Our visiting Stanford resident, Dr. Tiffany Guo, presented a very interesting case of an elderly female with a heavy smoking history who presented with a subacute dry cough and progressive dyspnea on exertion with new unilateral shoulder pain.

An initial differential for any heavy smoker with a dry cough and dyspnea should be broad, but include the following tobacco-related diagnoses: COPD, lung cancer, pulmonary HTN, postobstructive pneumonia, and smoking-related ILD including Langerhans cell histiocytosis, respiratory-bronchiolitis associated ILD, desquamative interstitial pneumonia, and sometimes, IPF, acute eosinophilic pneumonia, and pulmonary alveolar proteinosis. The smoking-related ILDs are a heterogeneous group, but in general, they tend to be asymptomatic or present with dry cough and dyspnea, occasionally with systemic symptoms like weight loss and fever. Physical exam may show rales or clubbing and PFTs show a restrictive lung defect. The diagnosis becomes more clear with specific findings on HRCT scan. Although these disorders are rare, they are important considerations because some have treatments and patients may be eligible for lung transplantation.

With this patient’s new onset shoulder pain, we also discussed Pancoast syndrome as a possible diagnosis. Pancoast syndrome consists of shoulder pain (most common initial symptom), Horner syndrome (ipsilateral ptosis, miosis/pupilary constriction, and anhidrosis/loss of sweating on the face), and weakness of the muscles of then hand due to a superior pulmonary sulcus tumors. This was not the diagnosis in our particular patient, but is an important diagnostic thought.

Our patient’s chest X-ray revealed a right hilar mass in the lung. While waiting for biopsy and counseling your patient on your initial concerns for malignancy, it is helpful to have a basic knowledge of the main types of lung cancer and their treatments.