CASE

A 56-year-old white male was referred to our clinic for further evaluation of right-sided lymphadenopathy and a suspicious finding on a chest radiograph. Approximately 6 months ago, the patient had an upper respiratory infection and a resultant nonproductive cough. The cough became progressively worse—both more frequent and more intense—and produced green-yellow sputum. A 2-week course of antibiotics resolved the phlegm but not the cough. The patient also noticed increasing dyspnea with exertion and a 5- to 10-lb weight loss. For the past 2 weeks, he intermittently coughed up dime-sized spots of blood. He also could not lie flat or on his right side without experiencing shortness of breath or chest discomfort.

HISTORY The patient's medical history included asthma, as well as tonsillectomy and appendectomy as a child; otherwise, he had been healthy all of his adult life. He admitted to some social smoking in college—about 1 to 2 cigarettes a week for 4 years. He had not smoked since, nor did he smoke currently. He denied alcohol or illicit drug use. The patient lived with his spouse, who did not smoke. He had no pets and had lived in the Midwest all his life.

PHYSICAL EXAMINATION Findings were as follows: temperature, 99.5°F; pulse, 92 beats per minute; respira-tions, 24 breaths per minute; BP, 130/60 mm Hg; pulse oximetry, 90% to 92% on room air; weight, 170 lbs; and height, 5 ft 11 in. The patient had mild cervical adenopathy, decreased breaths sounds on the right lower lung field with scattered coarse rhonchi, and occasional expiratory wheezes. Some mild accessory muscle use was noted. No clubbing or cyanosis in the extremities was seen. The rest of his examination results were normal.

LABORATORY TESTS Results were as follows: WBC count, 14,600/mm3; hemoglobin, 14.5 g/dL; hematocrit, 35.1%; and platelets, 380,000/mm3. Results of the metabolic panel were normal. CT of the chest revealed a centrally located right upper lobe mass with some atelectasis in the lower right lung fields (see Figure 1). An infiltrative process was apparent, as was lymphadenopathy in the right paratracheal, hilar, and pretracheal areas. The FEV1 was 1.85 L. A purified protein derivative test was nonreactive.

WHAT IS THE MOST LIKELY DIAGNOSIS?

• Small cell lung cancer
• Bacterial pneumonia
• Pleural effusion
• Pulmonary hamartoma

DISCUSSION

This patient had a hamartoma, the most common type of benign pulmonary nodule.1 Pulmonary hamartomas usually manifest as solitary peripheral lesions, but endobronchial hamartomas make up 3% to 20% of all reported hamartomas.2,3 Age of onset can be anywhere from the late 30s to a peak incidence in the 60s. The ratio of occurrence favors men to women, 4:1.4 On radiograph, hamartomas commonly look like tumors, pneumonia, or atelectasis. The majority of endobronchial hamartomas occur on the right side and in the proximal bronchial airway.2,4 They vary in size, can have calcifications, and may be a composite of different tissues. Despite its benign nature, endobronchial hamartomas may necessitate a lobectomy or pneumonectomy because of their location and the symptoms they cause.4

TREATMENT Bronchoscopy indicated that an endobronchial component to the mass appeared to be obstructing 85% of the patient's right mainstem airway. Resection of a 4.4-cm  X 3.5-cm smooth, well-circumscribed mass was performed via thoracotomy and right upper lobectomy. Histologic examination identified a mix of fibrous, fatty, endothelial, and cartilage components. The mass was diagnosed as a chondromatous hamartoma.

COMMENT Patients who are eventually found to have endobronchial hamartomas may be asymptomatic on presentation because of location or size of tumor. Because hamartomas are usually covered with a normal bronchial epithelium, it can be difficult to obtain a definitive diagnosis with a bronchial biopsy. The general symptoms of cough, dyspnea, hemoptysis, and weight loss make for an extensive differential diagnosis, including infections, cancers, pulmonary venous hypertension, or no identifiable source.5 Early detection and resection give patients the best chance for long-term survival. JAAPA

Nancy Stasik practices with the Division of Hematology/Oncology at Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio. She has indicated no relationships to disclose relating to the content of this article.

Erich Fogg, PA-C, MMSc, department editor

REFERENCES

1. McDonald JR, Harrington SW, Clagett OT. Hamaratoma (often called chondroma) of the lung. J Thorac Surg. 1945; 14(10):128-143.

2. Sharkey RA, Mulloy EM, O'Neill S. Endobronchial hamartoma presenting as massive haemoptysis. Eur Respir J. 1996;9(10): 2179-2180.

3. Kang MW, Han JH, Yu JH, et al. Multiple endobronchial chondroid hamartoma. Ann Thorac Surg. 2007;83(2):691-693.

4. Tajima H, Hayashi Y, Maehara T. Endobronchial hamartoma treated by an Nd-YAG laser: report of a case. Jpn J Surg. 1998;28(10):1078-1080.

5. Bidwell J, Pachner R. Hemoptysis: diagnosis and management. Am Fam Physician. 2005;72(7):1253-1260.