will be so helpful in the future.  Thanks for letting us know, now you can have TWO milkshakes!   ❤️ 

[Judy M2]

What great news! And I learned something from your diagnosis. Thanks for being with us. Enjoy those well-deserved milkshakes!

[LexieCat]

Terrific news! Thanks for updating us.

[BridgetO]

Having "something else" (not cancer) is a real reason to celebrate!

[Tom Galli]

WONDERFUL!

Stay the course.

Tom

[LouT]

Excellent news!

Lou